Chairman, Cardiac Sciences, Fortis Hospital, Noida
Part 3 of 8 in Transforming Cardiac Care: Advances in Diagnosis, Surgery and Management
Valve Replacement and Coronary Bypass Surgery Without a Full Sternotomy
December 1, 2024
Valve replacement and coronary bypass surgery, the two most common major cardiac operations, no longer require the same access as they did a generation ago. Dr. Ajay Kaul, Chairman of Cardiac Sciences at Fortis Hospital, Noida, walked through the side by side difference between the conventional and minimally invasive versions of both procedures during a Jivo Healthcare masterclass for doctors across Africa.
Valve Replacement: Conventional Versus Minimally Invasive
In a conventional valve replacement, the surgeon works through a full sternotomy. In the minimally invasive version, the same valve is replaced through a small incision, and Dr. Kaul described one patient in whom two separate valves were replaced through this approach in a single operation, without the larger incision that used to be assumed necessary for a double valve case.
Coronary Bypass Through a Small Incision
Coronary bypass surgery follows the same pattern. Where a conventional bypass is done through a long incision down the chest, the minimally invasive version achieves the same grafting through a small cut, with Dr. Kaul showing the direct comparison between a routine bypass incision and the equivalent minimally invasive access.
Harvesting the Graft Vein Endoscopically
Bypass surgery also requires harvesting a vein, usually from the leg, to use as the graft. Conventionally, this means a long, full-length incision down the leg to remove the vein. Endoscopic harvesting instead removes the same vein through one or two small cuts, using an endoscope to access it, avoiding the long leg incision entirely while retrieving the same graft material.
Why Both Changes Matter Together
Taken together, a minimally invasive valve or bypass procedure combined with endoscopic vein harvesting means a patient having bypass surgery today can avoid both a large chest incision and a long leg incision, the two most visible and slowest-healing wounds of a conventional operation, while receiving the same underlying repair.
This guide is based on a live Jivo Masterclass: Dr. Ajay Kaul taught doctors across Africa on December 1, 2024.
FROM THE LIVE Q&A
Moderator
What are the different complications of getting an artificial heart (LVAD)?
Dr. Ajay Kaul
There are three main complications. First, because the device requires blood thinners, there is a risk of bleeding. Second, there is a risk of infection. Third, an artificial heart is only designed to function for about five to seven years, so it should ideally be converted to a transplant as early as possible rather than treated as a permanent solution, though I have seen patients go 10, 12, even 15 years on the device without a transplant.
Frequently Asked Questions
Can the same minimally invasive technique be used for a carotid artery aneurysm?▼
Yes, if the CT angiogram of the carotid artery shows that a stent can be placed, the aneurysm can be treated with an intravascular stent through a single small puncture in the leg, making it a minimally invasive procedure.
Following up on the complications of artificial heart transplantation, what about a further concern he described as 'autonomic surgery' in this context?▼
Dr. Kaul reiterated the transplant complications he had already covered, then said that there was nothing called autonomic surgery that he was aware of, and that the term appeared to be a translation error. The exchange closed with a request for Dr. Kamba to put the question in writing in the chat so it could be understood correctly.
Are there any techniques available for treating tetralogy of Fallot?▼
Tetralogy of Fallot is very well treatable, and children who are operated on go on to lead a normal life. I have patients who are now 25 to 30 years old and doing very well. Depending on the exact type of tetralogy, the results are very good.
How does an artificial heart actually work?▼
The heart is essentially a pump: blood comes in from the body, is pushed to the lungs to be purified, and is then pushed back out to the body. Building an artificial pump that does not damage or clot the blood took nearly 50 years to perfect. The device is based on magnetic levitation technology, similar to Japan's high-speed trains that run without touching the rails, so the pump's rotor never actually makes contact with the blood it is moving. In India, one artificial heart costs around 1.5 crore rupees, which is the major cost barrier.
Is heterozygous (mismatched donor-recipient) heart transplantation possible?▼
It is technically possible, but very few doctors would attempt it. A heart is a precious, scarce organ with a long waiting list of patients, so we always give it to the best-matching recipient rather than risk it in a less compatible match where rejection is more likely.
How is the graft vein for coronary bypass surgery removed in the minimally invasive approach?▼
It is harvested endoscopically through one or two small cuts, instead of a long, full-length incision down the leg.
Can a double valve replacement be done without a full sternotomy?▼
Yes, Dr. Kaul described performing a two-valve replacement in a single operation through a small incision rather than a full sternotomy.
Does minimally invasive coronary bypass surgery use the same grafting technique as conventional bypass?▼
Yes, the underlying graft and repair are the same; only the access incision, and the way the graft vein is harvested, differ.
In This Series: Transforming Cardiac Care: Advances in Diagnosis, Surgery and Management
- 1.Transforming Cardiac Care
- 2.Minimally Invasive Cardiac Surgery: A New Standard for Heart Operations
- 3.Valve Replacement and Coronary Bypass Surgery Without a Full Sternotomy
- 4.Treating Aortic and Carotid Aneurysms With a Minimally Invasive Stent
- 5.Heart Failure and the Case for Heart Transplantation
- 6.The Artificial Heart (LVAD): A Bridge to Transplant
- 7.Tetralogy of Fallot and Eisenmenger Syndrome: Two Very Different Outcomes
- 8.A Cardiac Surgeon's Guide to Preventing Heart Disease