Heart Beating Surgery

INTRODUCTION

The heart bypass surgery reroutes the blood supply around clogged arteries
to improve blood flow and oxygen to the heart. The arteries that bring blood to the
heart muscle (coronary arteries) become clogged by plaque (a buildup of fat,
cholesterol and other substances). This can slow or stop blood flow through the heart's
blood vessels, leading to chest pain or a heart attack. Increasing blood flow to the
heart muscle can relieve chest pain and reduce the risk of heart attack. So the surgeons
go for this surgery by taking a segment of a healthy blood vessel from another part of
the body usually from leg and make a detour around the blocked part of the coronary
artery. The surgery involves an incision in the middle of the chest and separation of
the breastbone and after detouring, the breastbone is joined using wire and the
incision is sewed. The entire surgery can take 4-6 hours. After the surgery, the patient
is taken to the Intensive Care Unit. For a few days after the surgery, the patient is
connected to monitors and tubes.

Patient may experience side effects such as:

• Loss of appetite, constipation.

• Swelling in the area from which the segment of blood vessel was removed.

• Fatigue, mood swings, feelings of depression, difficulty in sleeping.

• Muscle pain or tightness in the shoulders and upper back.

The incision in the chest or the graft site (if the graft was from the leg or arm) can be
itchy, sore, numb, or bruised. The surgery may also lead to loss of memory and mental
clarity. To overcome all these problems that are involved in the bypass surgery, a nanorobot
is used, which can replace this techniques efficiently and effectively. This nanorobot will
remove the clot without any surgical procedure. Just a small incision is made into the femoral
artery to insert this Nanorobot, from where it is moved to the site of the plaque by the use of
its nano components that are attached to it.
STRUCTURE OF THE HEART:

The heart is an amazing organ. It beats thousands of times each day, every day,
for the entire life. In the process, it pumps about 5 million gallons of blood through the
entire body. The human heart resembles the shape of an upside down pear. It is a
hollow muscle that pumps blood throughout the blood vessels by repeated, rhythmic
contractions. An adult human heart has a mass of between 250 and 350 grams and is
about the size of a fist. It is located anterior to the vertebral column and posterior to the
sternum. The heart is enclosed in a double-walled sac called the pericardium. It has
two leaflets, the superficial is called the parietal pericardium and the inner one is the
visceral pericardium. The outer wall of the human heart is composed of three layers.
The outer layer is called the epicardium, or visceral pericardium since it is also the
inner wall of the pericardium. The middle layer is called the myocardium and is
composed of cardiac muscle which contracts. The inner layer is called
the endocardium and is in contact with the blood that the heart pumps. The human
heart has four chambers, two superior atria and two inferior ventricles. The atria are
the receiving chambers and the ventricles are the discharging chambers.
BLOOD FLOW IN HEART:

The heart is a complex organ, using four chambers, four valves and multiple

blood vessels to provide blood to the body. The flow through the heart is equally
complex, with blood moving through the heart, then the lungs, before returning again
to the heart.

Blood returns to the heart from the body via two large blood vessels, called the
superior vena cava and the inferior vena cava. This blood carries little oxygen, as it is
returning from the body where oxygen is used.

Fig. Circulation of Blood flow in Heart

 The blood first enters the right atrium. It then flows through the tricuspid valve
into the right ventricle. When the heart beats, the ventricle pushes the blood through
the pulmonic valve into the pulmonic artery. This artery is unique. It is the only artery
in the human body that carries oxygen-poor blood.

The pulmonic artery carries blood to the lungs where it “picks up” oxygen, and
leaves the lungs and returns to the heart through the pulmonic vein. The blood enters
the left atrium, and then descends through the mitral valve into the left ventricle. The
left ventricle then pumps blood through the aortic valve, and into the aorta, the blood
vessel that leads to the rest of the body.

The valve at the top of each ventricle opens to allow it to fill, while the valve at
the bottom makes sure the blood doesn’t leak out. When the ventricle is full, the top
valve closes and the bottom valve opens. The ventricle squeezes the blood out
forcefully through the bottom valve. Essentially, the valves keep the blood flowing in
the correct direction through the heart.

Beating Heart Bypass Surgery

When your arteries cannot supply enough blood to your heart, your doctor may recommend
coronary artery bypass graft (CABG) surgery. One of the most common heart surgeries in the
United States, CABG surgery restores blood flow to your heart.

Approximately every 10 minutes, someone has beating heart or "off-pump" bypass surgery.
Beating heart bypass surgery is - in simple terms - bypass surgery that is performed on your
heart while it is beating. Your heart will not be stopped during surgery. You will not need a
heart-lung machine. Your heart and lungs will continue to perform during your surgery.

Surgeons use a tissue stabilization system to immobilize the area of the heart where they need
to work.
Beating heart bypass surgery is also called Off Pump Coronary Artery Bypass Surgery
(OPCAB). Both OPCAB and conventional on-pump surgery restore blood flow to the heart.
However, off-pump bypass surgery has proven to reduce side effects in certain types of
patients.

Indications for Beating Heart Bypass Surgery

All patients with coronary artery disease are possibly candidates for off-pump coronary artery
bypass.
Some surgeons in certain settings prefer the more traditional CABG technique : -

 younger patients
 where the coronary arteries are small and several bypasses are indicated
 patients whose hearts may not tolerate the various manipulations required during
beating heart surgery

Currently, the categories of patients with coronary artery disease who are potential
candidates for this type of surgery include : -

 Those with poor heart function (very low ejection fraction)

 Individuals with severe lung disease (chronic obstructive pulmonary disease, and
emphysema)
 Those suffering from acute or chronic kidney disease
 Those at a high risk for stroke
 patients with a calcified aorta

Advantages of beating-heart surgery

 Better preservation of heart function

 Better survival rate, especially among high-risk patients
 Reduced hospital stay
 Quicker recovery
 Less chance for heart rhythm, kidney, or liver complications
 Reduced risk for neurological injury, including stroke and memory complications

Surgeries are performed on a beating heart

 Coronary artery bypass graft surgery (including robotic and minimally invasive
procedures such as TECAB and ThoraCAB, as well as open-chest, beating-heart
bypass)
 Surgery for atrial fibrillation
 Treatment of some congenital heart defects, such as closure of atrial septal defect
 Valve repair (mitral, pulmonary, or tricuspid)
 Valve replacement (mitral or tricuspid)
Before Surgery

Members of the specialized surgical team counsel the patients who are to undergo the bypass
surgery. They are given instructions to help prepare the patient for the surgery. These include
advice on eating, drinking and taking medications.

The cardiologist, heart surgeon, anesthesiologist and nurse clinician meet with the patient.
Questions are encouraged and attempts made to allay doubts. Admission is done at least a day
prior to surgery.

Before surgery, certain tests are advised. : -

 an echocardiogram (ultrasound of the heart) to evaluate the structure and function of

the heart
 cardiac catheterization (if not already done), to check for coronary artery disease or
other cardiovascular disease
 basic diagnostic tests, including blood tests, an electrocardiogram and a chest x-ray
 customized more specialized tests such as an electrophysiology study (EP), maybe
advised

Beating Heart Bypass Surgery Procedure

First, your surgeon removes a section of a healthy vein or artery from an area of your body.
This is called a graft. The surgeon attaches one end of the graft to an area of the heart above
the blockage in your artery. The other end is attached to an area of your coronary artery
below the blockage. Once the graft is attached, blood flow to your heart is restored.
Two types of graft bypasses : -

The challenge in beating heart CABG surgery is that it can be difficult to suture or "sew" on a
beating heart. The surgeon must use a "stabilization" system to keep the heart steady.

The stabilization system consists of a heart positioner and a tissue stabilizer. The heart
positioner guides and holds the heart in a position that provides the best access to the blocked
arteries. The tissue stabilizer holds a small area of the heart still while a surgeon works on it.

The stabilizers are designed to position and to hold the heart to give the surgeon easy access
to the blocked vessel requiring the bypass graft. The Stabilizer minimizes limits the motion of
a small area of the heart while the rest of the heart continues to beat normally. This allows the
surgeon to perform CABG surgery without stopping your heart and without using the heart-
lung machine.

Conventional On Pump Coronary Artery Bypass Surgery

More than 70%2 of all bypass surgeries are performed on a stopped heart. Unlike beating
heart surgery, during conventional on pump heart bypass, medication is used to stop your
heart.

A heart-lung machine takes over the function of your heart and lungs during the surgery. The
heart-lung machine is also called a cardiopulmonary bypass machine. It has a pump to
function as the heart and a membrane oxygenator to function as the lungs.

A patient is placed on cardiopulmonary bypass (the heart lung machine) during conventional
open heart surgery. The Performer CPB System, an advanced heart-lung machine, takes over
the job of keeping oxygen-rich blood circulating throughout the body during conventional
CABG surgery. This allows the surgeon to perform the surgery on a still heart.

Heart-Lung Machine

This mechanical "heart and lungs" keeps oxygen rich blood circulating throughout your body.
The heart-lung machine collects the blood. Carbon dioxide and other waste products are
removed. The oxygenator adds oxygen, and the oxygenator's heat exchanger warms (or
cools) the blood. The blood is gently circulated back through the body. This process is called
perfusion. The person who operates the heart-lung machine is the perfusionist.

Stopping the Heart

Your heart will usually be stopped for about 30-90 minutes of the 3-6 hour surgery. The
heart-lung machine makes it possible for the surgeon to work on a still heart. This technique
has been used for many years with excellent results. Once the surgery is over, the surgeon
and perfusionist restart your heart.

After Surgery

After surgery, the patients are shifted to the intensive care unit. The ICU stay is generally two
to three days. While in the intensive care unit, a ventilator is used to assist the breathing
process. Once the patient stabilizes and is able to breathe adequately unassisted the breathing
tube is removed.

While recovering from the general anesthesia, grogginess and some disorientation maybe
experienced. Pain medication is used to help reduce the pain from the incision.

Intravenous fluids maintain hydration. The one or more temporary drainage tubes are placed
in the chest cavity drain any excess blood or fluid that may build up after surgery. Blood
transfusions maybe required during or even after the operation. There may be a need to use
some medication to support the heart function during and after the operation.

Off-pump beating heart surgery patients typically spend one day in the surgical intensive care
unit before being moved to a regular surgery unit, where they receive cardiac rehabilitation.
The average hospital stay is 5 to 7 days.

After Leaving the Hospital

Recovery is usually rapid. Following bypass surgery, a recovery period of about 6 to 12

weeks can be expected. The main limitation to activity is healing of the sternum, which
typically can take up to 12 weeks.

People in sedentary jobs frequently return to work after six weeks. It may take 12 weeks or
more before returning to physically-demanding jobs.

Full energy levels usually start to return in about three months. The patients initially tire
easily and their stamina may not be completely normal. Most return to normal activities after
six months.

Most are able to drive in about three weeks. Sexual activity can be resumed in three to four
weeks. Most people resume normal activities while more than 90 percent have substantially
less angina after a bypass surgery. Coronary artery disease is a progressive disease. New
blockages may occur while older blockages can progress. A second bypass, angioplasty or
other procedure, or a change in medication maybe required. The risk for this can be reduced
by discontinuing smoking; eat healthy, taking prescribed medications and regular physical
activity.

Cardiac rehabilitation after surgery helps. The focus is on customized lifestyle changes; diet,
exercise as well as psychological issues.
BYPASS SURGERY AND ITS NEED

Heart bypass surgery  is used to treat heart disease when the coronary arteries are
blocked. The doctor treats the problem by giving the blood a new pathway to the heart.
Hence the name Bypass surgery. There are two main coronary arteries--the right
coronary artery and the left coronary artery. The right coronary artery splits off into
two more arteries, known as the right marginal artery and the posterior descending
artery. The left coronary artery splits into two additional arteries as well--the
circumflex artery and the left anterior descending artery. This makes six total arteries
in the human heart.
If one of these outer arteries gets blocked, it causes a heart attack. A blockage like
this is normally caused by fatty deposits that build up in the heart's arteries over the
course of many years. When one of the heart's arteries gets blocked and a person has a
heart attack, one common procedure is to perform heart surgery and sew in a new
piece of blood vessel to bridge over (bypass) the blockage. In many cases, the surgeon
will fix not only the immediate problem, but also other arteries on the heart that are
starting to look blocked.

In some cases, the surgeon can perform this operation while your heart is still beating.
This is called "off-pump" coronary bypass surgery.

Fig. Coronary artery Bypass graft

 If the surgeon repairs three of the arteries, it is called a triple bypass. If four arteries are
repaired, it's a quadruple bypass. The blood vessel used to create the bypass is taken
from the chest or the leg as the body has several vessels that can be removed without
doing harm.

 Arteriosclerosis is a common arterial disorder characterized by thickening, loss

of elasticity, and calcification of arterial walls, resulting in a decreased blood
supply.
 Atherosclerosis is a common arterial disorder characterized by yellowish
plaques of cholesterol, lipids, and cellular debris in the inner layer of the walls
of large and medium-sized arteries.

ROUTINE PROCEDURE OF BYPASSS SURGERY:

 The patient is brought to the operating room and moved on to the operating table.

 An anesthetist places a variety of intravenous lines and injects a painkilling agent
followed within minutes by an induction agent to render the patient unconscious.
 An endotracheal tube is inserted and secured by the anesthetist and mechanical
ventilation is started. General anesthesia is maintained by a continuous very slow
injection.
 The chest is opened via a median sternotomy and the heart is examined by the surgeon.
 The bypass grafts are harvested – frequent conduits are the internal thoracic
arteries, radial arteries and saphenous veins. When harvesting is done, the patient is
given heparin to prevent the blood from clotting.
 In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart.
 If the case is "on-pump", the surgeon sutures cannulae into the heart and instructs
the perfusionist to start cardiopulmonary bypass (CPB). Once CPB is established, the
surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to
deliver cardioplegia (a special potassium-mixture, cooled) to stop the heart and slow its
metabolism. Usually the patient's machine-circulated blood is cooled to around 84
°F (29 °C)
 One end of each graft is sewn on to the coronary arteries beyond the blockages and the
other end is attached to the aorta.
 The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In
cases where the aorta is partially occluded by a C-shaped clamp, the heart is restarted
and suturing of the grafts to the aorta is done in this partially occluded section of the
aorta while the heart is beating.
 Chest tubes are placed in the mediastinal and pleural space to drain blood from around
the heart and lungs.
 The sternum is wired together and the incisions are sutured closed.
 The patient is moved to the intensive care unit (ICU) to recover.

NANOROBOTS:

 Nanorobots are theoretical microscopic devices measured on the scale of

nanometers (1nm equals one millionth of 1 millimeter). When fully realized
from the hypothetical stage, they would work at the atomic, molecular and
cellular level to perform tasks in both the medical and industrial fields.
Nanomedicine’s nanorobots are so tiny that they can easily traverse the human
body. Scientists report the exterior of a Nanorobot will likely be constructed of
carbon atoms in a diamondoid structure because of its inert properties and
strength. Super-smooth surfaces will lessen the likelihood of triggering the
body's immune system, allowing the nanorobots to go about their business
unimpeded. Glucose or natural body sugars and oxygen might be a source for
propulsion and the Nanorobot will have other biochemical or molecular parts
depending on its task.

ELEMENTS OF NANOROBOT:

Carbon will likely be the principal element comprising the bulk of a medical
Nanorobot, probably in the form of diamond or diamondoid/fullerene nano
composites. Many other light elements such as hydrogen, sulphur, oxygen,
nitrogen, fluorine, silicon, etc. will be used for special purposes in nanoscale gears
and other components. Morphological examination revealed no physical damage
to either fibroblasts or macrophages, and human osteoblast like cells confirming
the biochemical indication that there was no toxicity and that no inflammatory
reaction was elicited in vitro. The smoother and more flawless the diamond
surface, the lesser is the leukocyte activity and fibrinogen adsorption.
 The exterior surface with near-nanometer smoothness results in very low
bioactivity. Due to the extremely high surface energy of the passivated diamond
surface and the strong hydrophobicity of the diamond surface, the diamond exterior
is almost completely chemically inert.

NANOROBOTS IN MEDICAL FIELD:

Nanomedicine is the medical application of nanotechnology. The approaches towards

nanomedicine range from the medical use of nonmaterial’s, to nanoelectronic
biosensors, and even possible future applications of molecular nanotechnology.
Medical nanodevices could augment the immune system by finding and disabling
unwanted bacteria and viruses. When an invader is identified, it can be punctured,
letting its contents spill out and ending its effectiveness. If the contents were known to
be hazardous by themselves, then the immune machine could hold on to it long enough
to dismantle it more completely.

NANOROBOTS IN HEART SURGERY:

Heart blockings are occurring more and more. The most common methods of surgery
for heart attacks are By-Pass surgery and Angio Plaster. But these methods are risky
and bring several side-effects with them. Surgery with nanorobots is safer and the
surgeon doesn’t even have to touch the patient. Nanorobots as a heart surgeon could
replace the mentioned, current surgeries and thus manage the same result without the
side effects. The procedure would consist of locating and serving the block. After
locating the blockade, nanolasers could be used to tackle the block after getting
confirmation by the practitioners.
PROPERTIES OF THE NANOROBOT USED IN BYPASS

SURGERY:

The nanorobots structure will have two spaces that will consist of an interior and
exterior. The exterior of the nanorobot will be subjected to the various chemical liquids
in our bodies but the interior of the nanorobot will be a closed, vacuum environment
into which liquids from the outside cannot enter. A nanorobot will prevent itself, from
being attacked by the immune system by having a passive, diamond exterior. The
diamond exterior will have to be smooth and flawless to prevent Leukocytes activities
since the exterior is chemically inert and have low bioactivity. An electric motor is
attached to this nanorobot for its propagation inside the circulatory system in the blood
vessels. The microprocessor, artery thermometer, camera, rotating needle are also
incorporated in this nanomachine, which perform the vital role of the nanorobot. The
microprocessor controls the overall operation of this nanorobot .The radioactive
material is impregnated and is made as a part of the exterior surface, which helps us to
trace the nanorobot at any period of time. The magnetic switch is also provided to
switch on and off the nanorobot at any point of time.
 ADVANTAGES AND DISADVANTAGES

ADVANTAGES:

 The nanorobots do not generate any harmful activity as they work only in specific site
as told by the physician.
 Rapid elimination of diseases.
 Nanorobots might also reproduce copies of themselves to replace worn out unit, a
process called self replication.
 The major advantage of Nanorobot is the durability which in theory is thought be for
bout decades and centuries.

DISADVANTAGES:

 The Nanorobot should be very accurate otherwise harmful events may occur.
 The initial design cost is very high.
 The design of this robot is very complicated.
 Hard to interface, customize and design.
CONCLUSION:

It is a proposed idea that can be made practical by the existing engineering technology.

a) The Nanorobot to be designed must be biocompatible.

b) The size of the Nanorobot should not be more than 3 micron so as, not to block any
capillary.

c) The Nanorobot should resist the corrosive environment of the blood vessels.

d) The nano particles that are attached to this Nanorobot should be held tightly and
must be durable.

With the application to healthcare, nanotechnology is indeed quite the exciting and
revolutionary technique in the pursuit of quality healthcare. Nanomedicine endeavors
to improve human health utilizing molecular tools and nano particles. The technology
and the applicability of it to the human body is still at preliminary stages 
 BIBLIOGRAPHY

 Replacement Of Heart Bypass Surgery By Nanorobots, International Journal

Of Advanced Research And technology, www.ijart.org/2012/IJART080.pdf
,Shinob M.C, Department of ECE,Roever Engineering College,Perambalur
Jidhin G, Department of ECE,Roever Engineering College,Perambalur
 www.frost.com,www.frost.com/sublib/display-market-insightop.do?
id=130393722
 Possibilitieswithnanorobotics,3407713mcfilmer.files.wordpress.com/2012/11/r
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Robots.pdf
 Discoveryhealth,health.howstuffworks.com/medicine/surgeriesprocedures/ques
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 wiseGEEK, www.wisegeek.com/what-are-nanorobots.htm
 John Hopkins
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