Cardiac Surgery Treatment Options

Coronary Artery Bypass Surgery

Coronary artery bypass surgery, also called coronary artery bypass graft (CABG), is used to route blood around hardened or narrowed portions of the coronary artery (coronary artery disease) to improve oxygen-rich blood supply to the heart muscle.

During coronary artery bypass surgery, an incision is made down the center of the chest and through the sternum (median sternotomy) to allow the surgeon to visualize and access the narrowed coronary artery. The heart is stopped and the patient is placed on a heart-lung machine to allow the surgeon to perform the graft on the stilled heart. A section of healthy blood vessel taken from the chest, arms or legs is then sewed onto the coronary artery (“grafted”) above the blockage and reattached below to allow blood to “bypass” the blockage and provide greater blood supply to the heart muscle

Off-Pump Coronary Artery Bypass Surgery

Coronary artery bypass surgery, also called coronary artery bypass graft (CABG), is used to route blood around hardened or narrowed portions of the coronary artery (coronary artery disease) to improve oxygen-rich blood supply to the heart muscle.

During coronary artery bypass surgery, an incision is made down the center of the chest and through the sternum (median sternotomy) to allow the surgeon to visualize and access the narrowed coronary artery. A section of healthy blood vessel taken from the chest, arms or legs is then sewed onto the coronary artery (“grafted”) above the blockage and reattached below to allow blood to “bypass” the blockage and provide greater blood supply to the heart muscle.

In traditional coronary artery bypass surgery, the heart is stopped and the patient is placed on a heart-lung machine to allow the surgeon to perform the graft on the stilled heart. In recent years, an “off-pump” technique has become more common. In the off-pump procedure, the surgeon performs the graft on the beating heart by “stabilizing” the portion of the heart where the operation is being performed.

The off-pump procedure reduces the risk of complications that may occur with the use of the heart-lung machine, including heart damage, excessive blood loss, renal (kidney) complications and an increased risk for post-operative stroke. Because of this, the off-pump procedure is especially appropriate for elderly patients and patients that are too ill to undergo the stress of stopping the heart and using a heart-lung machine.

Emory has performed more off-pump coronary artery bypass procedures than any other hospital system in the US. In fact, more than 80% of coronary artery bypass procedures at Emory are performed off pump, compared with a national average of less than 25%. In addition to the surgical off-pump procedure, Emory also offers a minimally invasive off-pump procedure for select patients.

Robotically Assisted, Minimally Invasive Bypass Surgery

Performing coronary artery bypass surgery (CABG) without opening up the chest cavity might sound like a description of a cardiology procedure of the future, but at Emory, this groundbreaking advance in the surgical treatment of heart disease is now a reality.

The minimally invasive CABG procedure, called endoscopic atraumatic coronary artery bypass surgery (endo-ACAB), uses robotics-assisted endoscopic techniques that allow CABG to be performed using small incisions between the ribs rather than an open-chest approach with a large incision through the sternum (median sternotomy).

The advantages of the endo-ACAB approach are numerous, including the fact that it does not require the use of a heart-lung machine (cardiopulmonary bypass), often one of the riskiest aspects of open-heart surgery. In addition, recovery from endo-ACAB is drastically shorter and associated with significantly fewer complications than the open surgical approach. Most patients are able to leave the hospital within 48 hours and return to full activity, including work, in two to three weeks, rather than the two to three months generally needed for recovery after traditional CABG surgery.

Currently, Emory is the only cardiac surgery service in Georgia that offers the endo-ACAB procedure. Nationally, fewer than 10 institutions are using this technique.

Hybrid Minimally Invasive Coronary Artery Bypass Surgery & Stent Placement

Endoscopic atraumatic coronary artery bypass surgery (Endo-ACAB) and angioplasty are now being combined into one procedure. During this “hybrid” approach, a surgeon performs endo-ACAB, and then an interventional cardiologist places stents (thin, metallic mesh tubes) where needed to open narrowed arteries.

Currently, Emory is the only cardiac surgery service in Georgia that offers the hybrid endo-ACAB/angioplasty procedure. Nationally, fewer than 10 institutions are using these techniques.

Complex Aortic, Mitral and Tricuspid Valve Surgery

Valve surgery is used to correct narrowed or leaking valves (heart valve disease). Some repair and replacement procedures can be performed using minimally invasive techniques, such as balloon valvuloplasty and transcatheter aortic valve implantation, but in many cases, an open surgical approach is required.

Mitral valves are more likely than aortic valves to be able to be repaired. Generally, a damaged aortic valve will need to be replaced with either a mechanical valve (made of artificial components) or a bioprosthetic valve (made of human or animal tissue).

Mitral valve repair is usually performed to correct a leaking valve that is damaged as a result of either a congenital (present from birth) condition or, more likely, degenerative disease, which often occurs with age. A severely damaged mitral valve may require replacement.

The tricuspid valve surgery is less common and often performed as part of a mitral or aortic valve repair or replacement.

Minimally Invasive Mitral Valve Repair or Replacement

The minimally invasive approach to repair or replace a damaged mitral valve involves a significantly smaller and less traumatic incision. This three-inch incision on the right side of the chest allows access to the heart between the ribs, as opposed to the traditional median sternotomy, during which an incision is made along the full length of the sternum. Advantages of the minimally invasive approach include less blood loss, less trauma and a shorter recovery.

Minimally Invasive Aortic Valve Repair

Most damaged aortic valves must be replaced, but in some cases, the valve can be repaired using minimally invasive techniques to correct stenosis or regurgitation (heart valve disease). Aortic valve repairs include separating fused valve flaps, repairing tears or holes in valve flaps and reshaping of the valve. During these procedures, small incisions are made between the ribs or through the upper sternum to allow for the insertion of specialized surgical instruments. Minimally invasive aortic valve surgery has a number of advantages over the traditional open-heart approach, including minimization of blood loss and trauma and significantly shorter recovery.

Ventricular Assist Device (VAD) Placement

While transplantation is definitive therapy for end-stage heart failure, the number of cardiac transplants performed in the U.S. each year is limited to approximately 2,200 due to donor availability. Left ventricular assist devices (LVADs) are a type of mechanical circulatory support device that have been in use for more than 25 years primarily in patients with heart failure who are awaiting transplantation. Emory University Hospital has been at the forefront of VAD therapy, implanting our first device in 1988 and more than 65 devices since then.

As part of a clinical trial, Emory also offers implantation of continuous-flow LVADs as “destination therapy” for heart failure in patients unwilling or unable to undergo heart transplantation.

Surgical and Endovascular Treatment of Aortic Aneurysm

If a thoracic aortic aneurysm meets certain parameters, surgeons perform minimally invasive endovascular stent graft repair, delivering a graft to replace the weakened portion of the aorta using a catheter (thin, flexible tube) inserted through a small incision in the groin. The hospital stay is often only one or two days, with most patients returning to work and normal daily activities in about a week.

For those cases in which endovascular repair is not appropriate, the traditional open procedure will be performed. With both methods, long-term follow-up with periodic scans is necessary to monitor the site of the repair.

If the aneurysm is located near the aortic valve, valve-sparing aortic root replacement may be used to avoid replacing the valve.

Surgical Treatment of Aortic Dissection

Dissections in the ascending aorta (portion of the aorta near where it exits the heart) can be life-threatening and generally require surgery. The procedure involves replacing the damaged portion of the aorta with a tube graft (polyester tube). Sometime the aortic valve may also require repair or replacement, or, in some cases valve-sparing aortic root replacement may be used to avoid replacing the valve.

Dissections in the descending aorta (further from the heart, where the aorta descends toward the abdomen) often can be managed with medical therapy. However, if the dissection continues to grow, an endovascular procedure may be recommended in which a polyester-covered stent is used to reinforce the weakened portion of the aorta. The graft is placed using a catheter (thin, flexible tube) inserted in the groin area and threaded to the affected section of the aorta.

Valve-Sparing Aortic Root Replacement

Valve-sparing aortic root replacement is a technique used to repair an aortic aneurysm or dissection that occurs near the aortic valve. During the procedure, the heart is stopped and the patient is placed on a heart-lung machine (cardiopulmonary bypass). A section of the aorta, including the aneurysm, is removed just above the aortic valve and the coronary arteries. A tube graft (a woven Dacron tube) is then sewed onto the outside of the aortic valve to replace the section of the aorta that was removed. The other end of the graft is attached to the aorta and the coronary arteries are attached to the graft, just above where it is sewn to the aortic valve. Because the aortic valve remains intact, the patient will likely be able to avoid lifelong anticoagulation therapy (blood thinning medication).