Mrs Malliga, a 63-year old lady from Ambattur in Chennai, had been suffering from chest pain for the past six months. As her condition worsened and the chest pains increased, she was brought to Apollo Hospital Chennai, where she consulted with Dr. Mohammed M Yusuf, a cardiothoracic surgeon specializing in Minimally Invasive Cardiac Surgery and Dr Damodharan, Senior Consultant Cardiologist. Mrs Malliga complained of chest pain on minimal exertion. Her case history showed that she was diabetic and had slightly higher cholesterol levels than normal, two high-risk factors for heart disease.
An angiography revealed blocks in three major arteries that supply blood to the heart. Typically in such cases, an open-heart bypass surgery or stents would be indicated. Keeping the history of diabetes and cholesterol in mind, an open-heart bypass surgery was deemed the best treatment option. This procedure involves using a healthy blood vessel from another part of the body to allow blood to bypass the block in the vessel. For blocks in the left anterior descending artery, a healthy artery from the chest wall itself is preferred. However, for other less important arteries, surgeons may use veins from the leg as well.
“A bypass surgery is more effective for blocks in the major arteries, compared with stents. The majority of stents are beneficial for up to 5-10 years, after which blocks may reappear”, says Dr Yusuf. While the treatment outcome is excellent and mortality rates are extremely low in bypass surgeries, the procedure involves making a 6-8 inch long incision in the chest and cutting through the breastbone to access the heart, resulting in a considerably long recovery period that can last up to 4 months.
Recent advances in open-heart surgery techniques include minimally invasive approaches that require smaller incisions and offer faster recovery periods. Instead of the large 6-8 inch incision for the conventional bypass surgery, a smaller cut in the chest is sufficient for a minimally invasive procedure. This reduces morbidity and brings the recovery time to 2 weeks. Dr Yusuf and his medical team have been performing minimally invasive bypass surgeries for over a year with excellent results.
More recently, robotic assistance to perform the procedure has gained interest. Dr Yusuf and his team opted to conduct this minimally invasive operation using robotic assistance rather than the conventional approach. Two of the three major blood vessels of the patient were severely blocked and required bypass surgery. The blocks in other vessels could be treated with angiography stent insertion. Dr Yusuf’s team, therefore, decided on a 2-step approach. Under the guidance of Dr Frank Vanpraet, Director of Robotic and Minimally Invasive Cardiac Surgery, OLV Hospital, Aalst, Belgium, Dr Yusuf performed the minimally invasive coronary artery bypass grafting surgery using robotic assistance. In the second step, two days after the first surgery, Dr Damodharan performed angiography and drug-eluting stent insertion for the remaining blocks in Mrs Malliga’s coronary arteries. This was done with the assistance of a specialized intravascular ultrasound.
Robot-assisted minimally invasive coronary artery bypass grafting has several advantages, as it is the least invasive option among minimally invasive cardiac surgeries. This technique lowers the risk of complications such as stroke, excessive blood loss, and infection. Patients also have reduced pain, smaller scars and faster recovery periods and it is ideal for multivessel blocks. “Even though it is more expensive than conventional bypass surgeries, it should be recommended for young patients who would like to get back to work immediately and in high-risk patients with other comorbidities”, says Dr Yusuf. With our lifestyle changes, more and more young people are suffering from heart conditions and such quick recovery treatment approaches are likely to be more economical in the long run.
Robotic Minimally Invasive Hybrid Revascularization is already being performed in countries such as Japan, United Kingdom and the United States. However, this was the first instance of the minimally invasive approach with robotic assistance in India.
The multiple step approach used for Mrs Malliga showed excellent results as she was discharged in 48 hours after the procedure and has since returned to full normal activity. She will, of course, be regularly followed up to ensure that no new complications arise.