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Less Invasive Coronary Artery Bypass Graft Surgery

A Coronary Artery Bypass Graft Surgery (CABG) is a surgery which is performed to bypass blockages and improve blood flow to the heart muscle. A CABG uses a blood vessel (graft) which is taken from the arm, leg or chest to bypass a narrowed or blocked coronary artery.

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Standard Coronary Artery Bypas Graft Surgery

Standard or Conventional Coronary Artery Bypass Graft surgery (CABG) is done using the heart-lung machine (cardiopulmonary bypass) whereby the machine allows the heart to be stopped.

During that period of cardiac inactivity, the machine takes over the function of the heart and lungs.

After the heart is temporarily stopped, new blood vessels (grafts) are sewn in place, bypassing the point of narrowing.

Upon completion of the grafting, the heart is restarted and the patient is gradually weaned o­ff the heart-lung machine.


Are There Side Effects?

As safe as it is, personality changes and mental deterioration as well as damages to the kidneys and lungs are some of the known complications of being on the heart-lung machine.

 

With this possibility of “injury”, albeit small, questions that come to mind to many surgeons today is:

 

“Are there any options?” …YES, The “Off-­pump Coronary Artery Bypass Graft Surgery” technique.


Off-Pump Coronary Artery Bypass Graft (OPCAB) Surgery

OPCAB is also famously known as Beating Heart Coronary Artery Bypass Graft Surgery

This is a technique whereby the CABG is done in the usual manner but without connecting the patient to the heart-lung machine and not stopping the heart (thus called o­ff-pump). Parts of the heart where the necessary sewing takes place are stabilized using a specially designed apparatus called stabilizer.

 

This manoeuvre allows the sewing of blood vessels to be done safely and accurately without having to stop the heart. Indeed, it is as if the patient is undergoing any major operation as the circulation continues in the physiological manner and not artificially as in using the heart-lung machine.

The Advantages Of OPCAB Include:

  1. Earlier recovery – Shorter stay in the hospital and may be able to return to normal activities.
  2. Less bleeding –  Requires fewer blood transfusions.
  3. Less complications –  Lower risk of complications associated with the heart-lung machine such as stroke, lung and kidney problems.
  4. Less brain complications –  Less problems with mental clarity and memory.

Sternal Sparing Incision (Muscle Cutting)

Standard Approach (Sternotomy):

  1. A normal way to gain access to the heart to allow it to be operated upon is by sawing the breastbone and spreading it apart.
  2. This incision causes injury to the bone and stretches the ligaments and joints of the ribs and shoulder, often leading to excessive pain and needs prolonged period of healing as bone takes up to 6 weeks to achieve union as is seen in fractures. In addition, in the unfortunate event of a bone infection, the complication can be disastrous.
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Picture showing a scar from a full Sternotomy heart surgery approach.

Less Invasive Approach (Thoracotomy):

  1. In reality, the anatomic position of the heart is not midline but rather is located to the left side of the chest. The ribs and intervening muscles are more amenable to gentle retraction, very much like the shutter blinds.
  2. The ribs can be stacked against each other with the intervening muscles folded to allow an opening to be made this is the principle of the incision called thoracotomy, a sternal sparing incision.
  3. This technique can be applied to most patients except for the obese, those patients with unstable condition or with enlarged hearts.
thoraco

Picture showing the scar from a left Thoracotomy heart surgery approach.


Endoscopic Harvesting Of Veins

Standard Approach:

In harvesting the saphenous veins from the legs to be used as new vessels for the heart, a surgeon typically needs to incise throughout the length of the vein in order to expose it for the harvesting process. The incision is often as long as 2 and a half feet long.

 

In addition to the pain and poor cosmetic result of such a long incision, the patient, especially a diabetic, is often faced with the prospect of a possible wound infection especially around the ankle as the circulation is poor in that area.

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Picture showing scar after conventional vein harvesting.

Less Invasive Approach:

Armed with a miniature camera mounted on an endoscope, surgeons today are able to harvest the veins via tiny incisions as small as an inch. This minimally invasive technique certainly obviates the need for such long incisions, cutting down on the intensity of pain felt, improves ease of mobilization and offering improved cosmetic results.

 

Similar technique can also be used in harvesting the Radial Artery (from the forearm) to be used as a conduit.

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Picture showing small scar after endoscopic saphenous vein harvesting

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