New minimally invasive cardiac procedures are saving lives and aiding speedier recovery
Cardiac specialists at Sunnybrook Health Sciences Centre are pioneering new minimally invasive treatments for patients who are not well enough to undergo open-heart surgery.
“One of our key strategic priorities is to develop minimally invasive procedures. They are easier for complex-case patients to tolerate and offer earlier discharge and recovery compared to open-heart surgery,” says Dr. Bradley Strauss, chief of the Schulich Heart Centre.
These innovative procedures are all performed without splitting the breastbone or placing patients on a heart-lung bypass machine. Working together as a team, interventional cardiologists, cardiac and vascular surgeons, imaging technicians, anesthetists, specially trained nurses, and industry specialists collaborate on patient care.
Here are three of the innovative ways Sunnybrook is saving lives.
Susana Remenyi-Prentice, a harpist and teacher at the Royal Conservatory of Music in Toronto, was at death’s door with congestive heart failure due to a narrowed heart valve. Traditional open-heart surgery was deemed too risky due to space constraints in her aorta.
Susana Remenyi-Prentice, cardiac patient
photo by Tim Fraser
Sunnybrook’s Dr. Sam Radhakrishnan and Dr. Stephen Fremes placed an artificial valve in her heart using a state-of-the-art technique known as transcatheter aortic valve implantation, or TAVI. Using real-time X-ray imaging, they fed a catheter into her groin and through an artery to her heart and deployed the new valve inside a small mesh stent, fitting it snugly inside the old valve.
"The stent that contains the porcine leaflets of the new valve is made of nitinol, a self-expanding metal composite which is held in place by friction," says Dr. Radhakrishnan, interventional cardiologist and physician-lead for the TAVI program.
"It takes about three to four hours in total, but the valve deployment takes about two minutes," says Dr. Stephen Fremes, TAVI program surgical lead. “Patients are taken off the breathing machine at the end of the operation. It's pretty astounding to see how well they look so soon after the procedure.”
"Many patients who were previously out of breath just walking across the room are up walking two days after a TAVI procedure," adds Dr. Radhakrishnan.
TAVI patient Susana says: “For me, TAVI saved my life. I am a testament to miracles that can be achieved, even for patients at a critical stage.”
Since it began in September 2009, Sunnybrook’s TAVI program has saved the lives of more than 180 seriously-ill patients. The program started with seed money from donors and received provincial funding for 75 more procedures last January. Each procedure costs about $35,000. Sunnybrook is one of six TAVI sites in Ontario and one of three in Toronto.
While the program is only currently approved for inoperable patients, the future lies with program expansion to include moderate risk patients. "TAVI has been pioneered by Canadians and we continue to lead in this technology," says Dr. Radhakrishnan.
While the program is only currently approved for inoperable patients, it is hoped that it will expand in the future to include moderate risk patients.
Sunnybrook’s MitraClip program is the first in Toronto and one of only four programs in Canada to offer minimally invasive mitral valve repair.
Mitral regurgitation is a common heart disease as people age. When the valve no longer closes properly, blood flows backwards into the heart and patients find themselves out of breath during normal activities. Left untreated, the condition can be fatal.
The MitraClip is a simple device that holds the delicate leaflets of the mitral valve together. Dr. Gideon Cohen, head of cardiovascular surgery and Dr. Eric Cohen, deputy chief of the Schulich Heart Centre, work together to pass a catheter through a vein in a patient’s groin and install the clip. Because every patient has different anatomy, the procedure is planned carefully with sophisticated imaging and requires surgeons with an established track record in mitral repair surgeries.
“MitraClip is a very gentle minimally invasive procedure. Our patients are usually up walking the day of the procedure,” says Dr. Gideon Cohen.
So far, Sunnybrook has treated 37 patients with MitraClip. The program currently depends on donor support, but doctors and patients are optimistic that it will receive provincial funding in the future.
Sunnybrook is also the first centre in Toronto to perform minimally invasive, beating-heart bypass surgery, helping more than 30 patients so far.
A bypass operation restores blood flow to the heart for patients who have plaque buildup in their coronary arteries. A graft is taken from a vein or artery in another part of the body and sewn to the coronary artery to reroute and restore blood flow. Cardiac surgeon Dr. Fuad Moussa uses a small 5 cm-long chest incision under the left breast to gain access, operating without placing the patient on a heart-lung bypass machine.
“Minimally-invasive beating heart bypass offers major advantages for patients. The vast majority are taken off the ventilator in the operating room and returned to intensive care awake and alert. They return home within days and can return to normal activities in a couple of weeks rather than months,” says Dr. Moussa.
“Single bypasses work well with the minimally invasive technique and I have done two double-bypasses. In the future, hybrid strategies will become more prevalent where we perform double bypasses and stenting operations to completely revascularize patients,” says Dr. Moussa.