March 8, 2012
In recent months, NYU Langone’s robotic cardiac surgeons have begun teaming with the Medical Center’s interventional cardiologists to perform a remarkable new “hybrid” procedure that combines non-invasive angioplasty with a minimally-invasive, robot-assisted coronary artery bypass operation. The new approach restores optimal blood flow to the patient’s heart through previously clogged arteries, without having to cut through the chest bone or place the patient on a heart-lung machine - allowing a much swifter recovery, while significantly reducing post-operative discomfort.
“This approach combines the best of angioplasty and the best of cardiac surgery,” explains Dr. Didier Loulmet, NYU Langone’s chief of cardiac surgery, who has performed the bypass portion of numerous hybrid procedures. “Angioplasty is always the first-line treatment for coronary artery disease, but many patients have one artery that is simply too occluded for angioplasty. Typically this is the main coronary vessel, the left anterior descending [LAD] artery.”
In the past, the only option for the occluded artery was open-heart coronary artery bypass surgery - a highly invasive procedure that involves a large chest incision and weeks of painful recovery. Over the last dozen years, however, Dr. Loulmet and others have pioneered another option: a robot-assisted coronary artery bypass procedure, in which the surgeon introduces miniaturized instruments through small incisions between the ribs, instead of sawing through the patient’s breastbone.
When this bypass is done only on the LAD, the operation becomes even easier on the patient, since the arterial graft can be done using the mammary artery, which lies on the chest wall just in front of the LAD. This requires a relatively simple surgery that can be performed on a beating heart in just two hours, eliminating the additional stress of being placed on a heart-lung machine during the procedure.
Because robotic coronary artery bypass on the LAD is so forgiving, doctors are now realizing they can combine it with angioplasty and stenting on the patient’s other clogged arteries, all with very little disruption to the patient. “Theoretically, we could even do the two procedures at the very same time, using NYU Langone’s hybrid surgery room,” says Dr. Loulmet, referring to the Medical Center’s new, multimillion-dollar operating facility that combines state-of-the-art surgical equipment with a full catheterization lab. “Usually, though, we do the robotic bypass first, then interventional cardiologists do the angioplasty three days later. That way, the patient is recovered enough from the robotic procedure to actually walk to their angioplasty procedure.”
With this approach, patients typically go home the day after their angioplasty is performed, for a total hospital stay of just five days. Even more importantly, they’re discharged with minimal trauma to their body and a new blood supply to their heart that is built to last. “Grafting a mammary artery onto the LAD has been the most successful procedure in coronary artery bypass surgery,” notes Dr. Loulmet. “The data shows that 97 percent of these grafts remain open ten years later.”
The pool of candidates for this hybrid technique - people who can benefit from angioplasty on some of their coronary arteries, but have an LAD artery requiring surgery - is huge, adds Dr. Loulmet. “The potential for this approach is enormous,” he says. “When you tell patients that there’s a solution that doesn’t require getting cut open, they can’t believe it. Once surgeons and catheterization lab physicians begin to accept this approach, we will do many surgical bypass cases this way. I really think it could become the standard of care.”