Minimal Access Cardiac Surgery soon to be a norm rather than an exception in treating heart ailments
The history of Cardiac Surgery is beset with spectacular advances in technology. The technological progress has rendered cardiac surgery safe for majority of the patients across the globe.Before the era of the Heart-Lung Machine (HLM) which revolutionised cardiac surgery and allowed the surgeons to carry out procedures within the heart attempts were successfully made to perform similar operations by as cross – circulation . This was done on children where the baby’s mother was used to support the baby’s heart and lungs .
However for decades sawing open the sternum (the breast bone) remained the mainstay of approach to the heart. This gave the surgeon the ease and confidence needed to perform complex procedures on the heart. In any eventuality he could put the patient on the heart lung machine easily in minutes with this approach. He also had ready access to any part or all of the heart. Cardiac Surgery became safe and the results were pretty much predictable with high success rates the world over.
From being accessible to a few elite and the rich it became available to one and all. While the Cardiac Surgeons were striving to achieve the best results their colleagues across the spectrum, the cardiologist were innovating to achieve similar results or sometimes better results by their approach through the vein and artery from the groin. They could open the blocked arteries of the heart by dilating and stenting them using alloy metals to keep the clogged arteries open. This method is called as per cutaneous interventions. They were able to achieve their goal with “a prick of an injection’ as they popularly tell their patients. They went further to open cringed heart valves through a similar approach called Percutaneous Trans Mitral Commissurotomies (PTMC). They went even further to close the holes inside the hearts using “devices” through the groin.
Presently artificial heart valves are being inserted into patients by minimal invasive methods. These advances in interventional cardiology made the Surgeons ponder over the methods to perform heart surgeries through smaller incisions. Another important hurdle on the way to achieve this goal was to avoid cutting the breast bone which was hitherto being Surgeon’s forte. Cutting the breast bone makes the heart surgery looks big, increases the length of hospital stay and it takes months before the patient resumes his daily chores like driving his car to work . Because the breast bone takes nearly three months to heal if not more. In some category of patients with diabetes the healing ability may be impaired. The Surgeons needed a paradigm shift . They wanted to inflict less “injury” on their patients. They also wanted to use less paraphernalia like the Heart-Lung Machine. They were now able to perform coronary bypass surgeries without using the Bypass circuit. This method came to be known popularly as the “beating heart ” surgery. There was no need for the surgeon to dwell into the heart but work his way on the surface to fix the blocked arteries, a kind of plumbing the human heart. But still he was cutting the breast bone with its consequences as mentioned above.
In the mid 1990s various teams in Europe as well as North America were doing rigorous experiments on animal models to achieve minimal access to the heart. Cosgrove and Crohn and their colleagues reported their series of minimal access valve surgery. Video scope was introduced by Kaneko in 1996 and in the same year Port-Access Mitral Valve replacements were performed in Malysia by the Stanford team with new aortic balloon occlusive technology called the endo balloon. In February 1996 Carpentier performed the first video assisted mitral valve repair. In 1998 Carpentier and Mohr and colleagues independently performed the first MV repair using an early prototype of the da Vinci system. In 2000, Chitwood and colleagues performed complex mitral repair using the da Vinci system. Hence late 1990s were the watershed years in the development of Minimal Access and Robotic Cardiac Surgery.
The advantages of minimal access cardiac surgery are myriad. Apart from avoidance in use of blood and blood products, very short ICU stay and early ambulation and discharge from the hospital it gives the patient a cosmetic scar. And the patient ‘s recovery from heart surgery is fantastic. I am sure in a short while from now MACS(Minimal Access Cardiac Surgery) wil become a norm rather than an exception in surgically treating heart ailments.
The writer is Dr. G .Chandrashekar, HOD of Cardiac Surgery at Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru.