A heartbeat away? MIDCABG debate emerges
A heartbeat away? MIDCABG debate emerges
Patient’s need ultimately calls shots
You’ve probably noticed the "beating heart-arrested heart" controversy simmering among cardiac surgeons and staff. It centers on whether minimally invasive direct coronary artery bypass grafting (MIDCABG) a stopped heart is more effective than performing the procedures on a beating heart. A lot depends on the patient’s condition and prognosis, or course, but there is some crossover, and the debate is one that won’t go away soon. Proponents of beating heart revascularization say the procedure is less expensive than the non-beating variety. Opponents say working on a beating heart limits the surgeons’ options to one- and two-vessel procedures, and the number of patients who are candidates is small.
The fact is, either method the surgeon chooses, money is saved over the more invasive, traditional sternotomy coronary artery bypass grafting. But will any cost-savings generated by shortened lengths of stay and quick recoveries following new minimally invasive cardiac procedures beating or arrested be eaten up by increased equipment costs?
In discussing the the various systems that enable procedures on a beating heart, Mark A. Groh, MD, a heart surgeon at Memorial Mission Hospital in Asheville, NC, notes, "What bothered us about the beating-heart procedure is that it limits the surgeon to one- or two-vessel bypasses, and we typically don’t see patients that just need one or two. We needed a system that would open the door for multivessel bypasses. Because we’re able to deal with a number of different problems rather than just single-vessel bypasses, the non-beating heart method is more applicable to our population."
The beating heart devices eliminate the need for routing blood through a heart-lung machine and lessen the need for anti-clotting agents. While procedures are limited to the anterior side of the heart a disadvantage proponents of the beating heart systems point out that key vessels in the anterior region (the left anterior descending artery and right circumflex artery) provide most of the blood flow to the heart. Critics point out that only single- and double-vessel bypasses can be done and may result in inferior long-term patency in the grafted vessels. Single-vessel grafts account for only 5% to 10% of all CABGs performed today, and double-vessel grafts account for only 15% to 20%.
Some surgeons are skeptical that joining tiny blood vessels on the surface of the heart can be done successfully while the heart is beating, even if it is immobilized. As it is, the surgeon peers through magnifying goggles as he performs the delicate task of joining a replacement vessel to a coronary artery using a tiny needle and a barely visible suture.
Up until new equipment became available, some surgeons had been performing minimally invasive CABGs using instruments already available to them. "The minimally invasive program doesn’t have to be expensive," says Janis Richmond, RN, CNOR, a cardiovascular-thoracic specialist in the cardiac OR at Washington Adventist Hospital in Takoma Park, MD. "We performed our first beating-heart procedures with no initial capital outlay. We used the instrumentation we already had. CardioThoracic’s MIDCAB kit contains an item that looks like the foot on a sewing machine. It’s used to stabilize the heart; then the surgeon sews between the two sections." Richmond’s team uses a right-angle clamp fitted with rubber to accomplish the same effect. A physician’s assistant holds it in place.
New and improved’
Now, companies are rushing to provide "new, improved" devices at a price. The use of the new equipment depends upon the type and progression of the patient’s disease but fall into two categories: those used to perform surgery on beating hearts and those used for procedures on non-beating hearts.
• Non-beating equipment. Heartport Inc., in Redwood City, CA, has developed a $5,000 per case kit of instruments used to stop the heart while performing bypass surgery or repairing defective valves. Port-Access system includes a device that inserts a balloon into the aorta, inflates it, then injects potassium and other agents. The Port-Access system has been criticized as adding complexity and expense to the traditional procedure. The patient still requires a heart-lung machine, critics say, all just to make a smaller incision. The kit has been used in 500 cases so far. (See story about new drug to reduce heart-lung complication, at left.)
• Beating equipment. CardioThoracic Systems Inc., in Cupertino, CA; Medtronic in Minneapolis, MN; and U.S. Surgical in Norwalk, CT, market devices that, at under $2,000 an operation, enable surgeons to perform bypasses on beating hearts, avoiding the need to put patients on a heart-lung machine. Going "on the pump" can add upward of $2,300 to the cost of each bypass operation. Included in CardioThoracic’s MIDCAB kit is a device resembling a bent, two-pronged fork that presses down on the heart to stabilize the area. Nine hundred patients underwent surgery using the CardioThoracic devices during the first quarter of 1997. The Medtronic Octopus technique uses suction cups to accomplish the same thing at a cost of $788 for a single-vessel graft and $1,559 for multiple grafts. U.S. Surgical’s system costs between $500 and $1,000.
Those three companies and HeartPort provide training programs where surgeons learn the new techniques in two to three days.
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