Coronary Artery Bypass Graft (CABG) Keyhole Surgery

Keyhole Bypass Surgery

Coronary artery bypass graft (CABG) surgery restores blood flow to the heart by creating a new path around the blocked arteries. While traditionally done as open-heart surgery, less invasive options now exist.

Heart bypass keyhole surgery or minimally invasive direct coronary artery revascularisation (MIDCAB) uses a small incision to bypass blocked blood vessels.

At The Keyhole Heart Clinic, we also offer Total Coronary Revascularisation via Anterior Thoracotomy (TCRAT), an advanced keyhole technique that allows multiple artery bypass grafts. It’s a highly skilled procedure, performed by only a few surgeons worldwide, including our lead surgeon, Mr Inder Birdi.

Learn more about coronary artery bypass grafts and the possibilities of using keyhole heart surgery.

What is Coronary Artery Bypass Grafting Surgery?

Coronary artery bypass grafting is the most common form of heart surgery performed worldwide. CABG restores blood flow to the heart by using healthy blood vessels from other parts of the body to bypass blocked or narrowed arteries. These grafts help improve blood flow to the heart muscle.

Also referred to as coronary bypass surgery or heart bypass surgery, this cardiovascular surgery is typically used to treat severe coronary artery disease when arteries become narrowed by a buildup of plaque.  Most patients refer to this surgery as “triple bypass” or “quadruple bypass”, depending upon the number of bypass grafts performed.

Grafts are commonly taken from the internal mammary artery in the chest, the saphenous vein in the leg, or the radial artery in the arm. The number of grafts performed depends on how many of the coronary arteries are affected.

What Happens During Coronary Artery Bypass Surgery

Heart Bypass surgery can be performed using either traditional open-heart surgery or a minimally invasive keyhole approach. The choice depends on the number and location of blockages, the patient’s overall health, and the surgeon’s expertise.

1. Preparation

The surgical procedure begins in the operating theatre under general anaesthesia. The patient is intubated, connected to heart and blood pressure monitors, and prepared for surgery. A breathing tube and intravenous lines are placed. Invasive monitoring lines and a transesophageal echocardiogram (TEE) may also be used for precise assessment.

2. Access to the Heart

• In traditional CABG, the surgeon makes a long incision down the centre of the chest and opens the breastbone (median sternotomy) to access the heart.
• In keyhole CABG techniques, such as MIDCAB or TCRAT, the heart is accessed through small incisions between the ribs, without breaking the breastbone. A camera and specialised instruments are used for precision.

3. Graft Harvesting

Healthy blood vessels, such as the left or right internal mammary artery or radial artery, are harvested to replace blocked coronary arteries, restoring optimal blood flow to the heart muscle. Grafts can also be taken from the left internal thoracic artery. This is done through either open or video-assisted techniques.

4. Bypass Setup

The patient is given anticoagulant medication, usually heparin, to prevent blood clotting. In most traditional cases, the patient is connected to a heart-lung bypass machine to take over the work of the heart and lungs during the surgery. In keyhole procedures, off-pump CABG techniques may be used, allowing the surgery to be performed on a beating heart. You are in incredible hands with an expert team that monitors blood supply and controls blood pressure.

5. Graft Placement

The surgeon attaches the harvested blood vessels to the left and right coronary arteries beyond the blockages. The other ends of the vein or arterial grafts are connected to the aorta or other suitable vessels.

6. Restarting the Heart

If a cardiopulmonary bypass machine, also known as a heart-lung bypass machine, is used, the heart is restarted and coronary circulation is restored. The surgical team checks each graft for good blood flow and confirms there is no bleeding.

7. Closure

• In keyhole CABG, only small incisions need to be closed, typically with dissolvable sutures.
• In traditional surgery, the breastbone is closed with stainless steel wires, and the chest incision is closed with dissolvable stitches.

After surgery, patients are transferred to the intensive care unit for close monitoring during the early recovery period. Cardiac rehabilitation is a key factor in a healthy recovery.

Possible Complications & Risk Factors

While coronary artery bypass surgery is a standard and often life-saving procedure, like all major surgeries, it has risks. Some are related to the procedure, while others depend on the general health of the patient.

General Risks

• Stroke: Occurs in about 1% of patients during or shortly after surgery. The risk is slightly higher than with stenting (PCI).
• Death: The risk is influenced by medical history, age, and overall health.
• Advanced age: Older patients have a higher risk of stroke, complications and lengthier recovery.

Patient-Specific Factors

Some patients have health conditions that increase their risk:

• Frailty (weakness or poor physical condition)
• High blood sugar due to diabetes
• Chronic obstructive pulmonary disease
• Other serious illnesses like liver disease
• Shortened life expectancy

Common Postoperative Complications

• Fluid buildup in the chest (hydrothorax): Affects approximately 11% of patients and may lead to extended hospital stays.
• Longer surgery times: Extended use of the heart-lung bypass machine and clamping of the aorta can increase the chance of complications.
• Low body weight (BMI): Linked to a higher risk of hydrothorax and other issues. A healthy weight helps to reduce further heart complications.
• Progressive angina before surgery: Patients with worsening chest pain tend to experience more post-op complications.
• Previous heart attack with heart muscle scarring (PMIMS): Increases risk of complications.

In addition to coronary artery disease, conditions such as peripheral arterial disease (PAD) also affect the arteries, leading to decreased blood flow to the limbs. PAD is a significant risk factor for heart disease and can complicate coronary artery bypass graft surgery

Everyone’s risk profile is different. That’s why we carry out thorough pre-surgery assessments and scans. By choosing an experienced surgical team and a personalised approach, we can reduce these risks and give you the best chance of a strong recovery.

Percutaneous coronary intervention (PCI), commonly called coronary angioplasty, is the primary alternative to CABG. While less invasive, it often holds a greater chance of requiring repeat procedures later on. A potential complication of open-heart surgery is deep sternal wound infections, which can occur due to the long incision made in the chest. This risk is lower in minimally invasive keyhole heart bypass surgery.

Understanding Keyhole Heart Bypass Surgery

In 2022, Mr Inderpaul Birdi performed the UK’s first quadruple heart bypass using keyhole surgery. Minimally invasive bypass techniques are changing the way we approach bypass heart surgery.

Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)

MIDCAB stands for Minimally Invasive Direct Coronary Artery Bypass. It’s used when one coronary artery needs to be bypassed, usually the left anterior descending artery (LAD).

Instead of opening the breastbone, the surgeon makes a small cut between the ribs on the left side of the chest. This incision is typically 6 to 10 cm in length. Special instruments and, occasionally, a small camera are used to access the heart.

The left internal mammary artery (LIMA), found inside the chest, is used as the bypass graft. In most cases, the surgery is done while the heart is still beating. This avoids the need for a heart-lung machine.

Patients often recover faster, with less pain and a lower risk of complications. MIDCAB is a good alternative to stenting for many people with single-vessel heart disease.

Total Coronary Revascularisation via Anterior Thoracotomy (TCRAT)

Total Coronary Revascularisation via Anterior Thoracotomy (TCRAT) is also called multi-vessel keyhole coronary artery bypass (Multi-MIDCAB). It’s used for patients diagnosed with coronary heart disease in multiple arteries.

Like MIDCAB, this technique avoids cutting through the breastbone. Instead, all grafts are placed through one small incision on the chest wall.

Surgeons use a mix of artery and vein grafts to bypass all blocked areas. Performing multiple grafts through such a small opening takes exceptional skill. Only a few surgeons worldwide offer this option.

Mr Birdi was the first in the UK to complete four bypasses using this method. His work demonstrates that even the most complex bypass operations can be performed through keyhole access, yielding excellent results.

Hybrid Keyhole Heart Bypass Surgery

Not all patients are suitable for Multi-MIDCAB. To widen the benefits of keyhole coronary artery bypass surgery to more patients, a procedure called hybrid keyhole coronary bypass surgery can be offered to some patients.

This treatment involves two procedures performed either on separate occasions or simultaneously, designed to offer the superior benefits of revascularisation of the LAD via the MIDCAB opening. This is followed by treatment of any remaining narrowed arteries using stents, the ultimate aim being to avoid the breastbone cut.

Until recently, little was known about the immediate and long-term outcomes of this approach. In an article to be published in The Journal of the American College of Surgeons, Hybrid Keyhole Coronary Bypass Surgery was compared with traditional multi-vessel bypass grafting via breastbone division.

Hybrid keyhole coronary artery bypass surgery was associated with:

• Reduced rates of in-hospital major complications
• Reduced blood transfusion use
• Reduced chest tube drainage (blood loss)
• Reduced postoperative length of stay

Hybrid therapies can be used to treat coronary disease and valve disease through keyhole techniques. Contact us to learn more about these treatments.

Coronary Stent Insertion

This is a very effective therapy for certain types of isolated disease of the coronary arteries. A catheter is placed into the coronary artery using coronary angiography, and a small balloon can be used to inflate the diseased area. This area can then be held open with a coronary stent.

The advantage of this approach is that it can be performed as a day case and requires no surgery. The catheter is inserted into the body via a wrist or groin blood vessel. The disadvantage of this approach is that the stent can block over time, leading to the recurrence of symptoms. Stents are used very effectively in emergencies to stop a heart attack from creating irreversible cardiac muscle injury. This is why you must always call for an ambulance if you think you are having a heart attack.

Surgery for certain types of disease is more likely to offer you better long-term results. This is particularly true for multiple lesions and high-grade proximal lesions. Your cardiologist and surgeon will be able to make the correct judgment for you regarding the suitability of stenting or surgery.

If you’re considering heart bypass surgery or recovering from coronary artery bypass surgery, contact us today to learn more about your treatment options and recovery plan.

The Keyhole Heart Clinic: Where Innovation Bypasses Tradition

Modern solutions for heart conditions are now accessible through The Keyhole Heart Clinic. Our clinic is led by Mr. Inderpaul Birdi, a cardiothoracic surgeon and consultant with over twenty years of experience helping patients through minimally invasive surgery.

With qualifications including BMedSci (Hons) and BM BS FRCS (CTh), Mr. Birdi has focused his career on minimally invasive techniques.

Mr. Birdi’s extensive expertise covers a range of advanced keyhole procedures, including:

• Keyhole mitral valve repair or replacement surgery
• Keyhole tricuspid valve replacement
• Keyhole aortic valve replacement
• Keyhole atrial fibrillation ablation
• Keyhole atrial septal defect closure

The clinic also offers comprehensive heart screening services and follows strict clinical practice guidelines.

Excellent surgical outcomes begin with taking time to understand each patient’s unique situation. Our patients have shared their experiences through over 100 five-star reviews, and Mr. Birdi has received Topdoctor awards in both 2022 and 2023. We’re here to help you understand what minimally invasive options might be right for you.

Book your consultation with the industry innovator in coronary artery bypass graft keyhole surgery.