Overview of minimally invasive direct access heart surgery

Dr Suhas Bendre

There have been many advances, which took place in last ten years as far as heart valve surgery is concerned. It is important to understand what we mean as a heart valve and what is its function. Heart has four chambers two upper chambers or receiving chambers called atrium and two lower chambers or pumping chambers called the ventricle. Heart valve is like a door through which blood flows from one chamber to the other. The door has two or three parts which we called leaflets in medical terminology which closes and opens with each heartbeat. The frame of the door is called annulus to which the valve leaflets are attached. There are total four valves in the heart. The heart valves maintain the unidirectional blood flow in the heart.

The most commonly affected valves are mitral and aortic valve. When a disease process affects the heart valves they either become stenotic or incompetent. The diseases, which affect the heart valves, are rheumatic, degenerative and ischemic in nature and sometimes aortic aneurysms can cause aortic valve incompetence. In our country rheumatic fever is the most common cause of valvular heart disease.

In last few years minimally invasive and less invasive techniques have emerged as ways to potentially speed patient recovery. Conventionally heart valve surgery is performed through the full sternotomy and long skin incision. Nowadays we do valve surgery, either replacement or repair through partial sternotomy and just 6-7cm-skin incision. The advantages of this approach include improved cosmesis, decreased pain, decreased bleeding and infection, shorter intensive care unit {ICU} and hospital stay and reduced cost along with early resumption to work. This approach is called minimally invasive direct access valve surgery.

This approach is not possible without vacuum assisted venous return {VAVR} that means we put suction on the hear-lung machine to empty the patient’s heart effectively. As a result we can use smaller cannulas and thus get better exposure and more space for the operation. We also use trans-esophageal echo in the operative room before and after the repair. By doing this echo we make sure that all the air in the heart is removed and repair is satisfactory. Besides valve surgery we can also do Atrial Septal defect closure and Aortic aneurysm surgery through this approach. There are few centers in the Europe and USA where heart valve surgery is performed with video assistance and robotic instruments.

How it is important to our population?

This approach is called Minimally Invasive Direct Access Heart Surgery. Through this approach one can do many things such close the hole in the heart, which is there from the birth, heart valve repair and single or double heart valve replacement.

In our country rheumatic heart valve disease is the most common heart disease in young population. It needs valve replacement with artificial valve. Conventionally this operation is done through a long incision and cutting the chest bone completely. By this approach we can do all this things through 6-7cm incision & partially cutting the chest bone.

This has got the following advantages:

[1] Cosmetic benefits, which is important for every patient particularly young females in our country.

[2] Faster recovery, which means they are discharged from the hospital early. There stay in the ICU is also less. Hence the total hospitalization is less and thus it is cost-effective, which I think, is very important.

[3] Earlier resumption to work. Being a small incision & bone is partially cut , these patients don’t have to wait for long time to go back to work. I think this is one of the great advantage in young population who can start earning early after the operation.

[4] The requirement for the blood transfusion is less & thus there is less burden on the blood bank. There is a less risk of transfusion-induced diseases.

To perform this type of surgery one has to use vacuum controller & close circuit oxygenator. The vacuum controller is a one time buy for the hospital and this oxygenator does not cost more than 1000 Rs than the oxygenator used for the conventional open heart surgery.

It is very important to have training before performing this type of operation. At the same time it is not a difficult task if it is done consistently. Minimally invasive direct access heart surgery is practiced routinely at topmost centers in the world such as Cleveland clinic, USA I think it has a great potential in our country where large number of young population undergoes heart surgery.

The writer is consultant cardiac surgeon with PD Hinduja Hospital. Mumbai