During conventional open heart surgery, surgeons access the heart through a sternotomy, which is an extensive incision of the breastbone that averages 9-10 inches in length. The heart is also stopped and the body is supported on a heart- lung machine. While this method offers total access to the heart, it lengthens the post-operative recovery period to allow the patient's breastbone to heal.
The objective of minimally invasive cardiac surgery is to minimize postoperative pain and trauma to surrounding tissue, decrease scarring, resumption of the patient's normal function as soon as possible, lessen the risk of infection, and reduce recovery times compared to traditional open procedures. Although there is less risk for potential complications with minimally invasive cardiac surgery, not all patients are appropriate for minimally invasive cardiac surgery and each patient is evaluated on an individual basis. As with any surgery, and less invasive surgery is no exception, potential risks or disadvantages can occur. The potential cost of less invasive/ robotic cardiac surgery can reach as high as $1.2 million. Another disadvantage for the surgeon is the learning curve. It can sometimes take a surgeon 12- 18 procedures using the technology before they may feel comfortable with the procedure. And during this training, procedures can take extended periods of time which equates to; increased OR time and surgical staff, longer period for patient to be under anesthesia.
There are 2 frequently used methods for performing less invasive coronary artery bypass grafting, port-access coronary artery bypass (also referred to as PACAB or PortCAB) and minimally invasive coronary artery bypass (also called MIDCAB). Less invasive approaches are also being employed for heart valve replacement and repair, and repair of certain congenital heart defects such as PDA (patent ductus arteriosus), atrial septal defect, and patent foramen ovale.
MIDCAB or minimally invasive coronary artery bypass grafting, is performed without the patient being supported on the heart-lung machine or "off pump",and while your heart is still beating. MIDCAB is indicated when only one or two arteries need to be bypassed. Using this less invasive approach, the Left Internal Mammary Artery can be used to bypass the Left Anterior Descending Artery, and the same can be done with the Right Coronary Artery. MIDCAB combines the use of the small "ports" for the specialized instrumentation, as well as "key-hole"incisions made directly over the artery in need of bypassing. The bypass grafts are sewn into place while using a special device manufactured by Guidant that stabilizes the target area. Patients who are operated on "off pump" have potentially less risk of post operative bleeding, stroke and cognitive dysfunction, and chest wound infections. Average hospital stay for less invasive CABG is 3 days as opposed to 6-8 days for conventional CABG.
The American Heart Association's recommendation states: "Both surgeries appear promising but need more study. MIDCAB, for example, seems to be easier on the patient and less expensive than a coronary artery bypass graft. However, there may be complications that mean an open-chest procedure is needed. Neither procedure can be given an unqualified endorsement until more data on their effectiveness is obtained and analyzed. Information is being gathered and scrutinized at many medical centers in North America and elsewhere. If these surgeries can be refined to the point where they're no more invasive than angioplasty, they'll have a distinct advantage over angioplasty. However, at this point they're more invasive than angioplasty and require general anesthesia".
Endoscopic vessel harvesting is a less invasive procedure prior to open heart surgery where vessels needed bypass are removed. The first human case of EVH with a "closed system" was performed in 1995, and now it is used in approximately 60% of all cases. Endoscopic vessel harvesting minimizes the scarring and risk of infection associated with traditional harvesting procedures. With endoscopic vessel harvesting, the vessel is removed intact from the patient's arm or leg through a 2 cm incision. The "open" vessel harvesting procedures can cause significant pain and discomfort for patients during the recovery period and leave a scar that may run the full length of the patient's leg or forearm. In addition, the large incision that is required in an open vessel harvesting procedure is associated with a high rate of wound complications including dehiscence, hematoma and infection. Boston Scientific launches innovative technologies for less-invasive coronary artery bypass surgery, read more...
Endoscopic repeat sternotomy
- a certain percentage of cardiac surgery patients require a second operation. There is great risk of re-entering the heart through the same sternotomy from the first surgery. By doing an endoscopic sternotomy, the surgeon can view structures behind the sternum before the sternum is reopened.
Endoscopic pericardiectomy
- a less invasive procedure done endoscopically that removes the sac around the heart where fluid can collect due to certain disease processes. This recurrent collection of fluid restricts the movement of the heart.
Several benefits have been reported with EVH vs. traditional open vessel harvesting: Equal conduit quality and graft patency, reduced wound complications/ infections, reduced wound-related post-operative care and readmissions, reduced post-op pain, reduced time to ambulation & reduced length of stay, and improved cosmesis. See EVH video.
Transmyocardial Laser Revascularization - is a type of less invasive surgery that uses laser energy to create tiny channels through the heart muscle and into the lower-left chamber of the heart (the left ventricle), which is the heart's main pumping chamber. After the procedure, when oxygen-rich blood enters the heart's left ventricle, some of that blood can flow through the tiny new channels and carry much-needed oxygen to the starving heart muscle. TMR is indicated in patients who have severe angina refractory to medical management, where regions of the patient's heart muscle are not amenable to direct cardiac revascularization, and diffuse atherosclerotic disease and distal small vessel disease. Diabetic patients and redo CABG(coronary artery bypass graft) patients are good candidates for this minimally invasive procedure. TMR can be performed via a less invasive approach with or without robotic assistance. Cardiogenesis Inc. has the first FDA approved delivery system for minimally invasive TMR.
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During PACAB, your heart function is stopped and your blood is pumped through a "heart-lung" machine which oxygenates your blood during the surgery. This is called "cardiopulmonary bypass." Subsequently small incisions or “ports" are made in your chest. Arteries or veins are obtained either from your leg or your chest and are surgically attached to the heart to "bypass" the closed coronary artery or arteries. Specialized instruments are then passed through the “ports” by the cardiac surgeon to perform the bypasses. The cardiac surgeon is able to visualize these surgeries on video monitors rather than directly. Currently there are procedures being developed to replace damaged valves through limited access ports.
