Intro: This is Weekly Dose of Wellness, brought by Memorial Care Health System. Here's Deborah Howell.

Deborah Howell (Host): Technology advancements and new medications are making a huge difference in coronary disease, allowing patients to delay heart procedures. But for patients who may need a cardiac procedure, when is it time to ask their cardiologist about minimally invasive procedures that are best suited for them?

Welcome. I'm Deborah Howell. Today, let's find out more about minimally invasive treatments and the future of heart health. Our guest is Dr. Marc Sakwa, Chief of Cardiovascular Surgery, Memorial Care Heart and Vascular Institute and Medical Director, Adult Cardiovascular Surgery at Memorial Care Heart and Vascular Institute at Long Beach Medical Center. Welcome, Dr. Sakwa.

Dr Marc Sakwa: Thank you.

Host: So glad to have you back. So, what is minimally invasive heart surgery and how is it different from robotic or open-heart surgery?

Dr Marc Sakwa: When we talk about doing surgical procedures in a minimally invasive way, we're basically trying to give the patients an opportunity to have their heart disease corrected without opening the sternum. So, we can do valve surgery through incisions that are about three inches long, replacing any of the valves that need to be replaced or repaired. We can also treat coronary artery disease in this way, using a robotic device to take down the internal mammary artery, which we use to do the bypass graft.

Host: Very amazing technology. So, what are the benefits of minimally invasive heart surgery compared to open heart where some physicians may think open heart is, you know, really the only way?

Dr Marc Sakwa: So when we're speaking, and we use the term open-heart surgery, we're talking about a procedure where we open up the breastbone. We call that a sternotomy. And the advantage of that for the surgeon is it's excellent exposure, and it's the tried and true traditional method that surgeons are used to in performing these cardiac procedures. But like anything else, as technology evolves and patients want less invasive procedures, we now have the technology to do heart surgery without opening the breast bone. The advantage of that is that healing that bone takes significant amount of time. And so if we don't have to open it, or actually like break it, then we can have the patients get back to their activities of daily living, back to work, back to their sports, much earlier than if they've had the traditional incision to perform heart surgery. As well, the recovery period is much shorter, and the pain goes away much quicker. So, there's many advantages to it.

Host: And can you give us some examples of a procedure or a diagnosis when it's best to use minimally invasive heart surgery over all the other options?

Dr Marc Sakwa: So, it's very popular now for patients who have aortic stenosis, or leaky mitral valves, called mitral regurgitation, to be evaluated for a catheter approach. What happens in that situation for like an aortic valve is they mount a valve on a catheter, which can be placed up through the artery in the groin, and the valve can then be opened inside the patient's native aortic valve, treating their aortic stenosis. That's a good procedure, but it's not perfect. And the reason it's not perfect is it's not great for younger patients. So, in order to, in a way, compete with that, we can do a minimally invasive approach to treat aortic valve disease. By making a small incision on the right side of the chest and through the intercostal space, that's the space between the ribs, we can get adequate exposure to do the same operation that most surgeons do by opening the entire breastbone.

Host: Just incredible. So, here's a what if for you. Let's say a patient's mitral valve is leaking due to degeneration of the valve itself. How do you decide if the patient is appropriate for minimally invasive surgery or an interventional procedure?

Dr Marc Sakwa: What we do here at Long Beach is we have a valve conference where cardiologists, surgeons, anesthesiologists, even administrators participate once a week and we evaluate every single patient on an individual basis. For patients with mitral regurgitation, and they're not a candidate for surgery, then we can do a catheter approach where we take a clip and we clip the two leaflets of the mitral valve together, and that does reduce the amount of leakage. It's not as good as a surgical procedure, however, where we can repair the valve better or we can replace the valve. So at that conference, we sort of decide if the patient's a surgical candidate, then we move towards the less invasive approach. Again, the three-inch incision on the right side of the chest. We still put the patient on the heart lung machine, we still have to stop the heart in most cases, but we can repair or replace the valve just like you could through the full sternotomy approach.

Host: It's an incredible new era. We spoke about mitral valve repairs. So, what are some other examples of when it's best to use minimally invasive heart surgery?

Dr Marc Sakwa: I would like to just mention also, for mitral valve, there are surgeons who do use a robot to do that procedure. We do not do that here. We don't find it necessary. The incisions are the same size. The recovery is really about the same. To me, the disadvantage of the robot is there's no tactile sensation. And I feel, personally, you get a better repair by using long instruments, where you can get tactile sensation so you can feel the tissue in what you're doing. So, that's why we don't use the robot for mitral surgery, but there are institutions that do. So, that's even another less invasive way to approach the mitral valve. The patients that we see for leaky valves, we can usually repair those valves. The repair for those patients is a really good thing, because they keep their own tissue and there's less risk of infection. And of course, hopefully, the valve repairs last a longer time and they don't need to have another procedure.

Host: And which demographics, such as age, benefit most from minimally invasive heart surgery?

Dr Marc Sakwa: Well, I would say as someone who's a believer in minimally invasive approaches, we don't really turn anybody away based on age or any type of demographics. All patients are evaluated as candidates for minimally invasive surgery. Those that are not would probably patients who are morbidly obese, although we do consider them candidates for most of the part patients who have certain types of anatomical issues that we can't get to the area we need to get to; people who have had previous surgery are often turned down. And if there's difficulty with the femoral artery and vein, because that's how we cannulate to go on the heart lung machine, then those patients have to be looked at for some type of other methods to do a minimally invasive approach, or we have to convert back to the regular sternotomy approach.

Host: Okay, got it. Now, we understand you co-lead a weekly valve clinic where patient cases are reviewed with other cardiac specialists. What do you and your team at Memorial Care Heart and Vascular Institute at Long Beach Medical Center do at the valve clinic to ensure each patient receives the most effective course of treatment?

Dr Marc Sakwa: I personally think that the valve clinic is the best thing that we've done for our patient population. And I say that because we have multiple physicians in the room giving multiple opinions. We discuss the opinion based on the scientific data that we know from our literature as well as from the studies that we've done, the echocardiograms, the heart catheterizations. And then, we actually see some of these patients live in the clinic where we can evaluate them for what their physical appearance is, how well they walk, how difficult it would be for a post-op recovery. And by having this valve clinic and getting all these opinions, we really do come up with the best plan for these patients. And I think this is really the best thing for most big centers to do nowadays, is to have these multidisciplinary meetings in order to give patients the best approach to treat their complex heart disease.

Host: Rather than working in silos. I love it. So, how unique is it that you and the team at MHVI can offer a minimally invasive approach?

Dr Marc Sakwa: Well, you know, it's interesting if you look at the surgical database called the Society of Thoracic Surgery Database, the number of minimally invasive cases has not grown significantly in the past 10-15 years, which is a little surprising based on the advancements in the technology. So, only about, I would say, 10% of centers do minimally invasive surgery. And of that, I would say probably less than 5% do it on a regular basis. So as a patient, you really want to explore the option of having minimally invasive surgery and you want to go to centers that do this on a routine basis.

Host: For sure. Is there anything else at this point you'd like to add to our conversation before we wrap up?

Dr Marc Sakwa: I just would like to add that I think with social media being so prevalent nowadays that patients should take the opportunity to research different hospitals and different programs and find out what's best for them. And I think that if you're going to have a valve operation or even a minimally invasive coronary artery bypass operation, you should get online, look to see what centers do these things, and at least get a second opinion and see whether or not this works for you. I think most patients, when they find out that these options are available to them, would gravitate towards having them.

Host: Yeah, for sure. Well, thank you so much, Dr. Sakwa, for your time and your expertise today. We really enjoyed having you back on the podcast.

Dr Marc Sakwa: Thank you. I really appreciate the opportunity. Thank you.

Host: And if you'd like to learn more about minimally invasive surgery at MHVI, you can call 562-933-3370 or visit memorialcare.org/mhvi. Or to listen to a podcast of this show, please visit memorialcare.org. That's all for this time. I'm Deborah Howell. Have yourself a terrific day.