Heart Surgery Without Opening the Chest: Valves to Aneurysms

Heart surgery without opening the chest is now possible for valve replacement, coronary bypass and aneurysm repair. Dr. Ajay Kaul, Chairman Cardiac Science, Fortis Hospital, Noida, India, operates through incisions of one or two inches, removes bypass veins through two small leg cuts, and seals aneurysms with a tube passed through a puncture in the leg, often with discharge within days.

His point was that a big cut down the middle of the chest is no longer the default for many heart operations, although it remains standard for heart transplantation, most multi-vessel bypass and complex aortic surgery. This article walks through each technique he presented, what it replaces, and what a referring doctor or patient should understand about it. The overview of the whole masterclass, including recovery milestones, congenital heart disease and prevention, is in the complete guide to advances in heart surgery and cardiac care.

What heart surgery without opening the chest actually means

Conventional open-heart surgery is performed through a median sternotomy: an incision of roughly the length of the breastbone, which is then divided from top to bottom so that the two halves can be spread apart. Dr. Kaul's alternative works on the same principle as laparoscopic surgery in the abdomen. The surgeon makes small holes, typically one or two inches long, and performs the whole operation through them.

The term "minimal access" (or minimally invasive) cardiac surgery covers several routes. The commonest are a small incision between the ribs on the right or left side of the chest (a mini-thoracotomy) and a partial sternotomy that divides only part of the breastbone. The heart-lung machine is still used for surgical valve operations, and it is frequently connected through the blood vessels in the groin rather than directly at the heart. The heart is still repaired in the same way; what changes is the route in, and therefore the trauma to the chest wall.

Dr. Kaul framed the purpose of these techniques as three aims: less invasive, safe, and good long-term results. A small incision that compromised the quality of the repair would not meet that standard.

Double valve replacement through a small incision

Valve replacement was the first technique Dr. Kaul illustrated, setting conventional and minimal access operations side by side. The conventional operation leaves a long midline scar; the minimal access operation leaves a short incision.

Two of his cases show how far the approach now extends.

• A double valve replacement. In one patient, two heart valves were replaced through a small incision. Multiple-valve surgery was once considered a firm reason to open the chest fully.
• Valve surgery combined with closure of a hole in the heart. A patient who had travelled from East Africa underwent a major valve operation and closure of a hole in the heart through the same minimal access technique.

He also showed an endoscopic valve replacement, in which the surgeon works with a camera and long instruments through the small incision, viewing the operation on a screen.

For patients and families weighing the choice of valve itself, the comparison of mechanical and tissue heart valves covers the decision in detail, and the cost of aortic valve replacement is set out separately.

Coronary bypass without a full sternotomy

Coronary artery bypass grafting (CABG) creates new routes for blood to reach the heart muscle beyond blocked coronary arteries, using arteries from the chest wall or veins from the leg as grafts. Dr. Kaul showed a bypass operation performed through a small incision next to a routine bypass done through the full midline cut, to make the difference in access visible.

In minimally invasive coronary surgery, the grafts are usually placed through a small incision on the left side of the chest. The approach suits selected patients, depending on how many arteries need grafting and where the blockages lie. The technical choices behind it are explored in Dr. Udgeath Dhir's article on minimally invasive coronary bypass, and the cost of CABG is listed separately.

Endoscopic vein harvesting for bypass surgery

Bypass surgery often needs a length of the great saphenous vein, the long superficial vein of the leg, to serve as a graft. Traditionally this meant a long incision running down the leg to expose and remove the vein. Dr. Kaul showed the two approaches side by side: on one side, the full-length cut; on the other, endoscopic harvesting, in which the vein is removed through two small cuts using a camera and specialised instruments.

For many patients, the leg wound was the most troublesome part of recovery after bypass: slow to heal, painful, and prone to infection, particularly in people with diabetes or poor circulation. Endoscopic vein harvesting reduces leg wound complications and pain compared with the open technique, and it is now widely used. In Dr. Kaul's words, the patient is left with two small cuts instead of a whole leg that has been opened.

Robotic heart surgery

Dr. Kaul's team has also started robotic heart surgery. The surgeon sits at a console, away from the operating table, and the robot operates on the patient on the other side, translating the surgeon's hand movements into the movements of instruments placed through small ports in the chest.

Robotic systems give the surgeon a magnified, three-dimensional view and instruments that articulate like a wrist inside the chest. In cardiac surgery they are used most often for mitral valve repair and for harvesting the internal mammary artery for bypass grafting.

A related development is the hybrid procedure, which Dr. Kaul listed among the advances that have reduced morbidity and mortality. In coronary disease, a hybrid approach typically combines a surgical bypass graft to the most important artery at the front of the heart with stents placed by catheter in the other arteries, planned as one treatment. The broader case for robotic and minimally invasive cardiac surgery, including who qualifies, is set out in the minimally invasive and robotic cardiac surgery guide.

Aneurysm stent graft repair instead of open surgery

An aneurysm is a permanent ballooning of an artery, and in suitable patients a stent graft placed through the leg now replaces the large open operation once needed to repair it. Dr. Kaul showed an angiogram (an X-ray image of the arteries filled with contrast dye) on which the normal calibre of the artery gave way to a huge, balloon-like segment, and he stressed the danger: an aneurysm can rupture at any time. Rupture of the aorta, the body's main artery, is frequently fatal before the patient reaches hospital.

Until recently, he said, aneurysms were treated with very big operations. In open repair, the diseased segment is opened and replaced with a fabric graft. The modern alternative avoids that surgery entirely. Through a small puncture in the leg, a tube is passed up inside the artery and positioned across the aneurysm. Blood then flows through the tube instead of into the weakened sac, which is excluded from the circulation. In the case he presented, the image after treatment showed the whole aneurysm treated, and the patient was discharged within 24 hours.

This procedure is known as endovascular aneurysm repair (EVAR) in the abdominal aorta, and thoracic endovascular aortic repair (TEVAR) in the chest. The tube is a stent graft: a fabric tube supported by a metal frame.

Three points matter to referring doctors:

1. Timing. Abdominal aortic aneurysms are usually repaired once they reach about 5.5 cm in diameter in men and 5.0 cm in women, or sooner if they grow rapidly or cause symptoms.
2. Anatomy. Whether a stent graft can be used depends on the shape and length of healthy artery above and below the aneurysm, assessed on CT angiography. Not every aneurysm is suitable.
3. Follow-up. After endovascular repair, patients need lifelong imaging surveillance, because blood can leak back into the sac (an endoleak) or the graft can shift over time.

The cost difference between open and stent graft repair of an abdominal aortic aneurysm is set out in Dr. Biswarup Purkayastha's article on peripheral arterial disease treatment and aneurysm repair.

Carotid artery aneurysm treatment

A carotid artery aneurysm can be treated with the same minimally invasive stent technique when the anatomy allows it. A doctor at the session asked whether the technique applies to an aneurysm of the carotid artery, the main artery supplying the brain through the neck. Dr. Kaul's answer was yes, provided an intravascular stent can be placed. The deciding step, he said, is to review the CT angiogram of the carotid artery first. If a stent can be put in, the treatment is minimally invasive and needs hardly more than one small puncture.

Aneurysms of the extracranial carotid artery are rare, and the choice between a covered stent and open surgical repair depends on the aneurysm's position, shape and cause. Where stenting is not anatomically possible, open repair remains the alternative.

When to refer for heart surgery without opening the chest

Across valve disease, coronary disease and aneurysms, the message for referring doctors is the same: a patient who has been told they need open-heart surgery may well be a candidate for a smaller operation, and the decision rests on imaging. Good-quality echocardiography (an ultrasound scan of the heart), coronary angiography or CT angiography, sent at the point of referral, allows the cardiac surgical team to say early which approach is feasible.

The same techniques that spare a fit patient a large scar are often what make surgery possible at all for an older or frailer one, the point on which Dr. Kaul closed his lecture.

When the heart muscle itself is too weak for any of these repairs, the options change, and they are covered in the companion article on artificial heart vs heart transplant. Questions doctors put to Dr. Kaul during the session, including the carotid aneurysm question, are on the Live Discussion page.