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Preliminary data suggest a new approach to coronary artery bypass graft surgery (CABG) can sharply curtail lengths of stay and costs per case for cardiac patients.
The technique, called minimally invasive CABG surgery, is also thought to shorten the time needed for patients to recuperate at home, allowing them to more quickly resume activities of daily living, says Robert Michler, MD, chief of heart transplantation at Columbia-Presbyterian Hospital in New York City.
"What we have is a technology and a technique that many of us have employed and found that, yes, this works," Michler says. "It seems like it could be reproduced regularly. It does seem as though patients can get out of the hospital earlier. And that may even be less expensive not just because of the short length of stay but because it can be done without a heart-lung bypass machine, which saves profusion time, anesthesia time, and overall operating room time."
In conventional CABG surgery, the surgeon makes a vertical incision about five inches long down the middle of the patient’s breastbone. Blood thinner is then applied, and the surgeon connects tubes to the heart that allow the blood to be removed from the heart and circulated through a pump. The pump, called a heart-lung bypass machine, oxygenates the blood before delivering it back to the patient. The heart is stopped from beating, and the lungs are stopped from breathing. "Once that’s done, the surgeon operates on a quiet heart," Michler says.
In one type of minimally invasive CABG surgery, the surgeon makes a small transverse, or horizontal, incision under the patient’s nipple. The transverse incision allows the surgeon to open the sac surrounding the heart. Special retractors and stabilizers immobilize the area of the heart where the surgeons wants to work. The surgeon then operates on a beating heart. That’s important, Michler says, because according to some experts, the cardiopulmonary bypass itself produces an inflammatory response in the patient that delays healing.
"Because you don’t need the heart-lung bypass machine for this technique, some say you can get the patient out of the hospital sooner," Michler says. "Anecdotally, that’s been my and many others’ experience."
A second type of minimally invasive CABG surgery, using Heartport port access technology still requires the use of a cardiopulmonary bypass machine, a significant drawback in Michler’s estimation. "But the port access technology is nice," he says, "because it does permit potentially additional blood vessels to be bypassed or valves to be operated on."
Currently, at Columbia-Presbyterian, conventional CABG surgery has an average length of stay (LOS) of about nine days. The fifty or so patients so far who have undergone the minimally invasive technique have averaged between four and six days in the hospital, with an accompanying reduction in morbidity and a return to normal function in "only a matter of weeks," Michler says.
"One of the nice things that managed care has done and that minimally invasive CABG surgery has done is that as we start to send patients home earlier in that category, we begin to say, why can’t we send patients home earlier with the standard bypass?’" Michler says.
He points to the recent case of an 84-year-old patient on whom he performed conventional CABG surgery several weeks ago. The man, who underwent a four-vessel bypass surgery, went home after only four days. "Two years ago, I would have thought, That’s really pushing it,’" Michler says. "Three or four years ago, I never would have thought of sending a patient home in that length of time. But now, as we grow more experienced, we know what to look for, and we’re able to send patients home earlier."
He also cautions that, given dropping lengths of stay for conventional CABG surgery, it’s important not to compare LOS for minimally invasive CABG to the traditionally accepted lengths of hospital stay. "It’s a bit of a moving target with both lengths of stay," he says. "We have to make sure that we’re actually comparing it to a chronologically coincident group of patients being managed aggressively to get them out of the hospital earlier."
Currently, the main criticism of minimally invasive CABG surgery is that, because the procedure is new, no data exist to establish its long-term efficacy. Conventional CABG surgery, on the other hand, has been performed for more than 20 years. "The simple fact is that we do not have enough information at this time to say whether the graft [in minimally invasive surgery] lasts as long as for the standard conventional operation. But there’s enough accumulated evidence that it’s sufficient to say, let’s go in this direction.’"
[For more information about minimally invasive CABG surgery, contact: Robert Michler, MD, Columbia-Presbyterian Hospital, New York City. Telephone: (212) 305-5933.]