Open-heart Surgery

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What is open-heart surgery?

As the term suggests, open-heart surgery is an operation where the heart is cut open. The purpose of the procedure is to gain access to the inside chambers of the heart in order to correct any anomaly, to repair or replaced disease heart valve, repair a hole in the walls of the heart, or to remove a tumor, etc.

How much schooling does a heart surgeon have?

After high school, four years of college (pre-med), five years of medical schooling, four years of residency training in General Surgery (a pre-requisite), two years of Thoracic (chest) Surgery, which includes Cardiac Surgery, six months or a year of vascular surgery and/or laboratory animal research (optional) and a year of fellowship in cardiac surgery (for refinement of surgical techniques). In short, a total of 16 to 18 years, after graduating from high school.

Is coronary bypass an open-heart procedure?

No. Technically, coronary bypass procedure is a close-heart, and not an open-heart, procedure, since the heart is not cut open when the coronary bypass is done. However, the term open-heart surgery has been loosely and commonly used for coronary bypass, not only by the lay people but also by physicians and nurses alike. Strictly speaking, this is a misnomer.

How can bypass be done without opening the heart?

Since the coronary arteries are anatomically on the outer surface of the heart (like the veins are visible on the surface of our hands), coronary bypass is done, in a simplistic term, by making a slit of opening in the artery beyond the blockage, and the "new arterial pipe" connection, or a vein taken from the leg, is connected end-to-side (like a sleeve is sown onto to the side of the shirt) beyond the blocked coronary artery to serve as a new plumbing to bring blood to the segment of the heart that was deprived of blood supply. And this procedure is done on the surface of the heart, so the heart does not have to be cut open.

What is the principle in bypass?

The basic objective of this surgery is to bring blood supply to the segment of the heart muscles that is not getting enough blood because the artery that was supposed to provide blood to that area is blocked by hardening of the artery. As a result, angina pectoris (chest pains) or acute myocardial infarction (heart attack) may ensue. A simpler way to understand bypass surgery is with this analogy: If a street is blocked by a traffic accident, you take a detour, go around the blockage by going to the street beyond it that is open, and proceed to the main street beyond the traffic jam, to get to the original destination. The "side street" (new passage way) in this example is the artery or vein graft that cardiac surgeons use as the bypass graft, which he hooks into the coronary artery beyond the blockage. This will now allow the traffic of blood to get to the original destination (muscles of the heart that were previously deprived of blood). All tissues and organs of the body need blood (carrying oxygen and nutrients) to stay alive and function well.

Does the heart have to be stopped during surgery?

Yes, in the standard technique, the heart has to be totally arrested (stopped) while the coronary bypass grafting is performed. After the grafts are connected to the coronary artery on the surface of the heart beyond the blockages, then the heart is re-started. However, in June of 1999, my team and I introduced a new procedure at the Cebu Cardiovascular Center, the OPCAB (Off-Pump Coronary Artery Bypass) technique, where we did a quadruple (4-way) coronary bypass on a beating heart, without (arresting) stopping the heart and without the use of the heart-lung machine.

Will stopping the heart not kill the patient?

Yes, stopping the heart even for as little as five or ten minutes will kill the patient, unless mechanically supported. This is the reason why we connect the patient to a heart-lung machine first, before stopping the heart. This machine acts as a temporary heart (pumping device) and lung (oxygen supplier) substitute, to support the patient and maintain life, while the patient's heart is arrested (stopped) during the conventional coronary bypass surgery.

Will the heart re-start for sure?

While there is no 100% guarantee in life in general, and much less in medicine or surgery, we have not personally encountered a heart that did not re-start when we were done with the grafting and ready for the heart to resume beating. Cardiac surgeons use time-proven strategies to induce the heart to re-start beating once the main heart surgery is done. While cardiac arrest in heart surgery is safe, there are some disadvantages in this technique, mostly attendant to the use of the heart-lung machine.

What are these disadvantages?

The use of the heart-lung machine has been proven safe for more than 40 years, but its use could be complicated by some destruction in the platelets (cells in our blood responsible for normal clotting) and other clotting factors, and/or by air, cholesterol debris or clot emboli (particles that travel to the brain or other vital organs), etc. This happens very rarely but nonetheless a medical reality.

Then, why not do OPCAB on all patients?

Not all patients with blocked coronary arteries are candidates for this new procedure. Only after evaluating the patients, reviewing the cardiac catheterization cine (coronary dye test "angiogram" film) and other medical details about the patient will the cardiac surgeon be able to tell if a patient is a candidate for this state-of the-art OPCAB technique or not.

Are all medical centers able to do OPCAB?

No, only those heart centers equipped with the special instruments required for OPCAB, and only those with cardiac surgeons with special training in OPCAB, are doing the procedure. The hands-on surgical course and additional training are given in a few selected renowned heart centers in the U.S., like the Boston University in Massachusetts, where we had ours.

How about Robotic heart surgery?

Robotic surgery, where the surgeon maneuvers the "joy stick" control box for this computerized technique, is being studied and refined in some specific FDA -approved centers in the United States. It was first tried in battlefield situations (where the surgeon at a remote area medical center miles away did the tele-robotic surgery looking at a TV monitor---in a makeshift operating room in near the battlefront, aided by onsite paramedical staff---to immediately control bleeding inside the body to reduce casualty. This type of bleeding can't wait for evacuation to a hospital. For completion of the routine procedure, the soldier patient is flown to the main hospital miles away where the surgeons are based. With the robotic coronary bypass technique, the patient's chest is not even cut open. Special straw-sized robotic surgical instruments (for dissection, cutting, electrocautery for bleeding control, tiny light source and magnifying fiberoptic camera, etc) are inserted through pen-sized openings in the chest, between the ribs, and the heart surgeon does the surgery with a "joy stick control box," much like a young kid playing Nintendo games. This procedure, which could take up to 2-3 times the usual operating time compared to the standard technique, is not generally available as yet, but it appears to be the wave of the future.

©2003Raoul R. Diez, M.A.O.D.