Minimally Invasive Cardiovascular and Thoracic Surgeries

What is minimally invasive heart surgery?

The benefits of minimally invasive heart surgery include:

• A smaller incision
• A smaller scar

Other possible benefits of minimally invasive heart surgery may include:

• Reduced risk of infection
• Less bleeding with minimally invasive heart surgery
• Less pain and trauma
• Decreased length of stay in hospital after the procedure: the average stay is 3 to 5 days after minimally invasive surgery, while the average stay after traditional heart surgery is 5 days
• Decreased recovery time: the average recovery time after minimally invasive heart surgery is 2 to 4 weeks, while the average recovery time after traditional heart surgery is 6 to 8 weeks

• Valve surgery
• Coronary artery bypass graft (CABG) surgery
• Epicardial lead placement: placement of leads for biventricular pacemakers (cardiac resynchronization therapy)
• Atrial fibrillation

Heart Valve surgeries, including valve repairs and valve replacements, are the most common minimally invasive heart surgery procedures.  Minimally invasive valve surgeries account for 87 percent of the minimally invasive cardiac surgeries performed at The Cleveland Clinic. A small, 3- to 4-inch incision is made down the center of the sternum (breastbone), whereas the incision made during traditional valve surgery is about 6 to 8 inches long.

Traditional heart surgery incision The incision is larger (about 6 - 8 inches), made down the sternum, through bone and muscle	Minimally invasive- upper partial sternotomy The small incision (about 3 - 4 inches) is made down the center of the breastbone
Minimally invasive - lower partial sternotomy	Minimally invasive - right mini thoracotomy A small incision (about 2 - 3 inches) is made in between the ribs

Minimally invasive direct coronary artery bypass graft (MID CABG) surgery is an option for some patients who require a left internal mammary artery bypass graft to the left anterior descending artery. A small, 2-3 inch incision is made in the chest wall between the ribs, whereas the incision made during traditional CABG surgery is about 6 to 8 inches long and is made down the center of the sternum (breastbone).

Saphenous (leg) vein harvest may also be performed using small incisions.

Several techniques for minimally invasive bypass surgery are being explored at the Cleveland Clinic, including surgeries performed on a beating or nonbeating heart.

Off-pump or beating heart bypass surgery allows surgeons to perform surgery on the heart while it is still beating. A medication may be given to slow the heart during surgery, but the heart keeps beating during the procedure. This type of surgery may be an option for patients with single-vessel disease (such as disease of the left anterior descending artery or right coronary artery).

beating heart bypass surgery

Traditionally, CABG surgery is performed with the assistance of cardiopulmonary bypass (heart-lung machine). The heart-lung machine allows the heart’s beating to be stopped, so the surgeon can operate on a surface which is blood-free and still. The heart-lung machine maintains life despite the lack of a heartbeat, removing carbon dioxide from the blood and replacing it with oxygen before pumping it around the body.

During off-pump or beating heart surgery, the heart-lung machine is not used. The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.

Keyhole Approaches

For some surgical procedures, an endoscopic or “keyhole” approach may be performed. This approach may also be referred to as port access surgery or video-assisted surgery.

The port access surgery technique allows surgeons to use one to four small (5- 10 mm) incisions or “ports” in the chest wall between the ribs. An endoscope or thoracoscope (thin video instrument that has a small camera at the tip) and surgical instruments are placed through the incisions. The scope transmits a picture of the internal organs on a video monitor so the surgeon can get a closer view of the surgical area while performing the procedure.

Types of minimally invasive heart surgeries that may be performed using the innovative port-access or “keyhole” approach include:

• CABG surgery and reoperations for select patients
• Valve surgery and reoperations for select patients
• Epicardial lead placement for cardiac resynchronization therapy
• Minimally invasive surgery for atrial fibrillation. The surgeon views the epicardial (outer) surface of the heart using an endoscope. Specialized instruments are used to create new pathways for the electrical impulses that trigger the heartbeat. Unlike traditional surgery for atrial fibrillation, there is no large chest wall incision, and the heart is not stopped during the procedure.
• Some types of thoracic procedures may use video-assisted thoracoscopy (VATS), also called thoracoscopy or pleuroscopy, such as partial lung resection, lung biopsy, lobectomy, drainage of pleural effusions, or pericardial and mediastinal biopsies.

Robotic-assisted heart surgery

Robotic surgery: Precise camera & instrument control allows the surgeon to control view & movements

Robotically-assisted heart surgery, also called closed-chest heart surgery, is a type of minimally invasive surgery performed by a cardiac surgeon. The surgeon uses a specially-designed computer console to control surgical instruments on thin robotic arms.

Robotically-assisted surgery has changed the way certain heart operations are being performed. This technology allows surgeons to perform certain types of complex heart surgeries with smaller incisions and precise motion control, offering patients improved outcomes.

First, three small incisions or “ports” are made in the spaces between the ribs. The surgical instruments (attached to the robotic arms) and one camera are placed through these ports. Motion sensors are attached to the robotic “wrist” so the surgeon can control the movement of the surgical instruments.

The surgeon sits at a computer console and looks through two lenses (one for each eye) that display images from the two tiny cameras placed inside the patient. From the two optical outputs, the computer generates a clear, three-dimensional image of the surgical site for the surgeon to view. Foot pedals provide precise camera control, so the surgeon can instantly zoom in and out to change the surgical view.

The surgeon’s hands control the movement and placement of the endoscopic instruments. The robotic “arm and wrist” movements mimic those of the surgeon, yet are possibly more precise than the surgeon’s natural hand and wrist movements. The surgeon is always in control during the surgery; there is no chance that the robotic arms will move on their own.

At Cleveland Clinic, the robotically-assisted surgical technique can be used in select patients during these heart operations:

• Mitral valve repair and replacement surgery and reoperations

  Robotic Heart Surgery Incision

• Tricuspid valve repair and replacement surgery and reoperations
• Combined mitral and tricuspid valve surgery
• Coronary artery bypass graft (CABG) surgery
• Atrial septal defect (ASD) repair
• Patent foramen ovale (PFO) repair
• Removal of cardiac tumors
• Lead placement on the surface of the left ventricle during a biventricular pacemaker or defibrillator implant
• Catheter ablation for the treatment of paroxysmal atrial fibrillation (an intermittent irregular heart rhythm in the upper chambers of the heart)

Click here for more information about robot assisted heart surgery

Your cardiac surgeon will review the results of your diagnostic tests before your scheduled surgery to determine if you are a candidate for minimally invasive surgery. The surgical team will carefully weigh the advantages and disadvantages of minimally invasive heart surgery against traditional surgery.

How will I feel after minimally invasive heart surgery?

There will be some incision discomfort for the first few days after surgery. Medications can be taken to help relieve this discomfort. Ask your doctor which medication you should take for pain relief. If you begin to have discomfort in your chest that is similar to the symptoms you had before your surgery, call your doctor.

Recovery after minimally invasive heart surgery

Patients who had minimally invasive surgery may be able to go home 3 to 5 days after surgery. Your health care team will follow your progress and help you recover as quickly as possible.

Your health care team will provide specific instructions for your recovery and return to work, including guidelines for activity, driving, incision care and diet.

In general, you may be able to return to work (if you have a sedentary job), resume driving and participate in most non-strenuous activities within 2 to 4 weeks after minimally invasive heart surgery. You can resume heavy lifting and other more strenuous activities within 6 to 8 weeks after minimally invasive surgery.

Distribution of Minimally Invasive Cardiac Procedures at Cleveland Clinic The graph above shows the distribution of minimally invasive cardiac surgery procedures from 1995 to 2006; 6,015 minimally invasive cardiac surgeries were performed during this time. In 1996, Cleveland Clinic cardiovascular surgeon Delos M. Cosgrove, M.D., performed the world’s first minimally invasive heart valve surgery. Since then, improvements in the type of incision and surgical techniques have led to proven, successful minimally invasive approaches to cardiac surgery. Click here for more information about surgical outcomes.

For more information:

• Click here to learn more about coronary artery bypass surgery
• Click here to learn more about valve surgery
• Click here to learn more about robot-assisted heart surgery
• Robotically Assisted Mitral Valve Surgery video
• Minimally Invasive and Robotic Assisted Heart Surgery (Dr. Mihaljevic 6/20/2007)
• Minimally Invasive and Robotic Assisted Heart Surgery Following Live Webcast of Robotically Assisted Mitral Valve Surgery(Dr. Mihaljevic 10/2/2007)
• Click here to find surgeons who perform minimally invasive heart surgery

If you have questions or need more information:

To obtain a surgical consultation, or if you have additional questions or need more information, you may contact us by email, using the Contact Us Form. Please state "Heart Center" in the Question or Comment Section.

You may also call the Heart & Vascular Institute Resource Nurse at 216/445-9288 or toll-free 866/289-6911. Webmail and phone calls are answered between 8:30 am to 4:00 pm on regular business days.

Resources:

• Gillinov AM, Banbury MK. Pre-measured artificial chordae for mitral valve repair. Ann Thorac Surg 2007; in press.
• Gillinov AM, Svensson LG. Ablation of atrial fibrillation with minimally invasive mitral surgery. Ann Thorac Surg 2007; in press.
• Gillinov AM, Liddicoat JR. Percutaneous transvenous mitral annuloplasty. Eurointerventions 2007.
• Gillinov AM. Is ischemic mitral regurgitation an indication for surgical repair or replacement? J Heart Fail Rev 2006;11(3):231-239.
• Gillinov AM, Liddicoat JR. Percutaneous mitral valve repair. Seminar Thoracic and Cardiovasc Surg 2006 Summer;18(2):115-121.
• Gillinov AM. Chordal transfer for repair of anterior leaflet prolapse. Multimedia Manual of Cardiothoracic Surg, 2005.
• Mihaljevic T, Cohn LH, UNic D, Aranki SF, Couper GS, Byrne JG. One thousand minimally invasive valve operations: early and late results. Annals of Surgery 2004 Sep;240(3):529-534.
• Gillinov AM, Cosgrove DM. Current status of mitral valve repair. Am Heart Hosp J, 2003;1:47-54.
• Gillinov AM, Faber CN, Houghtaling PL, Blackstone EH, Lam BK, Diaz R, Lytle BW, et al. Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease. J Thorac Cardiovasc Surg, 2003;125:1350-62.
• Gillinov AM, Banbury MK, Cosgrove DM. Hemisternotomy approach for aortic and mitral valve surgery. J Card Surg, 2000;15:15-20.
• Gillinov AM, Banbury MK, Cosgrove DM. Is minimally invasive heart valve surgery a paradigm for the future? Curr Cardiol Rep, 1999;1:318-22. Review.
• Gillinov AM, Cosgrove DM, Blackstone EH, Diaz R, Arnold JH, Lytle BW, Smedira NG, Sabik JF, McCarthy PM, Loop FD. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 1998;116:734-43.