Tuesday 3rd March 2015

Joseph Zacharias is a Consultant Cardiothoracic Surgeon at Blackpool Victoria Hospital. Here, he discusses mitral valve treatment.

Over the past 10 years, the proportion of mitral valve procedures done via a keyhole approach in Germany and Belgium has risen to near 60%. Sadly in the UK, less than 5% of mitral surgery cases are presently done by using a keyhole approach. There are good reasons for this disparity.

When we started to explore introducing a keyhole approach in Blackpool, the first hurdle we faced was to convince the hospital authorities that a new procedure needed to be introduced. Previous experience of this keyhole approach and its poor safety record led to much anxiety. The reasons for past failures need to be understood to move on.

In the past, the technology available for Thoracoscopes (keyhole cameras) was very basic. As technology got better, the light source and the definition of the picture on the screen improved greatly. Due to increased magnification of the valve (x5 magnification), high definition screens and cameras the detail that is now visualised is better than that seen by the naked eye of traditional surgeons. Another great advance has been the routine use of Trans Oesophageal Echocardiography (TOE) by cardiac anaesthetists which provide real time pictures of the function of the heart. I do believe that with better thoracoscopes and routine TOE, minimally invasive mitral surgery has become safer.

So, once the governance team was convinced that we had learnt lessons from the past and were confident that we would have results from small incisions that were comparable to traditional open heart surgery, we then had to convince the finance managers that this would save costs in the long run. This isn’t easy in the NHS. We made the case that patients with smaller incisions would spend less time in both intensive care and on the ward and that it was hoped that blood transfusions and infection rates would be lower. All this would even out the expense of single use instruments required for this type of procedure.

When we received clearance to start the keyhole approach program, we faced the huge pressure of offering this procedure without a learning curve. As the results of mitral surgery through a sternotomy (spreading the breast bone) are so good in the UK, improving on it is no easy task on a background of higher expectations from patients. However, after visiting teams elsewhere who had already implemented keyhole approaches, we at Blackpool also began to offer the approach.

To date we have performed over 250 cases using a keyhole approach, offering it to patients needing surgery on the Mitral and Tricuspid valve. We also offer it to patients with an Atrial septal defect (hole in the heart) and those with atrial fibrillation (irregular heart rhythm). We found a number of benefits:

  • An obvious cosmetic benefit to the patient
  • Less patients required a blood transfusion compared to cases done with a sternotomy at our institution
  • Patients seemed to go home at least a day or two earlier
  • Very few patients were affected by infections

The greatest advantage that patients tell us regularly is how quickly they get back to what they consider normal life. Despite the benefits, we did find some disadvantages too:

  • The procedure takes longer
  • A keyhole approach costs more up front
  • The concern that blood has to flow in the opposite direction in the body and the potential risk of having a small particle floating to the brain and causing a dreaded stroke is higher
    • We learnt early that doing some routine tests helped us to identify and exclude the those at a higher risk of a stroke. These patients are better served by sternotomy, until we have further technological advances.

Today, the NHS is noted to be cash strapped and new procedures that require capital funding are not easy to introduce which could be part of the reason keyhole procedures are not widespread. Small incision cardiac surgery is not an easy procedure to learn quickly. Cardiac surgeons have often spent 20 years to get a consultant job. With results being closely scrutinised, the incentive to start another learning curve is not high. There will always be cases that will need a sternotomy but the hope is that the percentage of sternotomy cases will get fewer by the year.

Keyhole surgery should not be seen as competitive technology, rather collaborative. There is no doubt that this type of surgery is not for all patients and we will find out over the coming years, if this kind of surgery is for all surgical teams. What I believe we should remember is, that the responsibility on us surgeons is to ensure patients do not end up coming to harm and are offered a keyhole surgery approach when appropriate.

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