New high-tech CABG saves money, reduces lengths of stay

Experts urge caution

Two patients who recently underwent minimally invasive direct coronary artery bypass grafting (MIDCABG) procedures were discharged much earlier than if their surgery had been performed using the traditional open-chest method. One patient was on his way in 21¼2 days; the other in three. In each case, lengths of stay would have been at least a week if new technologies weren’t available.

Adding to the savings from decreased stay is the fact that MIDCABG patients can sometimes skip the intensive care unit entirely. The best case scenario is for them to go to the recovery room following surgery and then go to a step-down unit. Aside from money matters, the innovative surgical procedure saves pain, trauma, scarring, and recovery time. Whereas "cracking the chest" can typically leave a patient recovering for two to three months, patients who undergo the methods involving small incisions return to normal activities within two weeks.

In 1995, before the new technology was available, Medicare patients spent, on average, 10 to 12 days in the hospital following their bypass surgeries. One- and two-vessel grafts cost $18,000 in those days, and three-vessel surgery ran $20,000.1 In contrast, the average cost of a minimally invasive surgery today is $10,000 — 40% to 50% less.

MIDCABG is coronary bypass surgery done without sternotomy, cardiopulmonary bypass, or cardioplegia. The anastomosis is done by direct vision on the heart and by a small incision and a pedicled arterial conduit. Cases done with a hemi-sternotomy for bilateral grafting, small lateral thoracotomy, or thoracoscopic assistance for harvesting of the internal mammary conduit would also be considered MIDCABG procedures. Video-assisted anastomotic techniques do not fall under the definition.

"We’ve only been doing the minimally invasive surgery since December of 1996," says Phil Rogers, RN, CCRN, case manager for cardiovascular surgery at Owen Heart Center, Mission Hospital in Asheville, NC. "An observation is, however, that the intraoperative cost of the procedure is a bit higher or about the same as a conventional sternotomy coronary bypass." That’s because the new procedure is more labor-intensive intraoperatively. (See nursing care protocol, p. 119.) "The cost savings come postsurgery," Rogers adds. "The patients go home sooner, so they are not consuming resources of the intensive care unit as traditional patients do. Sternotomy patients stay in the hospital longer, then often come back with sternotomy wound infections." He points out that savings are global because patients return to work quicker.

A recent study from the University of Pittsburgh Medical Center compared outcomes of the minimally invasive and standard procedures.2 Seventeen MIDCABG patients were compared with 33 patients with left ventricular ejection fraction greater than 0.50 who underwent the standard surgery. No significant differences existed between the two groups for preoperative variables that are known to affect cost and resource utilization. Patients undergoing new procedures stayed in the hospital for an average of 21¼2 days as compared with the six days spent by those undergoing the traditional surgery. Length of stay in the intensive care unit averaged 12.3 hours for MIDCABG patients and 32.3 hours for traditional coronary artery bypass grafting (CABG) patients. Fifty-nine percent of MIDCABG patients were sent home on the first or second postoperative day. Total ratio of cost-to-charge was $12,885 +/- $1,511 for MIDCABG and $21,260 +/- $5,497 for CABG. The average savings was $8,375. In addition, fewer patients from the MIDCABG group died.

A second study compared hospital stay and cost for CABG, MIDCABG, and angioplasty with similar results: The MIDCABG procedure was determined clearly cost-effective.3

5- and 6-vessel CABGs

The two patients who went home quickly had their operations this past July. Their surgeons, one in Odessa, TX, and one in Asheville, NC, performed their complex multi-vessel heart bypass surgeries using Heartport’s Port-Access system.

Sudhir Srivastava, MD, practicing at Medical Center Hospital in Odessa, successfully performed the first five-vessel CABG using the minimally invasive system. His 63-year-old patient was discharged three days following surgery. Mark A. Groh, MD, did the first minimally invasive six-vessel CABG at Memorial Mission Hospital in Asheville. Groh’s 43-year-old patient went home 21¼2 days after her operation.

Srivastava performed the operation through a 41¼2 inch incision or "port" on the side of the chest between the ribs — significantly smaller than the 12- to 15-inch sternum split required for traditional open-heart surgery. The surgeon was able to bypass five blocked heart arteries using the same techniques he would have used in an open-heart procedure — two saphenous vein grafts and one radial artery graft attached directly to the aorta. As is customary in conventional heart surgery, the patient’s heart was stopped and then supported by cardiopulmonary bypass (heart-lung machine). Surgeons could then manipulate the heart to reach the front, sides, and back to re-establish blood flow to all major vascular beds.

Groh performed his operation through two ports, each less than two inches long. In addition to the techniques Srivastava used, Groh used both the right and left internal mammary arteries to bypass blockages.

Over the past several months, surgeons at more than 200 hospitals nationwide have begun using new high-tech, patient-friendly methods to replace clogged arteries and repair faulty valves. In addition to Groh’s and Srivastava’s facilities, Cleveland Clinic in Ohio; Duke University Medical Center in Durham, NC; Johns Hopkins Hospital in Baltimore; Indiana Heart Institute in Indianapolis; Cedars Sinai Medical Center in Los Angeles; and Lenox Hill Hospital in New York City all offer at least one of the new procedures. Some surgeons operate on beating, others on non-beating hearts. (See related story on the beating vs. non-beating controversy, p. 120.)

But is the minimally invasive concept moving too fast for its own good? Some experts say that once they take hold, the techniques will fundamentally change the clinical and economic landscape of open-heart surgery. Groh is among those who are optimistic about the procedures, especially the nonbeating-heart technique. He says that as surgeons gain more experience using the technology, they can apply it to an ever-widening spectrum of patients who several months ago wouldn’t be considered candidates for surgery, including those with complex coronary artery disease, congenital defects, and a variety of heart valve problems.

"We don’t have actual cost data yet," Groh says, "nor a large enough patient sample, but we do see a trend toward shorter hospital stays, fewer unscheduled postoperative visits, and a quicker return to work. As experience with the procedure mounts, costs are coming in lower, and operative times are shortening. It looks encouraging."

Groh’s team has performed about 130 Port-Access procedures so far this year. "The system essentially allows us to perform the same sort of operation as the conventional method, but with a less traumatic, less painful incision. It utilizes the best of what has been learned about stopped-heart protection over the last forty years. The important thing is that we’re operating on a still heart — that enables us to do multiple bypasses and valve procedures." (See Groh’s clinical pathway for the Port-Access procedure, inserted in this issue.)

Others are not so optimistic about MIDCABG. Ten million open-chest operations were performed over the past 25 years, and the mortality rate has been 4% or lower at most of the 900 medical centers performing the traditional method. Repairs have lasted 15 years or more in 90% of patients. Will the new minimally invasive techniques sacrifice long-term benefits for short-term gains of reduced hospital stays, less pain, and faster recovery? The potential for serious complications remains with MIDCABG, and the American Heart Association has cautioned that the surge of interest is rushing ahead of scientific data. Because the lion’s share of the cost of a hospital stay accumulates during the first two days, is reducing the length of stay really contributing to cost-effectiveness? The numbers gathered so far say "Yes," but bottom-line evidence is not yet in.

References

1. Center for Healthcare Industry Performance Studies, Columbus, OH.

2. Zenati M, Donit TM, Saul M, et al. Resource utilization for minimally invasive direct and standard coronary artery bypass grafting. Ann Thorac Surg 1997; 63:S84-S87.

3. King RC, Reece TB, Hurst JL, et al. Minimally invasive coronary artery bypass grafting decreases hospital stay and cost. Ann Surg 1997; 225:805-809.

Suggested Reading

Acuff TE, Landreneau RJ, Griffith BP, et al. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1997; 61:135-137.

Landreneau RJ, Mack MJ, Magovern JA, et al. ‘Keyhole’ coronary artery bypass surgery. Ann Surg 1996; 224:453-459.

Ovrum E, Tangen G,. Am Holen E. Facing the era of minimally invasive coronary grafting. Ann Thorac Surg 1997; 64:159-162.

Subramanian VA. Less invasive arterial CABG on a beating heart. Ann Thorac Surg 1997; 63:S68-S71.

Tellides G, Maragh MR, Smith JM, et al. Minimally invasive coronary artery bypass grafting. Conn Med 1997; 61:135-141.

Vaca KJ, Daake CJ, Lambrechts DS. Nursing care of patients undergoing thoracoscopic minimally invasive bypass grafting. Am J Crit Care 1997; 6:281-286.