Professor Dr. Alexander Albert is undoubtedly one of the most renowned cardiac surgeons in the world and has earned an international reputation, particularly in the field of minimally invasive cardiac surgery. His areas of expertise include minimally invasive bypass surgery, minimally invasive mitral valve reconstruction, as well as artificial heart implants and heart transplants. With 30 years of professional experience and 20 years in leadership roles, he is considered a proven specialist in heart disease.
Since fall 2019, Professor Dr. Albert has been the director of the Heart Clinic in Dortmund, where he has established a major supraregional heart center. He began his career in 1994 at the private clinic of the Heart Center in Lahr, Black Forest, where he completed his training as a cardiac surgeon over the course of six years; following his advanced training abroad, he made this clinic the first in Germany to transition all bypass surgery to off-pump procedures. Prior to his position in Dortmund, he served for ten years as Deputy Director of Cardiac Surgery at the University Hospital of Düsseldorf, where he played a key role in establishing one of the most prominent cardiac and transplant centers. He furthered his expertise in other European countries, particularly in Switzerland and Belgium; in particular, his one-year stay 20 years ago at the University of Leuven under the “pope” of European off-pump surgery, Prof. Dr. P. Sergeant, had a profound impact on him both professionally and personally.
In addition to his outstanding reputation as a surgeon, Professor Dr. Albert is known for his interdisciplinary approach and compassion. He places great emphasis on making diagnostic and therapeutic decisions as a team, which involves not only medical specialists but also the patients and their families. His concept of personalized cardiac surgery places particular emphasis on the expectations and wishes of patients. Prof. Dr. Albert’s contribution to the development and application of minimally invasive bypass surgery is especially noteworthy. He developed this technique based on his decades of experience in off-pump surgery. His groundbreaking advances in minimally invasive bypass surgery have made him an internationally sought-after specialist in this field. Prof. Dr. Albert is therefore not only an experienced surgeon but also a teacher who enjoys sharing his knowledge; he is also the director of the European Training Center for Minimally Invasive Bypass Surgery. Every month, teams from all over Europe—and now beyond—come to Dortmund to learn from Prof. Dr. Albert.
For Prof. Dr. Alexander Albert, the patient is always the focus. This highly personalized and patient-centered approach is reflected in the range of individually tailored treatment plans he offers. Under his leadership works an international team of cardiac surgeons, each of whom specializes in a specific field with extensive experience and expertise. From minimally invasive bypass surgeries and minimally invasive procedures on the aortic valve or aorta, to minimally invasive mitral valve reconstructions and artificial heart implantations, his team offers a wide range of surgical treatment options at the highest level. The editorial team at Leading Medicine Guide once again had the opportunity to speak with this outstanding heart specialist, focusing in particular on minimally invasive heart surgery to learn more about the latest developments in this field.
Minimally invasive cardiac surgery has gained increasing importance in recent years; it represents an innovative approach to the treatment of heart disease and is very much in line with patients’ wishes and expectations. Compared to traditional bypass surgery, this advanced technique offers a promising alternative to conventional procedures and is associated with potentially less strain on patients. The development of minimally invasive procedures is set to revolutionize cardiac surgery by enabling more precise interventions and shortening recovery time.
Minimally invasive heart surgery has established itself as the new standard at Klinik Dortmund; innovative methods and technologies are used to make heart surgeries more effective and less invasive.
“Compared to conventional, invasive procedures, which require a large longitudinal incision in the chest (sternum), minimally invasive cardiac surgery allows for precise procedures through smaller incisions between the ribs, usually below the right or left breast. This advanced technique offers a variety of advantages. For example, it reduces the extent of surgical trauma, as it does not require cutting through the chest bone. However, in Germany, 90% of heart surgeries are still performed using conventional methods, i.e., with a heart-lung machine and sternotomy. Typically, the heart-lung machine is connected, and the heart is then stopped; during this time, the body continues to be supported by the machine. However, this well-established procedure also has side effects, particularly in bypass surgery. We do without the machine and operate on a beating heart. The reason so few do this is simply a matter of the surgeon’s habit, as it is often difficult to break away from routine—a change in approach means venturing into uncharted territory. “In my opinion, the most important aspect of bypass surgery is avoiding the use of the heart-lung machine. This allows us to avoid some of the potential complications associated with its use,” explains Prof. Dr. Albert at the beginning of our conversation.
The use of a heart-lung machine (HLM) carries several potential risks.
Blood clot formation: The CPB can lead to the formation of blood clots because the blood circulates outside the body. These clots can later lead to thrombosis or embolism.
Inflammatory reactions: Contact between the blood and non-bodily surfaces of the CPAP can trigger inflammation in the body.
Organ dysfunction: Blood flow to the organs is compromised during bypass via the CPB, which can lead to temporary dysfunction or damage to various organs.
Blood loss and transfusions: Blood loss may occur during the surgical procedure, which may require transfusions; these, in turn, are associated with certain risks, such as infections or immunological reactions.
Neurological problems: In some cases, neurological problems may occur during the use of the HLM, including temporary cognitive impairments or strokes. The main cause of strokes is manipulation of the aorta, which can dislodge calcium particles or similar substances that may travel to the brain.
“In general, thanks to the minimally invasive technique, the patient’s recovery time is significantly shortened, allowing them to return to their normal activities more quickly,” emphasizes Prof. Dr. Albert.
Minimally invasive techniques in cardiac surgery have proven successful for a wide range of heart diseases and conditions.
Despite the advantages of a minimally invasive procedure, there are also some challenges and limitations. Not all patients or all types of heart surgeries are suitable for minimally invasive techniques. This depends on the severity of the heart disease, the patient’s anatomy, and other individual factors.
“Whether a minimally invasive procedure is possible depends heavily on the surgeon’s expertise. There are five major categories of heart surgery. First, there are mitral valve procedures; then there are aortic valve and aortic surgeries; and there are bypass surgeries as well as artificial heart implantations. I generally perform mitral valve surgery—that is, nearly 100% of the time using a minimally invasive approach; through the incision under the right breast, you can access the mitral valve directly, which is even easier than operating from the front via sternotomy. I recently had a patient whose mitral valve I repaired using this minimally invasive technique; when he visited me three months later, he proudly told me that he had just placed third in the German (amateur) karate championship! “That certainly wouldn’t have been possible if I’d had to damage his sternum,” says Prof. Dr. Albert enthusiastically.
“For aortic valve surgeries, we perform over 90% of procedures using minimally invasive techniques—in other German hospitals, only 20% of these surgeries are performed minimally invasively. This means the sternum isn’t opened—after all, that’s something that frightens patients, and some older patients simply refuse to undergo such an operation that involves opening the sternum. Only if it’s determined before surgery that the aorta is severely calcified or pathologically dilated is a minimally invasive approach out of the question; in that case, I would advise the patient to undergo major surgery, as this allows for safer connection and monitoring of the heart-lung machine. “For this reason, we always perform a CT scan here before surgery to assess the extent of calcification and dilation,” Prof. Dr. Albert explains.
When it comes to bypass surgery, Prof. Dr. Albert is a true exception, as minimally invasive surgery is not at all common in this field of cardiac surgery. “I perform about 70% of bypass surgeries using minimally invasive techniques, and that percentage is rising as my techniques become increasingly sophisticated. Across Germany—and indeed worldwide—the figure is less than 1%. You need the right diagnostic findings; it also depends on the coronary anatomy and the extent of the blockages in the coronary arteries. There are, of course, three coronary arteries. If two of the three arteries are affected, it’s still possible to perform the surgery using a minimally invasive approach. If all three coronary arteries are affected and the patient is younger, I would perform the surgery from the front—that is, through an open chest—and, if possible, place four or five arterial bypasses that will last a lifetime. That would definitely be my recommendation to the patient. However, there is also the option of hybrid surgery. This means I perform the part of the procedure that can be done from the side—minimally invasively, using bypass grafts—while the cardiology team handles the rest using stents. “This is particularly well-suited for older patients,” explains Prof. Dr. Albert.
Minimally invasive heart surgery has established itself as the new standard in recent years and offers a variety of advantages over conventional, more invasive procedures.
This innovative approach to heart surgery relies on precise techniques and smaller incisions to perform procedures that traditionally required larger incisions. Smaller incisions and targeted treatment of specific areas of the heart result in less damage to the surrounding tissue. This leads to faster recovery and shorter hospital stays.
“Patients can return to their normal lives much more quickly after a minimally invasive procedure and are also able to resume full physical activity sooner. They do not have to be as careful as patients who have undergone open-heart surgery, who, for example, are not allowed to sleep on their stomachs for an extended period of time. Another positive aspect is the lower risk of infection. Smaller incisions mean fewer entry points for potential infections, which is particularly beneficial during the postoperative phase. Furthermore, minimally invasive heart surgeries are often associated with less blood loss during the procedure,” explains Prof. Dr. Albert.
The MIDCAB bypass procedure is a minimally invasive method that does not require the use of a heart-lung machine and does not involve any manipulation of the aorta. This technique is therefore particularly gentle on the patient. Prof. Dr. Albert has also introduced the terms “MIDCAB plus,” which refers to the minimally invasive placement of two bypass grafts on the anterior wall of the heart, and “multivessel (MV)-MIDCAB,” which refers to the minimally invasive placement of multiple bypass grafts extending to the lateral and/or posterior walls of the heart.
Aesthetic outcomes also play a role, as the smaller scars resulting from minimally invasive techniques lead to improved cosmetic results. This is also important from a psychological perspective, as patients often benefit from less visible scarring. The decision regarding the type of surgical procedure depends on the specific heart condition, the patient’s anatomy, and other individual factors. However, minimally invasive cardiac surgery undoubtedly represents a significant advance in cardiac surgery and has the potential to further improve treatment standards.
Without the ability to operate off-pump—without a heart-lung machine—it is not possible to perform minimally invasive bypass surgery.
“Many doctors and medical students still need to learn minimally invasive bypass surgery. I have been performing off-pump surgery for 20 years now, and, as I mentioned, I perform 70% of my bypass procedures using minimally invasive techniques. It is absolutely essential to first learn how to operate on a beating heart before performing MIDCAB procedures. Currently, there is great interest in being able to perform minimally invasive heart surgeries, partly because patients are demanding them. Many of my fellow physicians are also very interested in being able to perform bypass surgeries using minimally invasive techniques. But the prerequisite for this is the ability to perform high-quality off-pump surgery, and learning that doesn’t happen overnight; it requires a great deal of experience. I’m often invited to hospitals around the world to teach these techniques—but it’s simply not possible without off-pump expertise. I also enjoy inviting colleagues to my clinic to learn how to operate and master the skills of surgery without a heart-lung machine, particularly with regard to suturing techniques on a beating—that is, a moving—heart. These can best be practiced at home using small simulators, and experts can then review the results and progress via video. Of course, it’s best when the trainee can join me in the operating room; fundamentally, it’s always about first understanding the theory and then improving one’s practical skills. “I make a great effort to share my knowledge,” explains Prof. Dr. Albert.
Personalized bypass surgery has revolutionized heart surgery in recent years by enabling an individualized approach for each patient. This innovative treatment approach leverages advances in diagnostics, including more precise imaging techniques such as CT and MRI scans. These provide detailed visualization of the coronary arteries and enable surgeons to precisely locate blockages or narrowings. Another crucial step in personalized bypass surgery is the functional assessment of the heart. Modern diagnostic methods allow not only for the evaluation of pure anatomy but also for an assessment of blood flow and other functional parameters. This information is crucial for planning bypass surgery. Treatment is tailored to the individual when we can select from a wide range of options—namely, the treatment method that best suits the patient—from conservative drug therapy to stents to bypass surgery; and in the case of the latter, we also have the expertise to choose between open and minimally invasive procedures.
Minimally invasive heart surgery can be particularly beneficial for certain patient groups, thereby optimizing overall outcomes.
Older adults often face additional health challenges. Minimally invasive techniques allow for a less invasive procedure, which can lead to a shorter recovery time and less physical strain. For patients with obesity or diabetes, minimally invasive heart surgery can be beneficial due to the reduced tissue trauma and the ability to use smaller incisions, particularly to prevent wound healing complications in this patient group. Working individuals or those with family obligations can benefit from the shorter recovery time following minimally invasive procedures, as they can return to their daily activities more quickly. Additionally, minimally invasive procedures can result in smaller scars and an overall more aesthetically pleasing outcome, which may be an important consideration for some patients.
“There is no clinic in Germany that performs minimally invasive surgery as consistently as we do. This allows us to respond individually to our patients’ wishes. I regularly hold follow-up consultations with my patients two months after surgery; during which I explain once again in great detail why and what we did, and the goal is to encourage the patient to return to their normal daily routine and resume normal physical activity. The patient really needs to feel that we go out of our way to make the procedure as gentle as possible. Sometimes, the minimally invasive approach isn’t the deciding factor; for example, I recently operated on a patient who had been scheduled for a minimally invasive bypass surgery—which is why she had even traveled from far away to see us. Unfortunately, during the operation, I had to decide to proceed via open chest surgery instead. After the surgery, I was able to explain to her why I had made that decision. She was very disappointed at first; but later, to my surprise, I saw online that she had given us a 5-star rating on Google. So it’s not always just about the technical aspects, but also about the personal touch—ensuring that the patient feels comfortable and realizes that we—that is, the entire team, especially the nurses on the wards! —are doing our best and treating our patients with compassion and humanity,” explains Prof. Dr. Albert.
Among the significant technological advances is the introduction of robot-assisted systems.
Currently, so-called robot-assisted systems are in use in cardiac surgery; these are not—as the name suggests—technologies based on artificial intelligence (AI) that learn and make decisions on their own; rather, they are robotic arms that the surgeon controls remotely from a console. The advantages of these robot-assisted systems include, on the one hand, improved maneuverability of the instruments in all spatial planes, even in hard-to-reach areas. This precision is particularly important in minimally invasive procedures, where the surgeon has limited direct access due to small incisions. Furthermore, the intraoperative imaging provided by these robot-assisted systems, with their image-guided navigation systems, supports optimal 3D visualization of the surgical site. Combined with the high maneuverability and precision of the robotic arms, this enables extremely precise and gentle tissue dissection. These innovations in visualization are supported by advances in imaging techniques, such as 3D CT and MRI scans; these enable accurate visualization of the anatomy and function of the heart and surrounding vessels even before surgery. These advanced imaging technologies thus help create accurate maps of the affected area before planning the procedure. Precise diagnosis and planning are crucial for developing the best possible strategy for the procedure.
“Robotics is going to be a major ‘game-changer.’ However, it still struggles, particularly with the moving heart—such as in off-pump bypass surgery on a beating heart. The situation is different in surgeries where a heart-lung machine is used and the heart has been stopped. Robotic-assisted systems handle these situations better and can showcase their strengths. What’s still missing, however, is the tactile sensation of the hand; as a surgeon, you feel the tissue when you cut or suture; the surgeon at the console, on the other hand, relies solely on visualization and doesn’t feel what the remote-controlled instruments are doing to the tissue—he only sees it. In Germany, robotic surgery on the heart is not yet approved; it is used only in clinical trials or for harvesting bypass vessels such as the mammary artery. I was recently on a lecture tour in China, where the use of robot-assisted systems is more widespread than here—and, incidentally, so is minimally invasive surgery in general. I think that more practical robot-assisted systems than the very expensive and cumbersome da Vinci system—currently the only one available—will soon come onto the market. Conceptually, I find robotics very compelling, as the visualization, precision, and mobility of the arms are outstanding. I’m convinced that robotics, used as a guidance tool—much like a PlayStation—is the future, though it will still take a little while. For now, heart surgery is still manual work; this is where the highest precision can be achieved—sometimes less technology is more,” explains Prof. Dr. Albert, thereby emphasizing the indispensability of precise manual work in heart surgery, and thus concluding our conversation.
Dear Professor Dr. Albert—once again, our heartfelt thanks to you for the insight into the fascinating world of cardiac surgery!
