Coronary Artery Bypass Grafting (CABG)
CABG, or bypass surgery, is the most common type of heart operation. This procedure is designed to treat atherosclerosis (blockages) of the coronary arteries, to eliminate symptoms (angina, chest pain, shortness of breath), prevent myocardial infarction (heart attack), and ultimately minimize the risk of dying from cardiac disease. The CABG operation is performed by dividing the sternum (breastbone). Then, a vein from the leg (saphenous vein), artery from the chest wall (internal mammary artery) and/or arm (radial artery) are sewn onto the coronary arteries downstream from the blockages. This effectively reroutes the flow of blood around the blockages to nourish the previously oxygen-deprived heart muscle. The terms single-, double-, triple-bypass, etc. refer to the total number of coronary arteries bypassed, and varies considerably from patient to patient. Our surgeons perform minimally invasive harvesting of the saphenous vein to facilitate leg healing. In addition, they utilize multiple arterial grafts as much as feasible to facilitate long-term patient outcomes.
What is off-pump CABG?
Off-pump CABG, or OPCAB, is a specific type of coronary bypass operation in which the heart-lung machine is not used and the heart continues to beat throughout the procedure. Specialized equipment is used to stabilize the heart motion during each bypass graft. There are select circumstances in which it is preferable to perform OPCAB surgery. Our surgeons are facile in all OPCAB techniques and employ this approach whenever it will benefit our patients.
The function of the four heart valves (aortic, mitral, tricuspid, and pulmonic) is to maintain unrestricted blood flow in a forward direction. When a valve becomes diseased, two things may happen; the valve may become too tight and restrict the passage of blood through it (stenosis), or, the valve may not close properly so that blood leaks in a backward direction (regurgitation or insufficiency). If either of these situations is severe, surgical repair of the valve or replacement with a new valve is required. Sometimes more than one valve is diseased, such that multiple valves may need to be repaired or replaced during the same operation. Repair of a heart valve involves a variety of techniques designed to alleviate stenosis and/or correct regurgitation. When possible this is much preferred over replacement. Our surgeons are skilled in performing all of the state-of-the-art techniques for repair of any of the four heart valves. However, when the valve becomes so severely damaged that repair is impossible, outright replacement of the valve is necessary.
What are the different types of heart valves that can be used for replacement?
In general, there are 2 kinds of valves used for heart valve replacement. Each type has advantages and disadvantages. Biological valves, or tissue valves, are made from animal or human tissue. In general, tissue valves do not require long-term anticoagulation (blood thinning medication). However, in young individuals these valves may have limited durability and thus may need to be re-replaced. Mechanical valves are made from metal compounds such as stainless steel or pyrolytic carbon. They have great durability and will not wear out in your lifetime. They do, however, require lifelong anticoagulation with blood thinning medication, and regular blood tests to monitor such. Without this medication, blood clots will form on these valves. Our surgeons implant only those valves with the best track record in terms of safety, durability, and performance. Should you need a valve replacement, you and your surgeon will decide which is the best valve replacement option for you.
Surgical Treatment for Atrial Fibrillation
Atrial fibrillation is the most common disturbance of the heart's normal rhythm, affecting nearly 2 million Americans. This arrhythmia accounts for a significant number of strokes and heart failures each year. Our surgeons have been performing surgical procedures to treat atrial fibrillation since the early 1990s (the Cox-maze procedure). Currently, they use a state-of-the-art technique known as bipolar radiofrequency ablation (RFA) to abolish the irregular rhythm and restore the heart to its normal rhythm. Long-term results with this technique in terms of freedom from atrial fibrillation are on par with the best centers in the country.
Radio frequency ablation (RFA) is an adjunctive surgical treatment that can be used for patients with any history of atrial fibrillation. While the heart is accessible for an open heart surgery procedure, the surgeon uses a catheter with an electrode on the tip to perform the ablation. Radiofrequency energy is transmitted to the site of the heart muscle where the cells are giving off the electrical signal that has the abnormal heart rhythm. This radiofrequency “burn” destroys carefully selected heart muscle in a very small area, which will stop the area from conducting extra impulses that are causing the rapid heartbeats or atrial fibrillation.
Aortic Aneurysm Repair
An aneurysm is a balloon-like enlargement of the aorta which, when it becomes large enough, may rupture and cause sudden death. Repair of a thoracic aortic aneurysm is recommended when the aneurysm reaches a size that the risk of rupture becomes significant. The surgeons in our practice have performed traditional surgical repair of all types of thoracic aortic aneurysms for over 20 years. This open approach involves an incision in the chest to replace the diseased portion of the aorta with a synthetic tube (graft). Recently, our practice has begun using a minimally invasive technique called endovascular stent grafting to treat select aneurysms. The procedure involves making only a small incision in the groin or lower abdomen. The operative mortality of this approach is much lower than the open surgical approach, and is attended by a shorter hospital stay and faster return to work. Thoracic aortic stent grafting is especially suited to elderly and sicker patients who may otherwise be considered too high risk for traditional open repair. Lancaster General Hospital remains the only hospital in Lancaster County to offer this cutting edge technique for treatment of thoracic aortic aneurysms.
Surgery for Congestive Heart Failure
What is congestive heart failure?
Congestive heart failure (CHF) is a debilitating illness which currently afflicts nearly 5 million Americans. This condition results when the pumping action of the heart is insufficient to meet the needs of the rest of the body, resulting in congestion of the lungs and body tissues with fluid. There are numerous causes of CHF, but the most common are lack of blood supply to the heart muscle due to coronary artery blockages (ischemic cardiomyopathy) and disease of the heart valves.
What are the surgical treatments for CHF?
There are a variety of surgical options for treating CHF with which the surgeons in our practice have vast experience. Isolated coronary artery bypass grafting (see above) in a patient with a very sick heart muscle due to coronary artery disease is one such treatment. An increasingly common clinical scenario which our surgeons face is one of a patient with multiple coronary artery blockages, an enlarged and poorly functioning heart, and a leaky mitral valve, all of which are linked to poor blood supply to the heart muscle. These abnormalities conspire to create a "vicious cycle" in which the heart continues to enlarge and weaken, and results in profound heart failure or even death. Combined coronary artery bypass grafting and mitral valve repair is the surgical solution to this difficult entity, and is now one of the most common cardiac operations performed by Lancaster General Health Physicians Cardiothoracic Surgery. Despite the very high risk nature of this procedure, our outstanding results have been consistently superior to state and national standards. The "safety net" afforded by our newly established ventricular assist device program (see below) has allowed our surgeons to perform the highest risk operations on the sickest of hearts right here in Lancaster, rather than transferring such patients to a tertiary care university hospital for their surgery.
What is SVR?
Certain patients who suffer from CHF as a result of a previous heart attack involving the front wall of the heart may benefit from a specialized operation know as surgical ventricular restoration (SVR). This operation involves remodeling of the heart to exclude damaged areas and make the heart beat more efficiently. Although SVR is a relatively new addition to the cardiac surgical armamentarium, our surgeons have been offering this operation since the mid-1990s. The SVR procedure is commonly performed in conjunction with coronary artery bypass grafting and mitral valve repair.
What is a ventricular assist device?
A ventricular assist device (VAD) is a type of mechanical, artificial heart which supports the failing left and/or right ventricle(s) of the heart. This device is essentially a mechanical pumping chamber which substitutes for the inadequate pumping action of the patient’s own ventricle. Our practice has offered a VAD program since 2005 and has been highly productive and successful in using such a device in a variety of clinical scenarios. First, as mentioned above, the VAD can serve as a “safety net” if, after the performance of a high risk conventional cardiac operation (such as CABG or valve surgery), the patient’s own heart remains too weak to support his or her own circulation. In this circumstance the VAD is implanted in an effort to rest the heart for a few days or weeks until it recovers and the device can then be removed (bridge to recovery). In other circumstances we have implanted the VAD in an emergent setting when patients have arrived at the hospital in cardiogenic shock from a massive heart attack or viral infection of the heart muscle (acute myocarditis). In most situations the VAD has supported such patients until they are able to undergo heart transplantation (bridge to transplantation). Since 1995 we have used the Thoratec paracorporeal ventricular assist device for temporary (weeks to months) support of the failing left and/or right ventricle(s). More recently we have also acquired the Heartmate XVE device for longer term support of the diseased left ventricle. This pumping chamber is implanted completely within the body, allowing for longer term support (months to years) and even discharge of the patient to his or her own home.