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The softer heart surgery, sparing the trauma

C. Maya
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Despite the popularity of angioplasty and stenting, a coronary artery bypass graft (CABG) is still considered the gold-standard treatment for patients suffering from coronary artery diseases. After a major open-heart surgery, it can take a patient weeks to recover, not just physically but mentally too.

So, it certainly sounds nice when Ciro Campanella, renowned cardiac surgeon from Edinburgh, says that he sends home all his patients on the third day after a coronary bypass.

Dr. Campanella, senior consultant cardiac surgeon at the NHS Trust's Royal Infirmary of Edinburgh, U.K., has been specialising in minimally invasive cardiac surgery since 1997 and has to his credit several significant surgical innovations.

Minimally invasive cardiac surgeries, especially ‘off-pump' surgeries (cardiac surgeries that are performed without the aid of the heart-lung machine), are being popularised in the U.S and in the U.K. in a big way because they have major advantages for the patient, Dr. Campanella says.

He was in the city last month at SUT Royal Hospital, where he performed several minimally invasive cardiac surgeries, which were shown live to a gathering of select cardiac surgeons in the city.

A traditional bypass surgery has the surgeon performing a median sternotomy (sawing through the breast bone) and separating the rib cage for getting access to the heart. This is considered one of the most traumatic aspects of a coronary bypass as this injury takes time to heal.

Another aspect of the coronary bypass surgery which can have some serious side effects for the patients is the use of the heart-lung machine or the cardiopulmonary bypass. During this surgery, the patient is connected to the heart-lung machine, which draws out the blood from the patient and circulates it in the body through a cardiopulmonary circuit, while the heart and lungs of the patient are stopped for the surgeon to perform the graft.

“There is a three per cent risk of stroke, cognitive decline, bleeding, kidney failure or arterial fibrillation when the patient is put on a heart-lung machine because of the interaction between blood and air while the blood is passed through the cardiopulmonary circuit of the heart-lung machine,” Dr. Campanella says.

Only a few incisions

In a minimally invasive surgery, the surgeon puts a few incisions on the chest and accesses the heart through the endoscopic implements which are inserted through these incisions. By doing away with the heart-lung machine, the surgeon operates on a beating heart.

“The advantages of a minimally invasive cardiac surgery are many for the patient as there is less of pain, infection risk, bleeding, less complications and hence faster recovery. There is also a cosmetic angle as the trauma and disruption to the anatomy is minimal. Patients can leave the hospital on the third or fourth day and the waiting period for surgery and ICU beds is also lowered,” Dr. Campanella says.

Some of the major cardiac surgeries that he demonstrated included the keyhole mitral valve replacement, CABG (mid CAB) and minimally invasive aortic valve replacement, apart from redo operations and total arterial graft in a beating heart.

Surgeons need to develop a high level of skills and long hours of training (hand-eye coordination, working with the endoscope) before these techniques can be perfected and this is one of the reasons why there are fewer centres offering minimally invasive cardiac surgeries.

“There is no scope for improvisation because your surgical innovation should be a big step forward for the patient. Ultimately, it is the surgeon's confidence and the patient's choice whether the minimally invasive route should be opted for,” Dr. Campanella says. A beating heart surgery in the Indian population, with almost all patients presenting with a high level of diabetes, hypertension and small vessel disease, is difficult but not impossible. There are certain situations — the coronary arteries are too calcified or if the blood vessels in the heart are deeply embedded in the muscle or if there are more than two blocks in the coronary arteries — when the surgeon might have to opt for the open chest route.

The development of ‘off-pump' surgery came hand in hand with technological development and surgeons have the means of keeping the heart steady while performing graft. The coronary bypass and open heart surgeries were made possible because of the invention of the heart-lung machine. It is thus indeed an irony that today surgeons are trying to phase out the heart-lung machine, Dr. Campanella says.

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