Cardiac (Heart) Surgery

Making recovery faster for patients

Coronary Avenue Bypass Graft (Heart Bypass)

Conventional on pump
On pump beating
Off pump
Minimally Invasive
CABG
Endoscopic radial artery harvest
Endoscopic vein harvest

Valvular Surgery

Mitral valve repair / replacement
(including minimally invasive approach)
Aortic valve repair / replacement
(including minimally invasive approach)
Tricuspid valve repair / replacement
(including minimally invasive approach)
Homograft replacement after Terralogy of Fallot repair
Aortic root surgery
Valve sparing aortic root replacement / remodelling
David procedure
Florida sleeve
Bentall operation

Heart Failure Surgery

IABP insertion
Doc Procedure
(including minimally invasive approach)
ECMO therapy:
- Veno-arterial
- Veno-venous
Mechanical device theraphy

Arrhythmia Surgery

Atrial fibrillation / flutter
- MAZE procedure
- Radiofrequency ablation
- Cut & Sew
Ventricular tachycardia
- Radiofrequency

Cardiac Tumor Resection

myxoma resection
Sarcoma resection
Cardiac extension of renal carcinoma resection
(In conjunction with a urologist)
Cardiac thrombus removal

Hypertrophic Obstructive Cardiomyopathy

Septal Myectomy

Pericardial Disease

Pericardiectomy
Pericardial window
Pericardial biopsy

Congenital Cardiac Surgery

Atrial Septal Defect
Ventricular septal defect
Pulmonary homograft implant
(procedures are not limited to the above)

Aortic Surgery

Ascending aortic replacement
Type A aortic dissection repair
Descending aortic replacement
Endovascular stenting

Pulmonary Embolism

Acute pulmonary embolectomy
Chronic pulmonary endarterectomy

Peripheral Vascular Surgery

Femoral artery embolectomy
Vascular bypass
axillio-femoral bypass
Ilio-iliac bypass
Femoral-popliteal bypass
Vascular repair for traumatic injury

Emergent Cardiac Surgery

Acute ventricular rupture
Free wall rupture
Pericardial tamponade

Redo Cardiac Surgery

Composite Surgery
(Any combination of the above)

Hybrid Procedures

MIDCAB + PCI
MIDCAB + MIS valve surgery
MIS valve surgery + PCI

Minimally Invasive Cardiac Surgery

Making recovery faster for patients

Traditionally, over the past few decades, cardiac surgeries were performed through sternotomy (a large cut on the chest and splitting of the breast bone) to gain access to the heart. The large incision does not only result in a long, unsightly scar but more importantly, it translates into more pain, more physiological trauma, longer hospital stay and longer recuperation period.

FULL STERNOTOMY

As the understanding of cardiac surgery and technology improved over time, surgical techniques have been improvised to reduce the pain and sufferings for the patients while maintaining the safety and efficacy of the surgery.

Minimally invasive cardiac surgery (MICS) is well developed and now recognized in most part of the world. In fact, in most tertiary centers, for example in Cleveland Clinic in United States of America, most of the cardiac surgeries were performed via MICS. By strict criteria, the length of incision for MICS is defined as less than four inches.

Till date, minimally invasive heart surgery has been most widely applied for coronary artery bypass surgery (CABG) and cardiac valvular surgery.

For minimally invasive direct coronary artery bypass surgery (MIDCAB), left internal mammary artery (LIMA) which is unequivocally the best conduit and offers the best long term patency can be harvested via 3 different ways:

A small anterior thoracotomy of 6-8 cm in length
Video-assisted thoracoscopic (VATS)
Robotic-assisted

7CM Small Anterior Thoracotomy

VATS Approach

Robotic Assisted MIDCAB

Each of these approaches has its own pros and cons. There is a certain learning curve and hence, the surgeon needs to be well versed in such approaches.

Following the harvest of LIMA, the artery will then be anastomosed to the most critical left anterior descending artery to offer patients the best long-term outcome. During the operation, as a result of off-pump technique and minimal manipulation of the heart, the patient is more stable hemodynamically and the amount of bleeding is also much less.

MICS is also widely utilized now for isolated cardiac valvular surgery especially mitral valve repair/ replacement, tricuspid valve repair/replacement and aortic valve replacement. This is usually performed via partial sternotomy through a 6-8 cm incision. For mitral and tricuspid valve surgery, it can also be approached via a small right anterior thoracotomy or robotic-assisted.

6cm Upper Sternotomy, Aortic Valve Replacement

6 cm Lower Partial Sternotomy, Atrial Septal Defect closure and Tricuspid Valve Repair

In the hand of a trained cardiac surgeon, these minimally invasive heart surgery approaches will offer patients the least physical and psychological trauma while preserving the aim of the cardiac surgery in utmost safety. Typically, after MICS, the patient can be discharged from the hospital in three to four days and resume most of their usual activities within two to four weeks.

This development of MICS has continued to evolve and has also been successfully applied in other cardiac surgeries, including atrial septal defect closure, tricuspid valves repair, DOR procedure (chronic heart failure operation), removal of left ventricular thrombus, arrhythmia surgery and ventricular septal rupture.

9 cm Anterior Thoracotomy, Ventricular Septal Rupture Repair

Hybrid approach
In the current era of medicine, it may be difficult to offer the perfect treatment options for a patient with complex heart disease. In a patient with ischemic heart disease, some coronary arteries may be more suitable to be dealt with by angioplasty and stenting while others, especially the left anterior descending artery, may be better off with a CABG and LIMA anastomosed to it. In a patient with cardiac valvular disease coupled with coronary artery disease, by convention method, this patient will undergo a full sternotomy to fix both the valve and coronary artery stenosis.

However, with the development of MICS and increasing collegiality between cardiologists and cardiac surgeons, hybrid approach to a patient with cardiac conditions can now offer a new perspective in treatment planning and to the best interest of the patients.

In a patient with multiple coronary artery diseases, it is without argument that LIMA – LAD anastomosis offers the best long term patency and patient survival. Total artery coronary artery bypass is often raised by many surgeons and appears attractive in clinical outcomes. However, in real life, it happens only in less than 20% of the cases.

On the other hand, although PCI with stents is least invasive among all revascularization interventions and the technology of coronary stents have evolved dramatically, its outcome still cannot match LIMA – LAD which offers a 20 years patency rate of more than 90%.

With acceptance of the above knowledge and facts, it’s been increasingly acceptable for cardiologists and cardiac surgeons to work together to offer patients the best benefits from both worlds.

With hybrid approach, a patient with multiple coronary artery disease can then undergo a small thoracotomy and LIMA-LAD (MIDCAB) followed by PCI & stenting to the other two vessels within the same admission. The patients will then benefit from the best conduit to the most critical coronary artery (LIMA-LAD) and avoid a full sternotomy. The other two less critical vessels can then be revascularized with PCI and stenting. Bear in mind that the current stent technology offers equivalent or even better results than long saphenous veins and radial artery that were used in CABG. Typically, this group of patients will suffer the least trauma from surgery and benefit the best outcome from both specialties. Usually, the patients will be discharged within three days of hospital stay and resume work within two to four weeks.

Another common scenario where the hybrid approach has been adopted is in situation where patients have heart valve disease and non-LAD coronary artery disease. Traditionally, again, these patients will require a full sternotomy to allow heart valve repair/replacement and most likely a saphenous vein graft to the stenosed non LAD coronary artery. In the literature, the venous graft has been shown to have patency of less than 50% in 10 years. This result is far more inferior than the outcome of PCI and stenting. It is becoming obvious that a full sternotomy to achieve a less than inferior result is not plausible.

Instead of managing the patient alone by surgeons or cardiologists, the patient will be much better off undergoing a hybrid procedure of partial sternotomy, valve repair/replacement and followed by PCI to the coronary artery disease. It not only shortens the surgery time but most importantly, shortens the cardiopulmonary bypass time which has been well documented to cause harm with prolonged duration. All these combined efforts translate into less physical and psychological trauma, less pain, much faster recovery, and a much better aesthetic outcome.

Of course, nothing comes free in this world. With hybrid approaches, whilst the patients may benefit from both the specialties, they are also expected to face a 20-30% increment in the medical bills.

Nevertheless, every patient should be assessed and counseled individually to have the most appropriate treatment plan for his or her cardiac condition.

Dr Su Jang Wen
MBBS, MRCSEd, MMed, FRCSCTh, FAMS
Thoracic & Cardiovascular Surgeon