Cardiac Reoperations

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Marc Gillinov, MD:

I'm Dr. Marc Gillinov, Chair of the Department of Thoracic and Cardiovascular Surgery at the Cleveland Clinic.

Faisal Bakaeen, MD:

I'm Dr. Faisal Bakaeen. I'm the Director of the Coronary Center and the Director of Quality at the department.

Shinya Unai, MD:

I'm Dr. Shinya Unai. I'm the Surgical Director of Aortic Valve Center.

Marc Gillinov, MD:

Today we're going to talk about re-operations, operations and people who've had previous heart surgery, and at Cleveland Clinic we have the nation's largest experience with this sort of operation. We've done more than 30,000 re-operations over the years and we've developed ways to make the operation safe and effective. And Dr. Bakaeen, if you could summarize our experience in how we approach these patients who are complicated.

Faisal Bakaeen, MD:

Those numbers are staggering, and this study was an eye-opener. We have done over 160,000 operations of those, as you mentioned over 32,000, almost 33,000 are re-operations. We do more of those operations than probably anybody else in the world, and we do them really well. Experience is an important aspect and obviously the more you do it, the better you get. The tradition of saying, "See one, do one," doesn't really apply here. We see many. We see hundreds and we do thousands, so we're getting better and better. We have a process in place that guarantees good outcomes. We have an excellent culture. We have a teamwork that guarantees and secures the patient's safety and the efficacy of the operations. We found that basically the more you do, the better you get. It turned out that they gain skill and experience, and we can see that confidently up to the age of 75, because that was the oldest surgeon that was included in this study. 

The other thing is that when we take newcomers in, they are supervised. They are part of the team. Their learning curves are blunted, meaning that we don't have bad outcomes at the beginning. They go in with help, they go in confident that their results are going to be excellent, and we found out that even with time, they get incrementally better. So overall, the results have been excellent. They are actually comparable to primary operations, Marc. You've done that for valves. We've done that for coronary and we find out that re-operations, per se, are no longer in and of themselves a risk factor. It's really the patient's risk profile and we can say confidently that if you come to the Cleveland Clinic requiring a complex re-operation, your chances of surviving are excellent. The mortality is between one to 2 percent despite the acuity and complexity of the cases that we do.

Marc Gillinov, MD:

That means that if you are having a re-operation, our success rate is 98 to 99 percent, which is the same as we get if you've never had surgery before and you're having your first operation. Dr. Unai, how do we do this? How do we get 98 to 99 percent success with the world's most complicated patients?

Shinya Unai, MD:

I think the most important part is to do the preoperative workup meticulously. All of our patients get a CT scan before surgery to identify whether there's any structures behind the sternum that are close to major blood vessels, heart chambers, and previous bypass grafts and aneurysm and pseudo aneurysms.

In addition, we looked at the CT scan to identify alternative cannulation sites in the event of an emergency, are the axillary arteries not calcified, in good diameter? Are the abdominal vessels, iliac vessels, free of calcification? Are they able to be cannulated? When we identify if the patient is at high risk for reentry, we will cut down the axillary artery, expose it, cut down the groin, expose the vessels, and initiate cardiopulmonary bypass and cool, if needed. And we'll have a percutaneous retrograde canula placed for cardioplegia and sometimes placed in the balloon in the in aorta, to occlude and give cardioplegia, if needed.

The other important part of our workup is cardiac catheterization, and obviously we do that for most of our patients that have cardiac surgery, to identify coronary disease that needs revascularization.

But the other important aspect of that is to identify bypass grafts that are immobile, and that means, which means that it could be densely adherent to the sternum or the chest wall and peeling that off could be quite challenging, and in those cases, we will have a piece of vein graft available, in case of any injury.

The other point is cardiac protection during surgery. These kind of complex lung operations, we will need perfect myocardial protection and we have a very low threshold to place a purse string directly on the coronary ostia, and place a catheter directly into the coronary ostia, to ensure cardioplegia delivery, especially to the right ventricle. In addition to that, we do mild cooling, use ice slush, intermittent integrated cardioplegia, to ensure myocardial protection, and that gives us safety during sometimes long cardiac surgery.

Marc Gillinov, MD:

Yeah, they can be quite long and quite challenging. I think you brought up two categories of points which are very important that we've learned over the last several decades through these 30,000 operations. In the first point is the preoperative workup means we don't have any surprises. Every person's re-operation is their own unique experience, and we need to know everything, so that we don't have surprises. And then at the context of the time of operation, you and others like Dr. Pettersson and Dr. Bakaeen, have developed techniques to ensure that the patient's heart tolerates the procedure because these are long operations and having a plan, executing the plan and doing this daily, I think that's what leads to this 98 to 99 percent success. You need a team of surgeons who are experienced and who know how to do this because they do it every day.

Faisal Bakaeen, MD:

I mean, it's remarkable, Marc. I think, what is it? 25 to 30 percent of the cases that we do nowadays are re-operations.

Marc Gillinov, MD:

Yes.

Faisal Bakaeen, MD:

Today we're doing 27 cases on the board, excluding emergencies. I bet you, probably eight to 10 of them are re-operations. I'm doing one today.

Marc Gillinov, MD:

I think that's why we have visitors from all over the world who come to watch and see how we do these things. And I think as you said, you can't just watch and do it. It comes from years of personal, institutional and team processing, of how we do things. And we often operate with two surgeons at the same time. If it's a complex re-operation, we work as a team, and I think these are the reasons why. If I ever need an operation, or a re-operation, I'm coming here for that just shared experience.

Faisal Bakaeen, MD:

I might lean on you today in my re-operation or call Shinya, whoever's available, if I run into trouble. Hopefully, I won't.

Marc Gillinov, MD:

We are always available. We're always a team and we get the best results anyone can get.

Announcer:

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