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TOWARDS LESS INVASIVE CORONARY ARTERY BYPASS

Yesterday and Today. Technology advancement makes its safer, less painful and less expensive.

The first Coronary Artery Bypass Graft Surgery using the Heart-Lung machine was performed in the early 60s and to date, in many parts of the world, this ground breaking operation has undergone minimal changes. For most, it had stood the test of time and they see no need for any developments. This is very much similar to how the typewriter was perceived by many die-hard supporters. Yet, to some, change must come with the progress of technology, very much how the computers and word processing have changed the publishing world.


Conventional bypass surgery essentially encompasses 2 prominent facets:


  • Long incisions to allow access
  • Cardiopulmonary bypass and cardioplegia to achieve cardiac standstill, enabling surgery to be performed accurately.


These 2 prerequisites put strains upon the patient and essentially being the only way to do it, tailors the patient to the operation, regardless of the patient’s physical and mental states.The aim of less invasive coronary artery bypass surgery is to achieve all the desired objectives of conventional bypass surgery with the least possible injury to the patient. It is expected that this can be achieved by applying the following principles:


  • Avoiding cardioplumonary bypass
  • Minimising the size of incisions
  • Avoiding sternotomy if possible


It is with these objective in mind that this sub-branch of cardiac surgery is being developed the world over. It obviously require new skills and techniques but it finally allows the operation to be tailored to the patient’s needs.

Dr David Khoo Sin Keat
Consultant Cardiovascular and
Thoracic Surgeon

My own progress in this field had been achieved gradually and purposefully as can be seen in the growth from 5.5% in 2000 to 76% in 2007. With the experience of 400 cases of Offpump Coronary Artery Bypass (OPCAB) and 3 cases of Redo OPCAB via a Left Thoracotomy behind me, a slow progress in sternal sparing surgery ie Thoracotomy OPCAB took place in Nov 2006 following a stint at Bristol Heart Centre.

 

Today, with the experience gained, I have 5 options of conducting Coronary Artery Bypass operations:


  • Conventional CABG(on pump, arrested heart) – hardly needed, only in situations where concomitant surgery eg valve surgery, hole in heart, aneurysm is required.
  • Offpump CABG via a sternotomy – used in emergent situations or in which the coronary anatomy, heart size or physical shape of the patient dictates a sternotomy.
  • Onpump, beating heart CABG via a sternotomy – used in situations of cardiopulmonary instability, tight Left Main Stem Disease, poor Left Ventricular function or situations where following a sternotomy, off pump CABG is deemed not possible.
  • Offpump via a left thoracotomy – my method of choice except in situations that favour a sternotomy.
  • Onpump beating heart CABG via a left thoracotomy – in situations where following a thoracotomy, off pump surgery is deemed not possible.
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