"This technique puts together the best of both worlds", Dr. De Bruyne stated. "However, it is important to emphasize that this is a small pilot study, and that robotically enhanced minimally invasive direct coronary artery bypass (MIDCAB) is a recent technique that is used in only a few centres worldwide."
Robotically enhanced MIDCAB is a minimally invasive procedure in which one or both internal mammary arteries in the chest are harvested with the help of a robot. Doctors then suture them to the obstructed coronary arteries through a left, keyhole mini-thoracotomy of about 2 inches wide to supply blood below the obstruction.
"The fact that this key-hole surgery is performed without opening the chest and without arresting the heart offers patients the best postoperative comfort level and aesthetic results", stated Frank Van Praet, M.D., senior author of the report and staff member of the department of cardiovascular and thoracic surgery at the Onze Lieve Vrouw clinic in Aalst, Belgium.
Keyhole surgery involves cutting two small holes in a patient's chest, in addition to a larger hole, the mini-thoracotomy. The surgeon inserts a small light into the chest through one hole and a camera through the other. Surgical instruments are used in the larger hole. The surgeon holds instrument-like tools connected to a computer. Observing the heart on a monitor, the surgeon performs the delicate motions required by the operation. The computer interprets the surgeon's movements and maneuvers the instruments performing the surgery. The computer eliminates the slightest tremour in the surgeon's hands for a less risky operation.
Keyhole surgery is much less invasive than regular bypass operations, and patients recover more quickly with less pain and scarring. The procedure is for patients whose arteries are not suitable for angioplasty, a non-invasive procedure that uses a balloon catheter and a wire mesh stent to widen, then prop open blocked blood vessels.
"The hybrid approach has been reported before, but this is the first hybrid bypass performed without opening the chest and on a beating heart", Dr. De Bruyne explained. "There are few patients involved, but we needed to be certain that it could be done safely", he stated. "This combined technique might be applied to many similar patients. We had absolutely no complications with this approach."
If confirmed in larger trials, combining the two procedures should especially benefit patients with diabetes and coronary heart disease and patients whose narrowed arteries include chronic obstruction of the left descending coronary artery (LAD).
"Patients with diabetes often have long lesions in their LAD that are difficult to treat with angioplasty but can be helped with bypass surgery", Dr. De Bruyne stated. "They also have a greater risk of infection if you open the chest and are more likely to have a long period of healing; therefore, avoiding opening the chest might be particularly beneficial in these patients."
Patients in the study underwent their procedures between July 2002 and December 2003. All had fatty deposits narrowing the heart's three main arteries, including obstructions in the LAD that precluded treatment with angioplasty. The stents contained a time-release drug to reduce the risk of re-narrowing. Eleven patients had angioplasty an average 41 days prior to their bypass operation. The remaining patient underwent angioplasty three days after surgery.
Eleven patients received angioplasty on the right coronary artery or the left circumflex. One patient had angioplasty on both. Patients had a follow-up angiogram within a week after the surgical procedure, proving the patency of all bypass grafts and stented segments when performed prior to the operation. Patients had a clinical follow-up after six weeks and six months. During the six-month follow-up, none died, had heart attacks or needed additional procedures to re-open arteries. All patients were free of typical angina or chest pain.
Co-authors are Giedrius Davidavicius, M.D.; Frank Van Praet, M.D.; Filip Casselman, M.D.; Ivan Degrieck, M.D.; Francis Wellens, M.D.; Raphael De Geest, M.D.; Hugo Vanermen, M.D.; and William Wijns, M.D.