Wednesday, March 02, 2011

VATS LIMA and PCI: The Best of Both Worlds

I have some form of familial hypercholesterolemia which results in low HDL and high triglycerides. Consequently, I expect that at some point in the next 10-20 years, I may be needing some sort of cardiac intervention. Having observed and assisted with open heart surgeries while in medical school, I am amazed at the technical expertise involved with open heart surgery. Splitting the chest open and sowing vein grafts on a beating heart is a miracle of modern medicine. However, as many open heart patients can attest, recovery from a CABG is a bear, and those vein graphs never seem to last. On the other side, Interventional Cardiologist are trying to put the Cardiothoracic Surgeons out of business. I have seen some patients with up to 14 drug eluting stents placed in a single patient with few problems of in-stent re-stenosis.

But it seems that when it comes to a decision between CABG vs. PCI, it is either one or the other. For extensive 3-vessel disease, a patient is recommended to undergo a CABG. For more focal disease, PCI is the standard. But why not get the best of both worlds. What if it were possible to get all the benefits of a CABG without having to be put on cardio-pulmonary bypass, or getting your chest split open? That is what I want.

The best part of a CABG (Coronary Artery Bypass Graph) procedure is having the surgeon dissect down the Left Internal Mammary Artery (LIMA) which runs right over your heart on the inner chest wall. It's like God put this big fat artery right that isn't used for anything right in the perfect spot. When a cardiac surgeon graphs this big fat vessel into your LAD (Left Anterior Descending Artery), patients rarely every have any further problems. The high flow of the LIMA means it nor the LAD will ever go bad again. The rub is having to get your chest cracked to get this done. But, what if you could skip the chest cracking part?

Turns out that a few Cardiothoracic Surgeons are able to do the LIMA procedure without a thoracotomy. These CT Surgeons can do the LIMA part with a video camera and a scope (Video Assisted Thorascoscopic Surgery). The only thing you miss by getting your LIMA via VATS is the months of recovery pain after getting your sternum cut in half and wired back together, getting pump sickness after being on the bypass pump, and getting those pesky Saphenous vein graphs on the back of the heart which never last. Oh and did I mention that you would also miss out on getting your leg slit open up one side in order to harvest the Saphenous Vein.

Instead of dividing patients, as we do know, between an ALL CT Surgery solution, vs. and ALL Interventional Cardiology solution, why couldn't a patient get the best of both worlds. If I had my preference, I am hoping for PCI and stents to fix any acute problems together with a VATS LIMA to keep my LAD well perfused.

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