Last fall the University of Pittsburgh Medical Center (UPMC) launched a study to determine if there are advantages of performing direct coronary bypass (MIDCAB) in patients without general anesthesia the procedure is minimally invasive. This study was to evaluate the feasibility, safety and potential benefits of using a chest-numbing epidural, like that used in child delivery, so that the patients would remain awake during surgery.

The UPMC research team includes the cardiac surgeon and anesthesiologist, who on June 15 of this year, performed the United States' first cardiac procedure in an awake patient. Marco Zenati, M.D., assistant professor of surgery at the University of Pittsburgh School of Medicine and director of the Minimally Invasive Cardiac Program at UPMC, and Juhan Paiste, M.D., assistant professor of anesthesiology and critical care medicine at the University of Pittsburgh, performed MIDCAB in an awake 51-year-old man at the VA Pittsburgh Healthcare System.

"While the patient tolerated the procedure well, this limited experience can only tell us so much. The possible benefits of this procedure are better pain relief and earlier awakening after the operation. And, by not having to place a tube in the patient's throat, which is required for general anesthesia, we could avoid pain and possible injury. But none of these potential benefits has been proven. We hope this study will provide some important insights," said Dr. Zenati, who is the study's co-principal investigator.

MIDCAB, also called beating-heart bypass surgery because no heart-lung machine is used. This procedure offers several advantages as compared to standard cardiac bypass surgery. The prime three are a much smaller incision, a reduced risk of neurological complications and a shorter hospital stay. However, patients still must deal with the effects of general anesthesia, require a tube to be placed down the trachea and can expect at least one night in an intensive care unit as part of their hospitalization. With the patient awake, the UPMC researchers believe the procedure would be more tolerable and comfortable for the patient, perhaps on par with the less invasive angioplasty technique, with the added long-term benefits that bypass surgery affords.

The study will involve 20 patients undergoing MIDCAB who will have an epidural anesthetic delivered to the upper back, numbing the entire upper body and preventing the sensation of pain.

"Patients will remain awake, but if they feel anxious, we can administer medication intravenously to keep them comfortable," said co-principal investigator John P. Williams, M.D., associate professor of anesthesiology and critical care medicine at the University of Pittsburgh School of Medicine, and chief of anesthesiology at UPMC Presbyterian Hospital, where the study will take place. "While this type of anesthesia has seldom been used for MIDCAB procedures, we are actually quite experienced using the thoracic epidural for post-operative pain control after chest surgery," Dr. Williams added.

The anesthesiologist will monitor the patient's breathing and mental status throughout the surgery. If for any reason the surgeon or anesthesiologist feels that general anesthesia is warranted, the change can easily be administered.

Patients with coronary artery disease who are deemed appropriate candidates for MIDCAB and who meet other eligibility criteria will be considered for the study. Only patients able and willing to provide informed written consent may participate.

"This collaborative study with our anesthesiology colleagues is an extremely important one as we look for ways to make heart bypass surgery safer and more cost-effective for our patients," said Bartley P. Griffith, M.D., a co-investigator, chief of cardiothoracic surgery and the Henry T. Bahnson professor of surgery.

Other investigators include, from the department of anesthesiology and critical care medicine: John Caldwell, M.D.; Mark Hudson, M.D.; Teresa Gelzenis, M.D.: Joseph Quinlan, M.D.; and Erin Sullivan, M.D.

It all sounds good ha. Well on 15^th 2001 a 51-year-old patient did indeed have coronary bypass surgery while awake. The team of University of Pittsburgh Medical Center (UPMC) and VA surgeons and anesthesiologists performed minimally invasive direct coronary bypass (MIDCAB) with the patient's chest numbed by a more locally based analgesia. The case, believed to be the first time an awake cardiac surgical procedure was performed in the United States. This took place at the VA Pittsburgh Healthcare System (VAPHS).

"Our goal is to make bypass surgery an outpatient procedure and as comfortable as angioplasty is for the patient. Yet unlike angioplasty, which utilizes a catheter and balloon to open up blocked vessels, we'll be able to use surgical techniques to repair vessels for better long-term patient benefit," said lead surgeon Marco Zenati, M.D

The patient, who is a professional magician from Pittsburgh, was fully awake and talked to the operating room staff during the procedure. His entire chest area was numb so he was unaware of the surgical instruments at work on his beating heart.

"We used an epidural anesthesia delivered to the upper back area with sedation, and the patient tolerated the procedure very well. Combining two well-established techniques -- minimally invasive cardiac surgery and epidural anesthesia-- may become a new innovative approach to heart bypass surgery for select patients," said Dr. Paiste, assistant professor of anesthesiology and critical care medicine at the University of Pittsburgh, who was the attending anesthesiologist providing the patient's anesthetic management.

"As the cardiologist's interventional "medical" therapies have become more invasive and the surgical treatments have become less so, in the patient's eyes, and mine, the line that separates the two is becoming blurred. The use of general anesthesia with a breathing tube, although as safe as any anesthetic technique, has remained a clear marker for the patient that minimally invasive cardiac surgery must be the more difficult choice over an angioplasty," commented Richard Bjerke, M.D., chief of anesthesiology at the VAPHS and associate professor and vice chairman, department of anesthesiology and critical care medicine at the University of Pittsburgh School of Medicine.

"Simply knowing that there is an option for the use of epidural anesthesia for a MIDCAB can further assure patients that cardiac surgery can truly be minimally invasive," Dr. Bjerke continued.

While Dr. Zenati said the patient could have probably gone home the following day, he remained in the hospital for five days for closer observation and a post-surgery cardiac catheterization.

The types of patients who might be considered for the awake procedure are those who require MIDCAB. As the use of robotic instrumentation is introduced for endoscopic bypass surgeries, it is likely that the potential pool of patients who could benefit from the awake procedure will be quite large.

The team plans to perform more cases at both the VAPHS and UPMC.

"This represents an extremely important step for cardiothoracic surgery as we continue to try and make procedures more safe and cost-effective for patients," said Bartley P. Griffith, M.D., Henry Bahnson professor of surgery and chief, division of cardiothoracic surgery, at the University of Pittsburgh.

The procedure was pioneered in 1998 by Haldun Y. Karagoz, M.D., of Guven Hospital in Ankara, Turkey. To date, he has performed nearly 30 bypass surgeries in awake patients, a few being MIDCAB surgeries, such as the one performed in Pittsburgh.

MIDCAB was pioneered at the University of Pittsburgh in June 1995. Since then, more than 500 of the procedures have been performed with excellent results.