July 5, 2000 University of Pittsburgh and VA team performs U.S. first at VA Pittsburgh Healthcare System
PITTSBURGH, July 5 -- A 51-year-old patient recently underwent coronary bypass surgery while awake. The team of University of Pittsburgh Medical Center (UPMC) and VA surgeons and anesthesiologists performed minimally invasive direct coronary bypass (MIDCAB) with the patient's chest numbed by a more locally based analgesia. The case, believed to be the first time an awake cardiac surgical procedure was performed in the United States, took place on June 15 at the VA Pittsburgh Healthcare System (VAPHS).
MIDCAB, also called beating-heart bypass surgery because no heart-lung machine is used, offers several advantages compared to standard cardiac bypass surgery, including a much smaller incision, a reduced risk of neurological complications and a shorter hospital stay. But patients still must deal with the effects of general anesthesia, require a tube to be placed down the trachea and can expect at least one night in an intensive care unit as part of their hospitalization. With the patient awake, the procedure would be more tolerable and would perhaps mean only an over-night stay.
"Our goal is to make bypass surgery an outpatient procedure and as comfortable as angioplasty is for the patient. Yet unlike angioplasty, which utilizes a catheter and balloon to open up blocked vessels, we'll be able use surgical techniques to repair vessels for better long-term patient benefit," said lead surgeon Marco Zenati, M.D., assistant professor of surgery and director of the Minimally Invasive Cardiac Surgery Program, division of cardiothoracic surgery, at the University of Pittsburgh School of Medicine, and cardiac surgeon at the VAPHS.
Instead of delivering general endotracheal anesthesia, Juhan Paiste, M.D., gave the VA patient an epidural anesthetic, the kind of anesthesia most often associated with labor delivery and commonly used for chest surgery for post-operative pain control. The patient, who is a professional magician from Pittsburgh, was fully awake and talked to the operating room staff during the procedure. His entire chest area was numb so he was unaware of the surgical instruments at work on his beating heart.
"We used an epidural anesthesia delivered to the upper back area with sedation, and the patient tolerated the procedure very well. Combining two well-established techniques -- minimally invasive cardiac surgery and epidural anesthesia-- may become a new innovative approach to heart bypass surgery for select patients," said Dr. Paiste, assistant professor of anesthesiology and critical care medicine at the University of Pittsburgh, who was the attending anesthesiologist providing the patient's anesthetic management.
"As the cardiologist's interventional "medical" therapies have become more invasive and the surgical treatments have become less so, in the patient's eyes, and mine, the line that separates the two is becoming blurred. The use of general anesthesia with a breathing tube, although as safe as any anesthetic technique, has remained a clear marker for the patient that minimally invasive cardiac surgery must be the more difficult choice over an angioplasty," commented Richard Bjerke, M.D., chief of anesthesiology at the VAPHS and associate professor and vice chairman, department of anesthesiology and critical care medicine at the University of Pittsburgh School of Medicine.
"Simply knowing that there is an option for the use of epidural anesthesia for a MIDCAB can further assure patients that cardiac surgery can truly be minimally invasive," Dr. Bjerke continued.
While Dr. Zenati said the patient could have probably gone home the following day, he remained in the hospital for five days for closer observation and a post-surgery cardiac catheterization.
The types of patients who might be considered for the awake procedure are those who require MIDCAB. As the use of robotic instrumentation is introduced for endoscopic bypass surgeries, it is likely that the potential pool of patients who could benefit from the awake procedure will be quite large.
The team plans to perform more cases at both the VAPHS and UPMC.
"This represents an extremely important step for cardiothoracic surgery as we continue to try and make procedures more safe and cost-effective for patients," said Bartley P. Griffith, M.D., Henry Bahnson professor of surgery and chief, division of cardiothoracic surgery, at the University of Pittsburgh.
The procedure was pioneered in 1998 by Haldun Y. Karagoz, M.D., of Guven Hospital in Ankara, Turkey. To date, he has performed nearly 30 bypass surgeries in awake patients, a few being MIDCAB surgeries, such as the one performed in Pittsburgh.
MIDCAB was pioneered at the University of Pittsburgh in June 1995. Since then, more than 500 of the procedures have been performed with excellent results.
Coronary heart disease affects more than 12 million Americans and is the leading cause of death. According to the most recent data from the American Heart Association, more than 600,000 bypass surgeries and nearly 450,000 angioplasty procedures were performed in the United States in 1997.
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