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MCI (P) 050/02/2013
THURSDAY MARCH 7 2013
Your Life. Live it well.
ONLY
ONE
CUT
Singapore doctor develops
less invasive
heart valve operation
pages12-14
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THE STRAITS TIMES
MARCH 7 2013
Cover Story
Heart surgery with smaller scars
Doctors now
tackle defective
heart valves
through smaller
JOAN CHEW
incisions that
hasten recovery
I
t used to be that patients who had
heart valves repaired or replaced
would come out of surgery with a scar
that stretched the entire length of the
sternum or breastbone.
It would start right below the
neck’s hollow, run down the centre of the
chest and end above the abdomen.
Patients would carry a 15 to 20cm long
scar for the rest of their lives.
This traditional method of heart surgery,
called full median sternotomy, separates
the sternum to expose the fist-sized heart
muscle for surgeons to work on.
While this is still the standard approach
in cardiac surgery, less invasive techniques
have been used in recent years by a
handful of doctors here, with one even
developing his own method.
There is no formal consensus on what
constitutes minimally invasive
cardiothoracic surgery. It is understood that
the term refers to operations performed
through incisions other than the traditional
full median sternotomy.
They usually involve smaller incisions,
which reduce body trauma, hence
potentially reducing pain, scarring and
recovery time.
Minimally invasive cardiothoracic surgery
was first introduced during the 1990s,
driven by major improvements in
technology.
Associate Professor Theodoros Kofidis,
head of the division of adult cardiac surgery
at the department of cardiac, thoracic and
vascular surgery at National University
Heart Centre, Singapore (NUHCS), said the
move was also a response to changing
patient expectations.
He said patients used to be grateful for
coming out of open heart surgery alive, but
soon also expected to have the least
possible complications.
Improved cosmetic results were later
added to their wishlist, which prompted
surgeons to adapt to those needs, he said.
He set up the minimally invasive cardiac
surgery programme in NUHCS three years
ago. Since then, he has been using the
minimally invasive approach for four in
every 10 patients who require surgery on a
single heart valve. He has also developed
his own method (see page 14).
The National Heart Centre Singapore
(NHCS) has been using the minimally
invasive approach in heart valve surgery
since 2007.
SMALLER INCISIONS
Minimally invasive heart surgery can be
used to fix faulty heart valves, a hole in the
heart, irregular heartbeats and for coronary
artery bypass graft surgery to improve blood
supply to the heart. However, this
technique is not used when many defects
occur at the same time.
During heart valve surgery, sternotomy
can be done with a smaller incision which
cuts through half the sternum, said Dr Lim
Yeong Phang, a cardiovascular and thoracic
surgeon at Gleneagles Hospital and Mount
Elizabeth Novena Hospital.
The scar would be 6 to 8cm long.
The operation, known as upper
sternotomy, still involves cutting the
breastbone and joining it back with steel
wires.
Dr Lim said any bone fracture requires
six weeks to heal properly, during which
patients should not drive or lift anything
heavier than a newborn baby.
Thus, another approach which does not
involve bones but cuts through just soft
tissue and muscles would speed up the
healing process.
Prof Kofidis said a patient may be in
hospital for 10 days after undergoing full
median sternotomy and eight or nine days
after upper sternotomy.
A procedure called right minithoracotomy
could further reduce the stay to about five
days, he said.
In this procedure, the surgeon makes a
4 to 10cm incision between the ribs on the
right chest and another three to five
incisions, or portholes, near the area for
the passage of surgical instruments. Each
porthole is between 5 and 10mm. No bone
is involved.
The operation also requires a 4cm
incision in the groin, through which doctors
insert tubes, called cannulas, to be
connected to a heart-lung machine that
takes over the functions of the patient’s
heart and lungs during the operation.
This approach has been used on
patients at NUHCS since 2009 and with
robot-guided instruments since 2010.
Eleven patients of NHCS have also had
robot-assisted mitral valve repair through
minithoracotomy. The mitral valve is one of
four heart valves which should open one
way only to allow blood through.
Businessman Craig Andrew McEvoy, 49,
was lucky to benefit from less invasive
surgery. The Australian is the only patient
at NUHCS who has undergone Prof Kofidis’
modified minithoracotomy. His leaky mitral
valve was repaired through a single 6cm
incision in his right chest.
For three months last year, he was
hospitalised when a streptococcus
infection affected his brain and heart. He
also had other problems such as water
collecting in his abdomen, inflammation of
the pancreas and a fatty liver.
Mr McEvoy, who is moving to Bangkok
after living here for 20 years, said he used
to drink and smoke heavily while
entertaining customers at his pub.
Prof Kofidis said the bacteria had
perforated Mr McEvoy’s mitral valve so it
could not close tightly and caused blood to
flow back wrongly into the heart.
Mr McEvoy and his 48-year-old Thai wife,
Mrs Bunsri McEvoy, were sold on the
prospect of a faster recovery, as he was in
poor health and had lost 20kg during the
Fixing faulty valves
ST PHOTOS: NG SOR LUAN, AZIZ HUSSIN
Mr Craig Andrew McEvoy (left), who had a
minimally invasive procedure on his heart
valve, has a smaller scar compared with
Mr Choo Kok Weng (above), who had
conventional surgery.
three months when he was hospitalised.
He was admitted to NUH for 17 days
after the heart valve surgery – longer than if
he had been a healthier patient.
The businessman, who has cut down on
his smoking, recalled: “With me pushing 50
years of age, I was not too bothered by the
size of the scar. But as I love going to the
beach, the small scar was definitely an
added bonus for me.”
NOT FOR EVERYONE
Despite the appeal of smaller scars, not
everyone is suitable for less invasive
techniques.
Dr Tan Teing Ee, a senior consultant at
the department of cardiothoracic surgery in
NHCS, said patients who are unstable,
have other serious medical conditions or
lung disease, have a small rib cage or
require other cardiac procedures, such as a
bypass, at the same time are not suitable.
One such patient is church worker Choo
Kok Weng, 50, who was diagnosed with
coronary artery disease and mitral
regurgitation last December.
He had an operation on Jan 25 to repair
his mitral valve, which did not close as
tightly as it should, and also had a coronary
bypass to replace a blocked heart vessel
with one taken from the chest wall.
He was hospitalised for five days at
Gleneagles Hospital and now has an 18cm
scar, but he is not too bothered. Instead,
he is thankful his ailments were detected
before a heart attack endangered his life.
Sometimes, surgeons have to revert to
the traditional approach in the event of
complications during surgery.
In one study published in the European
Journal Of Cardio-Thoracic Surgery in 2008,
four out of 1,339 patients who went in for
minimally invasive mitral valve repair for
mitral regurgitation had to have the surgery
converted to sternotomy because of
problems such as excessive bleeding and
tears in the aorta, the main artery arising
from the heart.
The authors found that 83 per cent of
patients reached the five-year survival rate,
while 96 per cent did not require another
mitral valve-related operation in that same
period.
A drawback of this study was that there
was no control group to compare against
as the Leipzig Heart Center of the
University of Leipzig in Germany had made
minimally invasive mitral valve surgery its
procedure of choice since the late 1990s.
In other studies, 92 per cent of patients
who underwent sternotomy survived for at
least 10 years, while 93 per cent of
patients did not require another operation
in the five years afterwards.
Another study published in The Journal
Of Thoracic And Cardiovascular Surgery last
April compared early outcomes from 138
patients who had minimally invasive aortic
valve surgery by minithoracotomy and
matched them to a control group of 138
with conventional full sternotomy.
Overall, 0.7 per cent of patients died in
hospital, with no difference between the
two groups. The incidences of stroke, renal
failure and wound infection were similar.
Those who were operated on using the
less invasive approach also had a lower
incidence of post-operative irregular
heartbeat and blood transfusion and
shorter ventilation time and hospital stay.
CHALLENGES AND COMPLICATIONS
At least three cardiothoracic surgeons said
they did not think minimally invasive
approaches would become the standard of
care for heart valve surgery yet.
They said the promising results from
overseas studies are difficult to replicate
here as surgeons do not have a large pool
of heart valve patients to hone their
expertise in this technique.
Dr Lim has performed thoracotomy only
once, in 2009, on a patient whose “unique
anatomy” made him unsuitable for
sternotomy.
His heart was displaced to the right side
of his chest as his right lung had been
removed earlier, so the right thoracotomy
was optimal.
Dr Sriram Shankar, a consultant
cardiothoracic and vascular surgeon at
Gleneagles Medical Centre, said he offers
thoracotomy only to patients who have had
sternotomy previously.
Scar tissue forming on organs after the
first operation would make it complicated
to do another operation at the same spot in
the sternum, he said.
He said complications, such as internal
bleeding, can be more easily tackled if a
patient has had sternotomy, as doctors can
simply remove the steel wires on the
sternum to access the heart in intensive
care, which takes five minutes.
On the other hand, a patient who had
thoracotomy would have to be wheeled
back into the operating theatre to have
his chest cracked open using
sternotomy.
[email protected]
Improving technology has enabled
more people with defective heart
valves to have them repaired instead
of replaced, which preserves heart
function better and has a lower risk of
complications.
The mitral valve separates the two
left chambers of the heart – left atrium
and left ventricle – while the aortic
valve lies between the left ventricle
and the aorta, which pumps
oxygen-rich blood from the heart to the
rest of the body.
Among the four valves, the mitral
valve and the aortic valve are more
vulnerable to damage. The mitral valve
is prone to leakage and infections,
while the aortic valve endures high
blood pressure to prevent the backflow
of blood leaving the heart.
Associate Professor Theodoros
Kofidis, head of the division of adult
cardiac surgery at the department of
cardiac, thoracic and vascular surgery
at National University Heart Centre,
Singapore (NUHCS), said problems
with these two types of valves – mitral
and aortic – make up more than seven
in 10 of all heart valve diseases.
The National Heart Centre Singapore
(NHCS) handles 250 cases of heart
valve surgery a year, of which about
half are related to faulty mitral valves.
In 2005, 46 per cent of patients
who had mitral valve surgery had their
valves repaired rather than replaced, a
number that has gone up to
69.8 per cent in 2011.
At NUHCS, 48.6 per cent of patients
who underwent mitral valve operations
last year had repairs done, up from
30 per cent in 2010.
Valves control the flow of blood into
and out of the ventricles in only one,
correct direction.
They can fail due to age-related
degeneration, rheumatic heart disease,
endocarditis (infection of heart valves)
and heart attacks.
When a valve is unable to close
properly and tightly, some of the blood
that has already been pumped through
it can leak back in what is known as
regurgitation. This forces the heart to
work harder and, over time, can
damage the heart.
If a valve becomes narrowed,
sometimes due to the accumulation of
calcium deposits with age, blood flow
through it is restricted and again, puts
a strain on the heart.
Such problems give rise to
symptoms such as fatigue, chest pain,
shortness of breath and heart
palpitations, which may eventually lead
to heart failure, when there is
insufficient blood flow throughout the
body.
Patients may be treated with
medication first to relax the heart and
relieve their symptoms.
Dr Tan Teing Ee, a senior consultant
at the department of cardiothoracic
surgery in NHCS, said surgery is used
if symptoms become severe or if a
two-dimensional echocardiogram
(ultrasound of the heart) shows that
the heart is unable to maintain
adequate blood circulation.
NATURAL IS BEST
Less than 20 years ago, it was
conventional to replace faulty valves
with biological or mechanical
replacements, said Dr Sriram Shankar,
a consultant cardiothoracic and
vascular surgeon in private practice at
Gleneagles Medical Centre.
But increasing understanding of
valves means the different parts –
such as the leaflets (cusps of the
valve), their surrounding papillary
muscles and chords (string-like
structures that attach the leaflets to
the papillary muscles) – can be
repaired.
Dr Lim Yeong Phang, a
cardiovascular and thoracic surgeon in
private practice at Gleneagles and
Mount Elizabeth Novena hospitals,
said it was only in the last five years
that surgeons here have begun to do
repair work on valves more routinely.
This is preferable to valve
replacements, as people who have had
such surgery are required to take blood
thinners to reduce their risk of blood
clots forming on the replaced valve,
which can lead to strokes and death.
Dr Shankar said mechanical valves
made of titanium and pyrolitic carbon
are known to last 80 years but require
patients to be on blood thinners for
life.
On the other hand, biological valves
made of cow or pig tissue require up to
three months of blood thinners but last
only 10 to 12 years, so additional
operations would be needed for
younger patients.
Dr Shankar added that any type of
artificial valve replacement would not
be able to pump as much blood out of
the heart as the patient’s natural valve
could.
As a result, his heart function can
drop by 20 per cent.
Valve repair is generally preferred
now, unless the valve is so severely
damaged that it has to be replaced.
Only aortic valves are replaced more
often than they are repaired.
Dr C. Sivathasan, a consultant
cardiothoracic and vascular surgeon at
Mount Elizabeth Medical Centre, said
problematic aortic valves are usually
calcified or hardened, so it is not ideal
to repair them.
Doctors note that valve disorders
are set to rise with a growing and
ageing population.
Prof Kofidis said overseas studies
have shown that in industrialised
countries such as Singapore,
3 per cent of the population have heart
valve disease, of whom half will need
surgery.
The prevalence rises to 11 per cent
for those aged 75 and above.
By Joan Chew
14
THE STRAITS TIMES
MARCH 7 2013
FROM SIX CUTS TO ONE
Current method: Two incisions, four portholes
ATRIAL RETRACTOR
Device with three large ar ticulated ar ms
holds the incision in the hear t open
for the surgeon to reach the valves
inside. It is clamped to the bed
to prevent movement.
AORTIC CROSS-CLAMP
This clamps the aor ta to stop
the flow of blood. Its handles
protrude from the body .
CAMERA
CARBON DIOXIDE AND SUCTION TUBES
Carbon dioxide, which is denser than air , is
pumped around the hear t to pre vent air from
entering the bloodstream. An air bubble trapped
in a blood vessel can block an ar tery and cause a
stroke or hear t attack. Blood is constantly suck ed
out to k eep the surgical vie w clear for the surgeon.
MAIN SURGICAL INCISION
The surgeon gains access
to the hear t through
this incision, which
is betw een 4
and 10cm.
New method: One incision, no portholes
This new technique, a world-first, eliminates all portholes
occupied by the camera, clamp and tubes.
FEMORAL INCISION
Through this 3 to
4cm incision, tubes
are inser ted into the
femoral vein and
femoral ar tery and
connected to the
heart-lung machine
during surger y. After
surger y is completed,
the vessels and
incision are stitched
closed.
Note: Drawings have
been simplified for ease
of representation.
ONE SURGICAL INCISION
The new technique pro vides the
surgeon access to the hear t
from just one 6cm incision on
the side of the chest.
Aortic cross-clamp
with handles that
can be detached
FEMORAL HOLES
The two tubes connected to the hear t-lung machine are
now passed through two 5mm holes in the skin. After
surger y, a de vice deliver s sutures through these
holes to close the cuts in the blood vessels.
The holes do not need to be stitched later .
Getting inside the heart
3
Aorta
distributes
oxygenrich blood
to the rest
of the body.
2
DETACHABLE
AORTIC CROSSCLAMP
After the clamp is in
place, the handles
can be remo ved so
they will not tak e up
space around the
incision in the
chest.
Needles
Incision
Holes
2cm
8cm
1
Sutures
MODIFIED ATRIAL RETRACTOR
A newly developed flexible steel
plate is used to hold the incision
in the hear t open, without the
need for a bulk y retractor.
1 T wo sutures and their needles
are passed through the holes of
the retractor. The y are either 2
pulled out of the 6cm incision or ,
more frequently, 3 passed
through the skin of the chest,
before the y are clamped to hold
the plate in place. If the y are
pulled through the skin of the
chest, each hole is less than 1mm,
so it does not cause an y wound
that needs to be stitched later .
Source: Associate Professor Theodoros Kofidis,
head of the division of adult cardiac surgery at
the department of cardiac, thoracic and vascular
surgery at National University Heart Centre, Singapore
ST GRAPHICS: MIKE M DIZON
O
ne doctor here has entered the race to
make surgery on faulty heart valves
less invasive – using modified surgical
tools to reduce the number of cuts
made in the body from five or six to
one.
Associate Professor Theodoros Kofidis, senior
consultant and head of adult cardiac surgery at
National University Heart Centre, Singapore
(NUHCS) successfully repaired 49-year-old
businessman Craig Andrew McEvoy’s valve through
a single cut on the chest last December.
Prof Kofidis, 43, calls the procedure the single
incision minimally invasive cardiac surgery.
Most patients with mitral and tricuspid heart
valve disease, estimated to exceed 200 here each
year, may benefit from the new operation, he said.
The mitral valve separates the two left chambers
of the heart, while the tricuspid valve separates the
two right chambers. They can become torn or leaky
because of ageing, heart failure and congenital
defects and need to be surgically repaired.
His main innovations include modifying the atrial
retractor, a tool which holds the incision in the
heart open to expose the valves inside; and the
aortic cross-clamp, which is used to stop blood
flowing through the aorta during surgery.
The atrial retractor, which occupies a porthole in
the chest wall, is a bulky instrument with three
arms which takes up standing space in the
operating theatre.
Prof Kofidis’ replacement is a malleable steel
plate that is inserted through the single incision. It
is flexed to hold the incision in the heart open and
clamped outside the body to hold it in place. No
porthole is required. After the operation, it is simply
removed. A paper on this was published in
The Annals Of Thoracic Surgery in 2011.
The aortic cross-clamp occupies another porthole
in the chest wall. Prof Kofidis used one invented by
an Italian surgeon, which has handles that can be
detached and removed while it is in use.
This means that it can be passed through the
single 6cm incision between the ribs and will not
require a separate porthole.
Another innovation involves the incisions that are
made in the thigh. They allow blood to be pumped
out and in through the femoral vein and artery
respectively and passed through a heart-lung
machine, which takes over the function of the
patient’s heart and lungs during the operation.
In the conventional minithoracotomy, the blood
vessels are accessed through a 4cm skin incision.
After the surgery, the cuts in the vessels are
stitched closed before the skin incision is also
closed.
In Prof Kofidis’ procedure, the tubes to connect
these two blood vessels to the heart-lung machine
are passed through holes smaller than 5mm in the
skin, which do not require stitching.
Prof Kofidis then uses a special device that
delivers sutures through the skin to close the
vessels, without the need for any skin incisions.
This device is already used in less major heart
procedures such as the insertion of a stent to keep
a partially blocked blood vessel open, he said.
Besides the improved cosmetic outcome, the
new technique may also help cut complications
from surgery, though this will have to be shown in
clinical studies.
Patients who cannot have the procedure are
those who are severely obese, have aortic valve
leakage or have less conventional heart anatomy.
A thick layer of fat in the body can obstruct a
surgeon’s view during minimally invasive, single
incision surgery, Prof Kofidis said.
A subsidised patient at NUHCS pays between
$3,100 and $13,200 for the new procedure. This is
$2,000 more than what he would pay for full
median sternotomy, which costs between $1,100
and $11,200, depending on the level of subsidies.
By Joan Chew