Beating heart bypass dramatically cuts hospital costs and patient trauma
Beating heart bypass dramatically cuts hospital costs and patient trauma
It was just performed successfully here on a 90-year-old woman’
It may look like a sewing machine pressure foot on a stick, but this new disposable instrument and accompanying minimally invasive bypass procedure can cut hospital costs by 44% and dramatically reduce patient trauma, thus decreasing length of stay and recovery time. The secrets to the device’s success so far are that it allows surgeons to create a near motionless graft site on a still beating heart, and it eliminates the need for a heart-and-lung machine.
Called MIDCAB, short for minimally invasive direct coronary artery bypass, the procedure could potentially standardize minimally invasive bypass surgery nationwide because it dramatically reduces hospital cost and patient trauma, say leading cardiac surgeons who have performed the procedure. While the procedure is relatively new and more surgeries need to be done to fully explore its potential, surgeons say it has tremendous potential for some common cases.
"MIDCAB is creating a revolution in how we treat certain heart diseases," says Paul Corso, MD, FACS, FACC, director of cardiac surgery and MIDCAB instructor at Washington (DC) Hospital Center, a 907-bed tertiary acute care facility. "More importantly, it is the best and simplest way to provide a consistent surgery in the hands of the largest number of surgeons."
Washington Hospital Center is the first of six U.S. and international training centers to initiate a comprehensive theoretical and practical instruction curriculum for hospitals establish- ing a MIDCAB program. This COR Training Program, held in December, was sponsored in conjunction with the instruments’ developer, CardioThoracic Systems of Cupertino, CA.
Other leading hospitals are lining up to be at the forefront of this technology. Cardiac surgeons at Columbia/HCA’s 95 cardiac surgery centers are undergoing similar training and creating a clinical patient registry database to track both short- and long-term results and document the cost-effectiveness of the MIDCAB approach.
"With Columbia providing access to training for our affiliated surgeons in this new method of cardiac surgery, physicians will be able to offer this alternative to traditional open heart surgery to their patients much earlier than many other open heart programs," says Jamie Hopping, president of Columbia’s Western Group location.
Less trauma, improved outcomes
Although only 500 such procedures have been performed nationwide, cardiac surgeons are quick to point out that managed care organizations will likely look to this technology as a standard of care because of its lower procedural costs, reduction in postoperative complications, and decreased hospital stays.
Compared to CABG, for example, MIDCAB takes half the time, costs about half the price, and requires an average hospital stay of only two to three days vs. 10 days.
"We looked at patients who had undergone MIDCAB as well as CABG patients specifically those with DRG 107 over a three-month period," says Joy Drass, MD, MBA, vice president of professional services and clinical care resource manager. "Then we eliminated any who had been in the hospital for 30 days or more because we wanted to get a conservative look at the cost savings."
Drass found that the average cost per discharge for MIDCAB was 56% of traditional bypass. "That was variable cost only supplies, nursing not redistribution of hospital overhead."
The nursing cost was 65% lower because of the reduced length of stay, she adds.
"The main thing is that with MIDCAB, you eliminate the need for a heart-lung machine, so you also dramatically reduce the related complications" says Mercedes Dullum, MD, FACS, FACC, a senior attending surgeon and MIDCAB instructor at Washington Hospital Center. "This translates into lower operating and intensive care costs as well as reduced length of stays not to mention less trauma for the patient."
About 30% of CABG surgeries are associated with complications. The heart-lung machine is a contributing factor in 70% of those complications associated with traditional extracorporeal circulation, including stroke, multiple organ dysfunction, respiratory complications, inflammatory and internal bleeding complications, and respiratory failure.
Moreover, most patients recuperate in 10 to 14 days compared to six to eight weeks for traditional CABG. "That may not be a direct cost savings to the hospital, but it’s very important to patients," Dullum points out.
Tools of the bypass trade
Although a handful of highly skilled cardiothoracic surgeons worldwide have performed the MIDCAB procedure without specialized tools, the development and commercialization of the new instruments will bring these significant advantages of minimally invasive bypass surgery to a broader patient population, predicts Dullum.
The proprietary system of disposable instruments cost about $1,500, and the instruments particularly the access platform and stabilizer facilitate the procedure, she says.
After making a 3- to 4-inch horizontal incision between the fourth and fifth rib, surgeons insert the access platform to create an operating window in the chest cavity. (MIDCAB is not to be confused with another minimally invasive technique known as "keyhole" in which surgeons use the same size incision, as well as two or three more port holes but perform the procedure on a stopped heart, necessitating the use of a heart-lung machine.)
The instrument allows optimal exposure to the surface of the beating heart and provides a secure base for attachment of the stabilizer. Once the second instrument is properly positioned and locked in place, the surgeon applies light pressure to the myocardium and isolates the diseased artery. "This creates a near motionless graft site and minimizes the motion of the artery," Dullum says.
Then, the IMA retractor and the access platform provide the surgeon with a direct view of the operation site. The surgeon takes an internal mammary artery, which is then grafted onto the heart’s left anterior descending artery or the right coronary artery.
The whole procedure takes about two hours, compared to about four hours with CABG. The patients are extubated in the operating room, then transferred to the intensive care unit for only a few hours.
Dullum points out the advantages of MIDCAB are that it can be done on patients who are not amenable to angioplasty, patients who need a second bypass, patients with multi-vessel disease, as well as those who are high risk for CABG because of comorbidities or other factors such as age.
"It was just performed successfully here on a 90-year-old woman," Dullum notes.
Some disadvantages exist
Are there any disadvantages? Yes, Dullum says.
"Although some surgeons are working with different incisions, the current incision only allows access to the anterior portion of the heart," she says. "But the procedure is perfectly suited to bypass the left descending artery, the artery that shuts down during fatal heart attacks."
This artery is bypassed in about 50% to 80% of CABGs, Dullum adds.
Other potential disadvantages at this time include the relatively small number of surgeries performed and lack of long-term studies on how the procedure compares with existing CABG technology. Those are the questions surgeons expect to answer with more experience as the procedure gains wider application.
Currently, about 20% of bypass surgeries could be addressed through the MIDCAB procedure. "But this number is expanding very rapidly as we discover new applications," Dullum says.
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