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Minimally Invasive Cardiac Surgery

  • Understanding the procedure

    Gleneagles Singapore, Bladeless Cataract Surgery

    Traditionally, over the past few decades, cardiac surgeries were performed through sternotomy (a large cut on the chest and splitting of the breast bone) to gain access to the heart. Not only does the large incision result in a long, unsightly scar, but more importantly, it translates into more pain, more physiological trauma, a longer hospital stay and a longer recuperation period.

    As understanding of cardiac surgery and technology improve over time, techniques for cardiac surgery have been improvised to reduce the pain and suffering for the patients while maintaining the safety and efficacy of the surgery.

    Minimally invasive cardiac surgery (MICS) is well developed and recognised now in most parts of the world. In fact, in most tertiary centres, for example in Cleveland Clinic in the United States of America, most cardiac surgeries were performed via MICS. Following strict criteria, the length of incision for MICS is defined as less than 4 inches.

    To date, MICS has been most widely applied for coronary artery bypass surgery (CABG) and cardiac valvular surgery.

    For minimally invasive direct coronary artery bypass surgery (MIDCAB), the left internal mammary artery (LIMA), which is unequivocally the best conduit and offers the best long-term patency, can be harvested via 3 different ways:

    • A small anterior thoracotomy of 6-8cm in length
    • Video-assisted thoracoscopic (VATS)
    • Robotic-assisted

    Each of these approaches has its own pros and cons. There is a certain learning curve and hence it is important for the surgeon to be well versed in such approaches.

    Following the harvest of LIMA, the artery will then be anastomosed to the most critical left anterior descending artery to offer patients the best long term outcome. During the operation, as a result of off pump technique and minimal manipulation of the heart, the patient is more stable hemodynamically and the amount of bleeding is also much less.

    MICS is also currently being widely utilised for isolated cardiac valvular surgery, especially mitral valve repair / replacement, tricuspid valve repair / replacement and aortic valve replacement. Most commonly, this is performed via partial sternotomy through a 6-8cm incision. For mitral and tricuspid valve surgery, it can also be approached via a small right anterior thoracotomy or via robotic–assisted surgery.

    In the hands of a trained cardiac surgeon, these minimally invasive approaches will offer patients the least physical and psychological trauma while preserving the aim of the surgery in utmost safety. Typically, after MICS, the patient can be discharged from the hospital in 3-4 days time and resume most of their usual activities within 2-4 weeks.

    This state-of-the-art development of MICS has continued to evolve and has also been successfully applied in other cardiac surgeries, including atrial septal defect closure, tricuspid valves repair, DOR procedure (chronic heart failure operation), and removal of left ventricular thrombus, arrhythmia surgery and ventricular septal rupture.

    Hybrid Approach

    In the current era of medicine, it may be difficult to offer perfect treatment options for a patient with complex heart disease. In a patient with ischemic heart disease, some coronary artery may be more suitably dealt with by angioplasty and stenting, while some coronary artery, especially the left anterior descending artery, may be better off with a CABG and LIMA anastomosed to it. In a patient with cardiac valvular disease coupled with coronary artery disease, this patient will undergo a full sternotomy using conventional methods to fix both the valve and coronary artery stenosis.

    However, with the development of MICS and increasing collegiality between cardiologists and cardiac surgeons, the hybrid approach to a patient with cardiac conditions can now offer a new perspective in treatment planning and work towards the best interest of patients.

    In a patient with multiple coronary artery diseases, it is without argument that LIMA – LAD anastomosisoffers the best long-term patency and patient survival.Total artery coronary artery bypass is often raised by many surgeons and appears attractive interms of clinical outcomes. However, in real life, this happens only in less than 20% of the cases.

    On the other hand, although PCI with stents is least invasive among all revascularisation interventions and the technology of coronary stents have evolved dramatically, its outcome still cannot match LIMA – LAD, which offers a 20 years patency rate of more than 90%.

  • With acceptance of the above knowledge and facts, it has become increasingly acceptable for cardiologists and cardiac surgeons to work together to offer patients the best benefits from both worlds.

    With the hybrid approach, a patient with multiple coronary artery disease can then undergo a small thoracotomy and LIMA – LAD (MIDCAB) followed by PCI & stenting to the other two vessels within the same admission. The patient will then benefit from the best conduit to the most critical coronary artery (LIMA – LAD) and avoid the full sternotomy. The other two less critical vessels can then be revascularised with PCI and stenting. It is important to bear in mind that the current stent technology offers equivalent or even better results than the long saphenous veins and radial artery methods that were used in CABG.

    Typically, this group of patients will suffer the least trauma from surgery and obtain the best outcome from both specialties. Usually, the patients will be discharged within 3 days of hospital stay and resume work within 2-4 weeks.

    Another common scenario where the hybrid approach is being adopted is in patients with heart valve disease and non-LAD coronary artery disease. Again, these patients will traditionally require a full sternotomy to allow heart valve repair/replacement and most likely a saphenous vein graft to the stenosed non-LAD coronary artery. In the literature, the venous graft has been shown to have a patency of less than 50% in 10 years. This result is far inferior when compared to the outcome of PCI and stenting. It is becoming obvious that a full sternotomy to achieve a less-than-inferior result is not plausible.

    Instead of the patient being managed alone either by surgeons or cardiologists, the patient will be much better off undergoing a hybrid procedure of partial sternotomy, valve repair/replacement followed by PCI to the coronary artery disease. This not only shortens the surgery time but most importantly, shortens the cardiopulmonary bypass time, which has been well documented to cause harm with prolonged duration. All these combined efforts translate into less physical and psychological trauma, less pain, much faster recovery and a much better aesthetic outcome.

    Every patient should be assessed and counselled individually to have the most appropriate treatment for his or her cardiac condition.

    Gleneagles Hospital's established team of highly specialised cardiac surgeons and doctors, supported by our strong multi-disciplinary team of medical specialists, nurses and therapists, will guide you with professionalism and care through the entire process from surgery to recovery and back to independence. Rest assured that we constantly do all we can to bring about successful treatment outcomes for our patients.

  • We understand that patients value efficient and effective treatment above all else, and that is what we provide at Gleneagles. Our highly accomplished team of specialists and staff at Gleneagles Hospital will make it their priority to place your needs first in formulating a course of treatment. Let us help you move swiftly towards better health and better living today.

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