Willie Croswell was a strong man with a delicate heart. For more than 10 years, the former Jersey City Public Works employee grappled with ischemic heart disease, undergoing several catheterization and angioplasty procedures to open blocked arteries.

On February 28, 2000, Mr. Croswell collapsed at home and was taken to a local hospital. Ultimately, another catheterization was attempted, but without success. Now a candidate for triple bypass surgery, the 61-year-old man was transferred to University Hospital.

"My doctor was confident that everything was going to be okay," recalls Mr. Croswell. "I woke up from the operation and thanked God I was still alive. The next day, the nurse took me for a walk, and then I knew everything was fine. I was no longer suffering from the severe pain I used to have."

Unfortunately, people suffering like Mr. Croswell aren't new to the New Jersey Cardiovascular Institute (NJCI), where minimally invasive coronary artery bypass surgeries are routinely performed. Many patients referred to NJCI, for a variety of reasons, are not prime candidates for bypass operations using the heart-lung machine. "They might have lung disease or a great amount of calcification in the heart," says Dr. Barry Esrig, chief of the division of cardiothoracic surgery at University Hospital, associate professor of surgery at New Jersey Medical School, and assistant clinical professor of surgery at Columbia University. "These are patients who are high risk from the perspective of stopping a weak heart that might not be able to be restarted."

Dr. Esrig is one of the cardiac surgeons at University Hospital's New Jersey Cardiovascular Institute (NJCI) who performs what is known collectively as minimally invasive cardiac surgery, although there are two different procedures: Off-pump coronary artery bypass (OPCAB) and minimally invasive direct coronary artery bypass (MIDCAB).

To understand how these newer surgeries work, it's helpful to know how most bypass procedures have been done. For more than 30 years, coronary artery bypass grafting (CABG) has been the gold standard procedure for patients with severe coronary heart disease (CHD). In this "traditional" surgery, an 8"-12" incision is made to open the chest, and the patient is placed on a heart-lung machine that takes over the body's breathing and blood circulation functions while his or her own heart is stopped. The surgeon then grafts an artery or vein, typically taken from the patient's arm or thigh, onto the heart, creating a detour for blood to flow through. CABG has been a life-saving procedure for many patients, says Dr. Esrig. The use of the heart-lung machine carries the higher risk of post-operative stroke and other neurologic complications especially cognitive deterioration in addition to increased chance of kidney failure, and requirement for blood transfusion, and pulmonary complications requiring longer ICU stay. This difference is particularly magnified in the management of very high-risk patients where the life saving potential of the off pump revascularization becomes evident. This was the subject of a recent presentation from our institution presented at the International Society of Minimally Invasive Cardiac Surgery (ISMICS) in Munich,Germany. (To read more about risks of the heart-lung machine, click here.)

Advances in Minimally Invasive Cardiac Surgery

Among surgeons in all specialties, there's been a movement toward minimally invasive procedures. These surgeries generally feature a smaller incision, less pain, a shorter hospital stay, and a faster recovery time than the traditional "open" procedures.

While some types of heart operations are not conducive to off-pump techniques, coronary bypass is. "The arteries are on the heart's surface, so the surgeon doesn't need to gain access to inside the cardiac chambers," says Dr. Esrig. Using mechanical stabilizers, the skilled surgeon can immobilize the small area of the heart where the bypass graft should be placed without interfering with the natural pumping action of the heart. With MIDCAB, which is designed for single vessel bypass, the operation is performed through a smaller incision while in OPCAB, multiple bypasses are performed through the standard incision. The benefits are typically a smaller scar and a hospital stay of 4 to 5 days, as compared with 5 to 7 days for a traditional CABG. With both MIDCAB and OPCAB, the primary benefit is avoiding the need for a heart-lung machine and its associated complications. Edward Minson, who had triple bypass, says he has difficulty finding where the doctor made the incision. "If it wasn't for a slight bulge where I have my pacemaker, I couldn't find the incision."

Surgeons are able to operate on a beating heart and perform the coronary bypass. "We can stabilize the small area of the heart while we are working on while the rest of the heart keeps pumping blood through the body. With today's off-pump technique, all of the coronary arteries can be by-passed without difficulty," says Dr. Esrig.

When OPCAB first was developed, questions were raised about its efficacy: Does it do the job of revascularization as well as CABG? Today, a decade later, the answer appears to be yes. "So far, OPCAB appears to have the same durable result as the traditional technique [CABG], but with less
stress on the body," says Dr. Esrig.

Yet, there are times when off-pump or "beating heart" bypass is not the best choice for the patient. Each case must be decided individually, but in general, says Dr. Esrig, when a younger patient has small vessels and needs a multiple bypass or when it's believed that the patient's heart will not tolerate being moved about, it may be preferable to use the traditional CABG technique.

And when OPCAB is being performed at University Hospital, there is always a heart-lung machine available to the surgeon, should a change in operating strategy become necessary. "We're like a defensive team, never sure what the circumstances will bring, yet very good at adapting to what comes
our way," says Dr. Esrig.

In minimally invasive heart surgery for valvular disease, where the use of the heart and lung machine cannot be avoided, the focus is on the smaller size of the incision and its functional and cosmetic advantage. Adapted application heart and lung machine through the peripheral vessels and the use of special balloon tipped catheters, the heart can be stopped and the operation can be performed through a small incision using direct or endoscopic techniques.

What's Best for the Patient

Society teaches us from an early age, primarily through advertising, that "new" and "improved" are always better. But that line of thinking doesn't necessarily hold true when it comes to medicine. The most desirable treatment is the one that offers the best potential outcome with the least risk to the patient.

"The missed opportunity comes when the technique doesn't match the patient's needs," says Dr. Esrig. "At NJCI, we have a robust 'tool box' available to treat cardiac patients, and doctors who are highly skilled at selecting and using the right 'tools.' We are very focused on using the least invasive technique whenever possible."

There is no "one size fits all" approach to treating patients with CHD. For some people, medicines such as statins, beta-blockers, nitrates, or aspirin and other platelet inhibitors, combined with an exercise program, dietary changes, and smoking cessation, can be quite effective. In more advanced cases of CHD, as arteries "harden," balloon catheterization or stents may be used to open the blocked passageways. And, for the most severe cases, coronary bypass–whether by the CABG, OPCAB, or MIDCAB technique–may be necessary.

NJCI doctors seek the least invasive treatment possible–with possible being the key word. "We don't see patients as having suffered if they have not been able to have their bypass done off pump," says Dr. Esrig. "Quite simply, we don't do minimally invasive surgery for the sake of doing so. We seek what is safest and best for the patient."

For more information on minimally invasive cardiac surgery, and other cardiovascular health services, visit the NJCI Web site: www.TheUniversityHospital.com/njci