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A Mini-Revolution in Cardiac Surgery

Escorts Heart Institute Research Centre New Delhi India

Patients with heart disease have a number of expectations from their cardiac surgeon, which I would characterize as follows:

• They would like a cure for their symptoms and if possible treatment for the underlying disease.
  
• They want long lasting results from the surgical procedures they undergo.
  
• They expect a minimum risk to their lives.
  
• They want help at lowest cost since a large segment of the population have financial constraints particularly if insurance companies are not the payers.
  
• Patients would prefer techniques which give them minimum pain and trauma.
  

Over the past three decades, the state-of-the-art in cardiac surgery has progressed to the point where the first four of the above expectations are by and large fulfilled. For realizing the fifth requirement, revolutionary techniques like minithoracotomy and port-access surgery have become available after a long period of effort and research, pioneered by V.I. Kolessov in the 1960s, and F.J. Benetti and E. Buffolo in the mid-1990s.

Earlier, the techniques of minimally invasive coronary artery surgery (MICS) were only available at a few centers in the world, were being practiced by a few surgeons. During the last five years, there has been a significant increase in adopting minimally invasive coronary revascularization and valve procedures. This is, in large part, due to the pioneering work of A.M. Calafiore and his "beating heart" series using the "LAST" operation and V.A. Subramanian's innovative techniques which have made these surgical programs simpler and easier to implement in more hospitals.

The experience of these surgeons and ours at Escorts Heart Institute and Research Centre (EHIRC) clearly demonstrates that these operations can be performed safely with good early results. Thereby, reducing the cost of surgery, minimizing surgical trauma and patient's length of stay in hospital. Patient acceptability has increased because of these benefits and outcomes. The popularity and progress of these techniques and greater patient preference will ultimately be patient driven. However, we have to ensure that we maintain high quality of technique and care wherever these programs are carried out so that we do not "falter by default".

The development of techniques has included a variety of incisions, procedures on a beating or arrested heart, elimination of extracorporeal circulation, and designing "off-pump" operations, thus eliminating oxygenators, heart-lung bypass circuits and related procedures. These savings in time and materiels will provide higher throughput for surgical departments enabling them to offer help to a larger number of patients every year.

The "hybrid" approach of combining the MICS technique in conjunction with percutaneous transluminal coronary angioplasty (PTCA), percutaneous transluminal coronary stenting (PTCS) and transmyocardial laser revascularization (TMLR) has opened a new horizon for delivering a comprehensive cure to a cardiac patient using all available modalities of revascularization.

I selected myocardial revascularization as the primary focus of this editorial because patients and physicians are highly sensitive to the problem of coronary artery disease (CAD). This disease is considered the biggest killer in the developed and developing societies today; and the "Sword of Damocles" hanging over everyone's head or heart! The well-known standard modalities of revascularization can be appropriately modified to make them more patient friendly in minimizing patient anxiety and reluctance to undergo surgery. It is interesting that as cardiology becomes increasingly more interventional and invasive, the practice of cardiac surgery is becoming less invasive and more minimally invasive day by day.

The availability of stabilizing platforms makes beating heart revascularization relatively safe and effective as evidenced by published patency rates. In the USA, and elsewhere, patients are requesting this technique because of lower trauma and a faster return to work. In India, by using port-access surgery at EHIRC, we have brought a revolutionary change in the minds of our patients. Young females are now more willing to accept cardiac surgery to treat their congenital and valvular disease, when it is shown that there will be a very small scar – almost invisible – under the breast – which will not hamper the prospects of getting married. It is interesting that the cosmetic aspect of this port-access operation, has the greatest influence on the family's decision-making for their daughter's care. Their most serious concern is psychological in nature. In developing countries like India, where rheumatic heart disease is rampant, ease in motivating patients for early minimally invasive valvular surgery will have a tremendous positive impact on both social and economic outcomes.

Though these new techniques look promising at the moment, it will have to be demonstrated that their long-term results are as good, if not better, than conventional methodologies. Once MICS procedures are proven, patients themselves are going to opt for these procedures even if more expensive, as in the case of port-access surgery. Surgical teams all over the world will have to acquire greater skills and work with patience and diligence during the learning curve to develop these programs.

I believe that whatever we can conceive, the human mind and rapid technical advances will make a reality. In shaping the future, the primary key success factor will be developing technologies and our skills to fit the patient's therapeutic needs, rather than us marking time applying the same conventional approaches to the patient. Some of these technical advances are already being developed in the laboratory and finding daily use in general surgery.

In the future, new robotic technology combined with motion scaling, telemanipulation, field-of-view magnification, and micro-instrumentation will enable surgeons to perform complete endoscopic operations on the heart. Further developments in voice activation of essential operating room equipment will improve the consistency of patient outcomes and overall results.

The original Great Masters of cardiothoracic surgery had to have the "courage to fail" to operate on the heart. Their teachings and inspiration together with the enthusiasm of a younger generation of cardiovascular surgeons must open new surgical horizons and push the boundaries of our knowledge. Surgeons in the minimally invasive field must focus on excellence of results, change flexibly with technological advances, and adopt a multidisciplinary approach to serve and benefit their patients in the next millennium. This is the revolution which is in our hands today and will herald a new era in cardiac surgery for our patients.

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Naresh Trehan Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Trehan, N. Search for Related Content PubMed Articles by Trehan, N.