Subxiphoid Bypass Surgery is a new technique and cannot be used in every situation. Some
limitations do apply. At present, between 50% and 70% of patients needing coronary artery
bypass surgery are potential candidates, including those with:
Significant blockages (greater than 70%) in one or more of their coronary arteries,
No previous heart surgery (i.e. first time surgical patients),
Suitable anatomy of the coronary artery targets.
Good Internal Mammary Arteries.
Any age range
Male or Female
Diabetes is not a contra-indication. Since subxiphoid bypass surgery does not divide the
breast bone, wound complications and healing problems are less. This encourages the use of
both Internal Mammary Arteries even in diabetic patients.
Common conditions such as high blood pressure, emphysema, congestive heart failure (CHF), or
renal insufficiency (diseased or weak kidneys) are often associated with coronary artery disease
(CAD). Many patients with CAD have blockages in other arteries (such as the arteries in the
legs and feet). Some have suffered prior strokes or have blocked arteries to the brain (i.e.
carotid artery disease). None of these medical conditions interfere with the possible use of the
subxiphoid technique, but such patients are at a generally higher risk of complications no
matter what surgery is performed.
Patients who are not candidates for subxiphoid surgery fall into several general categories.
Emergency Status
Less invasive surgery is not appropriate for emergency situations. Patients experiencing a
recent major heart attack, episodes of shock, severe heart failure or dangerous heart rhythm
disturbances (ventricular tachycardia ("VT") or ventricular fibrillation ("VF"), pneumonia or other
major infections will not be candidates until they recover from the emergency and are stable.
Since subxiphoid bypass surgery takes more time than traditional sternal-splitting operations,
patients whose blood prdessure and heart function are not stable at the time of surgery may not
be candidates.
Body Type
The shape of a patients chest wall, ribs, or abdomen can make this new surgical approach very
difficult. Some patients with very strong (or rigid) bone and ribs will not allow enough exposure
to the heart when trying to lift the sternum. This is usually seen in young muscular males.
Also, the shape of the chest and rib cage can make a difference in the ability to work inside the
small incision. Only a physical exam by the surgeon and review of the chest x-ray or CAT scan
can determine if the chest anatomy is suitable or not.
Heart Size and Position
If the heart is positioned far to the patients left side, or it is enlarged, the surgeon may not be
able to reach every one of the blocked heart arteries through this small incision. Also,
patients with enlarged or shifted hearts may not remain stable when the heart is rotated into
different positions during the procedure. Sometimes the surgeon can tell prior to surgery if the
heart is too large or shifted too far towards the patients left side. However, final
determination of the heart size and position (and how they affect the procedure) is usually only
possible in the operating room.
Coronary Artery Anatomy
Sometimes the anatomy or condition of the blocked heart arteries is not suitable for less invasive
surgery, such as arteries that are:
Buried in the heart muscle (not visible on the surface of the heart),
Very small size (less than 1.5 mm in diameter)
Diffusely diseased (plaque build up everywhere so that no zone of the artery is easy to
bypass)
The only way to know if any of these conditions is present is to have your angiogram films
evaluated by the surgeon.
Unsuitable Internal Mammary Arteries
Over 90% of Internal Mammary Arteries ("IMA") are excellent vessels for use as bypass graft
material. However, in a rare patient, the IMA is too short, small, delicate, or even occluded or
blocked by vascular disease. If your cardiologist has taken a picture of the IIMA vessels at the
time of your last angiogram, then it will be possible to know if the vessel is good enough for this
type of less invasive surgery. If no pictures were obtained, then the only way to know is for
the surgeon to assess the IMA vessels in the operating room.
Prior Heart Surgery
If you have had previous heart surgery (not including stents or balloons), then subxiphoid bypass
surgery may not be possible. As the technique advances, some patients with previous heart
surgery may be candidates, but at this time only first-time patients are being considered.
There are a few exceptions. If you are still interested in exploring the possibility of subxiphoid
bypass surgery, then you may want to submit an Evaluation Form and ask Dr. Levinson for his
opinion.
Other Relative Contraindications
Patients needing other heart surgery at the same time as bypass surgery (heart valve
replacement/repair, aortic aneurysm surgery) are not candidates for this less invasive approach.
Some patients with severe lower extremity vascular disease (total occlusion of the abdominal
aorta or both iliac arteries) will not tolerate harvesting of both Internal Mammary Arteries and
so other vessels (such as leg vein) may be needed to construct the bypass grafts.
And Finally...
Some patients can receive successful subxiphoid bypass surgery to one or two of the most
important heart arteries while the cardiologist later performs a stent to less important heart
arteries. This strategy is called hybrid therapy. These patients are still candidates for
subxiphoid surgery, but will also need a stent procedure before release from the hospital.
