Coronary heart disease is currently one of the most critical health issues worldwide. Every year, millions of lives across all age groups are lost to sudden heart attacks. Unfortunately, technological advancements have not significantly reduced these deaths. On the contrary, the number of people affected by coronary artery disease continues to rise each year. Additionally, the age of onset is shifting from older adults to middle-aged and even younger populations. Key risk factors for developing coronary artery disease include family history, smoking, obesity due to poor nutrition, chronic conditions such as type 2 diabetes, a sedentary lifestyle, and uncontrolled hypertension.
When coronary arteries become narrowed or completely blocked, they cannot supply adequate blood to the heart muscle. Initially, this may cause chest pain or shortness of breath during exertion. If left untreated, it inevitably leads to a heart attack. Following a heart attack, a patient may survive but often loses part of the heart’s contraction capacity. If a significant portion of the heart muscle is affected, heart failure can develop, making treatment increasingly difficult.
The situation becomes even more complex if mitral valve insufficiency accompanies coronary artery disease, potentially rendering treatment challenging or impossible. For this reason, timely and accurate treatment of coronary artery disease is of vital importance.
In addition to medication, there are two main treatment options for narrowed coronary arteries. The first is the placement of a stent, a small metal mesh, into the narrowed section of the artery. The second option is bypass surgery, where the narrowed portion of the artery is bypassed by creating a bridge from a healthy part of the vessel. Both methods have advantages and disadvantages for the patient.
Stent placement is a relatively simple, non-surgical procedure. Patients typically go home the next day and can return to normal daily activities within a few days. However, the main drawback is that the stent—or its edges—may narrow again over time. The progression of coronary artery disease varies greatly between individuals, and this directly affects whether a stent will restenose and how quickly this may occur. If lifestyle changes are not adopted after stent placement, the risk of restenosis increases significantly.
In patients with diabetes, this process tends to progress even faster. The number and length of stents placed also play a critical role; longer stents and multiple stents are more prone to re-narrowing over time. A common patient perception is, “We’ll place a stent first, and if narrowing occurs later, we’ll do surgery.” However, in young patients who receive multiple or long stents, this approach can reduce or even eliminate the possibility of successful future bypass surgery.
Re-narrowing or blockage of stents can lead to recurrent heart attacks, which in younger patients may result in death or severe heart failure. Therefore, these factors must be carefully considered before deciding on stent placement. What initially seems like a simple procedure can potentially create irreversible problems in the medium term if not carefully evaluated.
Coronary artery bypass surgery generally provides patients with a more durable and long-term solution compared to stent placement. However, the perceived size of the surgery and often exaggerated concerns about the recovery period make some patients hesitant to choose bypass surgery. The relatively longer recovery period, typically taking two to three months before returning to normal physical activity and work, often leads patients to prefer stent placement instead. This can prevent some patients from receiving the “optimal” treatment—the most effective therapy for their specific condition.
In traditional bypass surgery, the surgeon accesses the heart by cutting through the sternum (breastbone). The patient is connected to a heart-lung machine via the main arteries and veins (aorta, right atrium, and vena cavae). The surgery is usually performed while the heart and lungs are stopped, with the machine maintaining circulation and oxygenation for the body’s vital organs.
This process exposes the blood to an artificial environment outside the body, which can occasionally trigger reactions affecting organs such as the kidneys and, rarely, the brain. Additionally, blood and blood products are often used during and after surgery, which may have further impacts on the patient.
The sternum healing period lasts about 2–3 months, during which patients are largely restricted to lying on their backs, cannot lift heavy objects, and are unable to drive. As a result, full recovery and return to work may take two to three months. Despite these challenges, coronary bypass surgery remains one of the most effective long-term solutions for severe coronary artery disease.
Minimal invasive coronary bypass surgery was developed as an alternative to the physical and psychological trauma caused by traditional bypass operations. Commonly referred to as closed or underarm heart surgery, in this method, a small incision of about 7 cm is made under the left breast, allowing access to the heart between the ribs without cutting any bones. The internal mammary artery is carefully exposed under direct vision, and depending on the patient’s condition, the bypass can be performed either on a beating heart or with the heart temporarily stopped using a heart-lung machine. Essentially, all the procedures performed in open-heart surgery can be carried out successfully using this minimally invasive approach.
One of the greatest advantages of this method is the much faster recovery since the sternum is not cut. Patients are no longer required to lie flat on their backs and can rest in the most comfortable position for them. This naturally increases comfort and reduces postoperative pain. Thanks to the minimally invasive approach, patients can return to their daily activities much sooner and can even start driving shortly after discharge. While traditional bypass surgery typically requires 6–7 days in the hospital and 2–3 months before returning to work, patients who undergo minimally invasive surgery are often ready to go home on the 4th or 5th day and can return to work within 2–3 weeks. They can resume sports and normal physical activities much sooner as well.
The main reason for the faster recovery is, of course, that the chest bone is not cut, but it is not the only factor. The term “minimally invasive” in this method refers not only to the skin and bone incision but to the entire surgical concept. Trauma to the heart is minimized; the less tissue is touched, the less trauma occurs. Smaller incisions, performing the bypass on a beating heart whenever possible, limited use of the heart-lung machine, and reduced use of blood products all contribute to a faster recovery. Another important point is that the risk of sternum infection, which patients often fear the most, is virtually eliminated with this method.
Cosmetically, minimally invasive coronary bypass surgery also provides a major advantage. In female patients, the incision is made under the breast, leaving no visible scars after surgery. In short, minimally invasive coronary bypass surgery offers patients a safe and effective treatment while providing faster recovery and excellent aesthetic results.
The introduction of 3D endoscopes, which we now use routinely in all heart valve surgeries, has also ushered in a new era for minimally invasive coronary bypass surgery. In most minimally invasive bypass procedures, the patient’s left internal mammary artery is carefully harvested under direct vision. Today, since many patients require bypass to multiple vessels, additional veins from one or both legs are also harvested using a closed (endoscopic) technique. This ensures that a sufficient number of grafts are available to bypass multiple vessels. One of the general principles in cardiac surgery is that using multiple arteries for bypass generally provides better long-term outcomes, and if possible, avoiding the use of veins altogether is ideal.
The use of 3D endoscopes now allows the internal mammary arteries to be harvested entirely endoscopically, not just under direct vision. This advancement makes it possible to utilize not only the left but also the right internal mammary artery in minimally invasive coronary bypass procedures. In some patients, the radial artery from the arm can also be used, allowing a completely arterial, minimally invasive coronary bypass. This approach provides a significant advantage, particularly for younger patients who prefer minimally invasive surgery.
In addition to all the benefits of minimally invasive coronary bypass surgery, performing the procedure entirely with arterial grafts offers patients long-term advantages that extend far beyond the immediate postoperative period. By relying solely on arteries, the patient gains a durable and effective bypass solution that supports heart health for the rest of their life.
In theory, all coronary bypass surgeries can be performed using minimally invasive techniques. However, for certain patients, we can combine the key advantages of both surgery and stenting in what we call “hybrid surgeries.” In this approach, we perform bypasses on the left side of the heart entirely using arterial grafts. If the right-side vessels are suitable, a stent is placed after the surgery, ensuring that all diseased arteries are effectively treated.
This hybrid method is increasingly being adopted in modern cardiac centers around the world as an innovative approach to coronary artery disease.
Our motto in cardiac surgery is: “Technology and experience always go hand in hand.”
If you require a coronary bypass procedure, our team is available 24/7 to provide patients with the comfort, safety, and confidence offered by endoscopic minimally invasive coronary bypass surgery.
"Coronary heart disease is one of the most significant health issues worldwide today. Every year, millions of lives across all age groups are lost to sudden heart attacks."
Narrowed or completely blocked coronary arteries cannot deliver enough blood to the heart muscle, which may initially cause chest pain or shortness of breath during physical exertion.