Awake cardiac surgery is performed without the use of general anaesthesia. Recent advancements in cardiac surgery, particularly the off-pump coronary artery bypass (OPCAB) procedure, have significantly mitigated complications associated with traditional cardiopulmonary bypass (CPB) techniques in awake cardiac surgery.

Procedure and Techniques

Awake cardiac surgery needs detailed planning, expertise, and advanced instrumentation. Before the procedure is started, patients undergo a thorough evaluation and preparation to assess their suitability for awake surgery. Using advanced imaging technologies, such as intraoperative echocardiography, surgeons visualise the heart's anatomy and plan the surgical approach. Here are the techniques used -

Local Anesthesia and Sedation: Awake cardiac surgery involves using local anaesthesia and sedation instead of general anaesthesia. Patients remain conscious and responsive during the procedure, allowing real-time communication with the surgical team.
Epidural Analgesia: Epidural analgesia directly relieves spinal nerves, reducing the need for general anaesthesia. This technique enables patients to stay awake while maintaining comfort during surgery.
Off-pump Cardiopulmonary Bypass (OPCPB): Recent advancements in cardiac surgery, particularly the off-pump coronary artery bypass (OPCAB) procedure, have significantly mitigated complications associated with traditional cardiopulmonary bypass (CPB) techniques. By bypassing the need for aortic cannulation and cross-clamping, OPCAB reduces the risk of adverse effects such as immunological changes and organ injuries, including those affecting the lungs, kidneys, heart, and brain. This innovative approach allows surgeons to perform coronary artery bypass surgery without stopping the heart, offering a safer and potentially more effective alternative for patients undergoing cardiac interventions.

Cardiopulmonary Bypass

Minimally Invasive Approaches: Some awake cardiac surgeries employ minimally invasive techniques, such as small incisions or robotic-assisted procedures, to access the heart while minimising trauma and recovery time.
Patient Selection and Monitoring: Proper patient selection and continuous monitoring of vital signs are crucial aspects of awake cardiac surgery to ensure patient safety and optimise outcomes throughout the procedure.

Benefits of Awake Cardiac Surgery

Awake cardiac surgery offers many benefits compared to traditional approaches:

Reduced Risk - This technique reduces the risk and complications from general anaesthesia. Since patients are not on the cardiopulmonary bypass, there is a minimised risk of systemic inflammatory response syndrome and organ dysfunction.
Enhanced Recovery - The postoperative recovery time is reduced significantly. The hospital stay is shorter as compared to conventional surgeries. There is a faster rehabilitation of respiratory function and early mobilisation.
Real-Time Assessment - Surgeons can assess the cardiac function and hemodynamic parameters in real-time, allowing for immediate adjustments and interventions as needed. It significantly reduces the need for postoperative revisions or interventions.
Patient Engagement - In awake cardiac surgery, patients have a sense of control, autonomy, and trust as they actively participate in their care and decision-making process. This results in higher satisfaction levels, reduced anxiety, and improved adherence to postoperative care protocols, leading to better long-term outcomes and patient experiences.

Challenges of Awake Cardiac Surgery

Psychological Distress - Staying awake during the surgery can be daunting and can induce stress, anxiety and fear in patients.
Pain Management - Patients undergoing awake cardiac surgery may not experience pain during the procedure. Yet, they may experience some discomfort from the incisions made by the surgeon and the tools used on their body.
Communication and Cooperation - Effective communication during the surgery is the key for the procedure to be successful. If the patient is not given clear and concise communication during the process, and their concerns are not addressed, it might lead to distress.
Patient Movement - Patients are put under general anaesthesia during traditional cardiac surgery. Thus, no bodily movements are involved. However, during awake cardiac surgery, there would be intervals of patient movements or repositioning during the procedure.

Considerations before going for the awake cardiac surgery

Patient Selection - As this surgery is not optimal for all patients, selecting the most suitable candidate for the procedure is crucial. Evaluating medical history thoroughly, including cardiac conditions, allergies, and previous surgeries, is essential. The patient's psychological readiness to cope with stress is needed.
Anaesthetic Management - Awake cardiac surgery needs a tailored anaesthetic plan, where the patient's needs, age, and experience of previous surgeries are to be considered. A protocol to sedate the patient during the procedure needs to be decided before the surgery based on the anxiety levels and surgical requirements.

Future Directions

Awake cardiac surgery promises continued innovation in the future. There is a scope for refinement and broader expansion of the applications of the procedure. With ongoing research, the focus has shifted to exploring novel techniques, optimising the patient selection criteria, and enhancing preoperative protocols to maximise the benefit of awake cardiac surgery. Patient outcomes from the procedure have been improved due to advanced surgical instrumentation, imaging technology, and anaesthetic management. It increases the scope of awake cardiac surgery, making it more accessible to a broader patient demographic.

Conclusion

Awake cardiac surgery can make a paradigm shift in cardiovascular medicine. It offers a safer, more precise, personalised, and patient-centred approach to heart surgery. It is a collaboration of precision medicine, interdisciplinary knowledge sharing, and patient engagement. Awake cardiac surgery has the potential to revolutionise the intervention in patient care and improve the quality of care for patients with cardiovascular disease.

Sources:

https://www.ncbi.nlm.nih.gov/books/NBK499963/
https://www.mcgill.ca/anesthesia/files/anesthesia/wk_7b_kaplan_10_echo1.pdf