cardiology

LESSINVASIVE.COM

An Online Resource for Less Invasive
& Minimally Invasive Procedures & Surgeries

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 posible, 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.

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 eitherfrom 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 are also being developed to replace damaged valves through limited access ports.

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. 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.

Endoscopic vessel harvesting is a less invasive procedure prior to open heart surgery where vessels needed bypass are removed. Endoscopic vessel harvesting minimizes the scarring and risk of infection associated with traditional harvesting procedures. 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...

The American Heart Association's recommendation states: "Both surgeries appear promising but need more study. MIDCAB, for example, seems to be easier on thepatient 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".

Numerous robotically -assisted, less invasive cardiac procedures are currently being performed using the da Vinci ® robotic system. It has been reported the approximately 70- 90 hospitals in the United States are currently employing robotic assistance for certain less invasive cardiac surgeries. The da Vinci robotic system offers three-dimensional visualization and remarkable technical precision, which has assisted and improved a cardiac surgeons' ability to perform difficult procedures with greater accuracy. Intuitive surgical has received FDA clearance for the following less invasive robotic assisted cardiotomy procedures: mitral valve repair, endoscopic atrial septal defect closure, mammary to left anterior descending coronary artery anastomosis for cardiac revascularization with adjunctive mediastinotomy, and internal mammary artery mobilization and cardiac tissue ablation. Many institutions have recently expanded the application of robotically-assisted MIDCAB to selected patients with multi- vessel disease. By combining coronary artery stenting and robotic MIDCAB, all territories may be revascularized through a minimally invasive approach. Robotics are currently being employed for the treatment of end- stage cardiomyopathy and congestive heart failure. Robotically assisted, less invasive placement of biventricular pacing wires has been effective treatment to minimize the symptoms (shortness of breath and fatique) associated with cardiomyopathy or congestive heart failure. Shrinking robots and growing processors are taking minimally invasive techniques where they have never gone before, read more...

Atrial Fibrillation affects almost 2.5 million people in the US alone, with 300,000 new cases diagnosed every year. 15% of all strokes that occur anually can be attributed to atrial fibrillation. There are numerous interventions available to help convert this rhythm to a more regular one, including medications, electrical cardioversion, atrial pacemakers, surgery or ablation. Less invasive techniques can now be employed to perform atrial fibrillation surgery or maze procedure.
Trans- catheter valve replacement - an investigational treatment for valve replacement currently
undergoing clinical study by Edwards Lifesciences. This investigational less invasive cardiac procedure shows great promise for patients how are too ill to undergo conventional valve replacement or repair surgery. Evalve has developed the MitraClip, a percutaneous, less invasive mitral valve repair system that is used by interventional cardiologists and is intended to reduce mitral regurgitation. A major benefit of this device is that it enables the interventional cardiologist to repair the mitral valve while the heart is beating, without cardiopulmonary bypass (CPB) and without the need for a thoracotomy or sternotomy. The Evalve Mitraclip is undergoing investigational use only.
The most common interventional procedure is angioplasty or percutaneous coronary intervention. Performed by an interventional cardiologist, this procedure is done to view the coronary arteries to determine the extent of a patient’s disease, if any. Once access is gained to the patient’s vessels, specialized catheters are advanced to the heart. Once in the heart, under real-time imaging, the interventional cardiologist injects dye that can be seen under imaging through the coronary arteries. If a significant blockage or narrowing is seen, after balloon angioplasty is done, a stent can be deployed to keep the blockage open. Under certain circumstances, specialized catheters may need to be used to remove fresh clots from within the vessel. Click here for video information on cardiac catherization.

Endoscopic Vessel Harvesting,less invasive