Combined Procedures are Performed in Specially-Outfitted Operating Room
People who need a common type of heart bypass surgery, as well as cardiac catheterization to open other blocked blood vessels in the heart, now can have both procedures done at once. The University of Maryland Medical Center is among the first hospitals in the U.S. to combine minimally invasive coronary artery bypass surgery with stented angioplasty in the same operating room, which is both a fully equipped surgical suite and a state-of-the-art cardiac catheterization laboratory. The combined procedures are the result of a unique collaboration between interventional cardiologists who perform the angioplasty and cardiac surgeons who do the bypass operation.
“This approach benefits our patients because it is more convenient and less stressful for them to have bypass surgery and stenting performed at the same time, rather than on separate days,” says Robert S. Poston, Jr., M.D., a cardiac surgeon at the University of Maryland Medical Center who works together with cardiologists to perform the dual, “hybrid” cardiac procedures. Dr. Poston is also an assistant professor of surgery at the University of Maryland School of Medicine.
So far, the team has performed five combined bypass/angioplasty procedures since December 2004 and more than 35 patients have had minimally invasive bypass operations without angioplasty at the medical center. “As far as we can determine, we were the first hospital in the U.S. to perform the bypass surgery immediately followed by the angioplasty in the same room,” says Dr. Poston.
He says ideal candidates for the hybrid procedure have a blockage in a major vessel called the left anterior descending (LAD) artery, which supplies 60 percent of the blood to the heart, as well as blockages in non-LAD arteries that can be treated with a stent, a small wire tube that keeps a narrowed artery open. “Most patients who undergo the hybrid procedure can go home in two or three days,” Dr. Poston adds.
Another advantage for patients is that this type of bypass surgery can be performed without a major incision. The hybrid procedure begins with a minimally invasive direct coronary bypass, known as MIDCAB. In contrast to open-heart bypass surgery, where the chest is cut open at the sternum to gain access to the heart, Dr. Poston creates a small, two-and-a-half inch opening between two ribs in the left side of the chest. He removes part of another artery from the chest through this keyhole-size opening and sews it to the heart to bypass the blocked artery.
With this minimally invasive surgery, the heart remains beating throughout the procedure, which is safer and poses fewer side effects than having the patient on a heart-lung machine to maintain circulation.
During these combined cases, Dr. Poston works with Barry Reicher, M.D., a cardiologist and specialist in cardiac catheterization at the University of Maryland Medical Center and assistant professor of medicine at the University of Maryland School of Medicine. When the bypass surgery is complete, Dr. Reicher takes over with angioplasty to restore normal blood flow in the remaining blocked arteries. He uses stents coated with a particular drug that prevents the vessel from becoming blocked again.
A major challenge with the combined bypass/stenting procedures is to carefully monitor the status of blood platelets before, during and afterward. Platelets are part of the body’s defenses against sudden blood loss. They form clots to stop bleeding, but clots during heart surgery could jeopardize patient safety by causing a stroke, and platelet clumping around a stent could impact the long-term success of the therapy. However, if the blood is too thin, it could increase the risk of bleeding, so it is a delicate balance.
“Blood clotting is an important issue with a hybrid procedure, and we use specialized tests to evaluate and monitor each patient’s blood clotting properties when we do these procedures,” says cardiologist David A. Zimrin, M.D., director of the catheterization laboratory at the University of Maryland Medical Center and an assistant professor of medicine at the University of Maryland School of Medicine. “Dr. Poston has a great deal of expertise in this area, and his research on this topic has provided information to help improve patient safety and achieve the long term success of these procedures,” adds Dr. Zimrin.
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