Maggie McKay (Host): Welcome to Wise and Well presented by Community Memorial Healthcare. I'm your host, Maggie McKay. Today we're discussing the role of cardiothoracic surgery with heart and lung surgeon, Dr. Ryan Vela. Thank you so much for being here.

Ryan Vela, MD: Of course, very happy to be here.

Host: So education, training, and experience. Could you tell us a little about yours?

Ryan Vela, MD: Absolutely. I actually came from a very small farm town in Tiffin, Ohio, just a little south of Toledo. I did high school. I went to college bizarrely enough, got a degree in both religion and chemistry as well as history. And then I went on to get a master's degree before going to four years of medical school.

Then I went to Dallas, Texas where I did five years of general surgery training, as well as three years doing basic science research on how to help preserve hearts that are going to be transplanted and extending the life that they have so that we can get more patients, more heart transplants. After that, I went to UCLA for two years to do heart and lung surgery, and now I'm here helping the people of Ventura, California.

Host: Wow, what a journey that is so interesting. It's so varied. How does your education and your experience impact the care you provide to your patients?

Ryan Vela, MD: So unlike a lot of physicians and surgeons who go straight through, you know, they did biochemistry or chemistry, physics, whatever science. I did a lot of degrees and courses in humanities. So religion, like I said, history, I learned how to argue, not to be contrarian or to make people upset, but how to lay out what I think is the correct thing to do and how to speak to everyday people so that everyone understands what my thoughts are, what my reasons for doing what I want to do are, and ultimately I think it helps with communication with patients so that they understand what I want to do, they trust me more, and ultimately we have a good understanding of what is to be expected during the surgery and afterwards.

Host: Absolutely. I can't tell you how many times I've been to the doctor and I have no idea what they're saying because it's doctor speak.

Ryan Vela, MD: No, exactly, and it's extremely frustrating or frightening when it comes to heart surgery, and then people are using these very big words that nobody understands. It can be very very scary.

Host: So why is experience important when it comes to cardiothoracic surgery?

Ryan Vela, MD: So one thing that I will say about heart and lung surgery is, especially in heart surgery, you really need a good reason to take a patient to the operating room. One thing I don't like to do is just say, yeah, I can do it. I could do it, I could do that. I need a reason. And our cardiologists here at Community Memorial are excellent.

They only really send us patients who do need to have heart surgery. Because sometimes it's not the right answer. Sometimes the patient has a little too high a risk and they have a high likelihood of not seeing that benefit that we're trying to do when we do heart surgery. And so a lot of what I try to do is make sure patients understand that this is my goal.

I want to be able to help you live a little longer. I want to reduce your risk of heart attack, or I want to help you remove that lung cancer and add a few more years to your life to make sure that that cancer doesn't come back.

Host: Dr. Vela, would you please describe the traditional role of the cardiovascular surgeon? Like what types of procedures do you perform and what conditions or diseases do these procedures treat?

Ryan Vela, MD: Yeah, I think especially here at Community Memorial, my group is very much the traditional cardiothoracic surgeon, being that the main bulk of the procedures we do is CABG, coronary artery bypass grafting. That's like when people say they had a triple heart bypass. A quadruple heart bypass. That's what we're talking about.

And so the way that I think about this procedure is if you think of the heart like an engine and the coronary arteries are the fuel lines to the engine, then a CABG procedure or a bypass procedure is when those fuel lines are a little too gunked up and you're not getting enough fuel to the engine.

And so my job is to create new fuel lines. Usually we do that with arteries from the arm or from the inside of the chest, and then we also use vein from the lower leg, and then we put those on as new fuel lines and get that engine running again. Other things that we do is we also work on the valves of the heart.

There's four valves, mostly the aortic valve is the most common one, but we also work on the mitral valve and the tricuspid valve. All of those valves help make sure that the blood moves forward and it's not getting backed up into the heart, which causes congestion or heart failure at times. One other thing that I do coming from UCLA and also from UT Southwestern in Dallas is I deal with aneurysms and dissections.

What that means is the big artery of the chest, the aorta, problems can arise there. Either it gets too big or part of the lining of the aorta can get diseased. And so not many surgeons fix these problems, especially very close to the heart. And so while I was at UCLA, I had special training in how to fix these problems.

Host: It always amazes me, Dr. Vela, how many things can go wrong with the heart? We take it for granted every day, and then you learn more about it. It's like, wow. There's a lot that could go wrong. So with the development of a number of minimally invasive options for treating conditions of the heart, how has the role of the cardiovascular surgeon evolved?

Ryan Vela, MD: So one area where it has improved, meaning we've done more minimally invasive surgery, especially is when it comes to lung cancer. We were one of the first surgeons. Not here in Ventura, but as a practice, as a specialty throughout the world to use the robot, the da Vinci robot. I would say probably now almost 95% of all thoracic cases, meaning lung or lung cancer cases, use the robot because it's minimally invasive and patients do really well.

They're very small incisions and we can still do everything we need to do with it. The best part is, unfortunately, and I'll get into this, when it comes to heart procedures, the lung procedures are very painful. It's just the nature of going through the ribs in order to access the lungs. And using the small incisions, it's a lot less painful.

Patients get up, walk around quicker, which helps the lungs recover faster and they can go home fast. Now, when it comes to the heart, there are different ways to do specific heart procedures, but almost universally, most surgeons will do a sternotomy. That means going through the breast bone and opening up the chest.

The reason being is we almost always use cardiopulmonary bypass. That's the heart lung machine in order to do our procedures, and so we need to be able to see absolutely everything very clearly and have no issues trying to get to certain areas of the heart or areas of the chest in a time of emergency.

One thing that we as cardiac surgeons do a little bit more minimally invasively is we do endovascular stents. That's been done a lot in the abdomen for aneurysms of the abdominal aorta, the aorta in the belly, but now we're starting to use them much more often in the chest. And at CMH, myself and Dr. David Blitzer, one of the vascular surgeons here are spearheading a new hybrid approach to treating aneurysms of what's called the arch of the aorta. That's a part of the aorta that gives blood to the brain. Obviously a very critical and important area right there. And so being able to treat this minimally invasively with stents is going to help a wide range of people where we'd otherwise be having to do a big incision and open up their chest in order to see everything very clearly.

Host: That's exciting. How encouraging is that? That's amazing. What role do you play in supporting minimally invasive procedures?

Ryan Vela, MD: Wonderful question, and one thing I really like about cardiothoracic surgery is part of my job is to be maximally invasive because I want to do everything I can to protect a patient when we're doing heart surgery. But at the same time, I also get to practice minimally invasive surgery, especially when it comes to lung disease and lung cancer.

Almost universally now, our field in lung cancer and lung cancer treatment uses the robot, the da Vinci robot to remove parts of the lung that has cancer. We also do it for a lot of other general thoracic procedures, things that are wrong with the chest wall or even patients that are having issues with some of their blood vessels being compressed by ribs or muscles. I really enjoyed seeing the robot when I was in medical school. It was incredible to see these physicians and surgeons take out parts of the lung in some incisions that were almost two or three centimeters big. Rather than making these big, huge incisions on the side of people's chests that didn't heal well or would have very large scars. It's really exciting to see how we can do some of these really lifesaving surgeries and treating people's cancer with just four or five one centimeter incisions. Plus using the robot is always really cool, now that we have the newest model that just got released this year at Community Memorial.

Host: What recent surgical advancements apply specifically to cardiothoracic surgery?

Ryan Vela, MD: So a lot of people have heard of what's called a TAVR valve. It's a very exciting new device that's been developed to save people who not only might be high surgical risk, but also just a normal person off the street to recover from having a valve replacement very quickly. TAVR stands for transcatheter aortic valve replacement, and one of the people who really spearheaded this across the world was Mick Jagger of the Rolling Stones. He had a TAVR valve done. Yeah, he had a TAVR valve done, I think 10 or 15 years ago.

I can't remember exactly, but very quickly after having his TAVR valve done, he was back on stage jumping up and down and running all over the place. So when patients saw that, wow, you can have a new aortic valve done through just a couple pokes in the groin and a poke in the wrist with maybe a day in the hospital; it was a game changer. Everyone wanted to get this new valve, and it really is exciting because we can treat so many more people that otherwise wouldn't be able to handle having to go on the heart lung machine, have the heart stop so we can open up the heart, see the valve, remove it, sew a new one in.

It's time consuming, and it puts a lot of stress on the heart. This procedure's done in about 30 minutes. Very rarely do we have a lot of bad complications. Some things can happen, and that's a conversation that both the cardiologist and myself have personally with these patients. We're also starting to do something that's called TMVR, transcatheter Mitral Valve replacement and just a couple weeks ago, we were told we're going to be one of the sites that are going to start trying to do transcatheter tricuspid valve replacements. So we're doing a lot of very new stuff here at CMH that many other hospitals across the country wouldn't even begin to offer. So that's also a very exciting thing to bring to the patients here at Ventura.

Host: That must be so fun for you as a surgeon to be able to be there and use all these new technologies. How have these advancements enhanced the care you're able to provide to your patients?

Ryan Vela, MD: So with heart and lung surgery, some of the hardest parts after the surgery is rehabilitation. The surgery is the easy part. I get to do it on the heart lung machine, which makes everything so much easier. But for the patient, having to go through the sternum or even those small incisions on the chest, they can cause a lot of pain.

And patients don't want to take deep breaths because of the pain. And so they want to lay in bed and they don't want to get up into the chair and start that rehab process. A lot of people don't understand how important the physical and respiratory therapy components of rehab are after these surgeries, and they can lead to some very bad problems.

Being able to do these valves, what we call percutaneously, just through the skin, people feel great. They want to take deep breaths. They immediately have better function of their hearts. They want to jump up and start the rehab process. So it's not weird to think that these patients will do better since they feel better, have less pain and can breathe easier.

Host: That's incredible. What cardiothoracic procedures are available at Community Memorial and what's the benefit to having these procedures done so close to home?

Ryan Vela, MD: So one of the biggest reasons I wanted to join CMH was the practice here with Lamar Bushnell and Jennifer Juan, we can do almost anything here at Community Memorial that cardiothoracic surgeons at UCLA, USC, Mayo, the tertiary care centers can do as well. Now, they might be a little bit better suited to be doing more of the higher risk patients who might need to end up looking at a transplant or a new device implanted into their chest to help with the heart that we just don't have the volume to offer at CMH. But the vast majority of cardiac, lung and aortic procedures we can very easily do here at Community Memorial. And I think it's extraordinarily beneficial for patients because it's about an hour and a half to Westwood.

I know I lived there for two years and would come out to Ventura pretty often, and sometimes you'd have to wait until seven, eight, or nine o'clock at night to make it a halfway palatable drive. USC is even farther. So I think having the means to offer the level of care that some of these tertiary care centers offer, really benefits our patients and really brings their family to help them after surgery a lot more often since they're right here in town and it can really help speed up their recovery process and rehabilitation.

Host: Tell us about the cardiothoracic surgery team and the benefit of having a team dedicated to these types of procedures.

Ryan Vela, MD: That's probably one of my favorite parts about being a part of what we call the heart team. At Community Memorial, just like most other hospitals throughout the country, there is a specific team who does only heart procedures. They are the only ones allowed to be with us in the room who do this. Now we have an army of nurses with us in the operating room, and each one is absolutely fantastic, and they can fill the roles that the nurses fill.

There's the circulator, that's the nurse that goes around the room making sure that they open up what other instruments we might need or goes and gets any types of devices we need. There's the scrub. They are in charge of handing over those instruments to us, the surgeons, in order to do what we need to do.

We also have a perfusionist. A perfusionist is a very special person who is trained to run the heart lung machine. And if we didn't have excellent profusionists at CMH, we wouldn't be able to do anything that we are trained to do as cardiothoracic surgeons. We also have extremely specialized anesthesiologists.

They're very good at placing very special lines inside the heart so that we can measure how the heart is functioning. And they also do a very special ultrasound of the heart during the surgery. It's called echocardiography, and they can read it very well and tell us in real time while we're doing the surgery or while we're on the heart lung machine.

Oh yeah. The heart looks so much better now. Those bypasses are really working, or the valve you put in looks excellent. There's no problems with it. We don't have to go back and fix anything. Everybody plays an extremely important role in the operating room, and then afterwards in the ICU, we have extremely specialized nurses who take care of heart patients exclusively, and they know exactly what to be looking for.

They give us a call all day, all night, because we want to know at every point in time, how's the patient doing? Are we moving in the right direction? And they know exactly what to be looking for. So having a bunch of people who are extremely talented, very smart, and also very enthusiastic about helping people, all come together to do these surgeries and make sure every patient really get on their way to recovery after the surgery.

Host: That's so interesting to hear behind the scenes, all the specific jobs there are. Just one person does this, one person does that. That's amazing. Are there any other technologies you feel are important to highlight?

Ryan Vela, MD: One thing here at CMH that we also offer from having specialized training, specifically with Dr. Juan and myself is we can help with something that's called thoracic outlet syndrome. So sometimes patients either have an extra rib, as weird as it sounds, or some of the muscles of their neck can get a little too muscular, a little too overgrown, and it can impinge a little bit on nerves in the neck or on blood vessels of the neck, and it can cause some really bad pain and weakness in the arms of either side. Sometimes patients have it on both sides. Usually, in order to recover from this as a surgical perspective, most patients had to get a kinda large surgery, a big incision down by their collarbone.

Or sometimes an incision through their armpit in order to help relieve the obstruction that those vessels or nerves are feeling. Now, Dr. Juan and I can offer this surgery through the robot, and it's a pretty rare surgery to be offered through the robot. Not many people around the country offer this. And luckily, while I was at UCLA, one of my mentors was a proctor.

What that means is he went around and whoever wanted to learn how to do this, he would teach them. So I got some extensive and fantastic training from some of the leaders in the world creating new minimally invasive surgeries to help people out more.

Host: Wow. So in closing, Dr. Vela, is there anything else you'd like to share?

Ryan Vela, MD: I think that Community Memorial is a fantastic hospital to go to. We are extremely lucky here in the Ventura County area to have a hospital that offers the full range and spectrum of cardiovascular and pulmonary surgeries. We can take care of lung cancer, esophagus cancer, problems with the lung or the chest, and we can take care of almost every single problem with the heart.

Sometimes we do it minimally invasively. That means using the robot, which just a few days ago we did a robotic bypass, which was very exciting. One of the first times it's been done out this way, and the patient did absolutely fantastic. So we're going to keep doing everything we can in order to offer the highest level of care for patients in the area so that everyone can stay closer to home and recover that much quicker with family and friends.

Host: Thank you so much for sharing your expertise. We appreciate your time and sharing all that interesting information. It was very informative.

Ryan Vela, MD: Absolutely. Thank you so much for having me on.

Host: Again, that's Dr. Ryan Vela, and if you'd like to learn more, please visit mycmh.org. That's mycmh.org. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Wise and Well presented by Community Memorial Healthcare.