High Risk and Complex Heart Surgery

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & 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!

Edward Soltesz, MD:

Hi, I'm Dr. Ed Soltesz. I'm a heart surgeon here at the Cleveland Clinic and I'm the Lewis Endowed Chair in Cardiothoracic Surgery and also the Surgical Director of the Kaufman Center for Heart Failure and Recovery. Today I'm here with my colleague, Dr. Anthony Zaki.

Dr. Anthony Zaki:

Hi, good to meet you all. My name's Anthony Zaki, one of the staff cardiac surgeons here at the Cleveland Clinic as well. We're happy to join you today to answer some of your questions and provide you with this information.

Edward Soltesz, MD:

We wanted to focus today on complex high-risk valve surgery and particularly focused on some areas such as multi-valve surgery and re-operations. So I'd like to just begin, and Anthony, why might a patient be told they're high-risk for heart surgery in general or particularly valve surgery?

Dr. Anthony Zaki:

Yes, this is something that we encounter quite a bit at the Cleveland Clinic. Patients come to us for an evaluation being told that they are, "High-risk." And that could be for several reasons. In general, we categorize risk into two categories. Whether that's for medical reasons or comorbidities or other medical issues that a patient may have. Or surgical risk. Whether they've had multiple surgeries in the past or whether they have some other technical factor that makes this surgery high-risk. And the third category, which is part of their surgical risk, is how many procedures do they need done at once? Whether it's an isolated valve or bypass or if it's a combination of multiple things. So a lot of patients come to us with that labeling of high-risk. And I'd like to say that that oftentimes is a subjective labeling and that varies center-to-center and surgeon-to-surgeon. We like to meet a patient for the first time, go through their medical complaints, go through their history and understand for ourselves what truly is their risk level.

Edward Soltesz, MD:

What we realize is that for many patients when they're told they're high-risk in one particular center or program, may not necessarily be high-risk at another program. Or it may be risk mitigation strategies that may be available at one program or another. And I think one of the things we have seen here at the Cleveland Clinic are a lot of patients are declined surgery because they are considered too high-risk. They're declined either because they have too many valves that need repair or replacement, that they have low ejection fraction and there's a concern that they will not tolerate surgery. So Anthony, what are strategies we particularly use to overcome some of these issues?

Dr. Anthony Zaki:

Well, the great thing about the Cleveland Clinic is we have access to several different tools, resources, tricks to get these type of patients successfully through an operation. So for example, if someone has been declined surgery at another center because their heart function is low, we have ways that we can support the heart through the operation. Whether it's through a temporary heart pump or some other technique to get the heart through that vulnerable operation period and onto recovery. So that's just one example. People are declined for other risks as well. Needing multiple valves repaired at once, having valve infections or even having transcatheter valves that have been placed in the past that need to be removed or revised or taken care of. So we have different tricks, different tools. We have just a wealth of experience and opportunity here that helps us get these higher risk patients through surgery.

Edward Soltesz, MD:

Excellent. Dr. Zaki brings up a very good point. And one of those was patients who've had TAVRs in the past. TAVRs obviously allow a minimally invasive valve replacement. But of course many times those TAVR valves need to be removed. Either they're failing, they've become infected or they are not in the correct position they need to be in. So tell me a little bit about removing a TAVR valve. If a patient's been told that they were high-risk for heart surgery in the past and they had a TAVR, then can they have a TAVR explant surgically?

Dr. Anthony Zaki:

This is something we encounter all the time. Just recently had a patient who said, "Well, if I had a TAVR a few years ago because surgery was too high-risk, now that I need to have something done now, has my surgical risk changed at all?" And what I would say to that person is that the comfort level with TAVR removal, especially at a large center like Cleveland Clinic, has increased as the number of TAVR implants has increased. So if you go to a center that's comfortable removing and revising and repositioning TAVR valves, then that risk is mitigated compared to the risk that you may have had upfront. So TAVR is a wonderful technology and it is indicated for a lot of patients. But just because you've had a TAVR in the past, it doesn't mean that it can't be removed if it needs to be and a surgical option available to you.

Edward Soltesz, MD:

Yeah, that's very true. And I also think that a theme you've heard us talk about is having another opinion. And I think second opinions are absolutely critical. I think receiving a second opinion from a specialist is critical for everyone. But I think it's essential for patients in their own decision-making as to what they want to do. Anthony, when you talk to patients many times they've been to other programs, they've seen other practitioners, they've come to see you for a second opinion. How do you relate with them how some of the things that we do here can affect their recovery after surgery? Because are focused also not only on getting through surgery, but on recovering well after surgery. So how do you talk to them about that?

Dr. Anthony Zaki:

Yeah, this is something... And I couldn't agree more with you, Dr. Soltesz, about getting a second opinion. And people are turned down for surgery for several different reasons, by different providers. So the first thing I like to do when I meet someone who's been turned down at another center is to try to understand why. So that involves taking a deep dive and do my own assessment and my own evaluation, and I try to get an understanding of those risks. So I agree 100%, a second opinion is always a good idea. I always welcome second opinions. We do them quite frequently and I think it's a great idea.

Edward Soltesz, MD:

Great. Now one of the things that we've heard patients ask is, "Can all valves be addressed in a single operation?" If you have multiple valves that need repair or replacement, can they all be done at the same time? And obviously when we talk about transcatheter valve technology, that is oftentimes not the case. But surgically, how do we deal with that surgically?

Dr. Anthony Zaki:

Again, this is something that has become more of a topic recently with TAVR valves and transcatheter valves becoming more common. The thought out there, which I don't necessarily agree with, is transcatheter approaches may address one valve and will just monitor the other valves. And what we see is that patients that may not correct all of their symptoms or all of their problems, and then they're referred to us or to the surgeons to say, "Well, I had one valve fixed with a transcatheter approach, but I have these other valves that are still leaking, are still not functioning well, and I still have symptoms, I don't feel 100%."

So what we can do surgically at the same time and in a single operation is address all of the valves at once. Whether a TAVR valve has been placed in the past or whether a MitraClip or any other transcatheter therapy has been used in the past, we not only can address that main valve or the valve that's already been addressed, but we can fix the other valves in the heart. And at the same time, we can do bypass surgery for coronary artery disease. And a lot of these patients with multi-valve disease have atrial fibrillation. So we can do surgical ablations to get people back into normal sinus rhythm at the same time as well. So whereas transcatheter technology is appropriate for many patients, people with multi-valve disease, atrial fibrillation, coronary artery disease, open heart surgery can address all of these concerns in a single shot.

Edward Soltesz, MD:

Yeah, I think that's a good point. And especially is the case with atrial fibrillation. Atrial fibrillation is a growing problem in the US and worldwide, and we know it's been associated with a lot of comorbidity. We are able, at the time of a surgical operation, whether it be the primary operation or even a re-operation, to perform an extremely durable ablation that has tremendously high success rates of getting patients out of atrial fibrillation and in sinus rhythm, which reduces not only their risk of stroke long-term, but reduces their risk of long-term heart failure, dementia and many other comorbidities that we have seen associated with atrial fibrillation. Anthony, I recently saw that you had done a fourth time re-operation on someone, someone who had had three previous heart surgeries. So can you tell me a little bit about how previous heart surgeries affect your ability to operate? I think there are many patients out there who are erroneously told that they've had too many heart surgeries so, "We can't go back in a fourth or fifth time." Can you tell us a bit about that?

Dr. Anthony Zaki:

Yeah, this is something that we encounter quite a bit. Patients who have had valve disease or heart disease throughout their lifetime may or have experienced multiple open heart surgeries. And whereas it is true that the second operation and the third operation, there is scar tissue. What we've learned in our experience here is that oftentimes re-operation is just as safe as the first operation. Whether that's the second, third or fourth time. And that's only true at centers that have that experience. So we're grateful and we're happy to be here at the Cleveland Clinic where we have that experience and we have that skill and that knowledge that's been passed down from mentors of mine, like Dr. Soltesz, who have passed on this understanding of how to deal with these re-operations. I think that adage of, "We've been in there too many times, we can't go back." It should be tested or it should be checked with a second opinion and may or may not be absolutely true.

Edward Soltesz, MD:

Yeah, very true. And I think one of the things we've heard repeatedly is this idea of team-based care. We all work together. We learn from one another. We have a very close connection with our cardiology colleagues. We have conferences together where we review high-risk patients. We have conferences within our surgical staff where we review complex operations. So I think one of the advantages of the Cleveland Clinic is just that it is a true team of team's approach to treating patients. But I also think on an individual level for a patient, it's important for us to be able to engage in a shared decision-making with our patients so that they understand what we can offer and we understand what they want for as their quality of life, their survival, their risk tolerance. So last question, Anthony, is when you talk with patients in the clinic, what does the conversation sound like? How do you engage patients? And what is a typical dialogue with you and the family?

Dr. Anthony Zaki:

The first thing I understand when meeting with a patient is that they've been through a long process before they've gotten to me. They've been through either a primary care, a cardiologist, and perhaps have been through several different centers until coming to me. And often I feel like the most important step is to hear from them what have they been through, what have they been told, and often what are their expectations? And that serves as a good starting point for me. And from there, I do my own evaluation and my own assessment, within our team approach that Dr. Soltesz described. And then from there we make a plan. And like Dr. Soltesz mentioned, not every patient is the same and not every valve disease is the same. And so a discussion with the patient about what are you looking for? What are your goals? What are your values? What are you expecting from your treatment plan? It really helps guide the discussion and together we come up with the best solution possible.

Edward Soltesz, MD:

That's great. Well, we're going to close now, but I just want to ask for one final comment, one recommendation for patients from your experience as a staff Cleveland Clinic heart surgeon.

Dr. Anthony Zaki:

My biggest advice, and this is what I share with anyone who asks or my family that has medical problems, I tell them is challenge what you've been told, getting a second opinion until you really feel at peace and comfortable with the treatment plan in place. And there's no harm in getting a second opinion.

Edward Soltesz, MD:

Yeah, and I would second that actually. I think second opinions are key. And it's important to recognize that as a patient, you have control of your health and it is in your best interests to ask questions, as you just heard, get a second opinion, and then make a informed decision with your family, with your practitioners as to exactly how to proceed. Thank you very much for listening today. We're excited to be able to share some of our practice here at the Cleveland Clinic.

Dr. Anthony Zaki:

Thank you.

Announcer:

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