Thanks to new discoveries in technology and knowledge, heart surgery has undergone amazing advancements in the last decade. Discover some of the new techniques and treatments available.
Surgeons have tried for centuries to help patients suffering from heart disease or trauma, but only recently has their desire been matched by knowledge, experience and technology. Here are four new areas of advancement in heart care.
Same Surgery, Sharpened Techniques
Just 60 years have passed since the first successful bypass surgery was performed in the United States. Yet the procedure has remained fundamentally the same: When less-invasive stenting in a hospital’s catheterization lab is not a viable solution, veins harvested from the patient’s legs, and arteries taken from the arms or chest wall, are used to replace blocked heart vessels.
Dr. Cynthia Steimle, a cardiovascular surgeon at Sherman Hospital in Elgin, has observed a major improvement in equipment quality and surgical techniques since her career began 16 years ago.
“The concept hasn’t changed,” Steimle says. “We do have better equipment and instruments, better sutures. But the biggest change involves how we harvest veins to replace the diseased arteries.”
Until relatively recently, veins were surgically cut from a patient’s legs or arms, leaving long, disfiguring scars, sometimes causing patients to complain more about the pain in their legs than the actual bypass surgery.
“Now, we make small incisions in the patient’s leg or arm and use an endoscope to harvest the selected vein,” Steimle explains. “Patients heal much faster and have far less soreness. Complications that can arise from a patient’s weight or diabetes are significantly reduced as well.”
In the beginning, cardiovascular surgeons performed “beating heart” surgery, in which the heart continued to pulse while the surgical procedure was taking place.
“You can imagine how hard that was, with the heart jumping around,” Steimle says. “Plus, the arteries we’re sewing onto – the coronary arteries on the heart – are really small, only a millimeter or two in size.”
The introduction of the heart-lung machine in the 1950s was a huge step forward in helping surgeons to work effectively, with less chance of complications. It allowed the heart to be stopped during surgery, with the machine taking over the functions of the patient’s heart and lungs. For more than 30 years, stopping the heart during bypass surgery was the standard. In the past few years, however, new devices that stabilize the heart have been developed, making surgery on a beating heart possible.
“For most people, stopping the heart gives the best outcome, but in some cases now we are trending more toward a hybrid of the two approaches,” says Steimle. “This gives us the best chance of getting really sick patients through high-risk surgery.”
Also improved is the tubing used in the heart-lung machine, which connects to the heart to circulate and oxygenate the patient’s blood during surgery. “One tube goes into the right atrium where the veins bring blood back into the heart, and the second goes into the aorta,” Steimle says. “The tubing materials are much less irritating than they were in the past.”
Other advancements have aided in diagnosing and treating heart disease. For example, ultrasound is now used to assure that the patient has no serious plaque buildup that might break up during the procedure, increasing the risk of stroke.
“But what is really remarkable and seldom given much attention is the change in how we think about bypass surgery,” says Steimle. “When you really think about it, we’re mostly working with patients in their 70s, 80s and even 90s, who are undergoing major surgeries lasting up to five hours. Yet the risk of death has dropped to 1 to 2 percent.”
She points out that cardiovascular surgeons have learned so much, not only about surgery, but also about aftercare, that it’s now possible to offer bypass surgery to most older, sicker patients, rather than leaving them to suffer pain and reduced quality of life.
“Results are really remarkable, and many patients can have the chance to feel better,” says Steimle.
Reinforcement for Angioplasty
While bypass surgery itself has remained basically the same, angioplasty, used to alleviate stenosis (narrowed or blocked arteries), has changed drastically since its introduction in the late 1970s. Today, stenting plays a major role in preventing and stopping heart attacks.
Prior to development of the stent, the main interventional treatment was balloon angioplasty. In this procedure, a balloon compacted onto the end of a small, straw-like tube, called a catheter, is fed by wire through the patient’s vessels via a small IV in the leg, wrist or arm. Surgeons use real-time X-rays to determine the exact location of the blockage, position the balloon and inflate it, opening the artery and loosening the blockage. However, with balloon-only angioplasty, there was an unacceptable rate of restenosis, or repeat artery blockage.
Adding a drug-eluting stent has lowered the risk of restenosis to less than 5 percent, says Dr. David Bromet, an interventional cardiologist at Provena Saint Joseph Hospital in Elgin. As chief of cardiac services, Bromet has seen firsthand the tremendous impact stenting has had on patient survival rates and on quality of life.
“Stents are metal mesh tubes that are wrapped over the balloon,” he explains. “They can be plain or covered with medicine. When the balloon opens, the stent snaps into place like a scaffold, to hold the vessel open. This can literally stop an acute heart attack in its tracks. Chest pain and pressure are eased as well. The patient can often go home the same day, with a prescription for blood thinners.”
Stenting is ideal for patients with less severe blockages. In severe cases, stenting can be the first step in stabilizing the patient, who then may be scheduled for bypass surgery within a day or two. In some cases, patients scheduled for a double or triple bypass procedure may be candidates for single bypass, with stents completing the treatment.
“We have the ability to do this hybrid procedure at Saint Joseph, but in general, we favor doing one procedure at a time,” Bromet says. “We stage the treatment depending on the patient’s condition and tolerance.”
Bromet does hundreds of stent procedures annually, usually on patients between age 45 and 85. “There’s a broad separation in age-appropriate patients,” he says. “The oldest patient I’ve stented was 94. Regardless of age, the procedure is anatomically specific and must be right for the patient. We don’t treat just the heart condition but also the whole patient. We find that more than 30 percent of patients with blocked arteries in and near their hearts also have blockages elsewhere in their bodies. Vascular disease isn’t just limited to the heart region. It’s systemic, and blockage can occur anywhere, increasing the patient’s risks of heart attack and stroke. This is why it’s vital to treat the whole body, not just the specific blockage.”
Non-cardiac blockages can include peripheral artery disease (PAD) in a patient’s legs. The same stent procedure used to stop heart attacks can be applied to relieve leg pain or ulcerations caused by PAD. But treatment doesn’t stop there; the underlying causes of any blockage must be addressed. Obesity, diabetes, drug or alcohol abuse, smoking, high cholesterol and high blood pressure can influence the development of blockages. Factors beyond control, such as genetics, also play a role.
Emergency responders educate the public on the “golden hour,” that critical window of time for saving a patient’s life and minimizing heart and brain damage caused by coronary thrombosis and stroke. Emergency room personnel, such as those at Saint Joseph, also observe a window of time critical to patient survival. From the moment a patient experiencing chest pain or other symptoms of a heart attack comes through the doors, to the time that person is catheterized, averages 90 minutes nationwide. Hospital emergency rooms strive to shrink that window to 60 minutes or less.
Smaller Instruments, Smaller Incisions
Blocked blood vessels aren’t the only cardiac health risks. The delicate valves that control blood flow within the heart’s vessels also are vulnerable to disease and the effects of aging. These can calcify and stiffen, weaken and begin to leak, or fail completely. Significant advances in the treatment of valve disease have made an enormous difference, not only in repairing or replacing valves but also in the procedure’s impact on the patient.
Dr. Timothy Votapka, cardiovascular and thoracic surgeon at Advocate Good Shepherd Hospital, in Barrington, says that a minimally invasive technique was introduced for the treatment of valvular heart disease several months ago.
“The procedure is similar to bypass surgery, in that we still need to stop the heart and use the heart-lung pump,” Votapka explains. “Comparatively small incisions allow us to follow the same steps with less scarring and quicker healing time. This also lowers the risks related to traditional open, conventional surgery.”
Both aortic and mitral valves can be replaced or repaired, with minor changes in the method.
“For aortic valve procedures, we make a two-inch incision between the ribs below the collarbone on the patient’s right side,” Votapka explains. “For mitral valve surgery, one incision is made under the patient’s breast near the armpit, and another small incision is made a little lower on the chest.”
Neither operation requires opening of the sternum, or breastbone, which necessitates the six to eight weeks of limited activity following open-heart procedures where this is done.
Several years ago, the surgical robot was used for cardiac valve surgery to minimize incision size and reduce recovery time. Surgeons soon realized it wasn’t the robot itself that gave them the advantage, but the long instruments developed for the robot that allowed the surgery to be accomplished through small incision. By modifying the instruments so that they can be used manually, heart surgeons accomplish the same results without the need for the bulky, expensive robot.
“While aortic valves usually need to be replaced, we can repair mitral valves in about 90 percent of patients, depending on the condition of both the valve itself and the patient in general,” Votapka says. “If at all possible, we try to repair mitral valves.”
Recovery is significantly quicker using this minimally invasive procedure, with patients remaining in the hospital for two or three days. Patients also experience reduced pain after the first day or two, less blood loss and lowered risk of infection.
“Post surgery pain is pretty much the same for traditional and minimally invasive valve replacement,” Votapka explains. “But patients experience a lot less pain later.”
The results of both procedures are comparable, depending on the type of replacement valves used.
When tissue valve replacements are used, no blood thinners are prescribed. But tissue valves are less durable than mechanical valves and may start to degenerate after 10 to 15 years.
If mechanical valves are used, patients will need to take blood thinners for the rest of their lives, but the risks of repeat surgery are extremely low. With mitral valve surgery, a successful repair doesn’t require blood thinners and almost never requires additional surgery.
“As more physicians realize what new techniques are available and see how much more can be done for patients, I expect procedures such as this to become more the standard,” Votapka says. “We still have a long way to go before some of the newer procedures become commonplace.”
Abatement with Ablation
Diseased valves can cause atrial fibrillation (A-fib), a condition in which errant electrical impulses cause the heart to beat irregularly and, often, much faster than normal. A-fib can make a person’s heart race at rates well over 100 beats per minute, even when at rest. Some patients may not feel the increased heart rate, but other symptoms are fatigue, loss of energy, breathlessness after average exertion and a tendency to tire easily.
When A-fib occurs episodically, it’s called “paroxysmal” or “intermittent,” and when constant, it’s referred to as “persistent” or “chronic.” Both types can be treated successfully with ablation.
“Ablation is relatively new,” says Dr. Eric J. Kessler, an electrophysiologist at Centegra Hospital-McHenry. “About 10 years ago, academic medical centers began using ablation on a narrow group of patients. Today, not only has ablation become more common, but it also can be applied to a wider range of patients with excellent results.”
In this minimally invasive procedure, a fine catheter is threaded up through a vein in the patient’s leg and maneuvered to the area in the heart responsible for the abnormal electrical impulses. The most important areas are associated with the pulmonary veins that drain blood from the lungs back into the heart. The catheter is used to cauterize the tissue in a circle around the veins. This creates a line of scar tissue that acts as an insulator, blocking the abnormal electrical impulses that cause A-fib.
“While serious valve disease should be taken care of surgically, intermittent or chronic A-fib caused by electrically abnormal tissue is usually first treated with drug therapy,” Kessler explains. “When we find that drugs aren’t controlling the condition, we frequently will consider a more robust solution like ablation.”
With ablation, the success rate for the first procedure is about 60 to 70 percent. About one-third of patients may need a second round. After that, the A-fib is expected to be under control in more than 90 percent of patients. For chronic A-fib, in which the heart is continually in the abnormal rhythm for many months or years, Kessler says approximately 80 percent of patients experience relief after multiple procedures.
“Now we can offer successful treatments with reasonable risks,” he says. “The chance of significant complications is down to two to three percent.”
Implanting a pacemaker to treat A-fib is usually done as a last resort, and generally considered only if the patient isn’t a viable candidate for ablation.
“Patients who also have advanced heart disease or other very serious medical problems may be unsuitable for ablation,” Kessler says. “In their cases, we electrically disconnect the chamber of the heart with atrial fibrillation, from the main pumping chambers of the heart. At that time, we implant the pacemaker, which takes over the control of the patient’s heart rate on a permanent basis.”
While heart disease continues to be the No. 1 cause of death in the United States, advances in surgical treatment over the past 50 to 60 years may ultimately bring that unacceptable situation to a tipping point. Until then, fundamental bypass surgery, supplemented with an increasing array of innovative, minimally invasive procedures, is already making a difference in the length and quality of life for millions.