Advances in Heart Surgery at Cleveland Clinic - Part I

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Lars Svensson, MD, PhD:

Thank you for joining us today. We would love to talk to you more about Love Your Heart. And appropriately so since it's Valentine's Day here in Cleveland today and go through some topics with you. With me today is our Chairman of Cardiothoracic Surgery, Dr. Marc Gillinov. Thanks for joining us, Marc. And I am Lars Svensson, I’m Chief of the Heart, Vascular and Thoracic Institute, and we look forward to chatting you today about various aspects of cardiac care.

So to start off, why would you want to come to the Cleveland Clinic? Well, the most important reason, in our view, is the high quality of care here and the likelihood that you will get the best care in the United States, if not the world. And we pursue this with great diligence, and work as a team to make sure everybody gets the best possible care. We are all on salary, so we all work as a team together to deliver the best possible care.

Marc, what would you like to add as far as comments as to why people should come to the Cleveland Clinic?

Marc Gillinov, MD:

It's a truly amazing place with a remarkable group of people. Today, Valentine's Day, we are sitting here in this room in a million square foot building that is dedicated to cardiovascular care. And within this building are 3,000 individuals – doctors, nurses, technicians, echocardiographers – every single one of them at the top of his or her game. So the building is fabulous, it truly is, but the people inside this structure can manage any cardiovascular condition better than anyone on Earth. It's a really special place.

Lars Svensson, MD, PhD:

Just to add what Marc was saying, it is a place that's really humming. Last year we did about 6,000 heart operations, and that takes a tremendous amount of coordination by, in this case Marc's team, in treating patients, and it's often 20 to 30 heart operations a day that we do here. Obviously our cardiologists are incredibly busy. The electrophysiologists did some 7,000 heart procedures like ablations last year, and about 13,000 cardiac catheterizations and over 100,000 echocardiograms, so a very busy place.

Let's just talk a bit about results and I'll touch on some of the cardiology outcomes. We run at better than the 90th percentile for outcomes for treatment of coronary arteries stenosis and acute MI [myocardial infarction], so among the lowest mortality rates for acute heart attacks and coronary interventions. And then when it comes to TAVR – transcatheter aortic valve replacement – which has become very popular around the United States, we do close to 700 every year. Last year, the risk of death was only 1%. And overall we run about 0.4-0.6% over many years for the risk of death.

Would you like to say a few words about the outcomes in cardiac surgery Marc?

Marc Gillinov, MD:

Oh, absolutely. We are very proud of the outcomes that we get with our teams. For each major cardiac surgical procedure, there's a star ranking in which every program across the country is ranked from one to three stars in one of seven categories. We, Cleveland Clinic, are amongst the only programs to have three stars in all seven categories. And this is consistent year after year. And what that means is that no matter what the cardiac procedure, we have the highest success rate and the best survival. And we have that because within each subspecialty of cardiac surgery, we have the best people in the world, whether it is heart transplant, aortic surgery, robotic surgery, minimally invasive surgery, coronary artery bypass grafting. We have a recognized expert, or two or three, that is going to deliver the finest operation that you can get anywhere in the world.

Lars Svensson, MD, PhD:

So, Marc, just to expand a bit more on that, you run the robotic mitral valve repair program. As I understand it, there’s over 2,600 mitral valve repairs with a robot since September 2016 without a death, how do you achieve those incredible results?

Marc Gillinov, MD:

The robot is a wonderful tool for doing mitral valve surgery. We can make an incision that's only this big on the right side, so we spare the sternum. And the way that we achieve excellent results is, I think, predicated on a couple of points. First is expertise. We have done more robotic mitral valve surgery likely than any place in the world, and if you do this much, you become very good at it. In addition, we are very keen on selecting the right patients for the right operation. We never cut corners. Sometimes, someone might come here and we find out they need another valve operated upon, or they need a bypass. And while that may not be perfect for the robot, it means that we're able to deliver a comprehensive plan in the operating room.

So I think the two things are expertise and appropriate patient selection, and we're doing robotic mitral valve surgery every day. We had a beautiful case this morning, in fact.

Lars Svensson, MD, PhD:

So, Marc, you are a world expert on mitral valve repair. You often give the talk on the five key things you need to know for mitral valve repair. How about telling us about that?

Marc Gillinov, MD:

It turns out that mitral valve repair is probably like anything else – if you do it often, you will do it well. And for surgery, it is really important to have a plan. To repair a mitral valve, and we're talking about mitral valve prolapse which is also called degenerative mitral valve disease, to repair these valves you really only need a combination of five specific techniques.

And those are what we call a triangular resection, in which you cut out a piece of the valve about as big as your thumbnail, and that triangle looks like a piece of pie. We can also do a quadrangular resection with what's called a sliding repair, and that's a second technique. A third technique is to make new cords to the valve, the cords being like the struts of a parachute. Imagine a parachute in one of the struts snaps. That may happen to the mitral valve. We can make a new strut or a new cord out of cortex. A fourth technique is to close one end of the valve, or one commissure, if there is a leak coming just from the commissure, or the extreme end of the valve on the right or on the left. Then the fifth technique that everyone gets is an annuloplasty band or ring around the valve, which is something like a washer to add support. The key, though, isn't knowing how to do those, it's knowing when to do them and when to combine them.

Lars Svensson, MD, PhD:

Just touching also on aortic valve repair, so we've done several thousand aortic valve repairs with excellent results. And we do a lot of bicuspid valve repairs. And then three leaflet valve repairs, often in combination with replacement of aortic root. And when we first pioneered some of the modified techniques for repairing the aortic valve with a bicuspid or three leaflet valves, we weren't sure how that was going to hold up long term. Now in the last year, we put out a number of publications on the excellent results with these repairs, and particularly with the re-implantation of the three leaflet valves inside a tube graft and repairing the valve, and looking both at patients with connective tissue disorders and patients without. For the three leaflet valves, at 15 years after surgery, 96% of those valves are still working, and the risk of death for the first operation has been essentially zero. So very good results and a great option for patients. If we talk about aortic valve replacements, we did over 400 last year without a single death, and that's been pretty much the case that most years we don't have a death after aortic valve replacements. And most of those isolated ones are done with a minimally invasive approach.

So, Marc, how about talking about the complex valve operations of patients who come here with multiple valve problems, infected valves, failed valves, and the fact that we treat everything that comes to us?

Marc Gillinov, MD:

These complex valve operations are the sorts of procedures that actually most heart surgeons never see or never do. On the other hand, in our case, it's a daily occurrence. Somebody has 2 or 3 valves that need repair or replacement or they've had multiple previous operations. We've been asked, can you have a second, third, fourth, fifth or six heart operation? And the answer is when necessary, of course we can do that. In fact, we do over a thousand re-operations per year. People who have previous heart surgery and perhaps a valve has worn out, or they have a new problem. These complex procedures really require an integrated team, and a plan. Oftentimes we will have two heart surgeons operating on the same patient at the same time because we like to merge our expertise. How can we do that? Well, we have 18 surgeons who do adult cardiac surgery, and that means that we have expertise across such a wide range of different operations that we can bring the expertise of two or sometimes even three surgeons to bear on a complex situation with a patient. Basically, “no” is not a word we use. Our word is “yes.” Yes, we can operate. Yes, we can fix whatever the problem is.

Lars Svensson, MD, PhD:

We’re using a lot of new technologies now for these complex operations and various devices to support patients through operations when they're particular high risk, or after operations, or when patients get transferred here basically on heart-lung machines for complex surgery, in other words, ECMO [Extracorporeal Membrane Oxygenation]. What about all these new devices we're using?

Marc Gillinov, MD:

It's really been a dramatic change in the sense that now when people have a lot of heart damage or severely reduced heart function, we have new ways to support the heart, to make it easier for the heart to work, pumps that take over a lot of the function of the heart, in particular the Impella pump, which is placed sometimes surgically, sometimes not surgically, such that it takes over or unloads the work of the heart for a period of time. This gives the heart a chance to recover, and the rest of the body a chance. If somebody has severely reduced heart function, perhaps they had a massive heart attack and their liver and kidneys and other organs are suffering, we can bring those organs back. This requires an intensive care team, a surgical team, an anesthesia team, and a nursing team that knows how to work these machines and knows how to manage them, because you really get one good chance to get such a patient through, and we know how to take that chance and how to maximize the outcome and optimize the patient's ultimate survival.

Lars Svensson, MD, PhD:

Yeah, that's a great point, Marc. Just this last week we had a patient transferred on all these various support devices, ECMO and Impella, and nobody else would take the patient and the patient came here. And we have a jet that is capable of carrying patients who are on ECMO, in other words cardiopulmonary bypass. We support from anywhere in the country and bring them here, and that's what happens, we have a lot of those patients that are really sick and occasionally we'll even have patients transferred, for example, from the Gulf states and come here for, let's say, a heart transplant or resuscitation and complex heart surgery. So we get patients from all corners of the world coming here. And especially for elective surgery, we have a lot of patients who are international who come here.

A discussion about particularly less invasive operations we do here at the Cleveland Clinic, mostly around valve surgery, but we also do robotic, coronary artery bypass assisted operations and various other types of operations. For example, we do a lot of lung operations with a robot or esophageal surgery for robot operations.

If you look at what we do for isolated aortic valves, because that's really where we use minimally invasive operations, many years ago, Toby Cosgrove, who was our former department chair, pioneered a right chest operation for doing aortic and mitral valves, basically what we call a right thoracotomy operation. And later we changed that slightly so we could do more complex operations to what we call a “J” incision or a hemisternotomy, either into the right chest or the left chest – right chest for aortic valves and ascending aorta, and even more complex operations, and into the left chest for the mitral valve. And over time, particularly for mitral valves, we've evolved into doing the mitral valves with the robot.

When it comes to the minimally invasive “J” incision for aortic valves and ascending aorta, we've done a lot of studies on this. The pain is less, the amount of bleeding is less, the breathing problems after surgery are less, and patients recover quicker. So we told patients they can start driving two or three weeks after surgery with the “J” incision for the aortic valve. On top of that obviously the incision’s a bit shorter, so about three inches would be typical for an aortic valve, ascending aorta replacement with the minimally invasive "J” incision. And the results are excellent and just the same as a full sternotomy. Whereas the full sternotomy, in other words, when a whole chest is open, takes about six weeks to recover, has a full-length scar, more bleeding, more breathing problems.

Marc, you've been very involved in the changes over time for the mitral valve. We used to do this big chest incision for just a regular mitral valve, and we went to what we call advanced video assisted thoracic surgery through the right chest and then robotic mitral valve surgery. You want to just comment about the history of that and how things have changed over time and your thoughts about less invasive mitral valve surgery?

Marc Gillinov, MD:

In the beginning, everyone received a full sternotomy incision from the top to the bottom of the sternum, and that worked very well. It gave the surgeon wonderful exposure, ability to attach the heart-lung machine right at the heart, but over time we realized that that incision might be this long but your mitral valve is maybe the size of an old-fashioned silver dollar. You don't really need that big an incision. So Dr. Cosgrove worked on a variety of smaller incisions. Dr. Svensson then developed this “J” incision, which is really versatile. You can do virtually any mitral valve operation through this “J” incision, which is in the middle, but quite small.

Since about 2016, we've favored the robotic approach to the mitral valve, and we actually started doing that in 2006. What the surgical robot enables is that we go through the side, actually through the right side of the chest, so there's no incision in the middle. And we can make an incision on the right side that is about three centimeters long. We do not cut any bone, therefore the recovery is quick, people can be driving a week after leaving the hospital. They tend to be in the hospital three or four days, so it is still an operation, but with a very high success rate. The operative risk is below 1 in 2,000. One of the things that I like about it, and I know the patients do as well, is that the day after surgery they don't look like they had heart surgery because they just have the incisions on the side. So in the appropriately selected patients, this robotic approach, again, more than 2,600 times we've used it, is a wonderful way to sort of sneak in there, fix the mitral valve, we can repair it or replace it, and leave a person with a very short recovery and really not looking like he or she had much in the way of surgery.

Lars Svensson, MD, PhD:

Marc, everybody probably would love to have a robotic operation on the mitral valve and/or the aortic valve. So why not? Who are the candidates for the robotic operations? Who are not the candidates for robotic operations?

Marc Gillinov, MD:

The candidacy is based largely on the findings on cardiac catheterization, echocardiography and CT. If you come for valve surgery and your catheterization shows that you need bypasses, then we will generally do a sternotomy to take care of both things at once.

On the other hand, one thing we didn't mention is that we can do some bypass surgery robotically, which we'll come to, but if you need a valve and bypasses, that will be standard surgery, which is extremely, extremely safe in our hands. On echocardiography, we need to make sure that it's only your mitral valve, with or without the tricuspid valve. If you need a mitral valve procedure and an aortic valve procedure, that is not suitable for the robot. Then on the CT scan, we need to make sure that we can safely attach the heart-lung machine to the femoral vessels, the upper vein in the leg. And there are some things we look for on the CT scan, including atherosclerosis of the thoracic or abdominal aorta, because if there is a lot of plaque in those areas, when we send the blood retrograde up the femoral artery, we could cause a piece to break off. So we're very, very careful to ensure that the cardiac catheterization, the echocardiogram and the CT scan tell us this is a candidate for robotic surgery.

Lars Svensson, MD, PhD:

So Marc, just to elaborate on the robotic mitral valve repairs, what have the results been for the robotic approach?

Marc Gillinov, MD:

For robotic mitral valve surgery, and this is primarily people with prolapse, our repair rate exceeds 99%. In general, a repair of a prolapsed valve is superior than a replacement, primarily because you live longer if you get a repair. So the repair rate exceeds 99%, and the risk of death from the surgery is 1 in 2,500, which makes it something like a gallbladder operation. Even though it's heart surgery, the risk is incredibly low.

Lars Svensson, MD, PhD:

So you touched a bit on robotic coronary artery bypass surgery. Perhaps you can just elaborate on that. We did a lot of research on that many years ago. We did patients, and we tried various approaches, and now we feel we've made a sufficient advances and people have become much more comfortable doing operations with the robot. Maybe some comments and thoughts about coronary artery bypass surgery with the assistance of the robot?

Marc Gillinov, MD:

We started doing coronary artery bypass surgery with the robot more than a decade and a half ago. And at that time, the results were pretty good, but the technology was not quite there. The newer robotic platform is far superior to the older platform. So we are now doing robotic coronary artery bypass grafting, the very best candidates are those who need the most important bypass, which is a left internal thoracic artery used as a conduit or used to bypass the left anterior descending coronary artery. So that's a single bypass, sometimes we can do two in selected patients through a small incision on the left side about that big, and we use the surgical robot to be able to see and to take that internal thoracic artery off the back of the chest. It's a very, very nice operation. That practice is growing, I think, largely because it is minimally invasive and because this particular bypass stays open in nearly everyone for their entire lives.

Lars Svensson, MD, PhD:

Thank you, Marc. And yes, so we continue to innovate and try new things, and we have some new things happening with a robot. The robot keeps evolving and getting better and better in its control. The magnification really helps when it comes to coronary artery bypass surgery, you have a lot of binocular magnification and so there are a lot of benefits. And it also results in a very steady hand for doing very intricate procedures. So we have some ideas of other new things we're going to be doing with a robot, apart from that, as Marc said, full sternotomy for patients who require the whole chest open to do the coronary artery bypass surgery and valve surgery. We again are a three-,star program for that in the United States. In other words, among the few best in the country doing those operations and the recovery takes a bit longer, but it's a very safe operation.

Let's just touch on one take home message that you didn't touch on, perhaps for, robotic mitral valve repair. As I recall, we haven't had a death for a robotic mitral valve repair since 2016. Just an amazing achievement by your team.

Marc Gillinov, MD:

It's been a tremendous run to the benefit of the patients. With over 2,000 patients and nearly ten years, every single one of them walking out of the hospital with a valve that's fixed. They traveled from all 50 states, dozens of countries, and they took airplanes to get here. They took trains, they took buses, they took cars, and since 2016 every single one of these patients has been able to walk out of the hospital knowing that they had a perfect or nearly perfect operation, a valve repair, and that they should enjoy a normal life expectancy.

Lars Svensson, MD, PhD:

Thank you very much for listening to us. You can find more information on our website, and we trust that you found this useful. We are always available for both patients and families and our referring doctors to send patients here to the Cleveland Clinic.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts, or listen at clevelandclinic.org/loveyourheartpodcast.