THE HEART OF THE MATTER
a special program of the National Emergency Medicine Association (NEMA) 

Week: 551.3 Guest: Dr. James Fonger, Cardiologist, Sinai Hospital of Baltimore Topic: Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Producer/Host: Steve Girard

NEMA: It's called MIDCAB, or minimally invasive direct coronary artery bypass, describing two important properties of the procedure...it's done through smaller incisions, and yet is still done under direct vision, not through a TV probe. Dr. James Fonger of Sinai Hospital of Baltimore says the procedure carries three important innovations to coronary bypass surgery...

FONGER: The first is that we don't use the heart-lung machine to accomplish this, as we do with conventional surgery, knowing that we work now instead of stopping the heart, on ways to mechanically stabilize the area of interest. The second is, that we do this through small incisions through various locations around the chest cavity, not dividing the breast bone, as is currently done with the 12 inch vertical incision for a standard heart surgery. That, of course, has some profound implications for reducing the time in hospital, as well as the time of full recovery. And then a third unique aspect of this is that we're not manipulating the great vessels that come off the heart, which also reduces the risk at the time of the actual surgical intervention.

NEMA: Because it is minimally invasive, are you limited in what can be done for the patient in this procedure?

FONGER: Three years ago, when we began this initiative, we had the view that this surgery would only be applicable to the artery in the front of the heart, would only be applicable to people with one-vessel problems, and would only be used in patients who were having their first time heart surgery. We were basically wrong on all three counts. And as of today, we address possibly three coronary targets, depending on where they are, and what the issues involved are. Secondly, we find that we work all around the heart, not just on the front of the heart...and finally, we found possibly the most important application for this...working on patients who have had prior cardiac surgery.

NEMA: Who is and who is not a good candidate for the procedure?

FONGER: Well, I think people who are good candidates, as common sense might suggest, are people who have inordinate risks for going on the heart-lung machine, for instance, if people have had a prior stroke or might have risks for having a stroke when they are on the heart lung machine. Secondly, people who have problems or risks facing another splitting of the breastbone.

NEMA: There is another benefit... in not having to take a vein from the leg to graft in the heart procedure....

FONGER: We are generally using the arteries from either the undersurface of the chest wall, or possibly an artery swung up from the curvature on the stomach, so in most cases, we're describing small incision operations that do not involve using a vein from the leg, so the patient not only has a smaller chest incision, but also has no leg incision...and both of these factors contribute to the accelerated recovery both in hospital and once they return home.

NEMA: What further developments do you see coming with this procedure...I understand it started with Sinai and another hospital...and is moving across the country?

FONGER: I would predict that over the next two or three years, you're going to see the consolidation of approaches and attitudes about this MIDCAB procedure...and a lot more clinical experience and information available about the capabilities and limitations of the MIDCAB approach.

NEMA: So you believe that MIDCAB will be accepted alongside traditional open heart surgery?

FONGER: Well, I think one of our objectives in this new surgical endeavor is to make sure that we demonstrate to the medical community that we can duplicate the excellent quality that surgeons have been able to show over the past two decades with conventional coronary surgery.

NEMA: Now there's an Internet registry for surgeons all over the world to input their MIDCAB results. Dr. James Fonger of Sinai hospital in Baltimore says this will help all cardiologists get clinical results more quickly. The address is www.heartnet.org. For more information on the procedure, call 410-578-6343. I'm Steve Girard.