Minimally invasive cardiac surgery

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Minimally invasive cardiac surgery
Other namesMICS CABG
Specialty cardiology

Minimally invasive cardiac surgery, encompasses various aspects of cardiac surgical procedures (aortic valve replacement, mitral valve repair, coronary artery bypass surgery, ascending aorta or aortic root surgery) that can be performed with minimally invasive approach either via mini-thoracotomy or mini-sternotomy. [1] [2] MICS CABG (Minimally Invasive Cardiac Surgery/Coronary Artery Bypass Grafting) or the McGinn technique is heart surgery performed through several small incisions instead of the traditional open-heart surgery that requires a median sternotomy approach. MICS CABG is a beating-heart multi-vessel procedure performed under direct vision through an anterolateral mini-thoracotomy. [3]

Contents

Advantages of minimally invasive heart surgery are less blood loss, reduced post-operative discomfort, faster healing times and lower risk of infections, reduced duration of mechanical ventilation as well as eliminating the possibility for sternal non-union. This procedure makes heart surgery possible for patients who were previously considered too high risk for traditional surgery due to age or medical history. [4] [5] Patients referred for this procedure may have coronary artery disease (CAD); aortic, mitral or tricuspid valve diseases; or previous unsuccessful stenting.

The procedure

MICS CABG is performed through one 5–7 cm incision in the 4th intercostal space (ICS). In some cases the thoracotomy may be necessary in the 5th ICS instead. A soft tissue refractor is used to allow for greater visibility and access. MICS CABG may be completed in an "anaortic" or no-touch off-pump technique, which has demonstrated reduced postoperative stroke and mortality compared to traditional CABG. [6]

Two access incisions are also made at the 6th intercostal space and xiphoid process to allow for instruments to position and stabilize the heart. [3] [7]

The McGinn Technique (Proximal Anastomoses)

The McGinn proximal technique is performed with the blood pressure lowered to 90-100 systolic which reduces stress to the aorta. A series of tools are used to position and stabilize vessels. The technique uses devices to support the surrounding heart tissues while vital surgery takes place. This is also known as off-pump CABG (OPCAB). OPCAB voids the use of cardiopulmonary bypass (CPB), which requires the heart to be stopped (arrested) with cardioplegia solution. Off-pump is also known as beating heart surgery.[ citation needed ]

Minimally invasive heart surgery has been used as an alternative to traditional surgery for the following procedures:

Pump-assisted beating heart bypass

A cannula with a pump and vacuum action is fed up through an artery in the groin to reduce the stress on the heart so that it may still function during the operation. This pump flows at 2-3 liters per minute to support circulation and eliminates the need for cardioplegia to arrest the heart.[ citation needed ]

Hybrid coronary revascularization

Hybrid coronary revascularization is a common procedure that takes advantage of coronary stenting in combination with CABG. Hybrid coronary bypass is a relatively new procedure and alternative to traditional bypass surgery that is defined by the performance of coronary bypass surgery and coronary stenting of different areas of a patient's heart. MICS CABG allows utilization of the left internal mammary artery (IMA; aka left internal thoracic artery, left ITA) to bypass the left anterior descending artery (LAD), which is termed as left IMA-LAD, as a preferable anastomosis whenever indicated and technically feasible (Loop et al.) and has been proven to benefit in event free survival (Acinapura et al.). The other one or two arteries will be stented, when appropriate, allowing cardiologists and cardiothoracic surgeons to work together. [8] [9]

After surgery

After a minimally invasive procedure, patients recover more quickly than from sternotomy and develop fewer complications. Most patients can expect to resume everyday activities within a few weeks of their operation. After surgery, patients are administered an anaesthetic pain pump and drains that will be removed prior to discharge. Patients are encouraged to move around as much as possible after their operation to recover quickly. Once discharged from hospital, patients require no further post-operative assistance. [10]

Minimally invasive heart surgery is a safe and broadly applicable technique for performing a wide range of complex heart procedures, including single or multiple heart valve procedures, bypass surgery, and congenital heart repairs.

Benefits of MICS CABG/ The McGinn Technique

Eliminating the need for median sternotomy greatly reduces the trauma and pain associated with open-chest surgery and improves quality of life for patients. In the hospital, reduced post-operative discomfort enables patients to quickly begin a shorter recovery process. Most patients ambulate more easily and participate more actively in their personal care. Additionally, this approach lowers risk of complications such as bleeding, infection and eliminates the risk of sternal non-union. [11]

Minimally invasive heart surgery improves cosmetic results. Rather than a prominent 10-inch scar down the middle of the chest, patients are left with smaller marks to the side of the ribs. For women, in many cases, this scar is completely unnoticeable as it sits below the breast. [11]

Benefits Include:

MICS CABG Study Results

2014

At the 2014 International Society for Minimally Invasive Cardiothoracic Surgery Annual Meeting in Boston, Dr. Joseph T McGinn presented a study titled "Minimally Invasive CABG is Safe and Reproducible: Report on the First Thousand Cases," which found a low rate of conversion to sternotomy and low rate of complications. Assessing survival and adverse cardiac events up to 8.0 years (average 2.9±2.0 years), MICS CABG is a safe, reproducible operation that yields survival (96.1±0.9%) and durability comparable to conventional CABG. [12] [13]

2013

The Journal of Thoracic and Cardiovascular Surgery published a study on November 1, 2013, that confirmed MICS CABG as safe, feasible, and associated with excellent graft patency rates at 6 months post surgery, with graft patency of 92% for all grafts and 100% for left internal thoracic artery grafts. Coronary artery bypass graft patency was studied through computed tomography angiography. 92% of patients were free from angina and none of the participants experienced any aortic complications, repeat revascularizations, cerebrovascular accidents, myocardial infarctions or death. The two-year study included 91 participants between the ages 48 and 79, averaging a hospital stay of 4 days (range, 3–9 days). Clinical Trial Registration Unique identifier: NCT01334866. [14]

2012

At 2012 American Heart Association's Scientific Sessions and Resuscitation Science Symposium, a study titled "Minimally Invasive CABG: Results to 6 Years" was presented, demonstrating MICS CABG feasibility and established alternative for multivessel sternotomy CABG. It was also noted that the procedure is associated with a short hospital length of stay, no deep wound infections and is safe. The study also proved survival and durability on par with sternotomy. [15]

2010

At the 2010 International Society for Minimally Invasive Cardiothoracic Surgery Annual Meeting in Berlin, Germany, duel center data was presented the standardization of MICS CABG in performance and reproducibility of its results. Its safety and effective alternative for performing surgical myocardial revascularization on the beating heart (OPCAB) is emphasized. "Shortened hospital stay is starting to be realized and its application to high risk and complex patients is now being done." [16]

2009

A 2009 publication in Circulation, titled "Minimally Invasive Coronary Artery Bypass Grafting: Dual-Center Experience in 450 Consecutive Patients" concluded MICS CABG as a feasible procedure with excellent short-term outcomes. At that time the study noted, "this operation could potentially make multivessel MICS CABG safe, effective and more widely available." [7]

History

Minimally invasive cardiac surgery was pioneered by Dr Joseph T McGinn, Jr. The first minimally invasive heart cardiac surgery was performed in the United States on January 21, 2005, at The Heart Institute at Staten Island University Hospital in Staten Island, New York by a team led by Dr. Joseph T. McGinn. This technique is an off-pump coronary artery bypass surgery. The procedure is much less invasive than traditional bypass surgery because it is performed through three small incisions rather than the traditional sternotomy. Since its first procedure, over 1000 MICS CABG procedures have been performed at The Heart Institute and elsewhere around the world. [5] Other centers that utilize the MICS CABG technique for coronary heart disease are the University of Ottawa Heart Center (ON, Canada), Houston Methodist DeBakey Heart Center (Houston, TX), and Vanderbilt University Medical Center (Nashville, TN). [17] [18] [19]

Related Research Articles

<span class="mw-page-title-main">Coronary artery bypass surgery</span> Surgical procedure to restore normal blood flow to an obstructed coronary artery

Coronary artery bypass surgery, also known as coronary artery bypass graft, is a surgical procedure to treat coronary artery disease (CAD), the buildup of plaques in the arteries of the heart. It can relieve chest pain caused by CAD, slow the progression of CAD, and increase life expectancy. It aims to bypass narrowings in heart arteries by using arteries or veins harvested from other parts of the body, thus restoring adequate blood supply to the previously ischemic heart.

<span class="mw-page-title-main">Cardiopulmonary bypass</span> Technique that temporarily takes over the function of the heart and lungs during surgery

Cardiopulmonary bypass (CPB) is a technique in which a machine temporarily takes over the function of the heart and lungs during cardiac surgery, maintaining the circulation of blood and oxygen to the body. The CPB pump itself is often referred to as a heart-lung machine or "the pump". Cardiopulmonary bypass pumps are operated by perfusionists. CPB is a form of extracorporeal circulation. Extracorporeal membrane oxygenation (ECMO) is generally used for longer-term treatment.

<span class="mw-page-title-main">Cardiothoracic surgery</span> Medical specialty involved in surgical treatment of organs inside the thorax

Cardiothoracic surgery is the field of medicine involved in surgical treatment of organs inside the thoracic cavity — generally treatment of conditions of the heart, lungs, and other pleural or mediastinal structures.

<span class="mw-page-title-main">Cardiac surgery</span> Type of surgery performed on the heart

Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease ; to correct congenital heart disease; or to treat valvular heart disease from various causes, including endocarditis, rheumatic heart disease, and atherosclerosis. It also includes heart transplantation.

Aortic valve replacement is a procedure whereby the failing aortic valve of a patient's heart is replaced with an artificial heart valve. The aortic valve may need to be replaced because:

<span class="mw-page-title-main">Cardiac catheterization</span> Insertion of a catheter into a chamber or vessel of the heart

Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes.

<span class="mw-page-title-main">Mitral valve repair</span> Cardiac surgery procedure

Mitral valve repair is a cardiac surgery procedure performed by cardiac surgeons to treat stenosis (narrowing) or regurgitation (leakage) of the mitral valve. The mitral valve is the "inflow valve" for the left side of the heart. Blood flows from the lungs, where it picks up oxygen, through the pulmonary veins, to the left atrium of the heart. After the left atrium fills with blood, the mitral valve allows blood to flow from the left atrium into the heart's main pumping chamber called the left ventricle. It then closes to keep blood from leaking back into the left atrium or lungs when the ventricle contracts (squeezes) to push blood out to the body. It has two flaps, or leaflets, known as cusps.

<span class="mw-page-title-main">Median sternotomy</span> Surgical access through vertical sternum incision

Median sternotomy is a type of surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided using a sternal saw. This procedure provides access to the heart and lungs for surgical procedures such as heart transplant, lung transplant, corrective surgery for congenital heart defects, or coronary artery bypass surgery.

Hybrid coronary revascularization (HCR) or hybrid coronary bypass is a relatively new type of heart surgery that provides an alternative to traditional coronary artery bypass surgery (CABG) or percutaneous coronary intervention by combining the two into one operation. It is this combining aspect that "hybrid" refers to. HCR is one of several types of hybrid cardiac surgery; it is not to be confused with a MIDCAB procedure, which uses the smaller thoracotomy incision but does not involve coronary stenting.

Minimally invasive direct coronary artery bypass (MIDCAB) is a surgical treatment for coronary heart disease that is a less invasive method of coronary artery bypass surgery (CABG). MIDCAB gains surgical access to the heart with a smaller incision than other types of CABG. MIDCAB is sometimes referred to as "keyhole" heart surgery because the operation is analogous to operating through a keyhole.

Postperfusion syndrome, also known as "pumphead", is a constellation of neurocognitive impairments attributed to cardiopulmonary bypass (CPB) during cardiac surgery. Symptoms of postperfusion syndrome are subtle and include defects associated with attention, concentration, short-term memory, fine motor function, and speed of mental and motor responses. Studies have shown a high incidence of neurocognitive deficit soon after surgery, but the deficits are often transient with no permanent neurological impairment.

<span class="mw-page-title-main">Off-pump coronary artery bypass</span>

Off-pump coronary artery bypass or "beating heart" surgery is a form of coronary artery bypass graft (CABG) surgery performed without cardiopulmonary bypass as a treatment for coronary heart disease. It was primarily developed in the early 1990s by Dr. Amano Atsushi. Historically, during bypass surgeries, the heart is stopped and a heart-lung machine takes over the work of the heart and lungs. When a cardiac surgeon chooses to perform the CABG procedure off-pump, also known as OPCAB, the heart is still beating while the graft attachments are made to bypass a blockage.

Cardiothoracic anesthesiology is a subspeciality of the medical practice of anesthesiology, devoted to the preoperative, intraoperative, and postoperative care of adult and pediatric patients undergoing cardiothoracic surgery and related invasive procedures.

Vessel harvesting is a surgical technique that may be used in conjunction with a coronary artery bypass graft (CABG). For patients with coronary artery disease, a physician may recommend a bypass to reroute blood around blocked arteries to restore and improve blood flow and oxygen to the heart. To create the bypass graft, a surgeon will remove or "harvest" healthy blood vessels from another part of the body, often from the patient's leg or arm. This vessel becomes a graft, with one end attaching to a blood source above and the other end below the blocked area, creating a "conduit" channel or new blood flow connection across the heart.

<span class="mw-page-title-main">Hybrid cardiac surgery</span>

A hybrid cardiac surgical procedure in a narrow sense is defined as a procedure that combines a conventional, more invasive surgical part with an interventional part, using some sort of catheter-based procedure guided by fluoroscopy imaging in a hybrid operating room (OR) without interruption. The hybrid technique has a reduced risk of surgical complications and has shown decreased recovery time. It can be used to treat numerous heart diseases and conditions and with the increasing complexity of each case, the hybrid surgical technique is becoming more common.

Dr R Ravi Kumar graduated from Stanley Medical College and obtained the FRCS from Edinburgh. He worked at the Harefield Hospital, UK, under Sir Magdi Yacoub involving himself with adult cardiac surgery including heart and lung transplant and aortic homografts. Dr Ravi Kumar then underwent surgical residency in Boston, MA, United States. Following this he worked with Dr Albert Starr in Portland, Oregon. He pursued his cardiothoracic residency at the University of Texas, South Western Medical Center, Dallas, Texas, U.S. He continued at the same institution as an advanced fellow in Heart & Lung Transplant and is UNOS, certifiable for Heart & Lung Transplant.

Uwe Klima is UAE based professor of surgery and a faculty member at the Hannover Medical School, Germany. He also is the medical and managing director at German Heart Centre, Dubai.

<span class="mw-page-title-main">Anil Bhan</span> Indian cardiologist

Dr. Anil Bhan is the Chairman of Cardiac Surgery Heart Institute, Medanta Hospital, Gurugram, India. He graduated from Medical College Srinagar. He has the largest experience in aortic surgery in India since he has designed and developed more than 50 surgical instruments in the field of cardiac surgery. He was one of the team members to perform the first successful heart transplant in India in1994. He served as a co-founder of Max Heart and Vascular Institute, Saket, New Delhi, Director and Chief Co-Ordinator, Cardio thoracic and Vascular Surgery, MHVI, Saket.Additional Professor, Cardiothoracic Surgery and Vascular Surgery, AIIMS, New Delhi.

John D. Puskas is an American researcher, author, inventor and cardiovascular surgeon. As of 2022, he is Professor, Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, and chairman, Department of Cardiovascular Surgery at Mount Sinai Morningside, Mount Sinai Beth Israel and Mount Sinai West. He holds 11 U.S. patents and co-founded the International Coronary Congress and the International Society for Coronary Artery Surgery. He is credited by ResearchGate with 330 publications and 15,234 citations and as of 2022 Scopus reports an h-index of 62. Puskas is known for advancing coronary artery bypass (CABG) surgery by refining surgical techniques for all-arterial, off-pump CABG and inventing finer instruments to be used for advanced coronary bypass surgical procedures. He is credited with performing the first totally thoracoscopic bilateral pulmonary vein isolation procedure. He is the co-editor of State of the Art Surgical Coronary Revascularization, the first textbook solely devoted to coronary artery surgery.

Mario F.L. Gaudino, MD, PhD, MSCE, FEBCTS, FACC, FAHA is an Italian cardiothoracic surgeon who is the Stephen and Suzanne Weiss Professor in Cardiothoracic Surgery (II) and Professor of Clinical Epidemiology and Health Services Research at Weill Cornell Medicine and an attending cardiac surgeon at NewYork-Presbyterian Hospital and Weill Cornell Medical Center. He is an expert in coronary revascularization and clinical trialist. He is known for conducting the PALACS trial, which demonstrated that posterior pericardiotomy at the time of cardiac surgery reduced the incidence of post-operative atrial fibrillation and pericardial effusion.

References

  1. ↑ Mihaljevic, T; Cohn, LH; Unic, D; Aranki, SF; Couper, GS; Byrne, JG (September 2004). "One thousand minimally invasive valve operations: early and late results". Annals of Surgery. 240 (3): 529–34, discussion 534. doi:10.1097/01.sla.0000137141.55267.47. PMC   1356443 . PMID   15319724.
  2. ↑ Sef, D; Bahrami, T; Raja, SG; Klokocovnik, T (June 2022). "Current trends in minimally invasive valve-sparing aortic root replacement-Best available evidence". Journal of Cardiac Surgery. 37 (6): 1684–1690. doi:10.1111/jocs.16453. PMID   35348237.
  3. 1 2 "MICS CABG Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure", "", 2010, p. 1
  4. ↑ "NYU Langone Medical Center", "", December 29, 2009
  5. 1 2 "The Heart Institute"," Archived 2016-08-04 at the Wayback Machine ", March 25, 2011
  6. ↑ Zhao, Dong Fang (February 28, 2017). "Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta: A Network Meta-Analysis". Journal of the American College of Cardiology. 69 (8): 924–936. doi:10.1016/j.jacc.2016.11.071. PMID   28231944. S2CID   33400664.
  7. 1 2 McGinn JT, Usman S, Lapierre H, Pothula VR, Mesana TG, Ruel M (September 2009). "Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients". Circulation. 120 (11 Suppl): S78–84. doi: 10.1161/CIRCULATIONAHA.108.840041 . PMID   19752390.
  8. ↑ Loop FD, Lytle BW, Cosgrove DM, et al. (January 1986). "Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events". The New England Journal of Medicine. 314 (1): 1–6. doi:10.1056/NEJM198601023140101. PMID   3484393.
  9. ↑ Acinapura AJ, Rose DM, Jacobowitz IJ, et al. (August 1989). "Internal mammary artery bypass grafting: influence on recurrent angina and survival in 2,100 patients". The Annals of Thoracic Surgery. 48 (2): 186–91. doi: 10.1016/0003-4975(89)90065-9 . PMID   2788393.
  10. ↑ "Medtronic", "", 2009
  11. 1 2 McGinn JT Jr, Usman S, Lapierre H, Pothula VR, Mesana TG, Ruel M (2009). "Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients". Circulation. 120 (11 Suppl): S78–84. doi: 10.1161/CIRCULATIONAHA.108.840041 . PMID   19752390.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ↑ 2014 International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) Annual Scientific Meeting- Boston,, May 2014
  13. ↑ McGinn JT, Shariff MA, Nabagiez JP, Sadel S, Sharma R, Abogato P, Daniele E, Fazio L, Lapierre H, Sohmer B, Ruel M. (May 2014) Minimally Invasive CABG is Safe and Reproducible: Report on the First Thousand Cases. Presentation at International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2014 in Boston,, 2014
  14. ↑ Ruel M, Shariff MA, Lapierre H, et al. (January 2014). "Results of the Minimally Invasive Coronary Artery Bypass Grafting Angiographic Patency Study". The Journal of Thoracic and Cardiovascular Surgery. 147 (1): 203–8. doi: 10.1016/j.jtcvs.2013.09.016 . PMID   24183338.
  15. ↑ 2012 American Heart Association's Scientific Sessions and Resuscitation Science Symposium, , 2012.
  16. ↑ De C, Laffery J, Lakhani M, Shariff M, Ramchandani M, McGinn J. Minimally Invasive Coronary Artery Bypass Grafting: An Alternative Approach to Perform Coronary Artery Bypass Grafting on the Beating Heart. Poster presented at: International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) June 2010, Berlin, Germany, , 2010
  17. ↑ University of Ottawa Heart Center, http://www.ottawaheart.ca/misc/marc-ruel_research-clinical-interests.htm
  18. ↑ Houston Methodist DeBakey Heart Center, http://www.houstonmethodist.org/DrMaheshRamchandani
  19. ↑ Vanderbilt University Medical Center, "Department of Cardiac Surgery - Steven J. Hoff, M.D." Archived from the original on 2014-07-14. Retrieved 2014-07-07.

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