New heart procedures arrive
Surgeons here are using less invasive techniques to minimize pain, trauma
Marlene MehlhaffNovember 20th, 1997
Heart surgery here and around the nation is going through a revolution.
In some cases, surgeons now are using a variety of much smaller incisions to get to the heart, rather than opening up the entire chest, and are avoiding the use of a heart-lung machine by operating on a beating heart. The handful of procedures that include those techniques are known collectively as minimally invasive cardiac surgery.
The idea is to cause less post-surgical pain and discomfort, speed up recovery, and trim costs through shortened hospital stays and other improvements, cardiac surgeons say. In addition, patients often get the added bonus of a smaller surgical scar.
To me, its exciting, says Dr. Samuel Selinger, who believes hes Spokanes most senior cardiac surgeon. With conventional open-heart surgery, we have something thats become standard and relatively low risk, he says. Now, we have the potential for less trauma, less recovery time, and ultimately less cost. He says that all of the heart surgeons here, including himself, have completed surgeries with less-invasive incisions and procedures in the last couple of years.
Its a big change from the way things have been done, says Dr. Richard Anderson, an assistant professor of surgery at the University of Washington School of Medicine. This is a big advance. Were using a completely different approach. Its probably the hottest topic in cardiac surgery right now.
Both Anderson and Selinger caution that U.S. heart surgeons havent reached a consensus on which techniques work best and add that applications for the new techniques still are limited.
Currently, theyre used only for the repair or replacement of aortic and mitral valves and for relatively simple coronary-bypass operations.
Not all patients undergoing those types of surgeries are candidates for the minimally invasive techniques. Selinger estimates, for example, that less than 5 percent of heart-surgery cases in Spokane are appropriate for the new techniques.Smaller cutsMinimally invasive cardiac surgery techniques include small incisions that replace the 12- to 15-inch-long cut through the sternum, called a sternotomy, that is used to crack open the chest during conventional open-heart surgery. The smaller cuts, which can be half the size of a sternotomy or even smaller, can be made through the upper or lower part of the sternum or between two ribs. Sometimes, other types of cuts are made that require the removal of part of a rib to expose the heart.
For some single-bypass operations, surgeons also are performing work on a beating heart. Typically, heart surgery requires the use of a heart-lung machine, which performs heart and lung functions so the heart can be stopped temporarily. Newly invented devices that help still a section of heart muscle during surgery have made beating-heart procedures more effective.
Meanwhile, a Redwood City, Calif.-based company, Heartport Inc., received U.S. Food and Drug Administration approval about a year ago to market its specially designed tools that are used for a minimally invasive approach the company calls Port-Access.
The Port-Access technique requires a three-inch-long incision on the chest wall between the ribs.
The specially designed instruments allow surgeons to operate through the small opening to repair or replace heart valves or perform a multiple coronary bypass. A number of openings, or ports, can be used if necessary.
Instead of hooking up a patient to a heart-lung machine through the chest incision, the patient is connected to the machine through the femoral artery in the groin.
Anderson, who joined the UW medical school in August, was on a team at New York University that conducted an FDA trial for the Heartport approach. He says he was recruited by UW to introduce the technique to the school, and he also provided expertise when the first Port-Access procedure in Spokane was done a couple of months ago.Driven by demandAnderson says most of the new minimally invasive techniques appear to offer the same results for patients as standard open-heart surgery.
Early results for the bypass surgery on a beating heart, however, werent as good as traditional bypass surgery, he says. He adds, though, that he believes those outcomes have improved with the invention of the stabilizing devices that are used to still a portion of the heart during surgery. Before those devices were invented, doctors would use drugs to slow the heart during surgery, he says.
In addition, Anderson stresses that since the minimally invasive techniques are so new, doctors dont have any mid-range or long-range outcome comparisons between the minimally invasive and traditional surgeries.
As a result, the move toward minimally invasive techniques is something that has to be kept in check until longer-term results are available, despite the advantages of less trauma, quicker recovery, and a smaller scar, Anderson says. Those are all nice things, but you cant compromise the end result, which is to repair the heart, he says.
The use of minimally invasive cardiac techniques has been adopted across the U.S. much more quickly than new medical techniques that were developed in the past, Selinger says. The rapid spread of the techniques has been driven, at least in part, by market demands, he says.
In the past, new medical procedures were proposed and a few larger medical centers would develop and refine techniques, study patient outcomes, and then pass on the new ideas to other physicians, Selinger says.
Now, patients read about new techniques and request them when they find out they need surgery, he says. What the public sees is the cut in the chest, Selinger says, adding that patients tell their doctors that they want a small incision and want to go back to work quickly.
Patients dont have all the facts, though. Selinger says, for example, that the use of a smaller chest incision sometimes means the use of a larger incision in the heart.
The market-driven process has led to the development of a variety of minimally invasive techniquessome better than others, Selinger says. In the next few years, heart surgeons likely will abandon some techniques and modify others to develop the best standards for such procedures, he says.
The ultimate outcome is going to be phenomenal, Selinger contends, adding that it will lead to even more advancements.
He predicts that not too far in the future, heart surgery will be done through small holes in the chest. A couple of cameras inserted into the chest will provide the surgeon with a three-dimensional video that he or she will watch through goggles and use to perform the work. A device that assists with circulation, rather than a heart-lung machine that completely takes over circulation, will be used, Selinger says.
Eventually, he says, such surgery could be done remotely, with a surgeon in one city guiding the arms of a robot that would perform the operation.
This is an evolving process, Selinger says. Thats the reason they call it the practice of medicine; its something youre never perfect