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  • Gleneagles Singapore

Minimally Invasive Cardiac Surgery

  • Understanding the Procedure

    Gleneagles Singapore, Bladeless Cataract Surgery

    Traditionally, heart surgeries were performed through a sternotomy (where a large cut on the chest is made to split the breast bone) to gain access to the heart. Not only does the large incision result in a long, unsightly scar, but it causes significant levels of pain, significant physiological trauma, a long hospital stay and a long recovery period.

    As heart surgery techniques and technology improved over time, surgical techniques have been improvised to reduce the pain and suffering for the patients while maintaining the safety and effectiveness of the surgery.

    Minimally invasive cardiac surgery (MICS) is well-developed and recognised now in most parts of the world. Following strict criteria, the length of the cut for MICS is defined as less than 4 inches.

    To date, MICS has been used 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 the best path 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 thoracoscopy (VATS)
    • Robotic-assisted thoracoscopy

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

    Following the harvest of LIMA, the artery will then be connected to the most critical left anterior descending artery to offer patients the improved long-term outcome. During the operation, because of the off-pump technique and the minimal handling of the heart, the patient has a more stable blood flow and reduced bleeding.

    MICS is also being widely used for isolated cardiac valvular surgery, especially mitral valve repair / replacement, tricuspid valve repair / replacement and aortic valve replacement. Most commonly, this is done through a 6 – 8cm cut in the sternum. For mitral and tricuspid valve surgery, it can also be approached via a small cut through the chest or via robotic-assisted surgery.

    In the hands of a trained heart surgeon, these minimally invasive approaches will offer patients the reduced physical and psychological trauma while preserving the aim of the surgery in 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 modern development of MICS has continued to evolve and has also been successfully applied in other heart surgeries, including atrial septal defect closure, tricuspid valves repair, DOR procedure (chronic heart failure operation), and removal of left ventricular blood clot, 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 ischaemic heart disease, some coronary arteries 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 connected to it. In a patient with cardiac valvular disease coupled with coronary artery disease, this patient will undergo a full sternotomy using standard methods to fix both the valve and coronary artery stenosis.

    However, with the development of MICS and increasing teamwork between cardiologists and cardiac surgeons, the hybrid approach to a patient's cardiac condition can now offer a new view in treatment planning and work towards the best possible outcome.

    In a patient with multiple coronary artery disease, LIMA – LAD anastomosis offers the long-term patency and patient survival. Total arterial coronary artery bypass often appears attractive in terms of clinical outcomes. However, this happens only in less than 20% of such cases.

    On the other hand, although percutaneous coronary intervention (PCI) with stents one of the least minimally invasive among all revascularisation interventions, and the technology of coronary stents has evolved dramatically, its outcome still cannot match LIMA – LAD, which offers 20-years patency rate of more than 90%.

  • It has become more acceptable for cardiologists and heart surgeons to work together to offer patients the best of both worlds.

    "With the hybrid approach, a patient with multiple coronary artery disease can undergo a small thoracotomy and LIMA – LAD (MIDCAB) followed by PCI and stenting to the other vessels within the same admission.

    The patient will benefit from the optimal path to the more critical coronary artery (LIMA – LAD) and avoid needing a large cut to be made along the sternum. The other less critical vessels can then be revascularised with PCI and stenting. Bear in mind that the current stent technology delivers similar or better results than the long saphenous veins and radial artery methods that are used in CABG."

    Without any complications, patients will undergo less trauma from the surgery while receiving benefits from both specialties. Usually, the patients will be discharged within 3 days of hospital stay and can resume work within 2 – 4 weeks.

    Alternatively, patients with heart valve disease and non-LAD coronary artery disease can also benefit from the hybrid approach.

    Traditionally, patients will need a full sternotomy (a large cut is made on the sternum) to allow heart valve repair/replacement and will most likely have a saphenous vein grafted to the stenosed non-LAD coronary artery.

    The venous graft has been shown to remain less than 50% open in 10 years, which is a less ideal outcome when compared to the results of a PCI and stenting.

    Instead of the patient being managed alone by either heart surgeons or cardiologist, the hybrid procedure has the advantage of providing a partial sternotomy (a small cut is made on the sternum), valve repair/replacement, followed by PCI to treat the coronary artery disease. This allows for a shorter surgery time and shortens the cardiopulmonary bypass time.

    All these combined, there is less physical and psychological trauma experienced, thus there is less pain, a faster recovery, and less scarring involved.

    Every patient should be assessed and counselled individually to have their treatment customised for their cardiac condition.

    Gleneagles Hospital's established team of specialised cardiac surgeons and doctors, supported by a strong multi-disciplinary team of medical specialists, nurses and therapists, will guide patients with professionalism and care through the entire process from surgery to recovery and back to independence.

  • Quality and customised healthcare has been our legacy for more than 50 years. Our skilled team of specialists and staff at Gleneagles Hospital is committed to your goal of getting the most appropriate treatment for your needs.

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