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Avoiding brain injury during cardiac interventions – Minimally Invasive Heart Surgery Leads the Way

Patients with stents in their coronary arteries are forever at risk of further occlusion of their arteries resulting in myocardial infarction or even death .

Most patients with severe coronary artery disease would nowadays undergo cardiac catheterization and coronary angiography before proceeding to angioplasty and stenting , often repeatedly in order to relieve them of their symptoms of chest pain or breathlessness . While in the majority of cases , the procedure is straightforward , the risk of complications is always present . One of the major concerns with any cardiac interventions is the possibility of stroke . While the risk of clinically evident stroke is low , the occurrence of silent stroke is much higher than previously thought . Using highly sensitive magnetic resonance imaging techni�ues , �apanese researchers found evidence of brain injury in 32.1 % of patients following routine cardiac catheterizations . The risk is increased in older patients and in those needing multiple catheters , wires , stents and other instruments . Fortunately most of these injuries are not clinically evident . Patients with stents in their coronary arteries are forever at risk of further occlusion of their arteries resulting in myocardial infarction or even death . This explains why in the long-term , patients with stents do not live as long compared to those who undergo coronary artery bypass surgery in the first place .

Heart surgery also carries a risk of stroke from the effects of cannulations , heart-lung bypass and prolonged general anaesthesia . This risk is often �uoted as higher than percutaneous interventions like stenting . A new concept has emerged to perform coronary artery surgery without manipulating the aorta since this may dislodge atherosclerotic material which can result in strokes . Anaortic , off pump coronary artery bypass can achieve this aim . By utilising the internal mammary arteries as bypass conduits , there is also no need to attach any top ends to the aorta . Thus , doing the whole procedure without ever touching the aorta would go a long way towards reducing or eliminating the risk of stroke . This concept of treatment is , in my opinion , the safer option compared to percutaneous interventions including angioplasty and stenting which inevitably involve inserting foreign bodies into the inside of the aorta before they could be introduced into the coronary arteries .

The advantages are combined elegantly in the emerging new concept of minimally invasive coronary artery bypass surgery through a small left thoracotomy which allows harvesting of both internal mammary arteries and off pump beating heart bypass surgery for all areas of the heart . There is no need for sternotomy , cannulation of the aorta or any manipulation of the aorta , no need for heart-lung bypass , and also no need for harvesting leg veins or radial artery . These mean that the recovery of the patient is enhanced , with much less pain and with patients being able to return to their usual occupation and activity within a couple of weeks of the surgery . There is the added bonus of superior long-term outcome with the use of total arterial revascularization . I believe this minimally invasive coronary artery bypass surgery is the best treatment option for patients with severe coronary artery disease with lower risk and better long-term results including the better survival of patients and the reduced need for repeat procedures .

Dr . Eng Ji Bah Consultant Cardiothoracic Surgeon

156 OCTOBER 2022 GlobalHealthAsiaPacific . com