Cardiovascular and Thoracic Surgery

Overview:

Overview:

During coronary angioplasty, a balloon is used to create a bigger opening in the vessel to increase blood flow. Although angioplasty is performed in other blood vessels elsewhere in the body, percutaneous coronary intervention (PCI) refers to angioplasty in the coronary arteries to permit more blood flow into the heart. PCI is also called percutaneous transluminal coronary angioplasty (PTCA).

There are several types of PCI procedures, including:

• balloon angioplasty - a small balloon is inflated inside the blocked artery to open the blocked area or
• atherectomy - the blocked area inside the artery is cut away by a tiny device on the end of a catheter.
• laser angioplasty - a laser used to "vaporize" the blockage in the artery.
• insertion of a coronary artery stent - a tiny coil is expanded inside the blocked artery to open the blocked area and is left in place to keep the artery open. Stents help prevent the artery from becoming blocked again, and are the most effective method for preventing re-blockage. Without the use of stents, about 30 percent of arteries become blocked again. The safety of stents has been vastly improved over the years and a wide range is also now available so the choice in device can be tailored to the patient.

Overview:

Most commonly referred to as simply "bypass surgery," this surgery is often performed in people who have angina (chest pain) and coronary artery disease (where plaque has built up in the arteries). During the surgery, a bypass is created by grafting a piece of a vein above and below the blocked area of a coronary artery (see vein harvesting, below), enabling blood to flow around the obstruction. Veins are usually taken from the leg, but arteries from the chest or arm may also be used to create a bypass graft.

Bypass surgery is used to divert blood around blocked arteries in the heart. This surgery uses a healthy blood vessel taken from your leg, arm, or chest and connects it to the other arteries in your heart so that blood is bypassed around the diseased or blocked area.

Conventional Coronary Artery Bypass Graft (CABG) Surgery, also referred to as “open heart” surgery. In open heart surgery, the heart is stopped. A heart-lung machine is used to circulate and oxygenate the blood while the surgeon works on the stopped heart. The heart is accessed by dividing the patient's sternum with a 10-12" long incision on the patient's chest.

After the bypasses are complete, the heart is restarted until it is beating normally, and the patient is removed from the heart-lung machine. A wire suture is used to close up the sternum, and sutures or clips are used to close up the chest and leg wounds. The sternum may also be repaired using a metal plate, which is favorable for some high risk patients and also helps reduce complications improve healing (performed using minimally invasive surgery—see Rib and Sternal Repair.)

While bypass surgery works well, it's also more invasive. For certain candidates, a minimally invasive approach to CABG can have many benefits. 

Overview:

Patients who have veins harvested using minimally invasive endoscopic removal experience less pain and swelling post-procedure. They are also up and moving more quickly than patients who undergo traditional vein harvesting—approximately two days sooner.

Overview:

Minimally invasive coronary artery bypass (MIDCAB) surgery is an option for some patients who require a left internal mammary artery (LIMA) bypass graft to the left anterior descending (LAD) artery or bilateral mammary artery (BIMA) bypass graft surgery.

The advantages of Minimally Invasive Surgery over traditional open heart surgery are numerous. During a minimally invasive procedure:

• The incisions are significantly smaller, which means there is also a reduced blood loss and a lower risk of infection.
• There is no need to divide the breastbone (sternotomy) during the robotically-assisted procedure. Research shows that there is no known significant difference in patient outcomes whether or not a sternotomy is performed; however, having not opened the chest, healing time is shortened, there is less pain, less bleeding and a lower infection rate. Patients who undergo minimally invasive procedures have been found to be much healthier 30 days after the procedure than those who undergo traditional open heart surgery.
• There is also no need to stop the heart during the procedure during minimally invasive heart surgery. While there is no significant difference in outcomes when a patient is placed on- or off-pump during their procedure, off-pump is considered a good option for high-risk patients, such as those with extensive ascending aortic atheromatous or calcific changes which might preclude safe aortic instrumentation.
• Generally, patients who undergo minimally invasive heart procedures have a shorter hospital stay after surgery, with an average stay of 3 to 5 days after minimally invasive surgery, compared to an average of 7 to 10 days after traditional heart surgery.
• Overall recovery time is shortened with minimally invasive surgery; healing time ranges from 1 to 4 weeks, while the average recovery time after traditional heart surgery is 6 to 8 weeks.
• UTMB employs an “aortic no-touch technique” using a “heart string” device that eliminates the need for partial clamping of the diseased aortae. When this technique is combined with the advantages listed above, the risk of stroke is reduced both during and following surgery. Patients experience superior outcomes over other techniques in experienced hands.

LIMA-LAD

The left anterior descending artery branches off the left coronary artery and supplies blood to the front of the left side of the heart. Single-vessel disease of the left anterior descending (LAD) coronary artery may be surgically revascularized by grafting to the left internal mammary artery (LIMA). This is considered the “gold standard” (best survival rate) graft in Coronary Artery Bypass Graft Surgery.

Most surgeons consider using minimally invasive CABG in patients with isolated proximal left anterior descending (LAD) coronary artery disease and occasionally with LAD and proximal right coronary artery disease.

Large observational studies have shown  that the use of an internal mammary artery graft to the left anterior descending (LAD) coronary artery improves survival and reduces the incidence of late myocardial infarction (heart attack), recurrent angina (chest pain), and the need for further cardiac interventions.

A minimally invasive approach to this procedure is associated with a lower incidence of postoperative complications (approximately 2 percent), lower reintervention rates (2.9 percent), a reduced risk of stroke, overall better long-term outcomes and lower mortality rates (2 percent) than conventional surgery.

*Based on an observational study of 274 patients

Bilateral Internal Mammary Artery Grafting (BIMA)

Most patients require grafting of the three main native coronary arteries. For the last 15 years, the "standard" operation has achieved this using a single internal mammary artery and supplemental vein grafts performed with cardiopulmonary bypass. Although this procedure achieves excellent short and medium term outcome, and over 70 percent of patients are alive 12 years after surgery, the long term results are limited by progressive vein graft failure.

A bilateral internal mammary artery (BIMA) graft approach is superior over single internal mammary artery grafting in select populations. Although more research is necessary, three recent studies suggest BIMA are favorable, and appear to have significant survival advantages in a wide range of aged patients. In a study published in 1999 by the Cleveland clinic group they reported better survival and reintervention–free survival after 10 years when BIMA was used.

• BIMA surgery is considered highly compatible, if not preferred, to be performed in a minimally invasive manner.
• It is particularly beneficial for elderly and diabetic patients and enhances their survival

Hybrid Surgery is a state-of-the-art procedure, combining the use of stents (angioplasty) with minimally invasive robotic surgery (LIMA to LAD MIDCAB)

• Superior outcomes at 18 months follow-up
• Combines the survival benefit of the LIMA to LAD graft and the less invasive nature of percutaneous coronary intervention (PCI)
• The hybrid procedure requires a slightly longer operative time, but results in a shorter intensive care stay and shorter in-hospital stay. There is typically also less chest tube drainage and blood loss. At a follow-up of 18 months, patients who underwent hybrid procedures saw greater freedom from major adverse cardiac or stroke-related events.

Overview

Heart failure is a chronic disease needing lifelong management. However, with treatment, signs and symptoms of heart failure can improve and the heart sometimes becomes stronger.

Heart failure, also called congestive heart failure, is a condition in which the heart cannot pump enough oxygenated blood to meet the needs of the body's other organs. The heart keeps pumping, but not as efficiently as a healthy heart. Usually, the loss in the heart's pumping action is a symptom of an underlying heart problem. Heart failure affects nearly 5 million US adults. It is on the rise with an estimated 400,000 to 700,000 new cases each year.

Treatment may help you live longer and reduce your chance of dying suddenly. Doctors sometimes can correct heart failure by treating the underlying cause. For example, repairing a heart valve or controlling a fast heart rhythm may reverse heart failure. But for most people, the treatment of heart failure involves a balance of the right medications, and in some cases, devices that help the heart beat and contract properly.

Specific treatment for heart failure will be determined by your physician based on:

• your age, overall health, and medical history
• extent of the disease
• your tolerance for specific medications, procedures, or therapies
• expectations for the course of the disease
• your opinion or preference

The cause of the heart failure will dictate the treatment protocol established. If the heart failure is caused by a valve disorder, then surgery is usually performed. If the heart failure is caused by a disease, such as anemia, then the disease is treated. And, although there is no cure for heart failure due to a damaged heart muscle, many forms of treatment for symptoms and improved quality of life have proven to be successful.

Treatment

The goal of treatment is to improve a person's quality of life by making the appropriate lifestyle changes and implementing drug therapy. Treatment of heart failure may include:

• controlling risk factors
• losing weight (if overweight)
• restricting salt and fat from the diet
• stop smoking
• abstaining from alcohol
• proper rest
• controlling blood sugar if diabetic
• limiting fluids
• medication, such as
• angiotensin converting enzyme (ACE) inhibitors - to decrease the pressure inside the blood vessels, or angiotensin II receptor blockers if ACE inhibitors are not tolerated
• diuretics - to reduce the amount of fluid in the body
• vasodilators - to dilate the blood vessels and reduce workload on the heart
• digitalis - to increase heart strength and control rhythm problems
• inotropes - increase the pumping action of the heart
• antiarrhythmia medications - keep the rhythm regular and prevent sudden cardiac death
• beta-blockers - reduce the heart's tendency to beat faster by blocking specific receptors on the cells that make up the heart
• aldosterone blockers - block the effects of aldosterone which causes sodium and water retention
• Biventricular pacing/cardiac resynchronization therapy - a new type of pacemaker that paces both sides of the heart simultaneously to coordinate contractions and improve pumping ability. Heart failure patients are potential candidates for this therapy
• Implantable cardioverter-defibrillators (ICDs). An ICD is a device similar to a pacemaker. It's implanted under the skin in your chest with wires leading through your veins and into your heart. The ICD monitors the heart rhythm. If the heart starts beating at a dangerous rhythm, or if your heart stops, the ICD tries to pace your heart or shock it back into normal rhythm. An ICD can also function as a pacemaker and speed your heart up if it is going too slow.
• AICD to BIV ICD upgrade

• Ventricular Assist Devices (VADs) - a mechanical device that is used to take over the pumping function for one or both of the heart’s ventricles. A VAD may be necessary when heart failure progresses to the point that medications and other treatments are no longer effective.
• Heart Transplantation

Overview

A ventricular assist device (VAD) is a mechanical device that is used to take over the pumping function for one or both of the heart’s ventricles. A VAD may be necessary when heart failure progresses to the point that medications and other treatments are no longer effective.

For persons with severe or end-stage heart failure, ventricular assist devices (VADs) may be required to support the heart in order to ensure an adequate cardiac output (amount of blood pumped out by the heart per minute) to meet the body’s needs.

Heart transplantation is an option for some patients with severe heart failure (HF), but during this late stage of HF, over 50 percent of persons on a waiting list for heart transplantation will die before receiving a donor heart. Organ donors are in short supply and do not meet the demand for patients waiting for heart transplant. The wait time for heart transplantation may often exceed 200 days.

Long wait times and decreased availability of donors strengthens the need to seek other methods to support the failing heart. Patients may die waiting for a transplant or important organs such as the liver and kidney may become permanently damaged before a donor heart is available. VADs have shown great promise in maintaining adequate blood circulation in cases of severe HF.
VADs may be used for the following situations:

• bridge to transplant - implantation of a VAD to support the patient with end-stage HF who is waiting for heart transplantation.
• bridge to recovery - implantation of a VAD to support the patient with potentially reversible HF. Once the heart has recovered sufficiently, the VAD may be removed.
• destination therapy - implantation of a VAD to support the patient with end-stage HF who is not a candidate for heart transplantation. A portable VAD may be used in this situation so that the patient may be discharged from the hospital and return home.