Combined cardiac procedures

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In patients presenting with a number of different conditions affecting the heart and/or blood vessels, it may be possible to combine surgical treatments in such a way as to perform them as part of one single procedure. One typical combination, for instance, is bypass surgery combined with heart valve surgery. In some cases, open surgery may also be able to be combined with certain catheter-based procedures.

What are combined cardiac surgery procedures?

Combined cardiac surgery procedures combine different surgical interventions, which are then performed as part of a single surgical procedure. It is, for instance, common for surgical procedures involving the coronary arteries and the heart valves to be performed at the same time.  
Particularly in elderly patients, who frequently present with different heart and vascular disorders, combined surgical procedures can help to avoid the need for multiple surgical procedures and repeated stays in hospital.

In order to reduce the patient's overall risk, surgical interventions may at times be combined with catheter-based procedures. The combination of surgical and catheter-based techniques is known as a hybrid procedure.

When are combined procedures used?

Combined cardiovascular procedures may represent a suitable option in patients with two or more of the following conditions:

Coronary heart disease requiring bypass surgery
Heart valve disease
Cardiac arrhythmias (Atrial fibrillation) that can be eliminated by destroying certain areas of the heart muscle responsible for producing abnormal electrical impulses (referred to as surgical ablation)
Aortic aneurysm (Enlargement of the aorta)
Carotid stenosis (Narrowing of the carotid artery)
Peripheral arterial disease (Narrowing of the blood vessels in the legs and pelvis)
Operable types of lung cancer

How can combined surgery procedures help?

Combined surgery procedures treat several conditions simultaneously. Over the past few years, combined procedures have become increasingly important in the field of cardiovascular surgery.

One of the reasons for this development is the fact that many cardiovascular disorders have the same underlying causes, with atherosclerosis a particular case in point. Over time, these underlying causes can lead to damage in different areas of the cardiovascular system. This is why elderly people frequently present with a variety of symptoms - such as when atherosclerosis affects the coronary arteries as well as the heart valves. It may sometimes be possible to combine surgical treatments, and therefore avoid the need for multiple surgical procedures.

Two procedures combined on a regular basis are bypass surgery and heart valve surgery. Cardiac surgery can also be combined with vascular surgery, which may become necessary as a result of carotid stenosis, an aortic aneurysm or atherosclerosis affecting the blood vessels in the pelvis and the legs. Combining different procedures that are to be carried out simultaneously is also possible in patients who present with a combination of heart disease and vascular disease affecting the abdominal aorta, the arteries in the pelvis, and the arteries of the legs.

Some patients with heart disease, particularly those who have been smokers for a long time, also present with lung cancer. As a result, specialist centers have to deal with combined surgical measures targeted at conditions affecting the heart and the lungs regularly. As with combined procedures involving the heart/vascular system, combined procedures involving the heart and lungs should only be performed by surgeons who are also qualified in thoracic surgery. Our Center offers such combined procedures. All combined procedures require an experienced team and careful evaluation of the most appropriate surgical approach, often requiring an interdisciplinary approach. Complex procedures involving the heart and vascular system usually require the use of cardiopulmonary bypass (a heart-lung machine).  

Nowadays, surgical procedures may be combined with specialist catheter-based procedures. This type of combined procedure is referred to as a hybrid procedure. As catheter-based interventions cause considerably less trauma to patients than conventional surgery, this hybrid approach can help to minimize surgical risk to the patient, particularly in elderly patients. In a patient who presents with several narrowed coronary arteries, for instance, it is possible to treat one of the arteries using minimally-invasive techniques that do not require the use of cardiopulmonary bypass (a heart-lung machine), while the other might be able to be widened using a balloon catheter introduced via a blood vessel in the groin.  

A hybrid procedure can also be of benefit in patients whose aorta is affected by an extensive aneurysm. In these cases, aortic repair can be combined with heart valve surgery, allowing sections of the thoracic aorta to be replaced with prostheses while the abdominal aorta would be reinforced using an endovascular stent. The stent would be introduced via an artery in the groin, and would then be connected to the surgically implanted aortic prosthesis.  

Due to the fact that catheter-based procedures have undergone enormous developments over the past few years, it is highly likely that hybrid procedures will come to play an increasingly important part in the treatment of complex disorders affecting the heart and vascular system.

What happens during combined surgery procedures?

Depending on the exact type of conditions being treated, there is a whole range of cardiovascular surgery techniques to choose from.
One of the more common hybrid procedures, which combines multiple bypass grafting procedures with heart valve surgery, typically consists of the following steps:

Once the patient has been placed under general anesthesia, the first step is to cut through the breastbone and open the chest.
The surgeon then dissects away the distal end of the left interior thoracic artery from the chest wall. This is used to establish a bypass route to the heart. At the same time, a second surgeon harvests a vein from the leg. Depending on the number of bypass grafts required, this may be cut into several sections.
The patient is then connected to a cardiopulmonary bypass (heart-lung) machine: after taking in blood from the superior and inferior vena cava, the blood is saturated with oxygen inside the machine and pumped back into the aorta. The machine effectively takes over the function of the heart.
The heart itself can now be stopped using a special infusion - the surgeon now works on a stopped heart.
The bypass routes are created using the thoracic artery and the previously harvested sections of the patient's own vein; the defective heart valves are either replaced with prostheses, or they are reconstructed using specialist surgical techniques.
In some cases, the surgeon may also have to treat an aortic aneurysm by implanting a vascular prosthesis.
When blood is finally allowed to flow through the heart, the heart is warmed up; in many cases, the heart will start to beat spontaneously, or it may be re-started using mild electric shocks.
Heart function and vascular function are carefully checked before the surgical team finally disconnect the heart-lung machine.
The breastbone is repaired using wire, and the chest is closed.

Relevant information

Universitätsklinikum der MHB

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Emergency numbers

Emergencies only:
112
Our emergency room:
+49 3338-69 45 21

Contact person

Univ.-Prof. Dr. med.
Johannes Albes
Head of Department of Cardiac Surgery at Brandenburg Heart Center

PA to the Head of Department Gudrun Gaal
Immanuel Hospital Bernau Brandenburg Heart Center
Ladeburger Str. 17
16321 Bernau bei Berlin
T +40 3338 694-510
F +49 3338 694-544
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