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Minimally Invasive Cardiac Surgery

  • Understanding the Procedure

    Gleneagles Singapore, Bladeless Cataract Surgery

    Traditionally, over the past few decades, heart 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 it causes more pain, more physiological trauma, a longer hospital stay and a longer recovery period.

    As understanding of heart surgery and technology improve 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

    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 connected to the most critical left anterior descending artery to offer patients the best long-term outcome. During the operation, because of the off-pump technique and the least handling of the heart, the patient has more stable blood flow and the amount of bleeding is also reduced.

    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 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 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 team work between cardiologists and cardiac surgeons, the hybrid approach to a patient with cardiac conditions can now offer a new view in treatment planning and work towards the best interest of patients.

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

    On the other hand, although percutaneous coronary intervention (PCI) with stents is least invasive among all revascularisation interventions, and the technology of coronary stents has evolved dramatically, its outcome still cannot match LIMA – LAD, which offers a 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 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 and stenting to the other 2 vessels within the same admission. The patient will then benefit from the best path to the most critical coronary artery (LIMA – LAD) and avoid a large cut along the sternum. The other 2 less critical vessels can then be revascularised with PCI and stenting. It is important to remember that the current stent technology gives equal 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 need a full sternotomy (a large cut along the sternum) 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 remain less than 50% open 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 poor 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 (a smaller cut along the sternum), valve repair/replacement followed by PCI to the coronary artery disease. This not only shortens the surgery time, but shortens the cardiopulmonary bypass time, which has been well documented to cause harm the longer it is in effect. All these combined efforts cause 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 suitable treatment for their cardiac condition.

    Gleneagles Hospital's established team of highly 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.

  • We understand that you value efficient and effective treatment above all else, and that is what we provide at Gleneagles Hospital. Our highly-accomplished team of specialists and staff will make it a priority to place your needs first in formulating a course of treatment.

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