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What happens during bypass surgery?
There are generally three therapy options available for the treatment of coronary heart disease. In cases where drug-based treatment alone does not achieve sufficient improvement, the doctor will assess whether blood flow to and from the heart could be improved via surgery, or a catheter-based technique called coronary angioplasty.
Surgical treatment will be selected if:
- There is no improvement in angina pectoris symptoms following drug-based treatment
- Despite drug treatment the patient's quality of life remains unsatisfactory
- It offers an improved chance of survival
- There is narrowing of the main branches of all three coronary arteries, or the left coronary artery
Compared to other types of treatment, bypass surgery generally offers a number of advantages. There is a reduced rate of recurrence of angina symptoms and patients are likely to remain symptom-free for longer and need fewer drugs.
What happens during bypass surgery?
The objective of bypass surgery is to restore sufficient blood flow to poorly perfused areas of the heart by redirecting the blood around the blocked or narrowed arteries. This is achieved by connecting one end of the blood vessel graft to the affected artery just below the blockage and the other end to the aorta. Blood vessels that can be used as grafts are harvested from either the arms or legs. For most bypass procedures our surgeons will use the "mammary artery", an artery from the anterior chest wall. This type of bypass graft is associated with excellent long-term results. During open heart surgery, a heart-lung machine takes over the functions of the heart and lungs.
The "Off Pump Coronary Artery Bypass" (OPCAB), a procedure similar to conventional bypass surgery, but performed without a heart-lung machine, is one of the more recent developments in coronary bypass surgery. It is used particularly in critically ill patients with multiple organ impairments (e.g. kidneys, lungs, liver) or patients where use of the heart-lung machine is contraindicated.
The difference between this procedure and surgery on a stopped heart is that there is no need to use a heart-lung machine. The procedures surrounding complete or partial sternotomy (opening of the sternum) and bypass grafting are identical to those used in conventional bypass surgery. Grafts harvested for this procedure include mammary arteries, radial arteries and leg veins. Stabilising systems are used to keep the heart steady during suturing. These systems are positioned to exert pressure on part of the heart. The positioning is chosen to ensure that a specific section of the heart does not move at all during suturing.
"Minimally Invasive Direct Coronary Artery Bypass" (MIDCAB) surgery, performed on the beating heart without the need for a heart-lung machine, is now a common bypass procedure for surgical treatment of a blocked left coronary artery, using internal mammary artery grafts. What makes this procedure minimally invasive is the need for a relatively small, 3-5" incision, which is placed between the ribs in the skin fold below the left breast. Harvesting of the mammary artery is performed either by direct vision or by a video-assisted procedure.
As the MIDCAB procedure only allows access to the front of the heart, the procedure is only suitable for bypass surgery involving the left anterior coronary artery. This is because access to the graft vessel is via the same opening in the chest. If multiple coronary vessels are affected by blockages or narrowing, MIDCAB is often used in combination with balloon angioplasty (PCTA), in what is termed a hybrid procedure. The only other option in this case is a conventional OPCAB (Off Pump Coronary Artery Bypass) procedure.
The decision as to whether minimally-invasive surgery techniques can be used is, therefore, dependent on the specifics of the coronary heart disease involved.
The first ever robot-assisted minimally-invasive bypass surgery, known as "Total Endoscopic Coronary Artery Bypass"(TECAB), was performed at Leipzig University Hospital on 25 May 1998. The procedure involves a number of specially developed cardiac endoscopes being inserted via small incisions (less than 1 inch). The surgeon operates via manipulation of a surgical console with integrated computer screen, which transmits the surgeon's hand movements to robotic arms attached to the operating table. Similar to minimally invasive direct coronary artery bypass surgery (MIDCAB), only the front of the heart is accessible via this procedure.
Robot-assisted surgery still subject to further research
Robot-assisted minimally-invasive bypass surgery is not yet used in routine practice and is offered by only a few cardiac surgery centres. Robot-assisted surgery is not yet at a stage where it can compete with other surgery techniques and it will be years before development of the robotic and endoscopic devices will have reached a stage where this technique will be able to be used for bypass surgery involving other coronary arteries. Robot-assisted bypass surgery has always required the use of heart-lung machines, and only a few robot-assisted bypass procedures have so far been performed on a beating heart. The aim of research in this area is to develop surgery techniques that will allow bypass surgery on a beating heart and without opening the chest cavity in order to minimise any potential complications associated with open chest surgery and use of the heart-lung machine. However, it will be some time before this technique becomes part of routine practice.
The future is bright for telemanipulated surgery
The development of surgical robots will enable surgeons to control several surgical theatres via one central control station and to switch from one theatre to the next simply by switching to a different monitor. This should then enable the surgeon to perform a number of operations in quick succession, without having to leave the control station.
There are also plans to develop remote-control surgery via the internet and video conferencing technology. As long as the necessary technology is available, this would allow life-saving surgery to be performed in places that do not have access to staff with the relevant training and expertise.
Heart valve surgery
There are four valves in the human heart. These are located in between the atria and ventricles (mitral and tricuspid valves) and between the ventricles and the large arteries (aortic and pulmonic valves). The valves are responsible for directing the flow of blood through the heart and for preventing blood from flowing back into the chamber it has just come from.
The most common reason for heart valve disease is age-related degeneration
Many cases are also associated with atherosclerotic changes. Another potential cause that is not to be underestimated is an infection affecting one of the heart valves (infective endocarditis). The demand placed on the valves of the heart is substantial over the course of a human life and, by the time a person turns 70 their heart valves will have opened and closed more than two million times.
When the valves no longer open or close:
Valve disease may result in the valves not opening fully (stenosis) or the valves becoming leaky (insufficiency). If a valve no longer opens fully, this causes an impediment to the flow of blood, placing excessive pressure on the heart. If a valve has become leaky, every contraction of the heart will cause blood to flow back from the ventricle into the atrium or from the aorta back into the left ventricle.
This "oscillating" blood places great strain on the heart.
Minor disturbances in valve function are easily compensated by the heart, while severe cases will require drug-based or surgical treatment. Surgery for acquired heart valve disease is the second most common reason for open heart surgery.
Heart valve surgery
Heart valve surgery is used to repair or replace diseased heart valves. Heart valve repair may be able to restore normal valve function. However, in more severe cases, valve replacement surgery will become necessary. Heart valve surgery delivers much improved results compared to drug-based therapy, or to allowing the disease to progress naturally. Heart valve surgery can be performed on patients of virtually any age. A wide choice of replacement valves is available, ensuring that a valve can be chosen to fit the specifics of each individual case.
The replacement valves available today can be broadly divided into two different types of valves.
- Mechanical valves
- Tissue valves
Artificial heart valves are expected to meet a number of requirements. They should last for as long as the patient lives, should not be rejected by the body, should not cause thomoboses or the excessive breakdown of red blood cells (haemolysis), should not impede blood flow and should always be available and easy to implant.
Unfortunately no single product available today can meet all of these requirements, with all valves having certain pros and cons
Mechanical valves are one approach to heart valve replacement, with two types being of particular significance:
- Tilting disc valves
- Bileaflet valves
Tilting disc valves work via an occluder disc, which regulates blood flow by opening and closing. Compared to caged-ball valves, these valves have a much larger opening area, are smaller and are associated with a much reduced risk of thromboembolism. In bileaflet valves, the occluder disc is effectively cut in half, resulting in two semicircular leaflets which pivot on hinges and, when open up fully, sit at right angles to the closed position. This allows for a large opening area even with valves of a small diameter. One of the drawbacks of this design is that in cases of larger diameter valves and a lower heart rate, there is an increased risk of insufficiency, i.e. blood flowing back into the chamber of the heart it has just come from.
Pros and cons of mechanical heart valves
- Constant availability in all sizes
- Do not wear out
- Implantation is relatively simple
- Implantation is easier due to artificial suture ring
- Patients with mechanical valves will require life-long anticoagulation therapy
- Increased risk of thrombosis, bleeding, haemolysis and endocarditis
- Any restriction of blood flow due to the presence of a mechanical valve will be particularly noticeable during increased physical activity.
Tissue valves provide another option in heart valve replacement surgery and include porcine (from a pig) aortic valves or valves made from bovine pericardial tissue (from a cow's pericardium). The big advantage of tissue valves is that anticoagulation therapy may not be necessary at all, or only temporarily.
There are two types of tissue valves:
Stented tissue valves; temporary anticoagulation therapy - three months - required, stentless tissue valves; no anticoagulation therapy required.
Pros and cons of stented tissue valves
- Constant availability (any size and number)
- Proven surgical procedures
- Anticoagulation therapy only required for three months (at normal sinus rhythm)
- Implantation easier due to artificial suture ring
- Take up more room
- Cause greater restriction to blood flow than mechanical valves
- Limited durability, increased problems of valve calcification in younger patients
Pros and cons of stentless tissue valves
Stentless tissue valves are only used for aortic valve replacement
- Blood flow (haemodynamic performance) comparable to natural heart valve
- Suitable even for use in aortas with small annular diameter
- Anticoagulation therapy not required (at normal sinus rhythm)
- Better durability compared to stented tissue valves
- Improvements in life expectancy and quality of life
- Technically complex surgical procedure
- Durability difficult to estimate
- New technology
Arrhythmia surgery Implantation of pace makers and defibrillators
Atrial fibrillation with slow
Single chamber pacemaker
AV block, sick
Dual chamber pacemaker
SSeverely reduced cardiac
Triple chamber pacemaker
Defibrillator (Single, double
Specialist surgery: Aortic aneurysm surgery
An aortic aneurysm refers to a dilation, or ballooning out, of the aortic wall. If the weakened, dilated section ruptures, this causes life-threatening internal bleeding. It is therefore not surprising that a number of patients with aortic aneurysms are admitted as emergencies. We also have an emergency surgical team on standby for such cases.
The aorta, which extends in a bow away from the heart, can be affected by aneurysms in three different sections: in the ascending aorta, the aortic arch and the descending aorta. During aneurysm surgery, the distended section of the aorta is replaced with a synthetic prosthesis.
Innovation and creativity ensure that we will be able to continue to offer our patients the best treatment options available, now and in future.