through Dr Ramji Mehrotra

Coronary artery disease, a common cardiovascular disorder (CAD), is treated in several ways such as optimized medical treatment, percutaneous catheter intervention (PCI), or coronary artery bypass grafting (CAP). If patients have severe coronary artery disease, they are considered for coronary bypass surgery. Patients with narrowed areas in their coronary arteries or blockages require treatment that leads to the restoration of normal blood flow to the heart muscle. Coronary artery bypass (CABG) surgery is done to restore this flow. While most bypass grafts are done with an arterial graft combined with venous grafts (veins) taken from the patient’s legs, research and results have consistently indicated longer patency and less morbidity in patients who experience a coronary bypass surgery with arterial grafts.

What’s interesting, then, is a procedure called anaortic, total arterial, pump-less anaortic coronary bypass surgery, also known as OPCABG-TAR. This is important because it is a technically difficult surgery which is also referred to as “contactless aortic beating heart” bypass surgery. This surgery is done while the heart is beating constantly and you are not touching the aorta. It is performed using the patient’s arteries rather than the veins as bypass conduits. The veins descend over time, but the arteries improve over time, which gives it the advantage of being a longer duration bypass. Usually both internal mammary arteries (AIMs) in the patient’s chest wall are removed and used for this. Sometimes an AMI and a radial artery (from the patient’s non-dominant hand) are used. The use of ART also allows beating heart surgery to be performed without aortic manipulation, resulting in a further reduction in the rate of stroke. Since arteries are used instead of veins in bypass surgery, they have a longer longevity and a better quality of life. This is a proven procedure with proven results. Recent technological advancements, in line with developing global best practices, have enabled us to perform OPCABG-TAR surgery using endoscopic and robotic technology which further leads to early mobility, less morbidity, increased faster recovery, shorter hospital stay, less pain and minimal blood loss. . Although complex in nature, the results are encouraging and we are optimistic that more surgeries of this type will be performed to help patients who need similar procedures.

Highlights of OPCABG-TAR surgery
While the PAC indicates the use of grafts to bypass blocked areas of the coronary artery, anOPCABG-TAR is a pump-less surgery. This is again beneficial over other surgeries, as the heart does not need the assistance of a heart-lung machine, which is the case with traditional coronary bypass surgery procedures. On the contrary, the heart beats at its normal rate throughout an OPCABG. Total arterial revascularization offers the advantage of longer term patency and ensures that the aorta is not manipulated, further decreasing the risk of stroke.

How anOPCABG-TAR works
We perform a battery of tests to identify the various blockages in the patient’s arteries and plan the surgery after having carefully planned it. Typically, both internal mammary arteries (AIMs) are taken from the chest wall and used in various configurations to perform multiple bypasses using a sequential anastomosis. The operation itself takes between three and four hours, although the exact duration depends on the number of blockages, as we can perform multiple bypasses in the same operation. After doing the transplants, we check them with what is called a flow probe to make sure they are working well. We also insert a few tubes into the chest cavity, which allows air or fluid to flow out as the patient recovers. These tubes later exit through the upper abdomen.

Benefits of anOPCABG surgery
AnOPCABG-TAR surgery is a safer bet for patients especially the elderly or for those with co-morbidities that may cause slow recovery after surgery. AnOPCABG surgeries trump traditional CAP surgeries in many ways. Not touching the aorta is one of them, and this ensures that no blood clot forms after surgery in the aorta, which can occur with a traditional CAP. The intact aorta helps prevent stroke or damage to other organs due to blood clots.

Those who will undergo an OPCABG have reduced incidents of kidney failure or complaints of irregular heartbeat after surgery. The risk of patient death following surgery is 50% lower than with traditional PAC. The procedure is minimally invasive, therefore the recovery period is reduced and the hospital stay is reduced.

Dr Ramji Mehrotra, Senior Director and Head – Cardiothoracic and Vascular Surgery (CTVS), BLK-Max Heart Center

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