Minimally Invasive Coronary Bypass Surgery

By Giovanni Ciuffo, M.D.

Minimally Invasive Coronary Surgery techniques have changed the way we cure cure coronary artery disease. In spite of all the exciting progress in the field of interventional cardiology (stents and angioplasties), many patients are best treated with coronary bypass surgery to enjoy a durable and reliable solution to their problems and a much better quality of life. One of my favorite analogies about choosing the right options in heart disease comes from the field of dentistry. If you have a toothache and a literally rotten tooth you might consider two basic choices…….

CHOICE #1: The DIY Cheap Way Out.

You might decide to go to the local drug store and get yourself some strong toothache medication to feel better for a while. Unfortunately, we all know what happens next. This remedy won't last too long and chances are that you will end up losing your tooth and/or experiencing the misery of a tooth abscess.

CHOICE #2: The Permanent Fix

….OR you might decide to see what a dentist can do to help. Chances are that our good dentist will recommend a root canal. It goes without saying that none of us particularly enjoys the prospect of needle sticks and gruesome drilling in the dentist's office. We can expect, though, to save our tooth and get a crown on it. Bottom line: the pain is gone, the tooth is saved and we are happy again. That's more like it!!

Let's go back to coronary disease. A lot more than a tooth is at stake but a great deal of patients are still in denial and will try any easy way out rather than facing their condition. Some of them are unsuccessfully treated with medical therapy and/or stents and show up again with the same or more chest pain, shortness of breath, profound weakness or even worse…a heart attack and/or a much weaker heart. In many cases these same patients subject themselves to a radical, often exaggerated decrease in their physical and social activity to avoid their symptoms of chest pain, palpitations or shortness of breath. Some others get more and more stents in spite of the fact that they are obviously not working for them. I recall the extreme example of a 58-year old coronary patient with multiple stents saying, and I quote: "I'm fine. I only get chest pain when I walk!!" I heard once this line: "Insanity is doing the same thing over and over again, expecting a different outcome each time". All coronary patients should be strongly encouraged to consult with a heart surgeon and get a balanced view of their options in the treatment of their disease. It is not unusual to see patients that had been insisting on non-surgical therapies that are not working and can eventually cause more problems and effectively take their quality of life away. I am always amazed by how little information is offered to patients and their families when they are "shopping" for their best options. You should always feel free to ask as many questions as you like to your primary care physician and to the heart specialist about your choices in treatment. Our low-impact and minimally invasive techniques in coronary bypass surgery have dramatically improved our results and have shortened the recovery time. The overwhelming majority of coronary patients in my service return to their homes two-three days after their surgery. Even frail and older patients can enjoy these excellent results and get their "permanent fix" instead of the "DIY cheap way out"

What is a Coronary Artery Bypass? Coronary bypass surgery is one of the most frequently performed surgical procedures in the U.S.. To put it in plain plumbing terms, this procedure deals with badly clogged pipes (the coronary arteries). We connect a new pipe (a bypass) between the aorta (the equivalent of the main water supply) and the coronary artery segment downstream from the blockage (the "clogged pipe"). This bypass serves the purpose of bringing back a normal flow of oxygenated blood to the portion of heart muscle supplied by the blocked coronary artery (see picture below).

The traditional way to perform this operation involved the use of a heart-lung machine and a midline incision through the breast bone (median sternotomy). A more recent development that has revolutionized the way we perform this procedure is the beating heart surgery technique. In other words, we are now able to perform a coronary artery bypass while the heart is beating, with no need for a heart-lung machine. In expert hands, this technique allows excellent results and a shorter and less complicated postoperative course, especially in the older and higher risk patient population. By avoiding the use of the heart-lung machine, we are also able to perform a much less invasive procedure. Clinical studies are beginning to show that this technique is associated to much less bleeding and very few patients require transfusions. It is better tolerated by the lungs and kidneys, which is a great advantage in patients with emphysema and/or renal insufficiency. It might also be beneficial in patients that have carotid artery disease (bad circulation to the brain). For all these reasons, it is my personal preference to use this technique in the overwhelming majority of my coronary patients. The operation is carried out by connecting the aorta to a small opening in the segment of coronary artery beyond the blockage. The connection is created with saphenous veins harvested from the leg, mammary arteries from the chest wall, radial arteries from the forearm or other arteries from the abdomen (see picture).

Which grafts? The first coronary artery bypasses were performed only with leg veins. In the 70's the internal mammary artery (IMA) was introduced in clinical practice. It was soon discovered that the routine use of this artery for bypass can guarantee long term results that are far superior to using only leg veins. Numerous clinical studies have in fact shown that even after 10 years over 96% of the IMA grafts are still open and function well. The use of the IMA to bypass the coronary artery that feeds the front of the heart has been proven to give our patients the greatest survival advantage over any other intervention in contemporary medicine. This the reason why the left IMA is now considered the graft of first choice all over the world, often in association with other grafts if more than one bypass is necessary. The excellent results we observed with the use of the IMA lead us to believe that the preferential use of more arterial grafts instead of veins might improve the duration and quality of the beneficial effects of the bypass operation. In addition to both IMA's (right and left), other arterial grafts such as the radial arteries from the forearm, the right gastroepiploic artery from the stomach, the inferior epigastric artery from the abdominal wall, etc. have been successfully used. It is again important to point out that every patient gets an individual evaluation to decide which particular procedure and grafts suit him or her best.

MIDCAB stands for Minimally Invasive Direct Coronary Artery Bypass. This technique truly represents the ultimate minimally invasive technique in the field of heart surgery because it is carried out through a small incision AND does not require the use of the heart-lung machine. This operation is performed on the beating heart and instead of the traditional big midline incision, a 3" long transverse incision is all that is necessary to access the heart. The incision is right on the skin fold underneath the left breast to insure an invisible scar.

The Left Internal Mammary Artery is harvested from the chest wall and prepared for connection to the blocked coronary in the front of the heart.

A mechanical stabilizer (that two-pronged fork) is used to immobilize the portion of the heart surface where the blocked coronary vessel is and allow the surgeon to connect the left internal mammary artery to it.

The wound is then closed with plastic surgery techniques and the scar will be effectively hidden in the skin fold underneath the left breast. This approach can basically afford our patients a scarless and often painless operation

After this minimally invasive operation, our patients experience minimal pain with a small surgical scar and can often go home within the next 48 hours with a left internal mammary artery graft. Once again, this mammary graft is by far the best life insurance that modern medicine can offer to coronary patients!!! Ask your cardiologist about it. It is important to remember, though, that each patient needs to get an individual evaluation by the heart surgeon in order to decide if he or she is a suitable candidate for this procedure.

More information about Dr. Ciuffo and his revolutionary minimally invasive techniques is available at http://www.bigappleheartsurgery.com

Dr. Giovanni B. Ciuffo is a "superspecialist" in Minimally Invasive Heart Surgery and Bloodless Heart Surgery. His accomplishments stem from an entire career dedicated to the development and improvement of these techniques. Dr. Ciuffo speaks fluent Italian and Spanish. He currently runs a busy Cardiothoracic Surgery practice at Mount Sinai Hospital in Manhattan, where he cares for numerous patients coming from the Tri-State Area and the rest of the country.

Giovanni B. Ciuffo, MD is board certified by the American Board of Surgery and the American Board of Thoracic Surgery. He is a member of the New York Society of Thoracic Surgeons. His current academic and clinical activity is entirely devoted to the surgical therapy of coronary, valvular and thoracic aortic disease with the most advanced bloodless, minimally invasive and beating heart surgery techniques.

He serves as cardiovascular surgeon and consultant in the Hospital Liaison Committee for the Jehovah's Witnesses for his expertise in bloodless surgery techniques and strategies. He is often invited to teach and demonstrate his minimally invasive techniques in European and American cardiac surgery centers. He is often an invited speaker to meetings and conventions of medical and civic associations and the author of a health column on America Oggi, a daily Italian language newspaper in the U.S.

Dr. Ciuffo lives in Queens, NY with his wife and his two children.