Minimally Invasive Cardiac Surgery
What is minimally invasive cardiac surgery?
Most cardiac operations today are performed through a sternotomy, which involves splitting the entire breastbone. Minimally invasive cardiac surgery encompasses a variety of operations performed through incisions that are substantially smaller and less traumatic than the standard sternotomy. Minimally invasive incisions measure about 3 to 4 inches compared to 8 to 10 sternotomy incisions. Specialized handheld and robotic instruments are used to project the dexterity of the surgeon’s hands through these small incisions in performing the operations.
What are the benefits of minimally-invasive cardiac surgery?
Minimally invasive surgery confers many advantages over standard approaches derived largely from the reduced trauma to the chest wall tissues. The benefits of minimally invasive cardiac surgery include:
- Smaller incisions
- Smaller scars
- Reduced infection risk
- Less blood loss
- Less pain
- Shorter hospital stays. Stays after minimally invasive operations are from 3 to 5 days compared to 5 to 7 days for traditional sternotomy-based cardiac operations.
- Fewer physical restrictions. Patients undergoing standard incision cardiac operations are restricted from driving an automobile or lifting objects weighing more than 5 pounds while patients undergoing minimally invasive cardiac surgery are not subject to these restrictions
- Shorter recovery time. Recovery times after minimally invasive operations are from 2 to 4 weeks compared to 6 to 8 weeks for standard sternotomy-based cardiac operations.
What minimally invasive cardiac operations does Johns Hopkins offer?
The Johns Hopkins Minimally-Invasive Cardiac Surgical Program, under the direction of Dr. David Yuh, currently offers the following operations using a minimally-invasive approach:
- Mitral Valve Repair
- Patent Foramen Ovale Closure
- Atrial Septal Defect Closure
- Biventricular epicardial pacing lead placement
- Surgical Radiofrequency Ablation for atrial fibrillation
Is minimally invasive surgery the right choice for me?
If you would like to find out if you are a candidate for minimally invasive cardiac surgery or if you would like more information regarding this approach, please contact us at (410) 955-9780 Monday through Friday 8:30 AM to 5:00 PM EST.
Minimally-Invasive Cardiac Valve Operations
Minimally-Invasive Mitral Valve Repair and Replacement
What is the mitral valve?
The mitral valve is a one-way valve comprised of two leaflets that conducts blood flow through the left side of the heart. When open, the mitral valve permits oxygenated blood from the lungs to fill the heart’s main pumping chamber, the left ventricle. When the left ventricle squeezes to deliver blood throughout the body, the mitral valve normally closes to prevent blood from flowing back toward the lungs.
What is mitral regurgitation or insufficiency?
Mitral regurgitation or insufficiency is a condition whereby the mitral valve permits blood from the left ventricle to leak back towards the lungs. Mitral regurgitation is most often caused by congenital malformation or damage due to trauma, infection, or heart failure. Depending on the severity of the leakage, this situation can lead to progressive lung congestion and heart failure. Symptoms commonly include shortness of breath, decreased exercise endurance, and swelling of the extremities.
How is mitral regurgitation treated?
The severity of mitral insufficiency can sometimes be reduced with medications, however the most definitive treatment involves surgical repair of the valve or replacement with a prosthetic valve.
In many cases, the mitral valve can be repaired by reconstructing the native valve tissues to restore normal valvular structure and function. In fact, the mitral valve is the most commonly repaired heart valve. Experimental and clinical research has shown that repair of the mitral valve is preferable to its replacement largely because native mitral valve is an intimately associated with the structure of the left ventricle. In cases when repair of the mitral valve cannot be performed successfully, Mitral valve replacement is another option. Mitral valve replacement involves removing much of the native mitral valve tissues and replacing it with an artificial valve consisting of animal and/or manufactured components.
How is the mitral valve repaired?
Many repair techniques have been developed for the mitral valve. The method chosen for any particular valve depends largely on the anatomic abnormality that has caused the valve to leak. One of the most common disease of the mitral valve is known as mitral valve prolapse. In this condition one or both of the mitral valve leaflets swings too far backwards during each heartbeat such that the leaflets do not close properly, allowing blood to leak between them. Repair techniques for this condition attempt to reestablish proper closing of the mitral leaflets by cutting out extra leaflet tissue, fixating the two prolapsing leaflets together, replacing or adjusting the valve suspension mechanism, and placing a prosthetic strut around the valve. All repairs require the use of cardiopulmonary bypass, otherwise known as “the heart-lung machine.” This permits the surgeon to safely open the left atrium and access the mitral valve in a relatively bloodless field. In most cases, the heart is also stopped for 1 to 2 hours to facilitate the repair. Repairs range from relatively simple operations to very complex intricate procedures. The total duration of the operation ranges from 3 to 5 hours.
Link: Mitral Valve Repair Techniques
Repair of the mitral valve is generally preferred over its replacement for several important reasons. Repairing the valve preserves the natural geometry and attachments of the left ventricle which permits it to function efficiently. This is most relevant in patients with abnormal heart function. Furthermore, patients with mechanical prosthetic valves must take a blood thinning drug known as coumadin or warfarin for the rest of their lives. Besides being somewhat of a nuisance, this confers a small risk of bleeding complications.
Although most mitral valves can be repaired with the properly selected techniques, some valves cannot and must therefore be replaced with a prosthetic valve. It is generally believed that mitral repairs are quite durable; approximately 10% to 15% of patients undergoing mitral repair require a reoperation for a failed repair later in life.
What are minimally invasive approaches to the mitral valve?
The most common surgical approach to the mitral valve requires the surgeon to saw open the breastbone and spread the edges apart to gain direct access to the heart. Although this approach provides excellent access to the heart, the resulting wound requires several months to heal completely, an extended recovery period with substantial activity restrictions, and can be subject to serious complications including infection, breakdown, and even death.
Mini-Mitral Repair
Currently at The Johns Hopkins Hospital, the most commonly employed minimally invasive approach to the mitral valve is a “mini-thoracotomy” which consists of a 3 inch incision made through the right side of the chest between the ribs. Heart-lung bypass is instituted with small tubes placed in the main artery and vein of the right leg through a 1 to 2 inch incision placed in the right groin crease. The heart is then stopped and the left atrium is opened to expose the mitral valve. At this point, specialized hand-held “chopstick” like instruments are inserted through this small incision by the surgeon to repair the valve. After the valve is repaired, it is tested. The heart is then closed and restarted. Finally, heart-lung bypass is discontinued and the incisions are closed.
Robotic Mitral Repair
Another approach which is also sometimes used at our center utilizes a surgical robotic system instead of the hand-operated instruments to perform the repair. Manufactured by Intuitive Surgical, Inc., based in Sunnyvale, California, the da Vinci robotic system is currently the most technologically advanced surgical robotic system in the world and is designed to perform complex operations through incisions that are much smaller and less traumatic than those used with traditional surgical approaches.
The first robot-assisted cardiac operation at Johns Hopkins Hospital, performed in June 2003 by Drs. David D. Yuh, consisted of successfully placing a biventricular pacemaker lead on a beating heart. Shortlly thereafter, Dr. Yuh performed the first robot-assisted open heart operation consisting of a mitral valve repair. Dr. Yuh has assembled a team of dedicated staff fully trained in using the da Vinci robot to perform minimally invasive robotic cardiac procedures and is prepared to offer several carefully selected cardiac procedures to patients desiring a minimally-invasive approach. These operations currently include mitral valve repair, atrial septal defect closure, and biventricular epicardial pacing lead placement.
The da Vinci robotic system is comprised of four principal components: a surgeon console, a computerized control system, two instrument "arms," and a fiberoptic camera. The surgeon sits at the console and views the heart in three-dimensions through the InSiteTM fiberoptic stereoscopic camera system while manipulating the instinctive operating controls.The surgeon's hand motions are relayed to a computer processor, which digitizes and relays them to the fine instrument tips placed into the chest cavity through small 1 cm port incisions. This computerized robotic system enhances the surgeon's ability to perform minimally invasive cardiac surgery in several ways. First, the computer interface permits the accurate translation of the surgeon's hand motions to a dexterous endoscopic "wrist" (EndoWristTM) placed within the chest cavity, conferring much higher degrees of freedom and precision than could be achieved with traditional hand-operated instruments. Second, the da Vinci's advanced two-camera stereoscopic optics provides unprecedented magnified, high-definition, full-color images of the heart and its structures in three-dimensions. This visualization provides much greater detail of the heart than is generally possible with the surgeon's eye.
Operating room setup for robot-assisted operations. The surgeon is seated at the master concole at the left.
da Vinci master console showing viewfinder and controls.
da Vinci surgial robotic system positioned over a patient.
Magnified view of da Vinci instrument tip (actual diameter approximately 1 centimeter). Each instrument possesses dexterity similar to that of a human wrist.
Minimally-Invasive Aortic Valve Replacement
What is the aortic valve?
The aortic valve is a one-way valve comprised of three leaflets that conducts blood flow from the main pumping chamber of your heart, the left ventricle, into the largest artery in your body, the aorta, which conducts blood throughout the rest of your body. When the left ventricle squeezes blood into the aorta, the aortic valve normally closes to prevent blood from flowing back into the left ventricle. Diseases of the aortic valve are functionally classified into those that cause the valve to leak, known as aortic regurgitation or insufficiency, and those that narrow its opening, known as aortic stenosis. These processes are caused by congenital malformations or acquired diseases including infection, degeneration and calcification, aortic aneurysms, tumors, and radiation.
What is aortic regurgitation or insufficiency?
Aortic regurgitation or insufficiency is a condition whereby the aortic valve permits blood ejected from the left ventricle to leak back into the left ventricle. Aortic regurgitation is most often caused by damage to the aortic valve from a recent infection (e.g., dental abscess), dilation of the aorta, and rheumatic heart disease. Depending on the severity of the leakage, this situation can lead to progressive lung congestion and congestive heart failure. Symptoms commonly include shortness of breath, decreased exercise endurance, and swelling of the extremities.
What is aortic stenosis?
Aortic stenosis is a condition whereby the leaflets of the aortic valve become abnormally rigid such that they do not open fully, causing narrowing of the valve. This narrowing presents significant resistance against the main pumping action of the left ventricle as it tries to eject blood throughout the body. Aortic stenosis is most often caused by degeneration with age whereby calcium is deposited on the valve leaflets rendering them stiff. Congenital malformation of the valve where by two of the three leaflets are fused into one, known as a “bicuspid” aortic valve, predisposes the valve to early calcific degeneration. Depending on the severity of the valve narrowing, this situation can lead to progressive lung congestion and heart failure. Signs and symptoms commonly include shortness of breath, chest pain/heaviness, fainting/lightheadedness, decreased exercise endurance, and swelling of the extremities.
How are aortic stenosis and regurgitation treated?
The severity of aortic insufficiency can sometimes be reduced with medications, but aortic stenosis has no effective medical therapy. For both conditions, the most definitive treatment involves surgical replacement of the valve with a prosthetic valve. Timely surgery is advised since significant delay can lead to irreversible congestive heart failure.
In many cases, the mitral valve can be repaired by reconstructing the native valve tissues to restore normal valvular structure and function. In fact, the mitral valve is the most commonly repaired heart valve. Experimental and clinical research has shown that repair of the mitral valve is preferable to its replacement largely because native mitral valve is an intimately associated with the structure of the left ventricle. In cases when repair of the mitral valve cannot be performed successfully, Mitral valve replacement is another option. Mitral valve replacement involves removing much of the native mitral valve tissues and replacing it with an artificial valve consisting of animal and/or manufactured components.
How is the aortic valve replaced?
Aortic valve replacements require the use of cardiopulmonary bypass, otherwise known as “the heart-lung machine.” This permits the surgeon to safely open the aorta and access the aortic valve in a bloodless field. In most cases, the heart is also stopped for about 1 hour to facilitate the replacement. The operation involves opening of the aorta and removal of the diseased aortic valve leaflets. Commonly, calcifications around the valve must also be removed carefully. The resulting valve ring or “annulus” is then measured to select the size of the valve prosthetic. A series of sutures are then placed around the valve annulus and subsequently through the prosthetic valve. The Valve is then lowered into the annulus and secured. The aorta is closed and the heart restarted. The total duration of the operation ranges from 2 to 3 hours.
There are two major types of aortic valve prostheses: mechanical and tissue. Mechanical prosthetic valves have lifelong durability, however a blood thinning drug known as coumadin or warfarin must be taken for the rest of the patient’s life to prevent blood clots from forming on the hinges of the valve. Besides being somewhat of a nuisance, this confers a small risk of bleeding complications. Tissue or “bioprosthetic” valves are made of either cow (bovine) or pig (porcine) tissue. Because they are made of organic materials, no blood thinning drugs must be taken, however they have a finite lifespan ranging from 15 to 20 years. Selection of the valve type depends on a variety of factors including the patient’s age, occupation, lifestyle, medical history, and preferences. This decision is made in close consultation with the surgeon.
What are minimally invasive approaches to the aortic valve?
The most common surgical approach to the aortic valve requires the surgeon to saw open the breastbone and spread the edges apart to gain direct access to the heart. Although this approach provides excellent access to the heart, the resulting wound requires several months to heal completely, an extended recovery period with substantial activity restrictions, and can be subject to serious complications including infection, breakdown, and even death.
Mini-Aortic Replacement
Currently at The Johns Hopkins Hospital, the most commonly employed minimally invasive approach to the aortic valve is a “mini-sternotomy” which consists of a 4 to 5 inch incision made through the upper portion of the chest, dividing only the upper portion of the breastbone. The conduct of the rest of the operation proceeds in the standard way described above.
Minimally-Invasive Atrial Septal Defect Closure
What is an atrial septal defect?
An atrial septal defect or ASD is an opening between the upper two chambers of the heart, known as the right atrium and the left atrium. A congenital heart defect, an ASD permits mixing of deoxygenated blood returning to the heart from the body (right atrium) and freshly oxygenated blood coming from the lungs (left atrium). The degree of mixing is largely related to the size of the defect and the relative pressures in each atrium. Early in life, blood from the left atrium preferentially moves into the right atrium, causing excessive blood to flow through the lungs. If this flow, otherwise known as “shunting” is significant enough, resistance to flow develops in the lung resulting in a gradual reversal of shunting of deoxygenated blood from the right atrium into the left atrium and subsequently through the body. This latter condition can lead to a condition called “cyanosis” whereby inadequately oxygenated blood is delivered to the body causing early fatigue and congestive heart failure.
How is an atrial septal defect treated?
Small atrial septal defects can often be followed conservatively without surgery, due to minimal shunting. Larger ASDs should be closed to prevent the late irreversible consequences of excessive left-to-right shunting. ASDs can be closed surgically by simply sewing them closed or, in the case of larger ASDs, placing a patch of the patient’s own tissue or synthetic material (e.g., Dacron) over it.
How is an atrial septal defect repaired?
ASD repairs require the use of cardiopulmonary bypass, otherwise known as “the heart-lung machine.” This permits the surgeon to safely open the right atrium and access the ASD in a relatively bloodless field. In some cases, the heart is also stopped for 1 to 2 hours to facilitate the repair. Repairs range from relatively simple operations to more complex procedures depending on the location, size, and characteristics of the ASD. The total duration of the operation ranges from 2 to 3 hours.
What are minimally invasive approaches to an atrial septal defect?
The most common surgical approach to the mitral valve requires the surgeon to saw open the breastbone and spread the edges apart to gain direct access to the heart. Although this approach provides excellent access to the heart, the resulting wound requires several months to heal completely, an extended recovery period with substantial activity restrictions, and can be subject to serious complications including infection, breakdown, and even death.
Mini-ASD Repair
Currently at The Johns Hopkins Hospital, the most commonly employed minimally invasive approach to ASDs is a “mini-thoracotomy” which consists of a 3 inch incision made through the right side of the chest between the ribs. Heart-lung bypass is instituted with small tubes placed in the main artery and vein of the right leg through a 1 to 2 inch incision placed in the right groin crease. The heart is then stopped and the right atrium is opened to expose the ASD. At this point, specialized hand-held “chopstick” like instruments are inserted through this small incision by the surgeon to repair the defect. After the defect is repaired, the heart is then closed and restarted. Finally, heart-lung bypass is discontinued and the incisions are closed.
Robotic ASD Repair
Another approach which is also sometimes used at our center utilizes a surgical robotic system instead of the hand-operated instruments to perform the repair. Manufactured by Intuitive Surgical, Inc., based in Sunnyvale, California, the da Vinci robotic system is currently the most technologically advanced surgical robotic system in the world and is designed to perform complex operations through incisions that are much smaller and less traumatic than those used with traditional surgical approaches.
The first robot-assisted cardiac operation at Johns Hopkins Hospital, performed in June 2003 by Drs. David D. Yuh, consisted of successfully placing a biventricular pacemaker lead on a beating heart. Shortlly thereafter, Dr. Yuh performed the first robot-assisted open heart operation consisting of a mitral valve repair. Dr. Yuh has assembled a team of dedicated staff fully trained in using the da Vinci robot to perform minimally invasive robotic cardiac procedures and is prepared to offer several carefully selected cardiac procedures to patients desiring a minimally-invasive approach. These operations currently include mitral valve repair, atrial septal defect closure, and biventricular epicardial pacing lead placement.
The da Vinci robotic system is comprised of four principal components: a surgeon console, a computerized control system, two instrument "arms," and a fiberoptic camera. The surgeon sits at the console and views the heart in three-dimensions through the InSiteTM fiberoptic stereoscopic camera system while manipulating the instinctive operating controls.The surgeon's hand motions are relayed to a computer processor, which digitizes and relays them to the fine instrument tips placed into the chest cavity through small 1 cm port incisions. This computerized robotic system enhances the surgeon's ability to perform minimally invasive cardiac surgery in several ways. First, the computer interface permits the accurate translation of the surgeon's hand motions to a dexterous endoscopic "wrist" (EndoWristTM) placed within the chest cavity, conferring much higher degrees of freedom and precision than could be achieved with traditional hand-operated instruments. Second, the da Vinci's advanced two-camera stereoscopic optics provides unprecedented magnified, high-definition, full-color images of the heart and its structures in three-dimensions. This visualization provides much greater detail of the heart than is generally possible with the surgeon's eye.
