These blockages can be treated by medicines, stents or heart bypass surgery depending on the severity and number of blockages. In cases of two or more arteries being blocked, surgery is the best option.
During heart bypass surgery one can use arteries from inside the chest called internal mammary arteries, of which there are two in number, or veins from the leg called saphenous veins to bypass the blocked arteries and supply blood beyond the blockage. The internal mammary arteries last more than 30 years whereas the commonly used leg veins block off in 10 years and the patient would require a redo surgery which is of high risk in nature. Further, it has been clearly shown that using both mammary arteries reduces reoperation rate and increases survival. However we still use only one artery and leg veins and this tradition has been going on since heart bypass surgery started in the 70`s. 8 lac CABGs are done worldwide and less than 1% get the mammary arterial grafts despite all its advantages. This is also not popular because of the technical difficulty and chance of sternal breakdown.
The Minimal access or keyhole surgery has revolutionized all fields of surgery. However, in heart surgery we are still following the much old and outdated procedure of making a big incision in the middle of the chest with all its complications and the associated patient fear and apprehension. Robotic surgery because of its cost factor, availability and technical difficulty is still not increasingly followed in cardiac surgery even in the West.
Now the gold standard in heart surgery would be by using both mammary arteries and using a keyhole incision giving the patient the best. The Keyhole surgery would enable the patient to be discharged from the hospital in three days and back at work in 10 days from discharge whether one is an executive or a manual laborer.
Considering the advantages of internal mammary arteries and keyhole surgery, and the fact that nearly 90% of Indians pay out of pocket, and getting back to work after surgery is important for financial stability, keyhole and total arterial grafting is the answer.
The answer to this has been provided by an innovative technique, started by an Indian cardiac surgeon [Dr.Pradeep Nambiar]; Senior consultant Max Hospital, Patparganj Delhi and Chairman Cardiothoracic Surgery Rockland Group of Hospitals [Qutab, Dwarka, Manesar] previously on the professional staff of the Cleveland Clinic Heart Center, Ohio, USA and has been in Delhi since the last 2 years.
Dr. Nambiar is the first person in the world to harvest both mammary arteries directly under vision through a 2inch incision under the left breast without any robotic or thoracoscopic assistance to carry out heart bypass surgery on a beating heart. This technique which is called The Nambiar Technique, was presented at the 2012 World Conference of the International Society of Minimally Invasive Cardiac Surgery [ISMICS] at Los Angeles in the USA as a video presentation and surgeons were of the consensus that this is the future. Further a manuscript has been sent to the Annals of Thoracic Surgery ,the leading journal of cardiothoracic surgery in the world in the world for publication, ciing over 150 consecutive cases done successfully through a 2 inch mini incision. Dr .NAMBIAR states that considering the regularity of the mini incision it is a matter of time that all cases are done through a mini incision and the chest splitting incision is history.
Presently Dr. Nambiar carries out 99% of his heart bypass cases through this mini incision with excellent outcomes and cutting the sternal bone is a rarity. [Even hearts with poor function are operated through this small incision]
Advantages of arterial grafting – increased survival, decreased reoperation rate and early mobility because there are no incision on the legs.
Advantages of key hole surgery- less pain, less infection, early mobility, minimal blood transfusion; discharge from hospital as early as 2 days and back to work in 10 days.
Dr. Sharma, Law Prof, University of Delhi, states, "I was out of the hospital on the third day after the operation and back at work within 10 days of discharge. We are lucky and proud to have Dr.Nambiar in India. Pandit Trilokchand who was operated by this technique states that after the operation the pain was negligible and he was walking around the ICU the same evening of surgery. Dr.Nambiar also operates on a lot of foreign nationals and he adds in humor that the door to door time for these patients is one week including the surgery. Dr. Nambiar is working out a media campaign to spread this revolutionary technique not only in India but worldwide. Plans are being made to inculcate this technique in the post graduate residency programs. Dr. Nambiar states that the advantage of this technique should reach all strata of society both in India and abroad.
MS,FRCS, FRCSC-Canada (Cardiac Surgery)
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