Patients who have a tight blockage in the most important of the three coronary arteries – the LAD, requiring bypass surgery, can undergo minimally invasive bypass surgery. This can either be done as an isolated procedure when the LAD is the only blocked artery, or can be done in conjunction with coronary stenting to any other blockages which may be present, as a Hybrid Coronary Surgery Procedure.
Bypass surgery of the LIMA to the LAD has the best long-term results of any bypass surgery and will last longer than a stent to the coronary artery. This is particularly suitable for patients who have disease that isn’t suitable for stenting because the artery is severely calcified or the diseased segment is very long. A cardiologist will discuss the applicability of stenting and if they think it is unsafe may refer a patient for single vessel minimally invasive bypass.
What is involved?
This operation can be done with specialised minimally invasive instruments or with robotic assistance. This completely avoids splitting the breastbone and significantly enhances recovery.
Under a general anaesthetic a 5cm incision is made in the left side of the chest and the left internal mammary artery (LIMA) is harvested from behind the breastbone. The LIMA is then attached to the LAD, the main artery of the heart, to form the bypass using ‘off pump’ techniques whereby the heart remains beating throughout the procedure. This new graft provides a completely new blood supply to the heart rather than just addressing the blocked area; this reduces the incidence of recurrence of angina or heart attacks. This is one of the key differences between bypass surgery and coronary stents – stents only open an individual blockage and don’t treat any future disease that might occur.
What is the recovery like?
The recovery after minimally invasive surgery is far more rapid than traditional open heart surgery. The operation takes 2-3 hours and you will generally wake up in intensive care later that day. Small tubes to drain any residual fluid from around the heart will be placed in your neck, as well as intravenous lines, to sample blood and administer medications. These tubes and lines will be removed after 1-2 days and then you will be transferred to the ward to continue your recovery.
Once on the ward, the goal is to monitor your blood pressure and heart rate and ensure adequate mobilisation. We work very closely with our nurses, physiotherapists and occupational therapists to work on breathing exercises and functional mobilisation. Every patient is different and the assistance is tailored to your needs. Most minimally invasive patients can go home after 4-5 days.
Once home, patients who have undergone minimally invasive surgery continue to recover a lot faster than those who have undergone open heart surgery with splitting of the breastbone. Mobilisation is far easier and there aren’t any restrictions on lifting. Patients are encouraged to take plenty of walks. Your body will let you know what it is capable of and there is no need to push it. Most patients will feel back to their usual selves after about 4 weeks following minimally invasive surgery compared with 3 months following traditional open heart surgery.
What are the benefits and risks of this procedure?
Although the operation is performed minimally invasively there are still some of the usual risks associated with major heart surgery. The main benefits are that there is no risk of sternal bone infection, and there is a reduced rate of blood transfusion. Other risks are similar to open bypass surgery including: death (1%), stroke (1%), kidney injury (2%) and blood transfusion (15%). The risk can be higher if patients have other co-morbidities including advanced age, previous heart disease or stroke, or lung disease.
Dr Bassin will explain these risks to each patient in person and how they pertain to their specific condition.
When can I drive?
You may drive 4 weeks following surgery, according to the national guidelines.