Q&A: Minimally invasive CABG transforming cardiac surgery
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Like other specialties in medicine, cardiology has seen an influx in interest in less invasive therapeutic options.
The rise of coronary intervention as a nonsurgical treatment for CAD is one of the foremost examples, but even its surgical counterpart has been getting increasingly less invasive over the years. Developed in 2005, minimally invasive CABG (MICS CABG) offers surgeons the ability to perform revascularization without either a sternotomy or, in most cases, cardiopulmonary bypass. Compared with regular CABG, one study found similar perioperative outcomes with MICS CABG, whereas a second reported improved 5-year survival in older patients with the minimally invasive approach.
However, despite these advances and the promising results, the vast majority of CABG procedures performed today rely on the techniques developed a half century ago.
“Right now, almost 90% of the coronary bypasses performed in the United States are done the same way they’ve been done for the past 50 years,” Joseph T. McGinn Jr., MD, chief of cardiac surgery at Miami Cardiac and Vascular Institute, told Healio. “Only around 10% are performed using advanced techniques.”
McGinn Jr., who developed the MICS CABG procedure, spoke with Healio about the impediments to widespread usage, along with the catalysts, recent advances and more.
Healio: What factors drove the development of the MICS CABG procedure?
McGinn Jr.: The first driver was I was seeing a lot of patients who were too high risk for traditional surgery. These patients did poorly with the big incision, and I thought they could recover more quickly if we developed a minimally invasive platform that obviated the need for the traditional incision.
No. 2, as I developed in the world of medicine, I watched fields around me evolve to a point where nearly every specialty had some sort of a minimally invasive surgical approach. Of course, the heart is a unique and complex organ, and it requires a lot of skill and dexterity even when there is a big incision and the heart is stopped. So I knew the challenge would be tremendous and the learning curve long, but I felt that if every other field could do this, we were obligated to figure out a way in cardiology.
Healio: What are the chief distinctions between minimally invasive CABG and traditional bypass surgery?
McGinn Jr.: The most important one is that the sternum is divided in traditional surgery. In most people, this is a painful incision. It also requires a tremendous amount of energy and inflammation to heal it, which causes complications and side effects. The incision that we make for the minimally invasive approach is nominal. Patients heal easily. I haven’t seen a single infection in these incisions because they’re so well tolerated and patients get back to normal activity much quicker. The other big difference is that I don’t ever stop the heart with minimally invasive surgery.
Healio: Who is the ideal candidate for this minimally invasive approach?
McGinn Jr.: I’d like to reverse that question and say who is not the ideal candidate because almost everybody is an ideal candidate. Right now, I’m using the minimally invasive technique in about 97% to 98% of my cases, so my crude answer would be everyone’s a candidate.
I would note, however, that there are relative contraindications. One of them is morbid obesity. With this procedure, you’re bringing the artery to a small incision on the side of the chest, and then you use regular instruments to create the anastomosis. If the target you’re bypassing is now 3 inches further away because of a thick fat pad, this reduces dexterity, which you need to create anastomoses.
But that’s not to say I don’t operate on people who are morbidly obese, because I do; I feel they’re very disabled people to begin with and making a big incision on the chest adds to that disability significantly. So I try to figure out a solution to perform minimally invasive surgery on these patients.
Another relative contraindication is diffuse coronary disease to a point where I’m not certain where I’m going to be able to bypass the arteries or how many I’m going to be able to do. That obviously doesn’t happen too often. It’s just a handful of patients per year who are not candidates for this procedure.
Healio: What have been some of the challenges to widespread adoption of this procedure?
McGinn Jr.: The biggest one is the learning curve, which is long. Many surgeons are busy and aren’t willing to take time out of their practice to learn how to do this. But we are gaining traction. The COVID-19 pandemic definitely set back our educational and training programs, and we are currently reinitiating them. Before the pandemic, I would have surgeons from around the globe watch the cases, and then we’d have sessions, videos, models and demonstrations on how to do the surgery. So we’re going to start that up again, and hopefully get more traction and widespread use of the procedure.
Healio: What have been some of the recent advancements to MICS CABG?
McGinn Jr.: I’m always evolving the procedure, and right now I’m creating an all-arterial solution. Veins don’t last anywhere near as long as the arteries that live inside the chest wall — the right and left internal mammary arteries. The radial artery in the arm can also be used. And with arteries, the future is unknown because they’re so durable that they could last 20 or 25 years. With the help of engineers and partners, I am trying to figure out how we can use this approach on more and more patients.
Healio: Where do you see the field of MICS CABG heading in the future?
McGinn Jr.: I lecture around the world on this and tell the audiences, which are almost always surgeons, that if they cannot do this procedure in the next 5 or 10 years, they’ll be out of business. This field is evolving just like every other field of medicine because our skills and equipment have changed over the last couple of decades.
As an example, I’ll often mention the gallbladder. Back in the late 1980s and early 1990s, someone decided to remove the gallbladder through three small holes in the abdominal wall. Everybody thought this was crazy. Then sometime during the late ’90s, the laparoscopic approach proved to be better for the patient. Now you would never find anyone who had a gallbladder removed through a standard incision.
So, we’re 16 years into the evolution of MICS CABG and are now at an inflection point. I believe we’ll start seeing this technology being used more readily, and I wouldn’t be surprised if, in the next 10 years, this becomes the standard approach to coronary artery bypass surgery.
References:
- Barsoum EA, et al. Eur J Cardiothorac Surg. 2015;doi:10.1093/ejcts/ezu267.
- McGinn JT Jr, et al. Circulation. 2009;doi:10.1161/CIRCULATIONAHA.108.840041.
- Teman NR, et al. Ann Thorac Surg. 2020;doi:10.1016/j.athoracsur.2020.06.136.
For more information:
Joseph T. McGinn Jr., MD, can be reached at 6200 Southwest 72nd St., Suite 604, South Miami, FL 33143; Twitter: @bypasstheordnry.
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