​The National Heart Centre Singapore (NHCS) has started a new minimally invasive method to implant a heart assist device in patients with advanced heart failure. NHCS performed the first case in Asia on a Chinese male patient on 24 September 2014. The potential benefits include minimising blood transfusions during surgery, shorter duration on cardiopulmonary bypass to avoid negative effects on the organs, greater ease for subsequent heart transplantation as the breastbone is kept largely intact, and a shorter recovery.

Conventional implantation of such heart pumps involves making a long incision on the chest to split the sternum or breastbone of a patient to access the heart. In the new minimally invasive method, heart surgeons make two shorter incisions on the chest: one below the middle of the collarbone and another under the left breast. As the sternum is kept largely intact, this will facilitate easier surgical re-entry when the patient undergoes heart transplantation in future.

“The minimally invasive approach potentially minimises blood transfusions during surgery,” said Adjunct Assistant Professor Soon Jia Lin, Consultant, Department of Cardiothoracic Surgery, NHCS. Multiple blood transfusions may sensitise patients which can affect the matching of a donor heart for subsequent heart transplantation.

The new method also shortens the duration for cardiopulmonary bypass, a technique that uses a heart-lung machine to temporarily take over the function of the heart and lungs during surgery and maintain circulation of blood and oxygen throughout the body. Prolonged use of the heart-lung machine may have negative effects on multiple organs.

Mr Lek Kwang San, 47, was the first patient in Asia to have a golf ball-sized ventricular assist device implanted in him via this new minimally invasive approach at NHCS on 24 September 2014. Known as the HeartWare ventricular assist device (HVAD), the pump is implanted right next to the heart and connected to an external controller and batteries to help the heart pump blood around the body. The multi-disciplinary team who were involved in the three-hour surgery includes Dr Soon, 

cardiothoracic surgeons, a cardiac anaesthetist, heart failure cardiologists, a perfusionist, nurses, clinical coordinators specialised in heart assist devices and paramedical staff.

Mr Lek was diagnosed with dilated cardiomyopathy in 2002 but the condition only worsened in 2014, where he was hospitalised three times in the same year for heart failure symptoms which include fatigue, lethargy and shortness of breath. His heart was functioning at 16 per cent before his device implantation surgery, while a normal heart functions above 50 per cent. Dilated cardiomyopathy is a condition where the heart muscle becomes weakened, stretched and is unable to pump blood properly. It is also a common cause of heart failure.

“I used to get breathless very easily and will feel lethargic after meals,” said Mr Lek, who has been active in overseas social work since about a decade ago, “After being implanted with the artificial heart pump, I can walk without feeling breathless and I can even climb the stairs.”

The 6-minute walk test is a standard test that heart patients go through to assess their functional capacity before and at regular intervals after their surgery. The aim is to see how far patients can walk on a hard, level surface within six minutes. Mr Lek was only able to cover 300 metres before his surgery. Five months following his heart pump implantation, he was able to walk more than 500 metres in six minutes.

“A ventricular assist device helps patients with advanced heart failure by prolonging their survival and improving their quality of life by relieving the symptoms. This group of patients have a 12-month survival rate of less than 50 per cent when treated with medications alone.” said Adjunct Assistant Professor David Sim, Consultant, Department of Cardiology and Director, Heart Failure Programme, NHCS.

Since 2009, NHCS has implanted a total of 56 newer generation heart assist devices (HeartMate II and HeartWare HVAD). NHCS was the first in Singapore to set up the mechanical heart device programme in 2001 and is currently the training centre for heart assist devices in Asia.

As the minimally invasive approach to implant a heart assist device is new, the NHCS medical team will carefully assess the suitability of patients. The next generation of micro heart pumps will be even more amenable for this new technique. “With technological and technical advances, we are hoping to further improve our outcomes in this group of very sick patients,” said Dr Soon.