Minimising the Invasiveness of Major Cardiac Surgery

Abstract

Minimally invasive surgery refers to modifications to traditional procedures that reduce the disruption of the body’s normal function. This thesis examined three techniques designed to reduce the invasiveness of major cardiac procedures. Coronary artery bypass grafting performed without cardiopulmonary bypass or any manipulation of the ascending aorta (anaortic off-pump) was found to reduce the incidence of post-operative stroke, mortality and other complications. An anaortic off-pump surgical technique that achieves achieve complete revascularisation and utilising total-arterial grafts was developed. Transcatheter aortic valve implantation (TAVI) is a novel minimally invasively method of treating severe aortic stenosis. Despite the complexity of the procedure, TAVI was successfully introduced into an Australian hospital with excellent perioperative outcomes. The transapical approach was demonstrated to be a feasible alternative in patients who were not suitable for transfemoral access, though there was increased risk of vascular and bleeding complications. Prophylactic extracorporeal membrane oxygenation in selected very high-risk TAVI patients may also help avoid the consequences of intraoperative complications and the need for emergent support. Lastly, a novel minimally invasive strategy for managing high-risk patients with combined aortic stenosis and multivessel coronary artery disease was described. Robotic ‘telemanipulators’ have enabled complex cardiac procedures to be performed via port-access. Systematic reviews of published studies demonstrated improved postoperative recovery in robotic-assisted coronary and mitral valve surgery, whilst maintain the quality of the procedure. High intra-procedural costs are largely offset by faster discharge from hospital and return to work. A step-wise program for introducing robotic-assistance into coronary surgery was developed and implemented in an Australian public hospital. Though major challenges limited progression.