A review of recent advances in the field of cardiothoracic surgery.

1. Recent advances in cardiac surgery
-Dr. Prashant Mishra
Professor,
Cardiothoracic and Vascular Surgery
Dr Vaibhav Shah
Lecturer
Dr Kuntal Surana
Lecturer

2. Recent Advances in Cardiac Surgery
Demonstration of open heart
surgery 50 years ago
Robotic cardiac surgery in a
hybrid OT

3. Introduction
New and evolving technology has always guided cardiac surgeons.
• The development of new technology has always shaped and
driven the field of cardiac surgery, from the initial development
of cardiopulmonary bypass to advancements in cardioplegia, to
the development of mechanical and bio prosthetic valves, or to
current technological advancements aimed at minimizing the
invasiveness of surgical intervention.
• As patients continue to grow older and sicker, they will require
progressively more complex procedures and will simultaneously
demand less invasive treatments of their disease, leading to an
increase in the number of combined procedures performed and
the number of interventions necessary.
Recent advances include use of minimally invasive surgeries, trans
catheter interventions and mechanical circulatory support

4. Ischemic Heart Disease
• The burden of ischemic heart disease in our society is increasing
• Coronary artery bypass grafting remains one of the most commonly
performed major surgeries, with well-established symptomatic and
prognostic benefits in patients with multivessel and left main coronary
artery disease.
• Surgery has been necessary for the mechanical complications of
myocardial infarction including mitral regurgitation, ventricular septal
defect, or cardiac rupture
• Conventional and yet gold standard for coronary artery bypass grafting
surgery involves use of left internal mammary artery (LIMA) to LAD and
saphenous vein grafts to other coronary vessels.

5. Advances include:
OFF pump CABG/ beating heart - does not involve arresting the heart
1) Total arterial grafting – use of bilateral internal mammary artery ( in-situ) or LIMA-
RIMA-Y with/without radial artery giving maximal longevity of grafts thus delaying the
need for redo intervention/surgery as the number of young patients with ischemic
heart disease continues to rise in Indian subcontinent
2) Endoscopic conduit harvest- saphenous vein or radial artery
3) Minimally invasive (MICAS)- avoiding sternotomy and complications.
- Via left anterior thoracotomy
- TECAB- totally endoscopic CABG
- RADCAB- robotic assisted CABG

6. Conventional CABG Total arterial graft CABG

7. Valvular Heart Disease
• Many patients with severe aortic stenosis are untreated because they are deemed
too old, too frail, or have too many comorbidities to undergo conventional or
minimally invasive cardiac surgery for
• This led to introduction of trans catheter aortic valve replacement (TAVR) clinical
trials and subsequent approval of the devices for the treatment of aortic stenosis.
• Heart Teams: Cardiologists (both clinical and interventional) and cardiac surgeons
evaluate all high-risk patients as an integrated team in a joint clinic setting and
make a single joint recommendation after consideration of the individual needs of
the patient to continue medical therapy or be a candidate for a TAVR or surgical
aortic valve replacement procedure
• the interventional cardiologist and cardiac surgeon are both scrubbed and
perform the procedure together

8. Trans femoral TAVR
• TAVR

9. Trans femoral TAVR

10. • Conscious sedation instead of general anesthesia which avoids intubation,
trans esophageal echocardiography, and an obligate stay in the intensive
care unit.
• The goal is to reduce morbidity, length of hospitalization, and procedural
cost.
• The trans apical, trans aortic, and subclavian approaches remain options
when a femoral access is not possible.
• Tans apical TAVI

11. Mitral valve interventions
• Surgery remains the mainstay for treatment in primary MR, several technological
advances within the last decade have made trans catheter mitral valve
intervention (TMVR) increasingly feasible and safe in clinical practice.
• TMVR is a minimally invasive technique for treatment of symptomatic chronic
moderate-severe or severe (3 to 4+) MR in high risk patients
1. Edge-to-edge clip (Alfieri-type) repair (MitraClip)
2. Chordal replacement (NeoChord, Harpoon Cords) and
3. Trans catheter MV replacement (Sapien-XT)

12. Tricuspid valve interventions
• Trans catheter techniques to either repair or replace the tricuspid valve are a
burgeoning frontier in structural cardiac interventions.
• Current approaches include:
1. edge-to-edge repair,
2. cooptation enhancement,
3. annuloplasty,
4. heterotopic caval valve implantation, and
5. percutaneous tricuspid valve replacement.

13. • The use of trans catheter valves for valve-in-valve
positioning will become routine in the future
• to treat structural failure of bio prosthetic valves
• expanded the choice of a bio prosthetic valve
to a younger age group
• a reduced need for mechanical valves that
require obligate life-long anticoagulation
and its attendant morbidity and mortality.
valve-in-valve(VIV)

14. Mechanical circulatory support
• Interest in mechanical circulatory support (MCS) developed concurrently with
interest in cardiopulmonary bypass and open-heart surgery in the 1950s.
• The lack of heart donors and contraindications to heart transplantation further
stimulated the necessity
• Patients with advanced heart failure needing MCS are severely limited with
symptoms on minimal exertion or rest, with circulatory insufficiency, on inotropic
support or awaiting transplantation
• The waiting time for heart transplantation can be long.
• Patients that are deemed ineligible for heart transplantation because of
underlying medical conditions related to heart failure may become candidates due
to the beneficial effects of MCS.

15. Mechanical circulatory support

18. A ventricular assist device
(VAD) is
an electromechanical device
for assisting cardiac
circulation, which is used
either to partially or to
completely replace the
function of a failing heart.
VADs are designed to assist
either the
right ventricle (RVAD) or the
left ventricle (LVAD), or to
assist both ventricles (BiVAD)

19. Arvind Doshi, a Mumbai businessman, suffered a myocardial infarction five years ago.
This led to a congestive heart failure, He was shortlisted for a transplant, but in the
absence of a donor, he was taken for LVAD implantation.
“The surgery, originally considered as a means to make the transplant easy, has now
become a permanent solution to end-stage heart failure management. It will work for
patients for whom a match is not found in time,” Dr Mulay.

20. TAH- Total artificial heart
The total artificial heart (TAH) is a
form of mechanical circulatory
support in which the patient’s
native ventricles and valves are
explanted and replaced by a
pneumatically powered artificial
heart.
Currently, the TAH is approved for
use in end-stage biventricular
heart failure as a bridge to heart
transplantation.
SYNCARDIA TAH

21. Stan Larkin diagnosed with familial cardiomyopathy ( both brothers) went a massive
555 days wearing an artificial heart backpack ( 13.5 pounds) , which filled in after his
ticker was removed while he awaited a transplant donor

22. Minimally invasive cardiac surgery (MICS)
The growing interest in
laparoscopic surgery in general
prompted exploration of
minimally invasive techniques for
use in cardiac surgery, with
Cosgrove describing the first
minimally invasive valve surgeries
in 1996
In order to avoid the
postoperative respiratory
dysfunction, chest instability,
chronic pain and incidence of
deep sternal wound infection
associated with a median
sternotomy, numerous alternative
incisions were evaluated for
MICS.

23. Minimally invasive heart procedures include:
• Mitral valve repair and replacement
• Tricuspid valve repair and replacement
• Aortic valve replacement
• Atrial septal defect and patent foramen ovale closure
• Atrioventricular septal defect surgery
• Maze procedure for atrial fibrillation
• Coronary artery bypass surgery
• Endoscopic Saphenous vein and radial artery harvest for coronary artery bypass
surgery

24. Conventional midline
sternotomy Upper hemisternotomy

27. • Potential benefits
• Minimally invasive heart surgery isn't an option for everyone, but it can offer
potential benefits in those for whom it's appropriate.
• Potential benefits of minimally invasive heart surgery compared with open-heart
surgery may include:
1. Less blood loss
2. Lower risk of infection
3. Reduced trauma and pain
4. Shorter time in the hospital, faster recovery and quicker return to normal
activities
5. Smaller, less noticeable scars
6. Facilitates redo surgery
7. avoids sternal complications
8. No difference in morbidity and mortality

31. Types of ECMO