Cardiac and Thoracic Surgery in Germany

Cardiac Surgery in Germany

Cardiac surgery in Germany is a medical speciality in its own right, with a focus on thoracic and cardiovascular surgery. It deals with the surgical treatment of congenital and acquired conditions of the heart, of the vessels that supply it and of the pericardium.

Related specialities are cardiology and vascular surgery. For many cardiovascular diseases, successful treatment depends on close interdisciplinary cooperation between doctors from these fields. In coronary stenosis, for example, both an interventional approach (angioplasty) and a surgical one (bypass grafting) are possible.

Which cardiovascular diseases do cardiac surgeons treat?

• congenital and acquired heart defects;
• heart valve disease;
• arrhythmias;
• coronary artery disease (CAD);
• heart failure (congestive heart failure);
• inflammation of the inner lining of the heart (endocarditis);
• pericarditis (inflammation of the pericardial sac).

The following surgical procedures are performed in Germany:

• coronary stenting and aortocoronary bypass grafting for coronary artery disease;
• heart valve replacement in Germany;
• pacemaker implantation;
• surgical treatment of severe arrhythmias;
• resynchronisation therapy for heart failure;
• defibrillator implantation;
• heart transplantation.

Coronary bypass surgery (aortocoronary and mammary-coronary grafting) at German hospitals

The most frequently performed cardiac operations in German hospitals are coronary artery bypass grafting (CABG, also called aortocoronary bypass grafting) and heart valve procedures (replacement or repair). German cardiac surgeons also correct congenital heart defects and operate on the ascending and descending aorta and its branches.

Bypass operations in German hospitals are performed using arteries, veins or a combination of both. CABG can be carried out not only with a heart-lung machine, but also minimally invasively, on the beating heart.

Coronary bypass grafting (bypass surgery on the coronary arteries of the heart) – an operation that restores an adequate blood supply to the myocardium by creating bypass channels (grafts) beyond the point where a coronary artery is narrowed (stenosed) by an atherosclerotic plaque in patients with coronary artery disease. The patient's own veins and arteries (aortocoronary bypass grafting) or the internal thoracic (mammary) artery (mammary-coronary bypass grafting) can be used as grafts. Coronary bypass grafting can be performed minimally invasively (without a heart-lung machine) or by the conventional method, with a heart-lung machine. Coronary bypass operations are an area of high specialisation for the dedicated cardiac surgery hospitals in Germany.

Coronary bypass grafting (bypass surgery on the coronary arteries of the heart) – an operation that restores an adequate blood supply to the myocardium by creating bypass channels (grafts) beyond the point where a coronary artery is narrowed (stenosed) by an atherosclerotic plaque in patients with coronary artery disease. The patient's own veins and arteries (aortocoronary bypass grafting) or the internal thoracic (mammary) artery (mammary-coronary bypass grafting) can be used as grafts. Coronary bypass grafting can be performed minimally invasively (without a heart-lung machine) or by the conventional method, with a heart-lung machine. Coronary bypass operations are an area of high specialisation for the dedicated cardiac surgery hospitals in Germany.

Minimally invasive techniques have also been developed for aortic valve replacement. Surgery is likewise used to treat cardiac rhythm disorders (surgical arrhythmology).

Combined operations are becoming widespread in German cardiac surgery hospitals: bypass grafting and a procedure on the carotid artery, for example, can be performed by a single surgeon during one and the same operation.

Alongside CABG and conventional valve operations, modern cardiac surgical practice has successfully adopted minimally invasive methods that allow heart valve surgery through a mini-thoracotomy, that is, repair or replacement of the aortic, mitral and tricuspid valves and implantation of new-generation sutureless aortic valves; coronary artery bypass grafting can now be performed through a left-sided mini-thoracotomy, and aortic valves can be placed via catheters.

Acquired or congenital disorders of the mitral and tricuspid valves in adults

The department has many years of experience with right-sided mini-thoracotomy and the thoracoscopic approach, which makes it possible to avoid a median sternotomy. These techniques offer advantages in every respect, from postoperative recovery to rehabilitation, as well as a considerable cosmetic benefit. Combined disorders of the aortic and mitral valves can also be treated with a minimally invasive technique. At the same time, concomitant coronary artery disease is usually treated percutaneously by coronary angioplasty (a hybrid procedure).

All types of degenerative or functional mitral valve disorder — ischaemic, rheumatic and infectious lesions of the mitral valve — are treated so successfully that in 99% of cases no repeat procedure is needed for more than 10 years. In addition, percutaneous mitral valve repair with chordal implantation can be performed on the beating heart.

Main valve pathologies:

• degenerative changes of the mitral valve;
• functional changes of the mitral valve;
• ischaemic, rheumatic and infectious lesions of the mitral valve;
• transapical mitral valve dysfunction;
• tricuspid regurgitation.

Main procedures:

• right-sided mini-thoracotomy;
• thoracoscopic approach;
• transapical mitral valve repair on the beating heart;
• chordal implantation.

Heart valve replacement in Germany and the choice of valve prosthesis

A whole range of factors is taken into account when choosing a valve. In particular, the choice between a mechanical and a biological prosthesis depends on:

• the severity of the underlying disease;
• the patient's age;
• any concomitant conditions;
• whether the patient is able and willing to take anticoagulants for life;
• whether blood clotting values can be monitored for life.

Biological valves have a limited service life because the valve leaflets calcify. This process is particularly rapid in young patients, which is why a biological valve is indicated for fairly elderly patients. Such a valve is also implanted when there are serious blood clotting problems, because although the mechanical counterpart of a biological prosthesis can last almost indefinitely, it requires lifelong anticoagulants (blood-thinning drugs) together with constant monitoring of clotting parameters. This is precisely why such prostheses are undesirable, for example, for women planning a pregnancy.

Responsibility for properly informing the patient about the advantages and disadvantages of the human heart valve prostheses currently available lies primarily with the treating physician.

The latest surgical techniques: mitral valve repair and replacement

Surgical repair or replacement of the mitral valve is the second most common heart valve operation. The condition is caused by degenerative, functional or inflammatory changes in the structure of the mitral valve, which lead to valve regurgitation and can significantly impair the work of the heart muscle.

An anatomically perfect mitral valve repair is the key to treating valve regurgitation effectively. German cardiac surgeons use a variety of surgical procedures for this purpose. In most cases a defective mitral valve can be repaired minimally invasively. In this procedure the heart is accessed through an incision between the ribs; the chest is not opened.

Many German hospitals use the DaVinci robot for this type of surgery. DaVinci technology allows extremely precise mitral valve repair. As an alternative to the minimally invasive technique, mitral valve repair can also be performed through a median sternotomy.

Catheter-based repair — the clipping technique (MitraClip)

So-called mitral valve clipping is a minimally invasive procedure based on the use of a cardiac catheter. The MitraClip procedure was introduced specifically to restore the function of the mitral valve. Clipping is an alternative to surgical treatment in patients at high risk or with progressive cardiomyopathy. This is precisely why the procedure has gained such importance in recent years.

Minimally invasive treatment of atrial fibrillation: the Maze procedure («labyrinth»)

Atrial fibrillation is one of the most common tachyarrhythmias; it can lead to the formation of blood clots (thrombi) and, as a result, to occlusion of vessels. A unique minimally invasive treatment is the so-called Maze procedure («labyrinth»), in which the atria are divided into separate segments using the «cut-and-sew» technique (MAZE IV), successfully preventing the spread or development of atrial fibrillation; in patients with persistent AF undergoing correction of heart valve defects, surgical correction of the acquired defects is combined with a modified technique of biatrial fragmentation using radiofrequency ablation (RFA) and the «cut-and-sew» technique.

Coronary artery bypass grafting with the DaVinci surgical robot

The latest-generation DaVinci surgical robot is used by German cardiac surgeons for certain heart operations, such as coronary artery bypass grafting, allowing a smaller surgical access and wound as well as faster recovery for the patient.

The robot has four arms which, besides the camera, can carry up to three instruments designed to be introduced into the operating field through small incisions. The mobility and precision available to the robotic system exceed human capabilities and thus open up new possibilities in cardiac surgery.

Ischaemic heart disease

German specialists offer minimally invasive single- and multi-vessel bypass grafting and hybrid treatment (MIDCAB + PCI) for ischaemic heart disease caused by disease of the left main coronary artery and three vessels, as well as for ventricular septal rupture, acute mitral regurgitation, pseudoaneurysm and heart failure.

Myocardial revascularisation with arterial grafts, for example multi-vessel MICS CABG on the beating heart performed under direct vision through an anterolateral mini-thoracotomy, left ventricular reconstruction and mechanical circulatory support.

Main pathologies:

• ischaemic disease of the left main coronary artery and three vessels;
• ventricular septal rupture;
• acute mitral regurgitation;
• pseudoaneurysm;
• heart failure.

Main procedures:

• myocardial revascularisation with arterial grafts
• MICS CABG for multi-vessel disease on the beating heart.

Atrial fibrillation

Atrial fibrillation is treated minimally invasively by radiofrequency and / or cryoablation of atrial tissue.

Main pathologies:

• paroxysmal and permanent atrial fibrillation;
• ablation of concomitant atrial fibrillation during valve surgery.

Main procedures:

• thoracoscopic ablation of atrial fibrillation confined to the atria;
• substernal ablation of atrial fibrillation and ventricular tachycardia;
• thoracoscopic placement of electrodes;
• thoracoscopic closure of the left atrial appendage.

Pacemaker implantation

This is used when a patient has persistent, life-threatening heart rhythm disorders (chronic arrhythmia and atrial fibrillation, bradycardia). In such cases an artificial pacemaker is implanted under the pectoral muscle. Modern pacemakers – high-tech programmable devices – can work without failure for up to 14 years.

The cardiac surgery, thoracic and cardiovascular surgery clinics and departments that partner with msp group germany offer the full range of outpatient and inpatient medical services in cardiac and thoracic surgery, as well as high-risk and highly complex cardiac operations.

All the hospitals we recommend hold leading positions worldwide in the treatment of cardiovascular disease in adults and children and are among the world-class specialised cardiology and cardiac surgery centres equipped with the very latest technology. Their consistent and extensive use of minimally invasive techniques has significantly reduced the number of complications and the length of hospital stays.

The surgical techniques developed at these medical institutions have largely shaped the development of cardiology and cardiac surgery in Europe and worldwide: for example, fully endoscopic mitral valve repair with the robotic system Da Vinci, as well as transapical transcatheter implantation of the aortic valve prosthesis Core Valve.

Besides cardiac surgery, these hospitals also specialise in minimally invasive surgery, so-called «keyhole surgery», which offers both medical and cosmetic advantages. Video-assisted mitral valve repair, for example, can be carried out through an incision only 5-6 cm long on the right side of the chest and does not require open-heart surgery.

The partner cardiac centres of msp group germany are among the world's leading centres for transcatheter transaortic heart valve implantation. Minimally invasive catheter-based cardiac surgery is attractive above all for elderly patients for whom open operations on the beating heart are contraindicated; access is gained by puncturing the wall of the iliac artery. If the abdominal vessels are severely deformed, the valve is introduced through a small incision between the ribs and implanted through the apex of the heart. This technique is as gentle as possible.

The operating theatres are equipped with the very latest technology for the full range of modern  procedures on the heart, the vessels and the thoracic organs under conditions of maximum safety for the patient. The coronary angiography and angioplasty methods used here considerably widen treatment options and minimise both risks and time spent in hospital. The cardiology centres have an additional operating theatre, a hybrid-room for so-called hybrid operations, which combines the features of an operating theatre and a cardiac catheterisation laboratory. This gentle approach shortens hospital stays and operating times. More than a thousand cardiac procedures are performed in Germany every year, half of them using mechanical heart and lung support systems.

Thoracic surgery in Germany

Thoracic surgery deals with the surgical treatment of diseases and tumours of the lungs, pleura, bronchi, mediastinum and chest wall. Most thoracic procedures are performed by opening the chest.

In recent years, however, video-assisted minimally invasive techniques such as thoracoscopy have become increasingly widespread.

Thoracic surgery as a minimally invasive field began to develop in the 1970s. At that time a rigid thoracoscope with limited capabilities was used. The main indications for thoracoscopy were spontaneous pneumothorax, pleurisy, haemothorax and hyperhidrosis. These were mainly diagnostic procedures such as biopsy of the lung, the pleura and the intrathoracic lymph nodes. With the arrival of fibre optics transmitting the image to a monitor and the development of endoscopic instruments in the 1990s, a new era in surgery began — video-assisted thoracoscopic surgery.

Today the range of procedures performed by thoracic surgeons covers:

• surgical treatment of malignant disease of the lungs, mediastinum, chest wall and pleura, including as part of multimodal treatment concepts (for example lung cancer, cancer of the thymus, chest wall cancer, pleural mesothelioma);
• surgery for metastases in the thoracic organs, in particular laser resection;
• treatment of mediastinal disease (thymomas, lymphomas, germ cell tumours);
• treatment of chest wall tumours;
• palliative procedures (pleurodesis, pleural drainage, interventional laser bronchoscopy, placement of an endobronchial stent, cryotherapy);
• surgical treatment of infectious diseases of the thoracic organs (pleural empyema, lung abscess, chronic infections with destruction of lung tissue);
• benign diseases of the lungs, mediastinum and chest wall (pulmonary hamartoma, bronchiectasis, emphysema, cysts, pulmonary sequestration);
• diseases of the trachea (stenosis, tumours);
• pneumothorax;
• funnel chest and pigeon chest deformities;
• hyperhidrosis (excessive sweating).

The following operations are currently performed for diseases of the thoracic organs:

• pneumonectomy;
• combined lung resection;
• bilobectomy;
• lobectomy;
• segmentectomy;
• removal of a mediastinal tumour;
• pleurectomy;
• costomyoplasty;
• simultaneous operations;
• diaphragm repair;
• operations on the bronchi;
• echinococcectomy;
• nodectomy.

The following operations on the thoracic organs are performed minimally invasively:

• mini-thoracotomy + VATS (video-assisted thoracic surgery), lobectomy;
• mini-thoracotomy + VATS with extrapleural pleurodesis;
• mini-thoracotomy + VATS, pleurectomy;
• mini-thoracotomy + VATS, segmental resection;
• mini-thoracotomy + VATS, removal of mediastinal tumours;
• mini-thoracotomy, diaphragm repair;
• mini-thoracotomy + VATS, echinococcectomy;
• mini-thoracotomy + VATS, nodectomy;
• VATS, excision of bullae of the lung and pleura;
• VATS, biopsy of the lung and pleura;
• mini-thoracotomy + VATS, removal of a foreign body;
• mini-thoracotomy + VATS, costomyoplasty;
• VATS, thymectomy;
• VATS, sympathectomy;
• VATS, pericardectomy.

The indications for video-assisted mini-thoracotomy are:

• bullous pulmonary emphysema complicated by pneumothorax;
• peripheral benign lung tumours;
• pleural tumours;
• solitary metastatic lung tumours;
• mediastinal tumours;
• pleurisy;
• echinococcosis;
• localised forms of cystic hypoplasia of the lung;
• disseminated and interstitial lung diseases;
• foreign bodies in the thoracic cavity;
• relaxation (eventration) of the diaphragm;
• diffuse lung diseases (alveolitis, granulomatosis);
• clotted haemothorax;
• constrictive pericarditis.