Peachtree Cardiovascular & Thoracic Surgeons is a leader in minimally invasive surgical techniques in all areas of heart and lung surgery.
We are the Southeastern Training Center for the daVinci Robotic System and have trained surgeons across the country and internationally in robotically assisted surgery techniques.
Our surgeons excel in advanced techniques in cardiac and thoracic surgery. We perform more minimally invasive heart surgery than any other group in the United States. We utilize both robotically assisted and by hand through small ports. It is no longer necessary in most instances to have a sternotomy (cutting open the breast bone) to have your surgery. Coronary artery bypass surgery for multiple vessels does still require a sternotomy, but can be done with a smaller incision. Ask your doctor for details. If he does not offer the procedure, he will be happy to refer you to one of his partners that specialize in a certain technique that may give you a better result.
When you come to Peachtree Cardiovascular, we work together as a team to offer you the best results possible. Your surgeon may feel it is necessary to have another surgeon perform the case for a specialized result, such as robotically assisted surgery. All of our surgeons can perform all types of heart surgery, however, some of our surgeons specialize in certain areas. They will work together to offer you the best solution for your clinical situation.
Our practice has performed a high volume of minimally invasive cases and we feel that these techniques benefit our patients by giving them;
Faster recovery
Less pain
Better surgical result
Minimally invasive surgery can be performed at any of our locations, however, only Saint Joseph's Hospital in Atlanta has a daVinci Robotic System to perform robotically assisted surgery. In 2009 Northeast Georgia Medical Center will also aquire a daVinci Robotic System.
To find out about these procedures, contact our office at 404-252-6104 or 404-355-9515 or 678-450-4944 or email to info@peachtreecardiovascular.com
Coronary artery bypass grafting is the most common heart surgery performed in the United States. Coronary artery bypass is performed on patients with significant blockages in their arteries, known as atherosclerosis. Your cardiologist will assess your candidacy for less invasive techniques, such as angioplasty prior to referring you to a cardiac surgeon for bypass surgery.
Conventional Surgery:
Conventional coronary artery bypass grafting consists of utilizing the Heart-Lung Machine, often utilizing a 12 inch incision down the middle of your chest and separating the breast bone. Once your chest is open, the surgeon uses arteries from your chest or vein from your leg to bypass the blockage. After surgery, your breast bone is rejoined using stainless steel wires and your incision is sewn up. It will take your breast bone about six to eight weeks to heal.
MIDCAB:
Minimally invasive direct coronary artery bypass is a method of performing coronary bypass on a beating heart. The heart-lung machine is not used. The location and size of the incision will vary according to the location of the blockage in the coronary artery. When the blockage is on the front of the heart, the procedure requires a 3-4-inch horizontal incision under the left breast. An incision in the upper abdomen at the base of the breastbone is used for blockages on the bottom of the heart. When the blockage is on the side or back of the heart, a 5-inch horizontal incision is placed in the left rib cage towards the back. The recovery time from this procedure is significantly less that that of conventional surgery, since the breast bone is not separated during this technique.
Why is it performed?
MIDCAB is primarily indicated for patients who have an obstruction in one or two coronary arteries. It can be performed on a variety of patients, including those who previously underwent conventional bypass grafting, patients who are not candidates for angioplasty, or whose angioplasty was unsuccessful, or patients with a medical history such as stroke or lung disease who would benefit from a less invasive procedure.
Minimally Invasive Vein Harvesting for CABG:
During heart bypass surgery, a blood vessel is taken from elsewhere in the patients body to create a bypass around the clogged heart artery. The surgical procedure during which this vessel is removed is called Vessel Harvesting. The most commonly used vessels for this procedure are the Saphenous Vein (which runs the length of the inner side of the leg), and the Internal Mammary Artery (in the chest). Recent advances have also made the Radial Artery (in the forearm) a viable choice.
In traditional vessel harvesting, a surgeon creates an incision along the entire length of the leg or forearm in order to remove the vessel. However, less invasive methods now require only one or two keyhole incisions to access the vessel. This technique is less painful for the patient and involves only minimal scarring. And because the area of incision is much smaller, the chances of infection are reduced.
The majority of our patients are candidates for minimally invasive vein harvesting.
Heart Valve Surgery:
Valve disease occurs when the valve doesn't work the way it should. If a valve does not open or close all the way, less blood can move through or blood may leak backwards. These problems make the heart work harder to pump the same amount of blood or blood may back up into the lungs or body because it is not moving efficiently through the heart. These problems happen from either stenosis (hardening of the valve) or regurgitation (weakening of the valve) which cause the valve to malfunction in either opening all the way or closing tightly. Since the mitral and aortic valves work on the left side of the heart to supply blood to the body, they work harder than the valves on the right side of the heart that supply blood to the lungs. For this reason, these are the valves that usually require replacement.
Conventional Heart valve surgery is performed to either repair or replace the damaged valve. Repairing a heart valve is performed when the valve can be strengthened or parts of the valve can be repaired to make it stronger and work more efficiently. This is done by both cutting and separating parts of the stenotic valve that is stiff or hardened to help them open wider. The valve can be strengthened and shortened to help the valve close more tightly.
If the valve cannot be repaired, then the surgeon will have to replace the valve with a prosthetic valve. Replacement of the valve can be done with either mechanical or biological valves.
Mechanical valves are created from manmade materials and require lifetime therapy with anticoagulant medication when this type of valve is used.
Biological valves are taken from a pig, cow, or human donor. They do not last as long as a mechanical valve, but they do not require long-term therapy with anticoagulant medication when this type of valve is used. Your surgeon will discuss which valve is best for you. Many factors are considered, including your age, the size of your valve, you occupation, how well you heart is currently working, your hearts rhythm, how many valves you need replaced and your ability to take anticoagulant medicine.
Stentless valves are often used in patients that have a small aortic root or in patients that are not candidates for homografts (valves from human cadavers) or autografts.
Atrial Septal Defect:
Atrial Septal Defect or ASD as it is commonly referred to is caused during fetal development of the heart. There is an opening in the heart wall (the septum) separating the left and right upper chambers of the heart. Normally, this opening closes before birth, but if it does not, the child is born with a hole between the left and right atria. This abnormal opening is called an atrial septal defect and causes blood from the left atrium to flow into the right atrium.
Different types of atrial septal defects can occur, and they are classified according to where in the separating wall they are found. The most commonly found atrial septal defect occurs in the middle of the atrial septum and accounts for about 70% of all atrial septal defects. Abnormal openings can form in the upper and lower parts of the atrial septum as well.
These abnormalities can go unnoticed if the opening is small, producing no abnormal symptoms. If the defect is big, large amounts of blood flowing from the left to the right atrium will cause the right atrium to swell to hold the extra blood.
People born with an atrial septal defect can have no symptoms through their twenties, but by age 40, most people with this condition have symptoms that can include shortness of breath, rapid abnormal beating of the atria (atrial fibrillation), and eventually heart failure.
ASD can now be repaired using the da Vinci Surgical System in patients which meet the criteria and offers a minimally invasive alternative to conventional surgery. Your surgeon can discuss with you the options available to you based on your medical history
Robotically Assisted Surgery
Endoscopic cardiac surgery refers to procedures on the structures of the heart performed with robotic instruments passed through small holes or ports in the side of the chest. There is no disruption of the thoracic skeleton like spreading of the ribs or sawing of the breast bone. These ports can be on the right or left side of the chest depending on the type of cardiac procedure performed.
Two technological advances of the last decade have greatly facilitated endoscopic cardiac surgery. First, specialized catheters called the Port Access System (Cardiovations, New Brunswick, NJ) were developed. These catheters are inserted through punctures in the neck and a small groin incision. Through these catheters surgeons can support the circulation with the heart lung machine, stop the heart and preserve its function while repairing heart defects.
Second, came the development of da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA) with which the surgeon can visualize the heart and repair defects using standardized techniques that previously required handheld instruments.
The da Vinci robot consists of an Instrument Cart with an endoscope (camera arm) and two instrument arms which is placed next to the patient. The Instrument Cart is connected by wire to a Master Console several feet from the patient. The surgeon slips the endoscope and instrument arm tips through small ports between the patients ribs and then moves to the Master Console placing his hands into glove-like controllers while looking into the camera viewer.
The da Vinci endoscopic camera has two side by side lens and a powerful light so the surgeon at the console sees a well illuminated magnified (10X) three dimensional view of the heart structures. The surgeon controls the instrument arms with the glove-like controllers and the robotic instruments follow the surgeons hands exactly. The computer of the robot can scale the surgeons hand movements to make them extremely accurate and also filters out any unintentional movements like tremor.
The surgeons of Peachtree Cardiovascular have extensive experience with Port Access catheters and have more experience with endoscopic robotic cardiac surgery with the da Vinci Robotic System than any other program in the United States. Unfortunately, not all cardiac surgery can be accomplished by the endoscopic robotic approach. The most common procedures that can usually be accomplished with this technique include:
Lobectomy - Partial or Full Removal of Atrial Masses (tumors) Removal of Atrial or Ventricular Thrombi (blood clots) Coronary Bypass Surgery (LIMA to LAD) Surgical Ablation for Atrial Fibrillation Placement of Pacemaker Leads Drainage of Pericardial Fluid Thymectomy for Myasthenia Gravis
Endoscopic robotic cardiac surgery can benefit the patient in two major areas. First, the primary procedure on the heart defect may be improved over more conventional large incision approaches. The remarkable visual and instrumentation capabilities of the da Vinci robot can allow very precise analysis of abnormalities and very accurate suturing.
Using mitral valve surgery as an example it is well established that mitral valve repair is a more effective therapy than mitral valve replacement with a man made valve. The current mitral valve repair rate in the United States using conventional large incisions is only 50%. Using the endoscopic robotic approach with the da Vinci system our repair rate has been nearly 100% in the last two years.
Second, an endoscopic procedure is the least invasive approach currently practiced in cardiac surgery. This offers the patient a host of benefits. The most obvious of these is a rapid recovery from the trauma of surgery with less pain and prompt resumption of full activities. Since there is no bone to heal there is no reason to restrict postoperative motion and patients are instructed to resume normal activities as soon as their soft tissue soreness allows. Most patients in our experience are very active by three weeks following surgery. With only small incisions we have experienced no chest wall infections, blood loss has been significantly reduced and the cosmetic appearance of the small ports on the side of the chest wall has been very well received. Another distinct advantage of this surgical approach may be better preservation of brain function following heart surgery. Since the entire cardiac procedure is performed in an environment of very high CO2 concentration the risk of nitrogen embolism to the brain is reduced. Additionally, this endoscopic technique may result in substantially less introduction of fat into the blood stream and embolization of fat particles to the brain may be a cause of brain dysfunction after heart surgery.
The da Vinci robot consists of an Instrument Cart with an endoscope (camera arm) and two instrument arms which is placed next to the patient. The Instrument Cart is connected by wire to a Master Console several feet from the patient. The surgeon slips the endoscope and instrument arm tips through small ports between the patients ribs and then moves to the Master Console placing his hands into glove-like controllers while looking into the camera viewer.
The da Vinci Surgical System is a computer-enhanced minimally invasive surgical system consisting of three components: the InSite Vision System, Surgical Cart and Surgeon Console. The InSite Vision System provides the surgeon with a true minimally invasive 3-D view of the surgical field including depth of field, magnification and high resolution. The Surgical Cart includes the EndoWrist Instruments. It has up to four robotic arms whereby the laparoscope and up to three EndoWrist Instruments are inserted. The EndoWrist Instruments are designed to mimic the movement of the human hands, wrists and fingers. The extensive range of motion allows precision that is not available in standard minimally invasive procedures. The Surgeon Console contains the master controls that the surgeon uses to manipulate the EndoWrist instruments. The handles or Masters translate the surgeons natural hand and wrist movements into corresponding, precise and scaled movements. The EndoWrist Instruments are only able to move when commanded by the surgeon.
With its 3-D view, the da Vinci Surgical System aids the surgeon in more easily identifying vital anatomy such as the delicate nerves and blood vessels surrounding specific anatomy. The EndoWrist Instruments provide the surgeon with the dexterity not available using conventional laparoscopic instruments to perform a delicate and precise surgical dissection , reconstruction or removal of specific tissue.
For more information or to find out if you are a candidate for robotically assisted surgery, please Contact us for more information or to schedule a consultation.
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It isnt always necessary to open the chest for many heart surgery procedures. Some patients may be eligible for an advanced technique called PORT ACCESS* Valve Surgery, which allows surgeons to operate through small openings (ports) between the ribs. This eliminates the need to cut through the breastbone. A heart-lung machine, also used in a less invasive manner, keeps the patients blood circulating while the heart is stopped. This technique is currently used for mitral valve surgery, ASD and can be used to harvest the internal mammary artery in some patients.
ROSS Procedure
The Ross procedure was first performed by Mr. Donald Ross ("Mr." is an honorary title for a surgeon in England) in 1967 in England. Considering the level of cardiac surgical technology at that time this was an extraordinary accomplishment. Prosthetic (artificial) heart valves were not readily available at that time. The Ross procedure was designed for people with aortic valve pathology. The patient's pulmonic valve (autograft) is moved into the aortic position to replace the defective aortic valve and the pulmonic valve is replaced with a pulmonary homograft from a cadaver.
The pulmonic valve is similar in morphology to the aortic valve. The pulmonic valve contains less calcium than aortic tissue and is thought to be a reason for greater longevity compared to the use of a aortic homograft. (Pulmonic homografts work well in the pulmonic position).
Advantages and Disadvantages
The Ross procedure is a long, complex operation when compared to a routine aortic valve replacement with a man-made aortic valve. It is necessary to replace two valves when only one valve is defective to start with. The use of blood products can be greater with a Ross procedure especially if the patient has a propensity to bleeding.
However, the advantages are many. No postoperative anticoagulant therapy is necessary. There is minimal risk of thromboembolism (blood clots on the valve) which can be a problem with prosthetic valves. There is no sudden failure of the Ross valves and a lower incidence of endocarditis (infection of the valve). Ultimately there is superior durability of the Ross valve, thereby making it the best choice of valve replacement in a specific subset of the population.
The Ross procedure is ideal for patients who live in a location where medical care is not geographically convenient or readily available. It is also advantageous in young women wishing to have children.
Operative Procedure
The Ross procedure is a very involved procedure and may take 3-6 hours to complete. The length of stay in the hospital is typically 3-5 days provided no complications arise. It requires cardiopulmonary bypass (heart lung machine) and cannot be done "off pump". Minimally invasive techniques are not ideal for this procedure. General recuperation at home is four to six weeks.
TMR
Transmyocardial Laser Revascularization (TMR) is a surgical procedure that uses a laser to make channels, or small holes, directly through the heart muscle. Several patient studies have shown that these new channels reduce or relieve longstanding angina that has not responded to other conventional therapies and can improve quality of life. The FDA has approved TMR for the treatment of angina due to advanced cardiovascular disease. Prior to the FDA approval, Peachtree Cardiovascular participated in a clinical research study regarding the efficacy of TMR in patients whose angina is not amendable to clinical therapy.
At this time, it is not fully understood how TMR relieves angina. Current theories include a direct increase in blood flow to the heart muscle through the laser channels and/or the stimulation of new small blood vessel growth within the neighboring heart muscle.
Patients with severe angina that is resistant to conventional medical treatments are considered for TMR. If they are candidates for conventional procedures such as balloon angioplasty or coronary bypass surgery, these procedures are performed before offering TMR. In some cases it may be appropriate to do TMR in conjunction with these procedures.
When TMR is performed as the only surgical procedure, the surgeon creates a small left chest incision to access the beating heart. A laser probe is placed on the surface of the heart and the laser beam creates a 1mm (size of a pin) channel through the heart muscle. The blood inside the heart acts as a backstop for the laser beam after it has penetrated the entire depth of the heart wall. Between ten and 50 channels are created to restore blood flow to an area of concern.
The patients post-surgical care and hospital stay are similar to that of patients undergoing other types of minimally invasive cardiac surgery. The full clinical benefits of TMR may take several months
Endoscopic Vein Harvesting
Heart Transplantation
Congestive heart failure is a condition in which the heart muscle is too weak to pump blood to the body. This results in weakness, fatigue, shortness of breath, swelling in the feet, fluid accumulation in the lungs, organ failure and eventually death. Congestive heart failure affects approximately 4.7 million people in the United States, and 550,000 new cases are diagnosed each year. The most common cause of heart failure include coronary artery disease, heart attack, viral illness, heart valve abnormalities, and cardiac muscle weakness of unknown etiology, termed idiopathic cardiomyopathy.
Treatment of congestive heart failure begins with medical therapy. If the cause of heart failure is coronary artery disease, then bypass surgery may be performed. Other treatment options include biventricular pacemakers, mitral valve reconstruction, left ventricular remodeling, and mechanical assist devices. Patients with end stage heart failure and no evidence of kidney, lung, or liver failure, who do not respond to medical therapy, may be candidates for heart transplantation.
Patients who are evaluated for heart transplantation are placed on a national waiting list for donor hearts. The survival for heart transplantation is 90% at one year and 60% at five years.
The surgeons of Peachtree Cardiovascular performed the first 100 transplants in the Atlanta area with a total of 330 transplants to date. Survival rates for the transplant program at Saint Joseph's Hospital far exceed the national average.
In addition, Peachtree Cardiovascular surgeons have implanted numerous mechanical assist devices and artificial hearts and are involved in ongoing research trials for the surgical treatment of congestive heart failure.
Thoracic Surgery
Thoracic surgery involves the surgical treatment of organs within the chest other than the heart. This includes surgery for lung disease, both malignant and benign; surgery of the esophagus, such as esophageal cancer, reflux disease, achalasia, and Zenkers diverticulum; surgery of the chest wall, such as pectus excavatum; and surgery involving tumors of the chest, including thymoma, lymphoma, teratoma, germ cell tumors, and neurogenic tumors of the spine.
Our surgeons utilize the latest and most advanced techniques in thoracic surgery, including muscle sparing mini-thoracotomy incisions, minimally invasive thorascopic surgery, and daVinci robotic thoracic surgery. Several procedures, such as sympathectomy for hyperhydrosis, lung resection for pulmonary nodules, and thorascopic resection of mediastinal tumors, can be performed via two inch "port" incisions with patients often being discharged home the same day of surgery. Peachtree Cardiovascular surgeons work closely with pulmonologists, gastroenterologists, and oncologists to provide state of the art, multi-modality treatment of lung cancer, esophageal cancer, and other tumors of the chest.
Hyperhidrosis:
Hyperhidrosis is a disorder characterized by excessive sweating that occurs in up to 1% of the population. The excessive sweating can occur in the hands (palmar hyperhidrosis), in the armpits (axillary hyperhidrosis), in the feet (plantar hyperhidrosis), or in the face with blushing (erythrophobia). Although nobody understands the exact cause of the excessive sweating in specific individuals, it is known that the sweating is controlled by the sympathetic nervous system.
Sympathetic Nervous System
The human body possesses two different sets of nerves: the somatic nervous system and the autonomic nervous system. The somatic nervous system is the system of voluntary nerves that give us sensation (pain, heat, touch) as well as the control of our muscles that allow us to move portions of our body at will. The autonomic nervous system is the involuntary nervous system. Many bodily functions occur wihtout conscious control such as breathing, heart rate, and sweat production. The autonomic nervous system is made up of two components: the sympathetic and the parasympathetic systems. It is the sympathetic nervous system that controls sweating.
Surgical Treatment
The surgical treatment of hyperhidrosis involves destroying a specific portion of the main sympathetic nerve. The sympathetic nerve destroyed is the T2 gangloin. The surgery involoves being put to sleep and having on 5mm incision below each armpit. Through these holes, a telescope is passed which is attached to a minature video camera. The sympathetic chain is identified (T2) and destroyed with a electrocautery device. Typically, the patient remains in the hospital for a period of 2-4 hours following surgery. There is some postoperative discomfort following surgery and most patients require pain medication by mouth for a few days.
Chances of Success
The probability of success varies with the location of the excessive sweating. The surgery will cure 95-98% of excessive hand sweating (palmar hyperhidrosis) and 75-80% of armpit sweating(axillary hyperhidrosis). Approximately 25% of patients with hyperhidrosis of the feet (plantar hyperhidrosis) will note some improvement, however, the operation is not to treat this disorder, and should not be used primarily if this is the only complaint.
Contact
BR>You may call our office for a consultation with the surgeon. At that time the surgeon will discuss the risks and expose you to a list of patients who have had the procedure so that you may contact them directly. The great majority of insurance companies cover the cost of the surgery.
For more information regarding signs and symptoms of heart disease and surgical technique, click here to visit the STS Patient Information web site.
