One of the most common types of heart surgery is bypass surgery. Can bypass surgery be done in a minimally invasive way?
Sure. Heart bypass surgery really was the mainstay in the treatment of blockages of the arteries of the heart, which was the primary cause of heart attacks. Cardiac surgeons were getting very good at performing the classic bypass operation where we would take a piece of vein from the leg and basically make a detour around the blockage in the heart artery.
We were learning to do that very well, and our colleagues, who are called cardiologists as opposed to cardiac surgeons, were learning how to fix those heart arteries on a good number of patients from the inside. This is done by using technology that really began with catheters that had little balloons on them that could open up the blockages and now extends from that technology to catheters that have little stents, or little wire meshes, on them that can open up the artery.
It’s amazing how much more treatment we can render without making any incision, compared to the past. The problem with that treatment is that not everybody has a blockage that they can get to from the inside, so we teamed up with the cardiologist to give the best possible care.
Aren't there some people who have multiple blockages and may be treated easily with the angioplasty and the stent but others where a bypass might be better in keeping the vessel open?
We believe so. There is a wonderful artery in our body called the mammary artery that runs along the left side of the breastbone. It's a good conduit to take blood into the heart. Once it's stitched into the heart it's immune from being closed off, so we love to put that artery into the closest artery to it, which is the left anterior descending artery. It's the master artery in the heart and it's basically in charge of giving blood flow to one of the most important portions of the heart. If we lose that artery, if it blocks off, the heart will never be the same and it will never work like the nice efficient pump that it's supposed to be. It will become more swollen and work more like a workhorse, a little tired and ultimately can fail from lack of muscle supply.
Our operating room is both a fully equipped surgical suite and a state-of-the-art cardiac catheterization laboratory.
So that vessel is in a perfect location for this mammary artery. Team members at the University of Maryland, have basically strategized a procedure that we think provides best practice for patients with multiple coronary artery blockages. In one single sitting, a patient goes into an operating room that's outfitted just like a heart catheterization laboratory, so we can do both a standard bypass operation and a stent procedure at the same time. This particular operating room has very, very fancy imaging capability, meaning we can look through the heart with X-rays and actually see where our catheters are going.
So the standard operation would be a very small incision in the left breast, not much bigger than a few inches long and no longer a big incision where we divide the breastbone. We can make an incision, take that artery under the breastbone and plug it into this master artery in the heart. When that's completed, before the patient wakes up from a short anesthesia, our colleagues are working through catheters to open the other arteries that are blocked.
It makes sense to have the cardiac surgeons and cardiologists work together in the same place at the same time, but that's not how it has been done for many years. The patient would see one or the other and had to be referred elsewhere and have separate procedures.
Right. Our theme or mindset at the University of Maryland is ‘Let's work together to give best practice,’ and I think others are beginning to pick this up as well. There are certain bypass operations that patients need that will really be better than a stent procedure and there are certain stent procedures that are better than coronary bypasses. The patient needs to think about the procedures as 'what's best for me for the next 10 or 20 years.' Combining best practice today offers a tremendous advantage to patients without big incisions and really with one modestly large procedure.
It used to be when you did heart surgery, you would put the patient on a heart-lung machine so the heart could be stopped and do the bypasses that way. But now you let the heart continue to beat while you do it, which you call "beating heart surgery"?
It's an amazing development to operate on the heart while it's beating. While we were learning about heart artery bypass surgery, we would always stop the heart and use the heart-lung machine, and patients were scared about that. The most common question I had from patients is ‘If you stop my heart, how do you know it will start again?’ it's terrifying to have all your blood drained and put into the pump and pumped back to you while your heart is not moving.
Beating heart surgery gives the surgeon very good exposure where we can stitch these angel hair-sized stitches into really tiny blood vessels. We have learned how to do this now with the heart beating and that's part of the upswing in technology. We have better tools to help us with this type of surgery. For example, the surgeons now wear these long glasses, not because they have poor eyesight, but because those glasses will magnify the surgical view by up to four times.
Plus, using the heart-lung machine to assist heart surgeons in doing their job does come with a certain price, and that price is maybe an increased risk of bleeding after the operation, and also of having a stroke.
So we think that beating heart surgery for heart bypass is preferred when it can be done well.