Beating-Heart Surgery an Option for Bypass

Jul. 26–The heart-lung machine, which made coronary artery bypass surgery practical when it came into use in 1953, is no longer a prerequisite for the operation.

Improved technology is allowing more doctors to perform the procedure without using a heart-lung machine. Dr. Alfred Casale of Geisinger Wyoming Valley Medical Center’s Heart Hospital said that performing “beating-heart” bypass surgery or “off-pump” surgery may make the procedure safer, which is good news to high-risk patients who need bypass surgery.

“Even that small, additional stress the heart-lung machine can provide could throw them over the edge,” Casale said. “With the patients who are the sickest, avoiding the extra trauma of using the heart-lung machine could make a difference.”

Casale was careful to emphasize two facts: first, bypass surgery done with the heart-lung machine is considered very safe and has a very low morbidity rate; and second, that tests to confirm that bypass surgery without using the heart-lung machine is safer are still under way. That said, he pointed out that beating-heart bypass surgery didn’t add additional risks for patients, and preliminary evidence suggests it may lower some risk factors.

National figures from the Society of Thoracic Surgeons said that 21 percent of bypass surgeries done nationally were performed off-pump, Casale said. He added that Geisinger Wyoming Valley’s Heart Hospital performs most coronary artery bypass surgeries without the heart-lung machine.

“The heart-lung machine causes every organ in the body, not to fail, but to notice that something is not right,” Casale said. “Most organs notice and ignore it. Some people who are really high-risk, if you have something already failing, that additional risk is something you are unwilling to undertake.”

Doing a beating-heart coronary artery bypass without a heart-lung machine is more difficult than doing it with one, Casale said. What makes the off-pump procedure more attractive, he said, is the benefits it can have for the patient.

In the beating heart procedure, doctors attach a suction cup to the bottom of the heart.

“When you put the suction cup on the apex of the heart,” said Dr. Deepak Singh, also of Geisinger Wyoming Valley’s Heart Hospital, “then you can actually move the heart around.”

To perform a graft, doctors use two rows of smaller suction cups. The device has four suction cups on each side, and as a result is called “the octopus.” It stabilizes the area of the heart where the doctor needs to perform work.

“The rest of the heart beats,” Singh said. “It is just the one area that is stabilized.”

The beating-heart coronary artery bypass has actually been around for 40 years, according to Internet sources. It was developed in 1965 by a Russian cardiac surgeon named Vassily Ivanovich Kolessov and was compared to cutting a gemstone while on horseback. The development of instrumentation in the mid-1990s to stabilize a small area of the heart made the procedure practical.

“Nobody was anxious to accept this without proof that it was working, because the standard conventional operation with the heart-lung machine was very safe,” Casale said. “You don’t start screwing around with something novel and jeopardizing these good results.”

The heart-lung machine is still needed for people who need valve surgery on their heart. Not using the machine for coronary artery bypass, Casale said, appears to have a number of advantages:

–Patients use less blood during the procedure, reducing the need for transfusions. “It is the difference of thinking of blood like oil or gas in your car,” Casale said. “We used to think of it like oil. If you were down a quart, you put in a quart. These days we think of it more like gas. If you have enough to get where you are going, you’re OK. You don’t want to subject the patient to even a small additional risk.”

–Patients tend to be released from the hospital sooner, and return to work sooner.

–There is less chance of a stroke, heart attack or the failure of other organs. “We know now that a lot of the morbidity associated with bypass operations is associated with being on the heart-lung machine,” Singh said. “It’s not normal for the entire blood stream to be in contact with a plastic surface.

“Your blood goes through this loop of plastic twice a minute” when on the heart-lung machine, Casale said. “Even though the technology has gotten remarkably good, we don’t trivialize the chance this can cause mischief.”

–There is less neurological compromise. These short-term changes include memory loss, difficulty thinking clearly and problems concentrating for lengthy periods. “It looks like there is a trend to be less neurological damage and less body organ dysfunction from off-pump surgery,” Casale said. “That is going to require large, randomized studies that are under way, and it will take several years to determine if it is less stressful on the body.”

Casale, though, said he and other Geisinger doctors don’t go into each coronary artery bypass surgery with the goal of doing it off-pump.

“You don’t compromise doing the right operation and doing it perfectly,” Casale said. “The whole idea is to not do anything more than you need to do.

“We hate calling this minimally invasive surgery. We focus on doing things in a minimally stressful way.”

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