Minimally Invasive Cardiac Surgery

What is minimally invasive cardiac surgery?

Minimally invasive cardiac surgery uses small chest incisions and thoracoscopic instruments to gain access to the heart. In contrast, traditional heart surgeries use a large cut in the chest to split the breastbone (also known as a sternotomy) to gain access to the heart.

As heart surgery techniques and technology improve over time, more conditions may be treated through minimally invasive surgery or keyhole surgery. This technique can help to reduce pain, scarring and enhances recovery while maintaining safety and efficacy.

Heart surgery at 80: Why Mr Chua opted for a keyhole bypass

What are the minimally invasive cardiac surgeries available at our hospitals?

Examples include:

• Minimally invasive mitral valve repair or replacement, which can relieve symptoms of mitral regurgitation or stenosis. The surgery can be done through a small thoracotomy or via camera (endoscopically).
• Minimally invasive aortic valve replacement, which treats aortic valve narrowing or regurgitation, reduces symptoms and preserves the function of your heart muscle. The surgery can be done – in qualifying patients – through a tiny cut on the side of the chest, by using a specialised camera.
• Coronary artery bypass surgery (for single or multiple vessels grafting), which can be a hybrid procedure combined with stents. This surgical procedure bypasses blocked heart arteries to restore normal blood flow to the heart muscle.
• Congenital heart diseases such as atrial septal defects (ASD) and ventricular septal defects (VSD) can also be repaired via incisions on the side, sparing the traditional sternal split.
• Heart tumour removals. Atrial myxomas, fibroelastomas and other growth in the heart can now be removed in a speedy procedure through a very small cut on the side of the chest, with or without camera.
• Certain redo cases can also be addressed in a minimally invasive fashion.

Compared to open heart surgery, the benefits of MICS include:

• Faster recovery
• Less pain and scarring
• Reduced physical and psychological trauma
• Better cosmesis
• Ability to resume most of your usual activities more quickly (usually within 2 – 4 weeks)
• Earlier discharge from the hospital (usually in 3 – 4 days)
• Better early lung function
• Less risk for infections and bleeding

Who should not undergo minimally invasive cardiac surgery?

Most patients assessed in Mount Elizabeth's heart programme, informed by the expertise of Prof Theodoros Kofidis, are suitable candidates for minimally invasive heart surgery. Our team performs a broad range of procedures across the heart-surgery spectrum with proven outcomes.

Some patients may not be suitable for minimally invasive or endoscopic approaches due to anatomical or clinical considerations. In selected cases, certain procedures can also be performed on a beating heart, depending on what is safest and most appropriate for the individual.

To determine whether you are a candidate for minimally invasive heart surgery, your doctor is likely to:

• Review your medical history
• Conduct a physical examination
• Perform tests (such as imaging tests, laboratory tests, pulmonary function tests and cardiac evaluation)

Your doctor and treatment team will work with you to determine the best option to treat your condition.

What are the risks and complications of minimally invasive cardiac surgery?

Minimally invasive heart surgery carries advantages over open-heart surgery. These include:

• Less risk for bleeding
• Less risk for infection
• Less risk for irregular heart rhythms (arrhythmias)*
• Same risk for stroke
• Same risk for death

If your surgeon thinks it is not safe to continue with the minimally invasive heart surgery approach, your procedure may need to be changed to open-heart surgery.

How do you prepare for minimally invasive cardiac surgery?

Before your surgery, your doctor will:

• Bring you through the surgical procedures of minimally invasive heart surgery
• Explain the potential risks
• Discuss any concerns you may have
• Talk about any advance directives or other information to consider prior to your surgery

In general, you may feel free to ask for your doctor’s experience and outcomes in any field of interest. Your preoperative preparation may involve some cleaning and shaving of the areas to be addressed. Your skin may be washed with special soap to reduce the risk of infection.

Before admission for your surgery, talk to your family about your hospital stay and discuss the help you might need when you return home. Your doctor and treatment team will give you instructions to follow during your recovery when you return home.

Food and medications

Talk to your doctor about:

• When you should stop eating or drinking the night before the surgery
• When you can take your regular medications and whether you can take them before your surgery
• Medications you have brought to the hospital and when you should take medications on the day of the procedure
• Allergies or reactions you have had to medications

Clothing and personal items

You may want to pack the following items for your hospital stay:

• A list of your medications
• Spectacles, hearing aids or dentures
• Personal care items, such as a brush, comb, shaving equipment and toothbrush
• Loose-fitting, comfortable clothing
• A copy of your advance medical directive
• Items that might help you relax, such as a portable music player or books

During surgery, avoid wearing:

• Contact lenses
• Dentures
• Jewellery
• Nail polish
• Spectacles

What can you expect in minimally invasive cardiac surgery?

In all types of minimally invasive cardiac procedures, your surgeon will reach your heart through small incisions. These incisions can be located at various sites, such as between the ribs of your chest, groin or armpit.

Your surgeon will insert a tool with a small video camera through one of the incisions to provide a magnified, three-dimensional image of the operating site.

Most minimally invasive procedures use a heart-lung bypass machine (same as in open heart surgery), but the access is different, in that we would not be touching the chest bone. The machine keeps blood moving through your body during the procedure.

Robot-assisted heart surgery

In robot-assisted heart surgery, your surgeon uses robotic arms to perform the manoeuvres used in traditional open-heart surgery.

During this procedure, your surgeon works at a remote console and views your heart in a magnified high-definition 3D view on a video monitor. From the console, your surgeon's hand movements translate precisely to the robotic arms at the operating table, which moves similarly to the human wrist.

A second surgeon and surgical team will assist at the operating table, changing surgical instruments attached to the robotic arms.

Thoracoscopic surgery

In thoracoscopic surgery (sometimes referred to as a mini-thoracotomy), your surgeon inserts a long, thin tube (thoracoscope) containing a tiny high-definition video camera into a small incision in your chest.

Your surgeon repairs your heart using long instruments inserted through small incisions between your ribs.

Hybrid approach

If you have:

• Ischaemic heart disease, some coronary arteries may be more suitably dealt with by angioplasty and stenting.
• Cardiac valvular disease coupled with coronary artery disease, you may have to undergo a full sternotomy using standard methods to fix both the valve and coronary artery stenosis.
• Multiple coronary artery disease can be treated in a minimally invasive or hybrid fashion in our programme. Our minimally invasive heart surgeon and his team will explore – together with you- an option that suits your needs.

Your doctor will assess and develop a treatment plan customised to your cardiac condition.

After the procedure

You will generally spend a day or so in the intensive care unit (ICU). You will be given fluids and medications through intravenous (IV) lines. Other tubes placed during surgery will drain urine from your bladder and fluid and blood from your chest. You might be given oxygen through a face mask or prongs in your nose.

Usually, MICS leads to shorter ventilation times and shorter stay in the ICU, as well as faster mobilisation in the hospital.

After the ICU, you will be moved to a regular hospital room for several days. The time you spend in the ICU and hospital will depend on your condition and surgery.

Your treatment team will:

• Monitor your condition and watch for signs of infection at your incision sites
• Monitor your blood pressure, breathing and heart rate
• Work with you to manage any pain
• Encourage you to get up and walk, and demonstrate how to gradually increase your activity
• Show you how to do deep-breathing exercises, including how to cough to clear your lungs

Care and recovery after minimally invasive cardiac surgery

Your doctor will give you instructions to follow during your recovery, such as:

• Watching for signs of infection in your incisions
• Caring for your incisions
• Taking medications
• Managing pain

Your doctor will let you know when you can return to daily activities, such as working, driving and exercise.

Do attend regular follow-up appointments with your doctor. You may be asked to do several tests to evaluate and monitor your condition.

As part of your recovery, your doctor may advise you to incorporate healthy lifestyle changes into your life — such as physical activity, a healthy diet, stress management and avoiding tobacco use.

Your doctor may also recommend that you participate in cardiac rehabilitation to help you improve your health and recovery after heart surgery.