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Winter 2008: Heart

Interventional Cardiologists and Surgeons Bring New Innovations

Rapid advances in technology and technique are blurring traditional lines between cardiac surgery and interventional cardiology in the 21st century. These remarkable breakthroughs also mean a new paradigm of care, bringing together interventional cardiologists, cardiothoracic surgeons and other experts to evaluate each patient and design customized treatment plans that meet individual needs.

And collaborative care, in turn, spawns new innovation.

 

During robotic procedures, the surgeon at the console views the image and controls the
instruments,
while a nurse and another surgeon at the patient's side change instruments
and deliver sutures.
  

“In addition to improving outcomes and overall patient satisfaction, the team approach creates opportunities for collaborative care and training that would never occur in a traditional treatment setting,” says Richard J. Shemin, M.D., who joined UCLA last year as the Robert and Kelly Day Professor, chief of cardiothoracic surgery and co-director of the new UCLA Cardiovascular Center.


Advances arising from this increasingly collaborative setting are rapidly expanding treatment options for the full range of cardiovascular diseases and procedures, including heart-valve repair and replacement, aortic-aneurysm repair, coronary-artery disease, and the ablation of arrhythmias, such as atrial fibrillation. When surgery is the best option, the goal is to reduce the trauma of surgery with less invasive approaches. For example, robotic devices have become an increasingly valuable tool to interface between the surgeon and the instruments used to perform an operation. The da Vinci robotic system, explains Dr. Shemin, allows cardiothoracic surgeons to perform mitral-valve repairs and bypass procedures through mini-incisions and a trio of keyhole openings no bigger than the width of a pencil for the operative instruments.

While seated at a console, the surgeon performs the robotic procedure with instruments that allow micromanipulation, and a three-dimensional camera provides a magnified view of the surgical site. Other advantages include full range of motion of the miniaturized instruments working in very confined spaces within the heart and computer software that cancels any perceptible micro-tremor.

Aesthetic considerations also factor into less invasive treatment options for cardiovascular disease. For example, mitral-valve conditions requiring repair of the valve are relatively common in young women. For those who require surgery, skinsurface scarring is limited by the minimally invasive robotic approaches. By strategically positioning incisions under the crease of the breast, the same location used by a plastic surgeon in placing breast implants, the surface scar is minimal and hidden.

Robotics also holds future promise for less invasive coronary-artery bypass surgery options. Research shows that the key to the long-term success of bypass surgery is the use of the left internal mammary artery (located beneath the chest bone) to bypass blockages of the main artery on the front surface of the heart (left anterior descending coronary artery), Dr. Shemin explains.

“If we have to take one vessel that’s most important in terms of symptoms and long-term survival, research has consistently shown that is the one,” says Abbas Ardehali, M.D., associate professor and surgical director of lung and heart-lung transplantation at UCLA.

Today, high-risk patients often have stents implanted to open the native coronary artery rather than undergo an invasive open procedure required for an internal-mammary-artery bypass. The robotic techniques make bypass surgery a minimally invasive alternative option, enhancing survival and symptom relief. Hybrid procedures can be performed allowing a robotic left-internal-mammary-artery bypass grafting to the left anterior descending artery (LIMA to the LAD) and stenting of other coronary-artery blockages.

Minimally invasive options for aortic-valve replacement are currently performed at UCLA. Dr. Shemin envisions stenting of coronary arteries and valve surgery performed as a single procedure in the same hybrid OR/cath room. Trials for percutaneous heart valves inserted via the groin or the chest wall are underway. Dr. Shemin and Jonathan Tobis, M.D., UCLA interventional cardiologist, will lead the team of surgeons and interventional cardiologists when trials of the percutaneous aortic valve begin at UCLA in Spring 2008.

Already, new interventional approaches allow cardiologists and cardiac surgeons to perform delicate ablation procedures to correct potentially deadly ventricular arrhythmias caused by tissue abnormalities on the surface of the heart and to treat the most common cardiac arrhythmia, atrial fibrillation. Minimally invasive ablation techniques previously were available only for arrhythmias originating from inside the heart. But now, epicardial ablation to correct ventricular arrhythmias can be performed on the exterior of the heart. Epicardial ablation involves threading the ablation device through the skin into the sac around the heart. The energy is transmitted to the epicardial surface of the atrial or ventricular muscle via catheters that can ablate tissue with either heat or cold.

“Irregular heart rhythms can originate anywhere, even on the heart’s surface. The closer the cardiologists can get to the origin of the arrhythmia, the more effective treatment will be,” says Kalyanam Shivkumar, M.D., Ph.D., director of the UCLA Cardiac Arrhythmia Center and Electrophysiology Programs.

For patients with intractable angina caused by lack of blood flow to the heart, transmyocardial laser revascularization (TMLR) offers relief to those who are ineligible for bypass surgery and whose arteries are too diseased to support a stent. TMLR utilizes a laser to create a series of tiny channels into areas of heart muscle lacking adequate blood supply. The laser stimulates growth of new blood vessels and may also destroy nerve fibers that radiate pain, thus improving the patient’s anginal symptoms.





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