BACKGROUND: According to the Centers for Disease Control, heart disease is the leading cause of death in the United States, contributing to almost 700,000 deaths across the nation each year. Heart disease encompasses more specific conditions, the most common being coronary heart disease, which affects about 14 million men and women in this country and can lead to a heart attack. Coronary heart disease occurs when fatty material, calcium and plaque build up in the arteries that transport blood to the heart. Sixteen million people alive today have experienced a heart attack, angina pectoris (chest pain) or both.
CLEARING THE ARTERIES: Doctors are now performing a minimally invasive direct coronary artery bypass (MIDCAB) to clear blocked coronary arteries. The procedure is radically different from traditional coronary artery bypass graft surgery (CABG) in two major ways. First, the traditional surgery requires a 30 cm incision through the sternum. MIDCAB eliminates this issue by taking a thorcotomy approach, requiring only a 10 to 12 cm incision in the left chest, where surgeons can use the mammary artery on the inside of the chest wall as a bypass graft to the artery in front of the heart. According to Stephen Ball, M.D., a cardiothoracic surgeon at Vanderbilt Medical Center in Nashville, Tenn., since the bone is sawed open and wired back together in the traditional sternotomy approach, it sometimes causes instability in the chest bone when it's put back together. With the new technique, the bone is not cut at all. Another advantage with MIDCAB is it reduces the risk of infection because less of the body cavity is exposed during surgery. If infection does occur using the new approach, it would be less severe, says Dr. Ball.
The second major advantage to the new approach is, unlike traditional bypass that requires using a heart-lung machine, the heart is never stopped. Instead, Dr. Ball says a device made by the medical company Medtronic is used. Because surgeons often find it difficult to “sew” while the heart is beating, the device is placed on the surface of the heart and has small suction cups that stabilize a portion of it. This allows doctors to sew a graft into the target artery without stopping it. The benefits to the patient not being on a heart-lung machine include requiring fewer blood transfusions and recovering faster due to less trauma during surgery; however, some experts assert that working on a non-beating heart allows them to more efficient and precisely restore the arteries. For bypassing one or two coronary arteries, MIDCAB is usually the choice procedure, but when three or more are bypassed, traditional CABG is often used.
One concern surgeons have when performing MIDCAB rather than CABG is that the bypass will not remain open. “It’s better to have a bigger operation if you can be more certain that your bypass works well,” Dr. Ball said. The way he and his colleagues have gotten around this drawback is by using a hybrid approach to surgery. Vanderbilt's hybrid operating room is essentially an operating room and cath lab, where multiple procedures can be performed on the same patient, such as stents, bypass surgery and valve surgery, followed by an anteriogram to assure the bypass is open and working well.
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