States of mind: #1 – less invasiveness (limited access cardiac surgery)

Cardiac surgery underwent a huge change since its beginnings. From an adventurous, dangerous but lifesaving endeavour carried out by real Mavericks to a surgery, which is perceived almost as routine and expected to be safe, with good and predictable results. While this latter is true (in the vast majority of cases), the change doesn’t end here: meanwhile, cardiac surgery is perceived as almost too invasive, mainly due to its standard surgical access, the median sternotomy (i.e. the longitudinal split of the long breast bone). The major invasiveness of the access to the heart is against the contemporary trend of minimal access to the internal organs, if possible through a catheter inserted in a peripheral vessel.

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The new role

The foundation board of the Cardiocentro Ticino recently appointed me as the new head of the cardiac surgery department. The first day in my new position is 1st February 2015.

In this new role all individual professional qualities, such as technical skills, clinical judgment and decision-making, are considered as granted. The new challenge is leadership.

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Emotions of the heart. Psychological aspects of heart surgery.

Introduction

It is a great pleasure for me to introduce to you a guest author on this blog, the psychologist and psychotherapist Martino Regazzi. Martino joined and reinforced the team of Cardiocentro Ticino about a year ago. He gives all of us (patients, nurses, cardiologists and cardiac surgeons) some precious help and structured insights on something right opposite of the spectrum of the highly specialized, cutting edge treatment we practice: the mind and soul. Although heart and soul are almost felt as a whole, we in the green and blue scrubs  mostly take care of its somatic dimension. Of course, empathy and reassurance of both patient and family is an integral part of our attitude: however, it is not sufficient and sometimes we painfully feel it. The “other” dimension is not easy to handle as it is far more complex than we think! Therefore I am especially happy that Martino accepted my invitation to write the following post. A heartfelt thank you Martino!  

(The artwork named “From the bottom of my heart” is  exposed with permission of its creator David Munroe).

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Let’s talk about research

Progress in medicine is based on continuous research.

The main drive in medical research is improvement of treatment and cure of diseases, which translates into improvement on life expectancy and / or on quality of life. The results of medical progress over the last 20 years are impressive. Mortality from various severe diseases has dropped dramatically (e.g. various forms of cancer, infectious and cardiovascular diseases), life expectancy and quality of life improved significantly.

What is “medical research” anyway?

For someone not involved in this sector it can indeed  be difficult to see clearly and understand the multiple forms and dimensions of medical research.

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Robotic cardiac surgery. A marketing fuss or a real benefit?

Robotic surgery has been hitting the headlines for years. Notwithstanding, it is not widely understood what robotic surgery is really about and what are the benefits and pitfalls of this technology.

Nowadays, when we talk about robotic surgery we mean surgery performed with the da Vinci telemanipulator (Intuitive Surgical, Sunnyvale, CA, USA). It is not the sole robotic system available, but it is indeed the most advanced authority cleared surgical robot. It is successfully commercialized worldwide and dominates almost 100% of the market.

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First in man implantation of the CARMAT total artificial heart

From the official press release as distributed on December 20th, 2013:

CARMAT (FR0010907956, ALCAR), the designer and developer of the world’s most advanced total artificial heart project, providing an alternative for people suffering from end-stage heart failure, announces the first implantation of its artificial heart, as part of its feasibility study and in accordance with the approvals granted by the ANSM (Agence nationale de sécurité du médicament et des produits de santé, the French health authority) and the Comité de Protection des Personnes (ethics committee).

The procedure was performed on December 18, 2013 by the Georges Pompidou European Hospital team in Paris (France) – a world first.

The implantation went smoothly, with the prosthesis automatically providing blood flow at physiologic conditions. The patient is currently being monitored in the intensive care unit. He is awake and talks with his family.

We are delighted with this first implant, although it is premature to draw conclusions given that a single implant has been performed and that we are in the early postoperative phase”, says Marcello Conviti, Chief Executive Officer of CARMAT.

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Complications

Complications can occur during or after any surgery. Before recommending a surgical procedure, the potential for postoperative complications is evaluated thoroughly by the medical staff.

In elective cases (i.e. when there is sufficient time to plan and prepare the surgical procedure), the preoperative surgical consultation is carried out also for the sake of this purpose: seeing the patient personally enables the surgeon to have an idea about his conditions and his strengths and energy store. This clinical evaluation, together with “technical” information drawn from medical exams, allows to better evaluate the surgical risk.

We distinguish between technical and general complications.

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Facing cardiac surgery

Receiving the news that cardiac surgery is needed is a real shock, not only for the patient himself but also for his family. Sometimes it’s just out of the blue, following a routine check-up. Some other times this revelation could be the peak of a fast path: chest pain, a sudden and sharp shortness of breath lead to urgent and quick exams.
The impact of the words “open heart surgery” is strong, it touches the core. Is life at risk? Will everything run smoothly? And then? How will it be? How is everything organised? What is to be expected?

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How to handle the ischemic mitral valve during CABG surgery

This post refers to two intriguing presentations of this year’s EACTS meeting, held in Vienna. Both presentations deal with the chronically ischemic mitral valve (graded at least moderate) as a concomitant finding in patients qualifying for coronary artery bypass grafting. The indication for revascularization is an important differentiator: chronic mitral regurgitation due to past myocardial infarction can also be an entity by itself (i.e. without the need for a revascularization procedure). This entity poses a delicate and difficult question on the best option of how to deal with it. Surgery does not always deliver the desired result, the newer interventional option of Mitraclip® is currently in evolving investigation. I will come back to this issue with a dedicated post. Stay tuned!

Our clinical situation:

  • Angiographically confirmed ischemic heart disease (IHD) needing surgical revascularization
  • Concomitant, at least moderate mitral valve regurgitation due to restricted leaflet motion (no prolapse – Carpentier class IIIB) and / or annular dilatation, called Ischemic Mitral Valve Regurgitation (IMVR)

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