Minimally invasive heart surgery, along with its advanced technology, is the most exciting evolution in the history of our specialty. We are constantly moving towards an improved, low-impact and soft-touch way to treat our cardiovascular patients.
Most cardiac patients can now enjoy a quicker and more comfortable recovery after a wide variety of cardiac surgery procedures regardless of their age and/or overall physical condition. While there is some recovery time, the average patient can return to their homes and families two or three days after minimally invasive heart surgery. Surgical scars are tiny and often completely hidden out of sight in the skin fold underneath the breast.
If your doctors are not familiar with these techniques and operations, we gladly provide support and additional clinical or technical information as needed.
Let me give you a straightforward perspective on how we achieved these improvements in our efforts to obtain the best results in heart surgery. Since the early 60’s cardiac surgery has been associated with three common assumptions in the training routine of all cardiac surgeons:
- The cutting of the breast bone (median sternotomy)
- The use of the heart-lung machine (cardiopulmonary bypass)
- The routine use of Blood transfusions
Each surgical assumption has been challenged and improved upon by new minimally invasive heart surgery techniques and technologies. Our patients enojy a rapid and uneventful return to a healthy and productive lifestyle. The ease and speed of recovery has become the focus of our clinical efforts to rapidly restore our patients’ life style back to normal.
Sternotomy vs. Minithoracotomy
The overwhelming majority of traditional open heart operations have required a 8″ to 12″ incision that cuts through the breastbone in the center of the chest. The following picture is to show you what a traditional sternotomy scar looks like.
Here are some of the clinical problems associated with the routine use of median sternotomies:
- More postoperative bleeding from the cut edges of the breast bone
- More postoperative pain and a slower recovery from the debilitating effects of a big surgical incision
- A 2 to 8% incidence of wound problems related to either infections or the failure of the breast bone to heal solid after surgery because of osteoporosis (brittle bones), a very common and prevalent condition in our elderly population.
- A delayed return to normal levels of physical activity and work, including lifting even light weights, using a cane or a walker, or driving a car. All this “down time” is often recommended after traditional surgery to avoid any mechanical stress on the recent sternotomy that could interfere with bone healing
- Unsightly scars
A new wave of interest in techniques that would be easier on our patients has opened new avenues and led us to think outside the box. The challenge was to be able to perform the same surgical procedure through a tiny incision with the same or better results in comparison to the traditional approach and without any compromise on the quality and safety of the operation.
Minimally Invasive Surgical Techniques Are Replacing Sternotomies
Minithoracotomies have replaced sternotomies in expert minimally invasive heart surgery centers. We now adopt the routine use of minithoracotomies in all types of open heart operations with excellent results. A minithoracotomy is a 2″ incision in between two ribs that is placed over the area of the heart that needs to be exposed to perform our cardiac procedure. This approach is used to treat the full range of aortic and mitral valve disease, Coronary Disease, Atrial Septal Defects, Ventricular Septal Defects, Septal Hypertrophy, Atrial Myxoma and other cardiac tumors.
The operation is performed through a tiny surgical window with specially designed instruments. There is no bone cutting involved and for this reason there is minimal bleeding and minimal pain with a much quicker recovery. In addition, these incisions heal very well. Wound infections are almost unheard of and the best cosmetic results are achieved. Patients can soon resume a good level of physical activity without any concerns about the wound healing.
For a good, contemporary in-depth review of the literature on the advantages of minimally invasive heart surgery in comparison to heart surgery performed through the traditional breast bone incision see: Jan D. Schmitto, MD et Al. Minimally Invasive Valve Surgery. J Am Coll Cardiol 2010;56:455-62. This review has an extensive bibliography to support each specific clinical advantage of these less invasive techniques in comparison to conventional sternotomy techniques, including survival benefits in higher risk groups, better cosmesis, less bleeding and less transfusion requirements, less wound infections and complications, less postoperative pain, faster return to normal activity, shorter hospital stay
Minimally Invasive Heart Surgery Scars
The following picture shows you the scar of a male patient in his 40’s who underwent minimally invasive coronary surgery four weeks earlier. The surgical incision is placed along the skin crease underneath the breast. A few months later that scar will turn into a thin white line that is barely visible. His hospital stay after surgery was less than 48 hours and he was back to work in less than two weeks. We do recommend our patients to avoid strenuous exercise and sports for at least a month after discharge. Such a quick recovery after bypass surgery is, needless to say, a fantastic progress in comparison to the same operation performed through a full median sternotomy.
In women the coronary bypass scar is tiny and completely hidden in the skin fold underneath the left breast, as you can see in the picture below:
Here is the same patient wearing her bra. Again, no scar is visible:
The next two pictures show you the postoperative results in a female patient who traveled from Florida to our center to treat severe leakage of her mitral valve. She is a Jehovah’s Witness and she could only accept a bloodless surgical option. She underwent a Minimally Invasive Mitral Valve Repair with strict bloodless techniques and was able to return home two days later. The first picture is a good demonstration of the superior cosmetic results we can achieve in comparison to a traditional median sternotomy. There are obviously no visible scars.
As you can see, in the case of surgery on the mitral valve the surgical incision is in the skin fold underneath the right breast. The same excellent cosmetic results along with a meticulous operation and a quick recovery were achieved in this case.
This incision is very similar to the one used by plastic surgeons to perform cosmetic breast surgery. I don’t need to tell you that she was ecstatic about not having a 12″ scar up and down in the middle of her chest. This approach can be used regardless of breast size or shape and even in patients with breast implants.
The next picture shows you a right mini thoracotomy scar in a gentleman who underwent a Minimally Invasive Aortic valve replacement. The picture was taken about two months after surgery.
OK….After two months it gets harder to see where the scar is! Here is a close up…..
This minithoractomy incision respects the muscle fibers of the chest muscles and allows patients to quickly regain their strength. This gentleman was able to go back to building construction within three weeks after the surgery. Such a fast return to a physically demanding job would have been unthinkable after a traditional sternotomy.
The next picture is in reference to a nice 68 year-old lady who underwent surgery for her diagnosis of severe aortic valve stenosis along with symptoms of profound shortness of breath, even with just a short walk. She returned home three days after surgery and the pictures were taken twenty days later. Please note that the aortic valve cannot always be operated on by using the same incision below the breast we routinely use for all the other types of surgery. Sometimes the surgical incision has to be placed a little higher on the right side of the chest. As you can see in the following pictures the cosmetic results are excellent and far superior to a median sternotomy. It is also important to remember that these minithoracotomy wounds heal very well and avoid cutting any bone, which is extremely beneficial in ladies because tey are nore frequently affected by osteoporosis (brittle bones).
The following picture is just to show you that this patient will never have to worry about hiding her scars when she wears a shirt, a blouse or an evening gown.
The Heart-Lung Machine and “Beating Heart Surgery”
Another way to be minimally invasive is to avoid, whenever it is possible, the use of the heart-lung machine. The function of this sophisticated machine is to take over the blood circulation in the body while we work on the heart. It uses centrifugal or roller pumps to filter, oxygenate and warm up the circulating blood. The entire blood volume flows constantly between the machine and the patient’s body through plastic tubings. Its use could certainly be deemed as invasive as a large incision, if not more, because the contact between the blood and the plastic tubings causes a total body inflammatory reaction that can affect the brain, the kidneys, the lungs. Don’t get me wrong: it is an invaluable tool that safely allows otherwise impossible operations inside the heart (i.e. valve surgery or ASD repairs) and on the aorta (our main pipeline) with excellent results. The great news is that it is no longer necessary to use it on patients who need coronary bypass surgery. We were able to design a technique that does away with the heart-lung machine when Coronary Bypass surgery is performed. It is commonly known as “beating heart surgery” because we do not need to stop the heart to perform this operation. You might say that it is like fixing an engine while it is running and it can be done because the coronary arteries are on the surface of the heart muscle. See the Hybrid Valve and Coronary Surgery page to learn more about coronary anatomy.
For a discussion on the merits and advantages of off-pump (beating heart) coronary surgery in comparison to traditional coronary surgery with the heart-lung machine see: John D. Puskas, MD et Al. Off-Pump Coronary Bypass Provides Reduced Mortality and Morbidity and Equivalent 10-Year Survival. Ann Thorac Surg 2008;86:1139-46
The Rise of Bloodless Heart Surgery Techniques
One more challenge to the old fashioned way to perform cardiac surgery was brought about by a renewed interest in bloodless heart surgery. The routine use of minimally invasive and beating heart surgery techniques has dramatically improved our ability to avoid transfusion in the majority of our surgical patients. The avoidance of the heart lung machine can in fact improve the body’s ability to stop bleeding after open heart surgery and smaller incisions that do not cut through bones are not as prone to bleeding as a full median sternotomy. Get more details in the page dedicated to bloodless heart surgery.