Making ‘simple’ heart surgery simpler, with minimally invasive techniques

minimally invasive heart surgeryTertiary care centers such as the Boston Children’s Hospital Heart Center have led the way in groundbreaking surgical innovations for years, pushing boundaries and correcting ever more complex abnormalities.

But innovation is also making a difference when it comes to more “common” procedures.

“We’re always trying to make the less complex procedures shorter and less invasive,” says Sitaram Emani, MD, director of the Complex Biventricular Repair Program at the Heart Center. “Making surgery and recovery less painful and disruptive for all of our patients is a priority.”

Emani and his fellow cardiac surgeons have pioneered a minimally-invasive “scope” approach, repairing a host of common problems normally requiring open-heart surgery — including ventricular septal defects, atrial septal defects, tetralogy of fallot, aortic valve defects, vascular rings and patent ductus arteriosis (PDA) — through small incisions.

The new method not only decreases pain discomfort, and scarring, but also gets patients in and out of the hospital in half the time.

Comparing surgical strategies

For example: let’s look at the standard strategy for vascular ring surgery.

A vascular ring is a condition in which abnormally configured blood vessels in the chest compress the airway and esophagus, causing shortness of breath, noisy breathing or difficulty swallowing food.  Treatment requires division of the vascular ring to release the pressure it is exerting. The standard approach is an open thoracotomy, in which surgeons access the heart and blood vessels by opening up the side of a child’s chest and moving the ribs. After the repair, the surgeon re-aligns the ribs and closes the incision, leaving a lengthy scar.

Because of the way the ribs are manipulated, patients risk developing scoliosis as they grow.  Plus, the incision can be painful, and kids have activity restrictions until the ribs and incision heal. Emani’s method doesn’t require a large incision, keeps the ribs intact and leaves a much smaller scar. In some cases, the use of a heart-lung machine may not be needed, and extra risks associated with bypass (such as clotting) can be avoided.

It means going out of your comfort zone at first, but now it’s my preferred approach.

Emani starts the procedure by making three small slits on the patient’s side. Then he inserts a specially designed surgical scope into the chest to visualize the vessels he needs to repair. Through the scope, he controls tiny tools that allow him to operate on a child’s heart from a distance.

Traditionally, surgical methods using a scope have only been used in adult surgeries, but Emani has developed the tools and techniques necessary to make these highly delicate, technical procedures possible in children. The skills take time to acquire, but he now feels even more confident with this approach than with open heart surgery, since the scope can magnify the view and provide perspective. “It just means going out of your comfort zone at first, but now that I have done over 100, it’s really my preferred approach,” he says.

New tools, better outcomes

big and small wrenches resizedBecause tools made for adults had to be adjusted and tailored for kids, they were largely designed “in house” at the Heart Center. Emani works with Pierre Dupont, PhD, of the Cardiac Bioengineering Lab as well as medical device companies to continually refine and redesign them.

The procedure also requires collaboration with pediatric cardiac anesthesiologists who have expertise in minimizing the impact of surgery on the lungs. “It’s difficult for surgeons at most hospitals to do this, but I hope we can develop the tools and techniques so others can benefit too,” says Emani.

At first, many of Emani’s colleagues were concerned that the more technical minimally-invasive method would mean longer surgeries.  But a recent study by Emani, which he presented this week at the American Association for Thoracic Surgery’s annual meeting, proves the overall length of surgery was no different between scope and open approaches.

What was different, however, was the length of hospital stay.

Patients who had the minimally invasive surgery stayed an average of 1.3 days compared to an average of 2.7 for open surgery.  In fact, many patients were home the next day, a difference which Emani says is due to less pain with scope approach.

And most children didn’t even need a chest tube. “We take the breathing tube out in the operating room,” explains Emani. Less pain and discomfort plus shorter recovery time means kids can get back to being kids more quickly.

“My son had surgery in 2015, and as a parent, I witnessed how much pain can impact a young child,” he says. “Most parents and patients with congenital heat disease don’t know that a minimally invasive surgery is an option for common surgeries. We want them to know what we’re doing to improve care at every level.”

Learn more about the Department of Cardiac Surgery.