Our institution, as a large academic center, has evaluated a variety of surgical techniques for minimally invasive CABG. Starting with MIDCAB operations via left-sided mini thoracotomy in 1996 moving to multiple vessel grafting on the arrested heart via mini thoracotomy using Port Access technology we changed our surgical approach to the more convenient partial lower sternotomy technique. This approach provides several advantages.
A paralell research effort was made evaluating the pros and cons of totally endoscopic robotically assisted technique. As an academic institution we analysed precisely the advantages and disadvantages of awake CABG surgery (ACAB). As a University Hospital performing more than 1800 cardiac procedures yearly, it was not our primary goal to pick up a new technique just for marketing purposes, but rather evaluate the most innovative techniques available in scientific manner.
Since March 2001 we performed ACAB in 68 patients. Besides of MIDCAB operations multiple vessel grafting procedures were performed in 12 patients via complete sternotomy in the awake setting.
With more than a 4 year experience in awake surgery it is my intention to communicate one important message not only to collegues, but also to all coronary patients who have to undergoe some type of revascularisation: ?The taboo of a heart operation as a risky and dangerous procedure has been broken.?���� There are severeal ways to achieve a good and long lasting revascularization of the heart. If we can offer the possibility of receiving a LIMA to LAD graft without standard anesthesia for cardiac surgery, we schould let the patient decide on the procedure! A stent with uncertain long term patency or a life time LIMA to LAD?
Let����s look at the critical issues:
Is there a true benefit of ACAB versus other surgical or interventional techniques?
Yes. For the first time in the history of cardiac surgery we have seen patients, who are able to eat a full lunch 2 hours postoperatively and walk over the ward the same afternoon, pain free,���� and able to go home on the first postop. day. Independent of the activity score that is used, such a fast track mobilization cannot be achieved by any other surgical techniques.
We perform fast track cardiac surgery routinely every day. As a surgeon who has a vast experience with both techniques I would like to state the following: the difference between awake surgery and fast track surgery is like the difference between day and night.
With the aging of the population, nowadays we have more and more elderly patients in their 80ies, who have considerable comorbidity����with impaired pulmonary function. Weaning such patients from the respirator is more and more difficult and dependent on the effects of drugs.
The same procedure performed under general anesthesia is also a good technique. But, the drawbacks are: hemodynamic compromise during induction of anesthesia, mechanical risk vocal chord injury, tracheal injury, malpositioning of the tube with ventilation of the stomach, etc.
Furthermore I have a question for the anesthesiologist: How long does it take to extubate a patient on the table while the next patient is waiting in line? What is the risk of transfer of fast track patients from the OR to the ICU? What about the reintubation rate? What about postoperative nausea and vomiting with the risk of aspiration?
The main aim of awake surgery is to increase the patient comfort during and after surgery. I believe, they have high comfort.
Isn����t it terrible to undergoe CABG and cardiac manuplation in fully awake condition?
Well, it really depends on which pair of eyeglasses you use when you look at this issue. And, dear collegues, it is time to visit your ophthalmologist and get a new pair of eyeglasses and look objectively at the trends, that are taking place in medicine:
What about a pecutaneous implantation of an AICD in a severely sick patients with low LVEF and an inclination for arrythmia. This procedure is nowadays performed in the cath lab even by the cardiologist, who has no surgical background or standby?
What about pace maker implantations in patients with symptomatic bradycardia and the endocardial manipulation during probe placement? Or explantation of pacer maker probe after several years? This procedure is done routinely, even though everybody knows, that in some cases we even observe ventricular perforation with all the consequences?
What about multiple stent implantation in one patient into the coronary vessels every day in many cath labs worldwide in the awake setting. It is done routinely enfacing the possible complications of such procedures in heavy calcified vessels. Sometimes more than 3, 4 even 5 hours procedure times?? What about left main stenting in the awake setting?
Why do interventionalists start to stent carotid arteries in awake patients enfacing a big neurologic risk. Are these guys crazy or are they practising latest state of the art medicine ?
Do not the ortopedic surgeons do arthroscopy and meniscus resection of 2 hours duration in spinal anesthesia? Many neurosurgical procedures are performed also in awake settings. In most of medical branches, the trend is towards patient comfort and ambulatory surgery.
I would like to hear from experienced OPCAB surgeon, if the LIMA-LAD in awake setting more dangerous than the above mentioned procedures?
What happens if the patient has episode of ventricular fibrilattion during the operation?
In such a scenario, with the surgeon and the anesthesiologist by the side, as well as the other members of the OR team, with the chest open, and the heart in your hands, one has the best and most optimal conditions to treat this complication. Internal massage can be started in 2 seconds, and internal defibrillation in 10-15 seconds.
What happens in the same patients undergoes Robotic revascularisation and sustains the same complication? How long before the thorax is open, hand massage and internal defibrillation are employed?
Or in the ICU? Or, even worse, on the normal patient ward? Or during PCI in cath lab in awake setting? It seams to me that cardiologists have more boldness than we, the surgeons.
Would I like to have an Awake CABG?
A classic question, and a classic response: yes. It is to me important the the anastomosis is well performed and the LIMA is nicely harvested. And one more contra-question: would you like to have your 80% stenotic left main stented in awake setting?���� Maybe you don����t like it, but it may well become a routine in a short time.
Some say that Awake CABG is not comfortable for the surgeon?
Many cardiac surgeons emphasize that suturing coronary anastomoses on the arrested heart and under general anesthesia is more comfortable than surgery on the beating heart. They say : ?Why schould I ride a Fiat Punto if I can afford a Mercedes??����
In my opinion surgical comfort is dependent on experience. The more cases one surgeon does in the same manner the safer it gets. I would like to ask one key question to all cardiac surgeons: The times are changing and I think it is time to make a decision what is more important: patient comfort or surgeons comfort.
Comfort is whatever keeps the surgeons adrenalin level in a normal range.
If one center follows the OPCAB philosophy all residents, OR nurses and anesthesiologists consider this bypass technique to be normal and standard.
Knowing that a certain procedure has potential benefit for the patient, we as a cardiac surgical community schould not be ignorant to refuse such innovation. At least we schould look into this new technique systematicly in multicenter trials before we ignore.
As an answer for the colleges: even if I have a Mercedes Maybach in my garage, for LIMA to LAD bypass I would prefer to ride my bicycle.
Come on guys, it just a matter of the perspective, that you take and how you want to look at a certain procedure !
Tayfun Aybek, MD
Cardiothoracic Surgeon
Thoracic and Cardiovascular Surgery
University of Frankfurt
Theodor Stern Kai 7
60590 Frankfurt/Main
GERMANY
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