Coronary Bypass

The coronary arteries are the blood vessels that provide the heart muscle with oxygen and nutrients. There are normally two -- one on the right side, and another on the left. The one on the left divides into two major branches: the anterior descending, which goes down the front, and the circumflex, which circles around the back.Arteriosclerosis is a disease process by which these arteries can develop blockages. A blocked coronary artery does not allow the normal flow of oxygen and nutrients to a highly specialized muscle that has no oxygen reserves. Consequently when the heart has to work harder, it sends a message (usually in the form of pain and a sensation of fear) that causes the patient to slow down until the pain goes away. This is commonly referred to as angina.

SPECIALIZED TECHNIQUES

SURGXL does a number of things differently in the field of coronary bypass. First, we use a high-powered operating microscope (above picture) to construct the connections for the bypass with a perfect visualization of the arteries and thus allow for a connection to be constructed in the safest possible manner. Over the past several years, we have perfected our technique for doing coronary bypass surgery without the use of the heart-lung machine and thus without the need to stop the heart or clamp the aorta. This is important because multiple scientific publications have confirmed a high incidence of brain damage during open-heart surgery, most often due to the use of the heart-lung machine and the clamping of the aorta. In 2008, over 96% of the coronary bypass procedures done by Dr. Bell-Thomson and his team have been "off-pump" -- that is to say, on the beating heart and without using the heart-lung machine, without stopping the heart or clamping the aorta.

SURGXL also recognizes the benefits of the Warm-heart technique Just as the heart lung machine was developed to enable surgical treatment of cardiac disease, hypothermia - or decreasing the patient’s body temperature – was also utilized in the early years of heart surgery. Recently, however, surgical outcomes and patient function after surgery have been improved using Normothermic – heart surgery at a little less than normal body temperature. This technique includes continuous normothermic blood suppy to the heart even when it is stopped. The heart itself resumes normal function more quickly and is less “stunned” when supplied with continuous flow of warm oxygenated blood during procedures

The choice of conduit is also important because it is well demonstrated that the use of the Internal Mammary Artery as a by-pass conduit is directly related to the patient's long-term survival. The use of arterial conduits is a measure of quality in coronary bypass surgery, and Dr. Bell-Thomson uses one or more arterial conduits in over 97% of the patients undergoing coronary bypass surgery. This includes right and left internal mammary arteries, radial arteries and gastroepiploic arteries. Saphenous veins are also used in bypass grafting. When the vein is harvested from the leg, a minimally invasive video assisted technique is used, allowing for a small (one-inch) incision made at the level of the patient's knee without the need for a long incision or multiple incisions on the leg. This accelerates the patient's post-operative recovery and is a lot more comfortable and aesthetically pleasing.

Transmyocardial Revascularization (TMR) Laser Procedure

When bypass surgery isn’t an option, patients can now take advantage of new laser technology to help reduce their symptoms of severe angina. This laser procedure, termed transmyocardial revascularization (TMR), allows a surgeon to create tiny channels, typically one millimeter in diameter, into the heart muscle. This reduces symptoms by increasing the blood flow to the heart and stimulating the growth of new small blood vessels within the heart muscle.

This procedure may be used by itself, but most commonly is used as an adjunct to bypass grafting.

SURGXL participates in the Society of Thoracic Surgeons national database and keeps a very clear statistical record of our results. Thus we can say that for coronary bypass surgery, in an elective patient, our success rate is over 99%. We also undertake to care for the much higher-risk patient with multiple combined disease processes, and still our results are far better than the national average for these subsets of patients.

Below is a chart of SURGXL's results in off-pump coronary bypass (OPCAB) surgeries.

Aortic Surgery

The aorta is the main blood vessel coming out of the heart carrying blood to the rest of the body. Portions of the aorta can stretch, forming a weakened area susceptible to fatal leakage or rupture. These balloon-like dilations, called aneurysms, can develop slowly and insidiously or quickly and painfully.

The surgery for the aorta can be divided into three separate categories: that which involves the ascending aorta, that which involves the aortic arch where the head vessels come off and the third would be the descending thoracic aorta and abdominal aorta.

For surgery on the ascending aorta, aneurysms can form as a result of aortic valve disease and/or simply because the segment of the aorta shortly after it leaves the heart, dilates. There are very seldom symptoms associated with these aneurysms and most often they are a finding that is concomitant with aortic valve disease or simply the appearance of the aneurysm on a routine X-ray examination. Size and the occurrence of symptoms such as pain or mini strokes are determining factors for surgical intervention and this is usually done with the use of the heart-lung machine. This may require replacement of the ascending aorta with a prosthetic Dacron tube and/or concomitant replacement of the aortic valve. In such instances, it is also necessary to reattach the coronary arteries that are the blood supply to the heart muscle and this is accomplished by suturing them to the Dacron graft.

Surgery for the aortic arch is more complex because the blood supply to the arms, head, neck and brain originates on the aortic arch and protection of the central nervous system is very important. Dr. Bell-Thomson uses a deep hypothermic circulatory arrest for protection of the brain along with a protocol of pharmacologic neuro protection. The patient is normally cooled on the heart-lung machine with a heat exchanger to a temperature below 20 degrees centigrade. The circulation is stopped for the length of time that it takes to reattach the head vessels to a Dacron graft, which would replace the arch portion of the aorta. On occasion, this becomes an extension of surgery for replacement of the ascending aorta.

Surgery for the descending thoracic aorta usually involves the presence of aneurysms that do not necessarily create symptoms until they are large enough to compress adjacent organs or structures and/or are discovered incidentally on x-ray examinations of the chest. These to require replacement of the aneurysm with a prosthetic Dacron tube. However, the most important aspect of this surgery is the protection of the spinal cord thus preventing the occurrence of the worst possible complication - paraplegia or paralysis from the waist down. Dr. Bell-Thomson has always used monitoring of the spinal cord by assessing the transmission of somato-sensory cortical-evoked potentials, which means that an electrical impulse is provided to the legs and sensed on the scalp to determine that the integrity of the spinal cord remains intact throughout the period of reconstructive surgery for the thoracic aorta. A pharmacological neuroprotection protocol is also instituted during these procedures. Another contributing factor to a successful outcome is that Dr. Bell-Thomson always uses some form of distal perfusion for the lower half of the body, which is important to maintain during the period of repair and reconstruction of the descending thoracic aorta.

Occasionally these aneurysms do extend into the abdomen as thoracoabdominal aneurysms that require a similar surgical approach and correction. However, the incision will extend from the chest into the abdomen to allow access to the visceral arteries that need to be reimplanted on the Dacron graft prosthesis.

Abdominal Aorta

Despite the use of intravascular stents for the treatment of abdominal aortic aneurysms, there are still indications for a surgical approach in preference over a percutaneous technique and Dr. Bell-Thomson has extensive experience in replacement of the abdominal aorta for the treatment of abdominal aortic aneurysms.