We can offer heart surgery within 2 weeks after assessment 
As a heart surgeon, I often get questions from patients and their families about different types of bypass surgeries and the latest minimally invasive techniques. In this article, I’ll explain what double, triple, and quadruple bypass surgeries are, discuss whether they can be performed using keyhole techniques, and introduce an innovative new approach we use at The Keyhole Heart Clinic called TCRAT (Total Coronary Revascularization via Anterior Thoracotomy).
Understanding Coronary Artery Bypass Grafting (CABG)
Before we dive into the specifics of double, triple, and quadruple bypasses, let’s review what coronary artery bypass grafting (CABG) surgery is. CABG is a procedure used to treat coronary artery disease, where the arteries supplying blood to the heart muscle become narrowed or blocked by plaque buildup.
In CABG surgery, we create new routes for blood to flow around the blocked arteries using blood vessel grafts. These grafts are typically taken from other parts of the body, such as the chest wall (internal mammary arteries), leg (saphenous veins), or arm (radial arteries). The number of bypasses performed corresponds to the number of coronary arteries that need to be bypassed.
Double, Triple, and Quadruple Bypass: What’s the Difference?
The terms “double,” “triple,” and “quadruple” bypass refer to the number of coronary arteries that are bypassed during the surgery:
– Double bypass: Two coronary arteries are bypassed
– Triple bypass: Three coronary arteries are bypassed
– Quadruple bypass: Four coronary arteries are bypassed
It’s important to note that the number of bypasses doesn’t necessarily indicate the severity of the heart disease or the complexity of the surgery. The decision on how many bypasses to perform is based on each patient’s individual anatomy and the location and extent of the blockages.
Traditional vs. Minimally Invasive Approaches
Traditionally, CABG surgery has been performed through a large incision in the chest, splitting the breastbone (sternotomy) to access the heart. While this approach provides excellent exposure and has a long track record of success, it also involves a longer recovery time and potential complications related to the large incision.
In recent years, there has been a growing interest in minimally invasive or “keyhole” approaches to heart surgery. These techniques aim to achieve the same results as traditional open surgery but with smaller incisions, potentially leading to faster recovery times and fewer complications.
Can Double, Triple, and Quadruple Bypasses Be Done by Keyhole?
The short answer is yes, but with some important considerations. Minimally invasive CABG (MIDCAB) techniques have been developed and refined over the years, allowing us to perform single and sometimes double bypasses through small incisions between the ribs. However, performing triple or quadruple bypasses using keyhole techniques has been more challenging due to limited access and visibility.
This is where the innovative called TCRAT (Total Coronary Revacularisation by Anterior Thoracotomy) approach comes in. I’ll discuss in more detail shortly. But first, let’s look at some of the keyhole techniques currently used for CABG:
1. Minimally Invasive Direct Coronary Artery Bypass (MIDCAB):
This technique is typically used for single-vessel disease, usually involving the left anterior descending (LAD) artery. It’s performed through a small incision on the left side of the chest, without stopping the heart or using a heart-lung machine.
2. Totally Endoscopic Coronary Artery Bypass (TECAB):
This is a fully robotic procedure performed through several tiny incisions in the chest. It can be used for single or sometimes double bypasses, but it requires specialized equipment and extensive training.
3. Hybrid Procedures:
These combine minimally invasive CABG for one or two vessels with percutaneous coronary intervention (stenting) for other blocked arteries. This approach can sometimes avoid the need for a full open-chest surgery in patients with multi-vessel disease.
Introducing TCRAT: A Revolutionary Approach to Multi-Vessel Keyhole CABG
At The Keyhole Heart Clinic, we’re proud to be at the forefront of minimally invasive cardiac surgery. We’ve helped to develop and refine a technique called Total Coronary Revascularisation via Anterior Thoracotomy (TCRAT), which allows us to perform multi-vessel bypass surgery – including triple and quadruple bypasses – through a small keyhole incision.
TCRAT is performed through a 5-8 cm incision on the left side of the chest, between the ribs. This approach allows us to access all the major coronary arteries without splitting the breastbone. We use specialized instruments and video-assisted technology to perform the bypasses with precision.
The benefits of TCRAT compared to traditional open CABG include:
– Smaller incisions and less tissue trauma
– No need to split the breastbone
– Potentially faster recovery and shorter hospital stays
– Less postoperative pain
– Lower risk of wound infections
– Improved cosmetic results
It’s important to note that while TCRAT offers many advantages, it’s not suitable for every patient. Careful patient selection is crucial to ensure the best outcomes.
Assessing Suitability for TCRAT: The Importance of CT Scans
To determine whether a patient is a good candidate for TCRAT, we perform a comprehensive evaluation, including a detailed CT scan of the chest and heart. This scan helps us assess:
1. Coronary anatomy: We can visualise the location and extent of blockages in the coronary arteries, helping us plan the optimal bypass strategy.
2. Chest wall anatomy: The CT scan allows us to evaluate the space between the ribs and ensure there’s enough room to safely perform the procedure through a small incision.
3. Aortic calcification: We can assess the condition of the aorta, which is important for determining the feasibility of certain bypass techniques.
4. Potential need for groin micropipes: In some cases, we may need to use the heart-lung machine during TCRAT. The CT scan helps us evaluate the femoral vessels in the groin to determine if they’re suitable for cannulation (insertion of small tubes) if needed.
The Role of the Heart-Lung Machine in TCRAT
While many TCRAT procedures can be performed on a beating heart (off-pump), there are situations where we may need to use the heart-lung machine. This decision is based on factors such as the location of the blockages, the stability of the heart during the procedure, and the patient’s overall condition.
If we anticipate the potential need for the heart-lung machine, we’ll assess the femoral vessels in the groin using the CT scan. This allows us to plan for the placement of small cannulas (micropipes) in the groin if needed, rather than having to convert to a full open-chest procedure.
The ability to use the heart-lung machine when necessary, while still maintaining the benefits of the minimally invasive approach, is one of the key advantages of TCRAT over other keyhole CABG techniques.
Patient Selection and Outcomes
While TCRAT offers significant benefits for many patients, it’s not suitable for everyone. Factors that may influence the decision to proceed with TCRAT include:
– The patient’s body habitus and chest anatomy
– The location and severity of coronary artery blockages
– Previous chest surgeries or radiation therapy
– Presence of other cardiac conditions requiring treatment
– Overall health and ability to tolerate a minimally invasive approach
In our experience at The Keyhole Heart Clinic, carefully selected patients undergoing TCRAT have excellent outcomes comparable to those of traditional CABG, with the added benefits of faster recovery and less postoperative discomfort.
Double, triple, and quadruple bypass surgeries can indeed be performed using keyhole techniques, thanks to innovative approaches like TCRAT. This minimally invasive method allows us to offer the benefits of multi-vessel coronary revascularization without the need for a large chest incision or breastbone division.
However, it’s crucial to understand that the success of these procedures relies heavily on careful patient selection, meticulous preoperative planning (including detailed CT scans), and the expertise of a highly skilled surgical team experienced in minimally invasive techniques.
At The Keyhole Heart Clinic, we’re committed to offering our patients the most advanced and least invasive treatment options available. If you or a loved one has been diagnosed with multi-vessel coronary artery disease and are interested in learning more about TCRAT or other minimally invasive options, we encourage you to speak with your cardiologist or contact our clinic for a consultation.
Remember, every patient’s situation is unique, and the best treatment approach should be determined through careful evaluation and discussion with your healthcare team. We’re here to help guide you through the process and provide the highest quality care for your heart health.
Citations:
[1] https://www.thekeyholeheartclinic.com/services/keyhole-therapies/coronary-artery-bypass/
[2] https://www.thekeyholeheartclinic.com/blog/keyhole-coronary-bypass-surgery/
[3] https://www.webmd.com/heart-disease/heart-disease-bypass-surgery
[4] https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/coronary-artery-bypass-graft-surgery
[5] https://www2.hse.ie/conditions/coronary-artery-bypass-graft/how-its-performed/
[6] https://111.wales.nhs.uk/coronaryarterybypassgraft/
[7] https://www.mayoclinic.org/tests-procedures/coronary-bypass-surgery/about/pac-20384589
[8] https://www.bhf.org.uk/informationsupport/treatments/coronary-bypass-surgery
