Minimally Invasive Cardiac Surgery

What is minimally invasive cardiac surgery?

Minimally invasive cardiac surgery uses small chest incisions and endoscopic instruments to gain access to the heart. In contrast, traditional heart surgeries use a large cut in the chest to split the breastbone (also known as a sternotomy) and gain access to the heart.

As heart surgery techniques and technology improve over time, more conditions may be treated through minimally invasive surgery or keyhole surgery. This technique can help to reduce pain and scarring while maintaining safety and efficacy, while revolutionising the overall patient recovery experience.

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What are the minimally invasive cardiac procedural treatments available at our hospitals?

Types of minimally invasive cardiac surgery include:

• Minimally invasive mitral valve repair, which can relieve symptoms of mitral regurgitation or stenosis and prevent hospitalisation for heart failure, can be done through a small sternotomy or anterior thoracotomy

• Minimally invasive aortic valve replacement, which treats aortic valve disease, restores normal blood flow, reduces symptoms and preserves the function of your heart muscle.

• Transcatheter aortic valve implantation (TAVI), which uses a catheter to implant an aortic valve in patients with severe aortic stenosis.

• Coronary artery bypass surgery (MIDCAB), which can be a hybrid procedure combined with stents. This surgical procedure bypasses blocked heart arteries to restore normal blood flow to the heart muscle.

• Minimally invasive multivessel coronary artery bypass surgery (MICS-CABG), a hybrid approach that combines surgical and percutaneous techniques to treat coronary artery disease without the need for a full sternotomy. This procedure typically involves the following steps:

  • Minimally invasive surgical bypass: The cardiac surgeon makes a small incision (mini-thoracotomy) between the ribs on the left side of the chest, below the nipple line. Through this incision, the surgeon performs a coronary artery bypass grafting (CABG) procedure, often using the left internal thoracic artery (ITA) to bypass the left anterior descending (LAD) artery, but also other vessels. This technique avoids splitting the sternum, reducing surgical trauma and improving recovery time and mobility.

  • Percutaneous coronary intervention (PCI): Following the surgical bypass, a cardiologist addresses any remaining significant coronary artery lesions that are not amenable to surgical bypass. This is achieved by inserting stents into these arteries to restore adequate blood flow. The PCI is usually performed in a staged manner, either during the same hospitalisation or shortly thereafter, depending on the patient's condition and the complexity of the lesions.

  This hybrid approach leverages the durability of surgical grafts for critical arteries like the LAD, while utilising PCI for other vessels, aiming to provide comprehensive revascularisation with the benefits of minimally invasive techniques. It is particularly beneficial for patients with multivessel coronary artery disease who are at higher risk from traditional open-heart surgery due to factors such as age, frailty, or other health conditions.

Who should not undergo minimally invasive cardiac surgery?

Not everyone is a suitable candidate for minimally invasive heart surgery, but the majority of patients are.

To determine whether you are a candidate for minimally invasive heart surgery, your doctor is likely to:

• Review your medical history
• Conduct a physical examination
• Perform tests (such as imaging tests, laboratory tests, pulmonary function tests and cardiac evaluation)

Your doctor and treatment team will work with you to determine the best option to treat your condition.

What are the risks and complications of minimally invasive cardiac surgery?

Minimally invasive heart surgery carries the same risks as open-heart surgery. These include:

• Bleeding*
• Infection*
• Irregular heart rhythms (arrhythmias)*
• Stroke
• Death

*Bleeding, infection, and irregular heart rhythms have been shown to occur less frequently with minimally invasive heart surgery compared to open surgery.

If your surgeon thinks it is not safe to continue with the minimally invasive heart surgery approach, your procedure may need to be changed to open-heart surgery. This is called “conversion”.

How do you prepare for minimally invasive cardiac surgery?

Before your surgery, your doctor will:

• Bring you through the surgical procedures of minimally invasive heart surgery
• Explain the potential risks
• Discuss any concerns you may have
• Talk about any advance directives or other information to consider prior to your surgery

You may need to have your hair shaved at the areas (typically around the chest) where the procedure will take place. Your skin may be washed with special soap to reduce the risk of infection.

Before admission for your surgery, talk to your family about your hospital stay and discuss the help you might need when you return home. Your doctor and treatment team will give you instructions to follow during your recovery when you return home.

Food and medications

Talk to your doctor about:

• When you should stop eating or drinking the night before the surgery
• When you can take your regular medications and whether you can take them before your surgery
• Medications you have brought to the hospital and when you should take medications on the day of the procedure
• Allergies or reactions you have had to medications

Clothing and personal items

You may want to pack the following items for your hospital stay:

• A list of your medications
• Spectacles, hearing aids or dentures
• Personal care items, such as a brush, comb, shaving equipment and toothbrush
• Loose-fitting, comfortable clothing
• A copy of your advance medical directive
• Items that might help you relax, such as a portable music player or books

During surgery, avoid wearing:

• Contact lenses
• Dentures
• Jewellery
• Nail polish
• Spectacles

What can you expect in minimally invasive cardiac surgery?

In all types of minimally invasive cardiac procedures, your surgeon will reach your heart through small incisions. These incisions can be located at various sites, such as between the ribs of your chest, groin or armpit.

Your surgeon will insert a tool with a small video camera through one of the incisions to provide a magnified, three-dimensional image of the operating site.

Most minimally invasive procedures use a heart-lung bypass machine, as is used in open-heart surgery. The machine keeps blood moving through your body during the procedure.

Robot-assisted heart surgery

In robot-assisted heart surgery, your surgeon uses robotic arms to perform the manoeuvres used in traditional open-heart surgery.

During this procedure, your surgeon works at a remote console and views your heart in a magnified high-definition 3D view on a video monitor. From the console, your surgeon's hand movements translate precisely to the robotic arms at the operating table, which moves similarly to the human wrist.

A second surgeon and surgical team will assist at the operating table, changing surgical instruments attached to the robotic arms.

Thoracoscopic surgery

In thoracoscopic surgery (sometimes referred to as a mini-thoracotomy), your surgeon inserts a long, thin tube (thoracoscope) containing a tiny high-definition video camera into a small incision in your chest.

Your surgeon repairs your heart using long instruments inserted through small incisions between your ribs.

Hybrid approach

If you have:

• Ischaemic heart disease, some coronary arteries may be more suitably dealt with by angioplasty and stenting.
• Cardiac valvular disease coupled with coronary artery disease, you may have to undergo a full sternotomy using standard methods to fix both the valve and coronary artery stenosis.
• Multiple coronary artery disease, LIMA – LAD (left anterior descending coronary artery) anastomosis (a surgical connection between the two) offers optimal clinical outcomes.

Your doctor will assess and develop a treatment plan customised to your cardiac condition.

After the procedure

You will generally spend a day or so in the intensive care unit (ICU). You will be given fluids and medications through intravenous (IV) lines. Other tubes placed during surgery will drain urine from your bladder and fluid and blood from your chest. You might be given oxygen through a face mask or prongs in your nose.

After the ICU, you will be moved to a regular hospital room for several days. The time you spend in the ICU and hospital will depend on your condition and surgery.

Your treatment team will:

• Monitor your condition and watch for signs of infection at your incision sites
• Monitor your blood pressure, breathing and heart rate
• Work with you to manage any pain
• Encourage you to get up and walk, and demonstrate how to gradually increase your activity
• Show you how to do deep-breathing exercises, including how to cough to clear your lungs

Care and recovery after minimally invasive cardiac surgery

Your doctor will give you instructions to follow during your recovery, such as:

• Watching for signs of infection in your incisions
• Caring for your incisions
• Taking medications
• Managing pain

Your doctor will let you know when you can return to daily activities, such as working, driving and exercise.

Do attend regular follow-up appointments with your doctor. You may be asked to do several tests to evaluate and monitor your condition.

As part of your recovery, your doctor may advise you to incorporate healthy lifestyle changes into your life — such as physical activity, a healthy diet, stress management and avoiding tobacco use.

Your doctor may also recommend that you participate in cardiac rehabilitation to help you improve your health and recovery after heart surgery.