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What is minimally invasive heart surgery?

Dealing with the fallout of heart disease and wondering what your surgery options are? In minimally invasive heart surgery, surgeons perform surgery through smaller incisions in your breastbone or chest, as an alternative to open-heart surgery. Dr Leonard du Preez, a cardiothoracic surgeon practising at Mediclinic Panorama, explains what this surgery option entails.

Did you know that heart disease causes more deaths worldwide than tuberculosis, HIV/Aids and malaria combined? Or that heart disease in South Africa is the biggest killer after HIV/Aids – five South Africans suffer a heart attack every single hour? In fact, more patients in South Africa die from heart disease than they do cancer, says Dr Leonard du Preez, a cardiothoracic surgeon at Mediclinic Panorama, Cape Town.

Local heart surgeons certainly have their hands full trying to repair the damage that heart disease wreaks in the body. ‘What makes the burden of this disease even more difficult is that there are only 103 registered cardiothoracic surgeons in South Africa with less than 10 000 cardiac surgeries performed each year, most of which are in the private sector,’ says Dr du Preez.

Fortunately, South African surgeons are pushing boundaries to find solutions. This has seen much innovation in the cardiac surgery sector, including the introduction of minimally invasive heart surgery. We discussed this surgery option with Mediclinic Panorama’s cardiothoracic surgeon team, Drs Leonard du Preez, Jacques van Wyk and Carl Vogts, who specialise in a minimally invasive heart surgery technique called transcatheter aortic valve replacement (TAVR).

What is the difference between conventional cardiac surgery and minimally invasive heart surgery?

Cardiac surgery comprises surgery to the heart, heart valves and the major blood vessels in the chest. These can be accessed through conventional, open-heart surgery where the breastbone is cut into and divided so that the heart can be exposed and worked on.

‘However, with minimally invasive surgery, an incision is made between the ribs to access the heart,’ Dr du Preez explains. ‘Some heart conditions can be addressed through smaller incisions, where the breastbone is only partially divided or multiple small incisions are made through the chest wall. There are also catheter-based approaches where the diseased structures are accessed via the large blood vessels elsewhere in the body.’

The primary goal of minimally invasive surgery to the heart and large blood vessels is mostly cosmetic (that is, to minimise the damage done to the skin through large incisions used in conventional surgery). However, in some circumstances, it can decrease pain and surgical stress response, and shorten the duration of a patient’s stay in hospital.

Minimally invasive surgery is actually a misnomer, Dr du Preez points out. ‘Although it allows for minimal access, the surgery is in many cases still quite invasive. Often it’s necessary to divert blood flow to the heart and the heart is stopped just like it is in conventional surgery. Managing this and protecting the heart muscle while the operation is performed can be a technical challenge when utilising small incisions,’ he explains.

Additionally, the time it takes to conduct this surgery can be significantly longer compared to conventional surgery, which can potentially offset its gains. ‘A major consideration when it comes to this surgery is that the quality and durability of the operative repair should be equal to, or better than, the conventional approach. Patients should always inform themselves of these important factors when consulting their surgical team about the specific approach to their problem,’ Dr du Preez cautions.

What is transcatheter aortic valve replacement (TAVR)?

Mediclinic Panorama’s main area of expertise with regard to minimally invasive cardiac surgery is TAVR, says Dr du Preez. ‘It involves placing a heart valve through a small incision or puncture of a large blood vessel into the outflow of the heart. This is mostly done for older, sicker patients with damaged aortic valves where the conventional surgical operative risk is deemed too high,’ he explains.

This option is not necessarily suitable for all patients and conventional surgery is still considered the gold standard. ‘TAVR procedures have their own inherent risks, including stroke, leaking valves and the requirement for a pacemaker. The high cost of these prosthetic valves are a factor to consider too,’ he adds.

Hybrid operating theatres for minimally invasive heart surgery

Ideally, minimal access surgery procedures should be performed in a hybrid operating theatre, which is a cross between a standard operating theatre and a catheterisation laboratory. This contains sophisticated imaging equipment to treat cardiac patients, says Dr du Preez.

‘These theatres are larger than conventional theatres to accommodate the large team of healthcare professionals and the equipment necessary to perform these procedures safely. Mediclinic Panorama has recently installed a hybrid theatre, which has allowed us to become the leader in the field of TAVR in South Africa. We collaborate with Mediclinic Vergelegen and are currently performing between 40 to 50 of minimal access heart surgery cases a year,’ he says.

Other than TAVR, other minimally invasive surgery options include the removal of vein grafts in the legs through an endoscopic approach (using a small camera inserted through smaller incisions in the legs and arms to remove veins or arteries to be used for coronary artery bypass grafting).

‘Aneurysms and traumatic rupture of the aorta or its major branches can also be approached endovascularly (a surgical procedure in which a catheter containing medications or miniature instruments is inserted through the skin into a blood vessel) by approaching it from another large blood vessel and inserting a large stent prosthesis into the diseased portion of the blood vessel,’ Dr du Preez explains.

References:

  1. https://www.nature.com/articles/nrcardio.2017.19
  2. http://www.cvja.co.za/archive/vol_27_issue_3_July.php
  3. Statistics South Africa

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