Minimally invasive cardiac surgery – a success story for the NHS

Toufan Bahrami
By Toufan Bahrami     11/12/2018

I began my career working on complex heart procedures and transplants –  by definition, one of the most invasive and radical kinds of surgery there is.

Minimally-invasive surgery, by contrast, is done by making tiny incisions instead of one large chest opening. It’s been performed since the mid-90s. This kind of surgery, also known as ‘keyhole’ surgery, has the advantage of quicker recovery times and less discomfort for patients, as well as less risk of infection — all with the same benefits. Since its development, I have had a strong interest in all the advantages it can offer.

It’s an exciting and fast-moving area of cardiac surgery, which research indicates gives better results than conventional methods.

Royal Brompton & Harefield NHS Foundation Trust – and Harefield in particular – has been at the forefront of minimally invasive techniques, such as aortic and mitral valve repair surgery and replacement.

Since 2002, I have found myself focusing on minimally invasive surgery. During this time, I pioneered and developed several new techniques including minimally invasive coronary artery bypass, mitral tricuspid valve repair, aortic valve replacement and endoscopic surgery for atrial fibrillation.

Other cardiothoracic surgical centres in UK have started performing minimally invasive cardiac surgery over the last five years, usually either mitral or aortic valve surgery.

However, at Harefield Hospital my team and I offer a comprehensive minimally invasive programme that includes coronary bypass, valve repair and replacement and surgery for arrhythmia. We routinely perform a wide range of these procedures – and have done so for the past 15 years.

To give a few examples, we started with the coronary artery bypass graft (CABG) in 2002, aortic valve replacement in 2003 and endoscopic vein and artery harvesting (EVH) – a technique where healthy veins from the leg are removed to be used in bypass procedures – in 2006. Mitral and tricuspid valve repair followed in 2008 and septal myectomy – a surgical procedure used to thin thickened heart muscle obstructing the flow of blood – in 2015.

In 2018, we performed the world first minimally invasive mitral valve, aortic valve and CABG – all in the same operation.

Recently, I added another minimally invasive procedure – radiofrequency ablation, which uses radiofrequency energy to destroy a small area of heart tissue that is causing rapid and irregular heartbeats and restores your heart's regular rhythm – without having to open the chest.

Our centre is one of the highest volume centres in minimally invasive cardiac surgery in the UK, with excellent surgical outcomes and fantastic feedback from patients. For example, Harefield Hospital’s success rate for mitral valve repair rate remains at over 98% for degenerative valve repair.

I believe we perform more minimally invasive cardiac procedures than anywhere else in the UK.

Why minimally invasive?

I am passionate about these new techniques. Evidence indicating the effectiveness of minimally invasive surgery has been published in many international publications.

Research has shown these procedures are safe, when they are performed regularly by surgeons who are experienced in these techniques. Benefits include a shorter hospital stay and less bleeding, so less likelihood of a transfusion being required. Patients also experience a reduced risk of wound infection, better recovery following their surgery and often less pain. And, of course, they also have much smaller scars too.

Although minimally invasive procedures may not have a huge reduction on how long patients spend recovering in hospital following their surgery, the patients and the cardiologists caring for them certainly notice the difference afterwards.

They are more energetic, able to do more and feel better, faster, compared to those who have undergone conventional surgery. They can walk further, take up their hobbies more quickly, become active and return to work faster. This is far better compared to patients who have had conventional open-heart surgery.

A significant advantage of these new vanguard of minimally invasive treatments, many of which use heart valves made from animal tissue rather than the conventional mechanical valves, is patients do not need to take blood thinning drugs for the rest of their lives.

Warfarin and other similar medications can be problematic for patients. For example, if they need further surgery, they will require infusions of other medications to counter the thinning effects of the drug.

In everyday life, a knock or accident could become more serious than it needs to be, which can limit the hobbies and activities that people choose to pursue, and warfarin is also unsuitable for those wishing to become pregnant. With the newest techniques and technologies, this risk is removed and patients have more freedom.

Generally, in terms of considering patients for minimally invasive surgery, I don’t just think of it in terms of age, but of overall fitness, suitability for the procedure and, of course, people’s wishes. But you don’t have to be young – I operate on patients in their 80s and 90s – the results are usually very good.

Beating heart surgery

An innovation which has gone hand in hand with less invasive techniques is beating heart, or ‘off pump’ coronary surgery, which was developed in the 1990s and introduced at Harefield Hospital in September 1996.

The heart remains beating, removing the need to stop the heart during the procedure. This technology allows the surgeon to stabilise part of the heart and operate on the congested arteries.

This technique is useful for patients with conditions such as diabetes, severe atherosclerosis (where plaque blocks the arteries), carotid artery stenosis (where the important carotid arteries which supply blood to the brain, neck, and face become narrowed) or a history of stroke. Beating heart surgery is associated with reductions in mortality, bleeding, and stroke, less risk of neurological damage or other complications to heart rhythm, kidneys, or liver.

Minimally invasive mitral valve repair

The mitral valve is a small flap in the heart that stops blood flowing the wrong way. When it gets leaky, it can cause shortness and breath and fatigue – and in some cases, heart failure; a leaky mitral valve can have a big impact on quality of life and life expectancy. The UK has the lowest rate of mitral valve repair compared to other similar countries in Europe and the USA.

Classically, the mitral valve is repaired by making a cut of between 20 to 25 centimetres through the breast bone. When I repair the mitral valve using minimally invasive techniques, I make a
five-centimetre incision on the right side of the chest, opening up the space up between the ribs in order to see the heart. 

Using a high-definition video camera, this allows me to have an excellent viewpoint.

In terms of risks, statistically there is 0.05 per cent chance of a stroke, and a mortality risk of less than 2 per cent – and the promise of an excellent long-term outcome.

Minimally invasive aortic valve replacement

Aortic valve replacement may be required due to narrowing, or regurgitation where the valve doesn’t close properly.  In a healthy heart, the aortic valve regulates the flow of oxygen-rich blood from the heart into the main blood vessel. The aortic valve is made up of three triangular-shaped flaps which fit neatly together.

The flaps open up to allow blood to enter into the artery, which then close to prevent regurgitation. However, the valve may wear out or become caked in calcium deposits rendering it inefficient.

The heart has to work harder to pump blood around the body. Symptoms resulting include chest pains, breathlessness and fainting – if untreated, it could lead to heart failure and death.

Traditionally, mechanical valves have been used to replace worn out aortic valves – but, of course, this is invasive surgery and patients will need to take warfarin for the rest of their lives.  New technologies such as the Inspiris Resilia valve are also providing great results for patients. The indications are that it will last longer than other animal tissue valves, which – although have advantages over mechanical valves – need to be replaced every eight to ten years.

It’s made from tissue from cow pericardium (the heart lining) and it uses new anti-calcification technology which prevents the valve becoming stiff and damaged, meaning it lasts a lot longer.

The new Edwards Intuity valve, which is also made from cow tissue, has all of these advantages too. It doesn’t need stitches as it’s held in place by a fibrous ring at the base of where the original valve was. The new valve is fixed to a stent (tube-like mesh) made of stainless steel which holds it under the fibrous ring.

These new technologies are game-changers, as they last for longer than previous animal tissue valves.

CABG and endoscopic vein harvesting

In coronary artery bypass surgery, coronary arteries with blockages or that have become narrowed are replaced with veins, usually from the patient’s leg. One end of it is attached to where the main artery that supplies blood to the body leaves the heart. The other end is connected below the blocked or narrowed part of your coronary artery. The blood bypasses the blockage or narrowing and so improves blood supply to the heart.

The CABG procedure can be performed by either using a cardiopulmonary bypass machine or on a beating heart.

Conventional vein harvesting from the leg brings with it problems, such as risk of infection at the site and significant scarring to the leg itself.

I was the first surgeon in the UK to routinely use endoscopic vein harvest (EVH), introducing it to Harefield just over ten years ago.  This enables the vein to be removed using a small
one-centimetre incision, rather than a cut of about a metre. The vein extracted is then used as a graft in exactly the same way.

At Harefield, 100 per cent of CABGs are performed this way. This has resulted in less pain for patients, shorter hospital stays and significantly improved patient satisfaction. Our research shows we have cut the rate of infection using the EVH method to only two per cent compared to up to 20 per cent with conventional methods. We have performed nearly 7,000 procedures – making us one of the busiest and most experienced centres in Europe.

What next?

Heart surgeons are performing more and more procedures that are less invasive; on the other hand, interventional cardiologists are undertaking more procedures in the catheter lab.

It strikes me that heart surgeons and cardiologists may be about to meet in the middle.

Patients recovering faster with fewer complications mean healthier people, being able to live active lives for longer.

This is something on which you cannot put a price.