Minimally Invasive Valve Surgery
The first cardiac surgeries were performed in the 1940’s. Technological advances such as the cardiopulmonary bypass machine introduced in 1953 allowed surgeons to undertake increasingly difficult pathologies. Improvements in technologies and technique have made cardiac surgery procedures routine cases with predictable outcomes. The golden era of cardiac surgery began in the 80’s and continued with massive growth into the late 90’s. Despite all of this growth and evolution, the traditional access point for the procedure, through the anterior sternum, did not evolve at all. In addition, the advent of angioplasty, and drug eluting stents have actually caused a sharp drop off for cardiac surgery case volume, as surgery is no longer the only option for treating heart disease.
What is the cause of this?
We know in nature, when given a choice, all things will take the path of least resistance. Therefore, when given the option of a single overnight stay, and a small groin wound over a multi day stay and an open chest procedure, all sane patients will pick the path of least resistance, even if it is slightly less effective over time. New technologies have closed the gap in outcomes between the interventional cardiologist and the surgeon.
In a way, the loss of case volume has benefited cardiac patients, forcing the innovative surgeons to come up with less invasive procedures and “give the customer what they want.” A new field of cardiac surgeons has begun. Theses surgeons practice the art labeled minimally invasive cardiac surgery (MICS.) MICS is a broad term that defines many types of procedures done in a manner that is less invasive than usual. Coronary Artery Bypass Grafting (CABG) has been done with the assistance of a Cardiopulmonary Bypass Machine (pump) for decades. This pump enabled surgeons to stop the heart, while running a patients blood through a circuit that added oxygen, removed CO2 and other waste products, and regulated body temperature for the duration of the surgery. Now, less invasive surgeons often perform bypass surgery on a beating heart to minimize the negative effects of bypass.
Almost all cardiac procedures have been performed through a median sternotomy which required a split of the breast plate (sternum) to show the front of the heart and its surrounding structure (Figure 1). Now surgeons perform the same procedures through lateral thoracotomies, partial sternotomies, and even port access which eliminates the need to saw through the breast plate. (Figure2).
There are several ways to perform MICS, or less invasive surgeries. The first, and most common is to avoid the median sternotomy. The benefits of avoiding this are vast, but include decreased risk of infection, faster recovery, and less pain. Most valve procedures can be performed in this manner, and some CABG procedures too. The second major way to be less invasive is to avoid the use of the cardiopulmonary bypass circuit. Though the bypass machine is very important in some procedures, it is not without risk. We have developed special instruments that allow the surgeon to operate on a beating heart. This results in less systemic inflammatory response, less blood loss, less time on the ventilator after surgery, and less organ damage for patients.
What does this mean to patients?
You can transfer some of the pain to your surgeon. MICS surgery requires a good surgeon, with advanced training in procedures. The learning curve is very long, and it takes a team approach to get surgery done in this less invasive fashion. The “pain” for the surgeon is the steep learning curve. Learning to do surgery with far less visualization is challenging. Using longer instruments to reach through small, crowded openings give surgeons slightly less control than they are accustomed too. Cases take longer at the beginning of the learning curve, but as surgeons master these skills, the operative times are comparable. Why would a surgeon go through this process? The patient benefits to MICS surgery our outlined below.
• Reduced trauma and pain
• Decreased blood loss
• Decreased wound infection
• Improved cosmetics & patient satisfaction
• No difference in morbidity and mortality
• Shorter ICU stay Quicker post-discharge recovery
• Facilitates re-do surgery
Where do I go to learn more about MICS?
The surgeons of Trinity Clinic Cardiothoracic Surgery have completed extensive training, allowing them to perform many MICS procedures during the past year. Some of the surgeries performed include aortic valve replacement (Figure 3) mitral valve repair (Figure 4) and replacement, surgery for atrial fibrillation (Figure 5), ASD closure, sub-aortic stenosis repair and more.
|Surgical Incisions (Click to view larger images)|
Traditional Sternotomy Incision
Aortic Valve Incision
Mitral Valve Incision