Cardiac Surgery

Open-Heart Procedures Performed Without Heart-Lung Bypass

Patients at the University of Virginia Health System requiring coronary artery bypass grafts or atrial fibrillation (AF) ablations may benefit from leading-edge open-heart procedures only offered in a small percentage of hospitals nationally.

Assistant Professor of Surgery Gorav Ailawadi, M.D., now performs ablations (together with electrophysiologist and Assistant Professor of Internal Medicine Srijoy Mahapatra, M.D.) and CABG through minimally invasive procedures that do not use the heart-lung bypass machine.

The open-heart technique "isn't applicable to every patient, but the fact that it's available is very important," says David Jones, M.D., Division Head of Thoracic and Cardiovascular Surgery at UVA. "The ability to avoid using the heart-lung bypass for select patients avoids all the complications and assorted morbidities of going on bypass."

 

Coronary Artery Bypass Graft

Four groups of patients needing CABG tend to benefit from undergoing the procedure without the heart-lung bypass machine, Ailawadi says:

  • Patients with severe aortic calcification. The heart-lung machine requires placing a clamp on the aorta, which can increase stroke risk in patients with aortic disease.
  • Patients with poorly functioning kidneys. Research data has shown that kidney function is better following surgery for patients who undergo CABG without the heart-lung machine.
  • Patients with poorly functioning hearts. Some data suggests these patients do worse when the heart is stopped with the heart-lung machine.
  • Patients taking the blood thinner Clopidogrel. These patients have a propensity to bleed, especially with use of the heart-lung machine.

While there is a lack of consensus about the benefits of performing CABG without the heart-lung machine, Ailawadi says, research shows it lessens some complication risks, including the need for blood transfusions, arrhythmias and a decline in kidney function. Patients undergoing CABG without the heart-lung machine also tend to leave the hospital about a half-day sooner.

 

Atrial Fibrillation Ablation

Surgical ablation is usually performed on AF patients resistant to standard ablations delivered with a groin-inserted catheter. The technique used by Ailawadi delivers the ablation through the side of a patient's chest through three small incisions - two incisions are about 1 cm, and the third is typically 3-4 cm.

AF originates on the epicardial surface of a patient's pulmonary vein, Ailawadi says. However, ablations delivered by a groin-inserted catheter deliver energy from the inside of the vein and work to the outside. Surgical ablation - while requiring general anesthetic - allows physicians to clamp the pulmonary vein at the source of the AF and deliver the ablation directly to the epicardial surface of the pulmonary vein, creating a more efficient ablation. Surgical ablations are almost 100 percent effective at obtaining pulmonary vein isolation and at least 90 percent effective at creating transmural lesions, Mahapatra says. A recent study in the Journal of Cardiovascular Electrophysiology showed an 88 percent AF cure rate with this technique, he adds.

The procedure also removes the atrial appendage, Ailawadi says, nearly eliminating a patient's stroke risk and the need for coumadin while reducing the risk for pulmonary vein stenosis and LA-esophageal fistula.

Following the ablation, Mahapatra performs electrophysiological pacing and rigorously checks for an electrical block to make sure the ablation is complete. "What we've done is combine the best of electrophysiology and the surgical field," Mahapatra says.

Those most likely to benefit from a surgical ablation include patients who:

  • Have failed a catheter ablation
  • Have large atriums
  • Need another cardiac or thoracic surgical procedure with their ablation
  • Are unable to tolerate Warfarin

 

UVA Performs Unique VT Ablation

About 500,000 Americans have ventricular tachycardia (VT), and about 80 percent of cases are refractory VT, which is typically treated with an implantable cardiac defibrillator (ICD). While the ICD is effective, Mahapatra says, the ICD's routine shocks can negatively affect a patient's quality of life, in some cases causing a form of post-traumatic stress disorder.

Endocardial VT ablations are only about 50 percent effective because 20 to 60 percent of VT cases have critical circuits on the epicardium, Mahapatra says. In those cases, an endocardial VT ablation is either less effective or requires so much energy that it raises a patient's stroke risk.

To better treat those patients, Mahapatra is performing epicardial VT ablations delivered through a needle inserted to the outside of the heart. Mahapatra performed more than 55 epicardial VT ablations while training on the procedure in Brazil, where it was developed, and has performed more than 10 epicardial VT ablations at UVA.

Ailawadi helps Mahapatra access the outside of the heart one of several ways, depending on the patient's anatomy. Ailawadi sometimes removes fat that blocks access to the epicardium or makes a 1 cm incision to break up adhesions on the epicardium to ensure a smoother, more effective ablation.

The primary beneficiaries of epicardial VT ablations, Mahapatra says, are patients with refractory VT who failed drug therapy or an endocardial ablation.

 

Leading-Edge Cardiothoracic Care

The partnership between Mahapatra and Ailawadi is just one example of UVA's multidisciplinary approach to cardiothoracic surgery.

UVA's team approach to cardiothoracic surgery includes specialized cardiac anesthesiologists, perfusionists, cardiologists and electrophysiologists from UVA's Atrial Fibrillation Center. Surgeons work closely with electrophysiologists to provide a multidisciplinary approach and individualized treatment for arrhythmias and atrial fibrillation.

"This is just one example of our efforts to bring clinical innovation to the Commonwealth and the Mid-Atlantic region," Jones says, pointing to UVA's pioneering work in repairing heart valves and the insertion of aortic stents.

To refer a patient for an ablation or CABG, call UVA Physician Direct at 800-552-3723.