Subxiphoid surgery is a new, less invasive technique which takes advantage of the normal

anatomy to expose the heart where the surgeon can perform the operation without dividing

the breast bone.     The potential advantages of this technique in most patients include:

Smaller Incision

Traditional heart bypass surgery uses vertical incision from the top of the breast bone down to

the upper abdomen (about 12 inches).      With subxiphoid bypass surgery, only the lower 4

inches of the traditional incision is used and the breast bone is not divided.      Instead, a special

lifting device is used to lift the breast bone forward, allowing the surgeon enough room

underneath the sternum to perform the operation.

Less Pain

There are a number of reasons why the pain with subxiphoid surgery is usually less than with

traditional surgery:

The incision is smaller

The breast bone is not split

Nerves, bones, ligaments,  muscles ,etc are not injured or divided

Local anesthetic is infused before the patient wakes up

Intravenous pain relievers are given as the patient awakes from anesthesia

Earlier Return to Full Activities

Patients undergoing traditional "sternotomy" for bypass surgery are advised to avoid manual

labor or activities with their upper body for 6 to 8 weeks after they leave the hospital.     During

this time the bone is allowed to form a solid union.     Too much activity before this time can

lead to a chronically unstable and painful breast bone.

Since the subxiphoid incision is smaller and the bone and muscles are not divided, it is possible

for the pateitn to return to normal activities much sooner than with traditional surgery.   Some

patients leave the hospital in 2 or 3 days and are ready to resume full activities in 1 to 2 weeks,

including use of their upper body.

Emphasis on Arterial Bypass Grafting

Ninety-five percent (95%) of patients undergoing traditional bypass surgery receive only a single

artery bypass (the Left Internal Mammary Artery or "LIMA").   The remaining bypasses are

usually taken leg veins.    The incisions in the legs are often the most painful part of the

procedure and the veins usually do not last as many years as artery grafts like the LIMA.

With subxiphoid surgery, most of the bypasses are constructed from arteries  (Left and Right

Internal Mammary Artery . the Radial Artery, or the Right Gastroepiploic artery).     Artery

bypass grafts typically last longer than veins from the leg.    By avoiding the leg veins, there are

no painful leg incisions.

Beating Heart ("Off-Pump") Technique

In most cases of bypass grafting using the subxiphoid technique, the "heart-lung" machine is not

needed and the heart is not stopped.     While the heart remains beating, the surgeon places a

stabilizing device on the heart surface to reduce motion of a small region while the bypass is

sewn to the coronary artery.  This allows the bypass to be constructed without stopping the

heart.    A temporary shunt (made from hollow silicone tubing) is placed inside the coronary

artery so that blood is always flowing to the heart muscle even while the bypass is being

constructed.

Easy Conversion to Traditional Bypass Surgery

Sometimes situations arise where the breast bone still needs to be opened, such as poor

exposure to the heart, a sudden drop in blood pressure, or changes in heart rhythm or EKG

during the procedure.    One of the advantages of the subxiphoid technique is the ability to

quickly extend the incision and create the traditional (sternal-splitting) incision without

any additional harm to the patient.   In other words, starting the surgery using the subxipoid

approach does not surrender any option should  less invasive surgery prove too difficult.   In

addition, converting to the traditional technique ("sternotomy") does not leave the patient with

"extra" incisions that become abandoned after opening the sternum.

Not every patient is a candidate for this new technique.   Descriptions of Potential Candidates as

well as Contraindications can be reviewed by clicking on these links ( or the menu at the top of

this page).    With any new technique there are always new challenges and subxiphoid is no

exception.    Here are some of the extra challenges faced when performing this operation

through a small incision:

Longer surgery times

With traditional bypass surgery, even a multiple bypass operation usually takes less than 4 hours.

However, with subxiphoid surgery, the time required to harvest multiple artery grafts while

working through a very small incision is longer than with traditional bypass surgery.     This can

be stressful on family members waiting to hear news from the operating room.    However, the

longer surgery times are usually not a sign of problems during the surgery.    It just takes longer

to do a more advanced type of surgery through a much smaller incision.

More technical challenges for the surgeon

Arterial bypass grafts are more delicate and can be damaged during harvesting.     Mobilizing

the Internal Mammary Arteries from the inside of the rib cage requires patience and delicate

technqiue.     However, these artery bypasses are worth the extra time because they will last

longer.  Also, they are smaller and less versatile than vein from the leg.     Usually one artery

graft is suitable for just one or two bypasses.    For the surgeon, vein grafts are easier to use

but for the patient, artery grafts give superior long term results.    Subxiphoid surgery tries to

use as many artery grafts as possible, but this requires more time in the operating room and

more technical challenges for the surgeon.     In some cases, not every blocked artery can be

reached through this small incision.     In such cases, the surgeon forgo a difficult bypass and

refer the patient for a stent to this vessel (a strategy known as hybrid therapy).

In summary, the procedure is more difficult to perform for the surgeon but easier on the

patient!