Innovative Procedures

Robotic-Assisted, Minimally Invasive Bypass Surgery at Emory

At Emory, we are constantly pushing the boundaries of modern medicine in an effort to discover safer, more effective ways of healing patients. At Emory Heart & Vascular, we’ve made remarkable strides in minimally invasive coronary artery bypass surgery (CABG) through the use of robotic technology.

Our minimally invasive CABG procedure utilizes a robotically assisted endoscopic technique, allowing the procedure to be performed with small incisions between the ribs, as opposed to opening the chest through splitting the breastbone (median sternotomy).

One of the many advantages of robotic-assisted CABG is that it doesn’t require the use of a heart-lung machine, or cardiopulmonary bypass, and can be performed without dividing the ribs or sternum. Therefore, the recovery from the procedure can be considerably shorter, and may be associated with a lower risk of some complications. Most patients are able to leave the hospital in as few as three days, and may return to normal activities in two-three weeks, as opposed to two-three months—the recovery time period generally associated with traditional CABG surgery.

Robotic-assisted CABG is most often performed on patients with single-vessel coronary artery disease. However, the procedure can be part of a hybrid approach for patients with multi-vessel disease. With a hybrid revascularization approach, surgeons work together with interventional cardiologists to combine the benefits of surgery with the benefits of stenting. Typically, the surgeon will perform a single-vessel robotic-assisted CABG for a blocked artery on the front of the heart, and cardiologists can perform a stenting procedure to the other blocked vessels.

Emory has been performing minimally invasive CABG since 2003, and is one of only a few medical facilities in the country offering the procedure.

Do you have questions about this or any other procedure at Emory Heart & Vascular? If so, please feel free to let me know here in the comments section.

About Michael E. Halkos, MD:

Joining the faculty in July 2009, Dr. Halkos received his MD and did his general and cardiothoracic surgical training as well as a two year research fellowship at Emory. He is currently Editor of the Resident Section of CTSNet and serves on the Executive Committee of the Thoracic Surgeons Residents Association. His clinical specialties include off-pump coronary artery bypass surgery, valve repair/replacement surgery, and minimally-invasive valve and coronary surgery, and his research interests are stroke after cardiac surgery and surgical outcomes.

An Innovative Emory Cardiothoracic Surgical Treatment


Imagine experiencing atrial fibrillation (A-Fib), or a quivering of the heart, half of each day, every day. Now imagine a solution—and it doesn’t involve open-heart surgery. The only after effects: a few half-inch marks beneath your armpit accompanied by a new approach to life.

In one anonymous case study, a 46-year-old female executive had suffered from seven years of disabling A-fib, and described how the symptoms of her condition resulted in “zero quality of life.” She was unable to participate in numerous medication trials due to a variety of negative reactions to anti-arrhythmic medications, and she underwent two unsuccessful percutaneous catheter ablation procedures out-of-state.

After thoroughly researching multiple surgery options across the region, she agreed to be Emory’s first patient for a trial of a “Totally Thorascopic Mini-Maze”, involving a fully endoscopic approach to bilateral pulmonary vein isolation, a procedure utilizing bipolar radiofrequency energy and “stapled occlusion” of the left atrial appendage procedures.

On February 14, the patient received three tiny incisions in her chest on each side of her armpit. We made no other incisions, and a thorascopic camera provided our only visualization. At the beginning of the procedure, we carefully measured the exit and entry areas across the pulmonary veins on each side. Electrophysiology measurements confirmed a conduction block across the pulmonary vein on each side.

We stapled the patient’s left atrial appendage shut with an endoscopic, or “no-knife” stapling device, a tool that safely closes the base of the left atrial appendage with three rows of staples and no incisions, thus reducing risk of hemorrhage. Consequently, the patient experienced very little blood loss, and the cosmetic results were ideal, as her three incision sites were hidden beneath her armpit.

The procedure allowed the patient to be discharged a mere three days after surgery, and she only experienced one single brief episode of irregular rhythm upon her return home. At both her 1-month and 3-month follow-up appointments, she showed no signs of A-fib. As part of our comprehensive follow-up, on the anniversary of her 3-month visit, we provided her with a small, portable cardiac rhythm monitor that she used for two weeks to record her heart beat 24 hours a day. The monitor also documented a complete absence of A-fib.

We’re thrilled with the success of this procedure—this pioneering patient, once disabled by severe A-fib symptoms, is enjoying life once again. For carefully selected patients, this procedure could very well be an ideal solution.

If you have questions about this procedure, or about A-fib in general, I’m happy to address them in the comments section below.

About John D. Puskas, MD:

Dr. Puskas specializes in adult cardiac surgery. He began performing coronary bypass operations on beating hearts without using a heart-lung machine in 1996. In 1997, he performed the world’s first triple off-pump bypass surgery using minimally invasive coronary artery bypass graft (mini-CABG) instrumentation. Dr. Puskas is PI of a grant from the National Institute of Health’s National Heart Lung and Blood Institute that makes Emory one of eight U.S. centers charged with rigorous scientific evaluation of newer methods of fighting cardiovascular disease.

Transcatheter Valve Implantation Trial at Emory

The transcatheter heart valve is as large as 26 mm in diameter when expanded (left) and as small as 8 mm when collapsed over a balloon catheter (right).

In my last post, I focused on the definition, symptoms, diagnosis and treatment of aortic stenosis, a condition that can lead to heart failure. Sadly, aortic stenosis affects tens of thousands of Americans each year. In this post, I’d like to expand on one innovative treatment that is reducing the risks of this potentially fatal condition: transcatheter aortic valve implantation.

However, before we delve into an explanation of the treatment, let’s first review the specifics of the condition.

The aortic valve is the valve that connects the heart to the body, and is located between the left ventricle and the aorta. Blood flows through this valve, carrying oxygen to the rest of the body. There are typically three leaflets of tissue over the aortic valve that open and close and ensure proper blood flow. When the aortic valve becomes narrowed – either by degeneration or because is it abnormal from birth, the valve must be replaced to prevent heart failure.

Transcatheter aortic valve implantation is a new, innovative procedure used to replace the aortic valve. Rather than opening the chest and stopping the heart, we make a small incision in the groin or chest. We then insert a catheter (a thin, flexible tube) with a new aortic valve made of animal tissue through a blood vessel, using X-ray or ultrasound imaging to guide the device to the heart. As an alternative to open heart surgery, transcatheter aortic valve implantation has a substantially shorter recovery time and is particularly important for patients who are too weak to undergo the traditional process.

Emory has been involved in this groundbreaking technology since 2007, after Emory interventional cardiologist Vasilis Babaliaros, MD, helped bring the procedure back to us from France. The first cardiologist to perform transcatheter heart valve replacement was French doctor Alain Cribier, MD, who performed the procedure in 2002. Since 2007, we have completed approximately 85 transcatheter aortic valve implantations as part of a clinical trial, and we anticipate that the transcatheter valve will receive U.S. Food and Drug Administration (FDA) approval in late 2011. (You may view an animation video of the procedure here.)

Emory Heart & Vascular Center is proud to be one of the five largest centers in the United States and the most comprehensive in the Southeast to offer transcatheter aortic valve implantation. We are currently accepting patients for a new trial; for more information or to find out if you or someone you know may be a candidate for transcatheter aortic valve replacement, please contact me at 404-712-7667, or you may call Vinod Thourani, MD, at 404-686-2513. For other questions or comments on the procedure, I invite you to contribute in the comments section below.