Breakthrough Medicine 03
Repairing Heart Valves
The conventional response to a failing heart valve has been surgery to install an artificial replacement—about 100,000 operations a year in the United States. But at Loyola University Medical Center, Mamdouh Bakhos, a cardiothoracic surgeon, is more often opting for repair. “We’re finding that it’s always better if you can save the patient’s own valve,” he says. “When you put in an artificial valve, you have to put the patient on blood thinners, and you have to worry about a foreign [object] being inside the heart.” Repairing the existing valve wipes out both downsides, Bakhos says, and in recent years he and other Loyola heart surgeons have been repairing about 95 percent of the failed mitral (or bicuspid) and tricuspid valves that they encounter, as well as about 30 percent of the faulty aortic valves.
An integral part of heart valve repair is the ring that a surgeon installs to seal the valve against leakage. Patrick McCarthy, a cardiothoracic surgeon at North-western Memorial Hospital (NMH), has invented three different types of rings, each with a specific use. The first, which has been available for about four years, is the most commonly used ring for repairs associated with the heart’s tricuspid valve. “The vast majority of leaky tricuspid valves are from the same underlying cause, so it only took one ring to solve the majority of problems,” says McCarthy. In use for about two years, the second ring—which McCarthy developed with the French heart surgeon Alain F. Carpentier and David H. Adams of Mount Sinai Medical Center in New York—was designed for patients who develop a leaky mitral valve following a heart attack. McCarthy’s third ring, which should begin arriving in hospitals in January 2007, treats mitral valve prolapse (that is, a failure of the mitral valve to open and close properly).
“The second and third rings are taking surgeons into a new area—special rings for special circumstances,” says McCarthy. “We are doing a lot of publishing and training so that everyone understands the idea behind two different rings for the same valve. The goal with these rings was to make the surgery more simple, so a lot more people can [undergo repair surgery] instead of replacing the valves.”
By anticipating who might ultimately need valve surgery, Nalini Rajamannan (also at NMH) hopes to drastically delay the need for surgery. After six years of research, she has identified the chemical pathways that send signals to the heart to calcify valve tissue. As a result, she can now help doctors determine which people need to go on intensive cholesterol-fighting programs while still in their 30s or 40s. “We can tell you now that you need to do this—or else,” Rajamannan says. “We can put people on statins [to fight cholesterol] much earlier to work against the risk. If it keeps them out of surgery, that’s not so bad”—so long as doctors continue to monitor their patients for any harmful side effects. “They might live into their 80s or 90s without any valve problems.”
Seeing The Heart
No matter how well lit the operating room, heart surgeons often work in the dark. “We look at pictures and films in the lab, but when we go into the operating room and open up [the heart for bypass surgery], it’s not exactly the way we saw it,” says Zev Davis, medical director of cardiac surgery at Edward Hospital in Naperville.
On top of that, he says, a doctor can’t tell if the surgery has been successful until after the patient has been sewn up and revived—which means that from 5 to 10 percent of all coronary grafts need to be performed again within a year.
But with the Spy Intra-operative Imaging System, Edward doctors can now precisely locate heart blockages and then inspect their surgery before sewing up the patient. Developed by Novadaq Technologies, the Spy system couples a fluorescent imaging agent, administered intravenously, with an infrared sensor positioned above the patient’s heart; the resulting video provides a high-resolution, real-time image of coronary vessels and any surgical grafts.
Since May 2006, when the equipment arrived at Edward, hospital doctors have performed some 400 bypasses on about 100 patients (most patients get three or more bypasses). Of those, says Davis, only 2 percent had to return for another round of surgery. (Northwestern Memorial is the only other Illinois hospital using the Spy system.) The procedure can add from $600 to $1,500 to the cost of bypass surgery—though for the time being, Edward Hospital covers the additional cost. “For the [return surgeries] we’re saving, we think it’s worth it,” Davis says.
At Loyola, Mamdouh Bakhos uses robotics to reduce recovery time from heart surgery. “We used to cut the chest bone open and make a [long] incision in the chest,” he says. “But the patient needed six or eight weeks to recover, and most of them didn’t want that. They wanted to get back to work right away.”
Using microinstruments and da Vinci robotic equipment, Bakhos has eliminated the need to cut into the breastbone for single bypass surgery, reducing most recovery times to about three weeks. He has also reduced the size of the incision, down from ten to twelve inches to two or three inches; on women, the scar can usually be hidden behind the breast.
Bakhos predicts that advances in robotic surgery will soon simplify multiple bypasses as well. “My expectation is that everything is going to change,” he says.
Removing a man’s prostate with conventional surgical methods leaves him with a scar from navel to penis and raises the risk of incontinence and impotency. But at Advocate Lutheran General Hospital, the urologist Gordon Gluckman leaves his prostate patients with tiny, almost invisible scars, and a greatly reduced likelihood of any unpleasant postoperative side effects.
The key to Gluckman’s success is the robotic da Vinci Surgical System, which is revolutionizing operating rooms across the city (see “I, Robot,” in ‘Chicago’s Top Doctors,’ Chicago, January 2006). “It’s really changing the whole game plan [in prostatectomies],” says Gluckman. “The advantage to the patient is that there is less blood loss and almost no scarring. The advantage to me is that I can see the operation in 3-D and be much more precise than ever before,” all of which reduces the possibility of nerve damage.
Most remarkably, Gluckman does all this without touching the patient. Though another surgeon attends the body, Gluckman usually stands about 20 feet away, outside the sterile surgical field, performing the operation at a console. “I’ve played Nintendo and Play-Station,” he says. “This [surgery] is using my hands and looking at a screen, just like in those games.”
Hip and Knee Replacement
Nearly three years ago, Richard Berger, an orthopedic surgeon at Rush University Medical Center, replaced one of Mark Couch’s hips. This past fall, Couch, a pilot based in North Carolina, made a return trip to Chicago to have Berger replace the other hip. Less than 24 hours after the surgery, Couch was strolling around Berger’s examining room with no cane, little pain, and only a hint of a limp. “I came up here to Dr. Berger because he’s got you back on your feet the same day,” says Couch. “The conventional guys rip you up with a 12-inch cut through your muscle, and you need months to recover.”
The key to Berger’s method is smaller incisions. “Everyone believed that the majority of the pain [following joint surgery] was from doing the bone work and putting the prosthesis in,” Berger says. “Therefore, doing a lot of work to minimize the injury to soft tissue wasn’t worth it.” But Berger determined that far more of the postsurgery pain was from muscles struggling to heal. He points to the traditional method of repairing a knee. The muscle that surgeons cut open—the quadriceps—is the very muscle that a patient needs to extend his knee and walk in physical therapy. “The muscle is saying, ‘Don’t move me,’” explains Berger, “and the physical therapist is saying, ‘You have to move your knee now or it won’t move later.’”
To avoid this problem, Berger begins knee surgeries with a small (three-and-a-half-inch) incision. He cuts connective tissue instead of muscles or tendons, and doesn’t dislocate the knee to get at the damaged area. Rather than inserting the replacement fully assembled through a large incision, he installs the pieces one at a time and assembles them “on site,” if you will. He uses these minimally invasive tactics in his hip surgeries as well.
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