Joey Wahler (Host): Like any medical procedure, it comes with risks. So we're discussing Beating Heart Surgery. Our guest, Dr. Geoffrey Cousins. He's a Cardiac and Thoracic Surgeon for Memorial Health System Ohio. This is Memorial Health Radio with Memorial Health System Ohio. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Cousins. Welcome.

Geoffrey Cousins, MD: Hello, thanks for having me.

Host: Oh, great to have you aboard. We appreciate the time. So first for cardiac patients, what are some of the alternative treatment options besides surgery and what are the basic pros and cons compared with being operated on?

Geoffrey Cousins, MD: Cardiac surgery, the bulk of our patients are referred to us either from their primary care physician or their cardiologist, mostly from the cardiologist. And the patients who typically are referred to us for potentially having heart surgery, have often exhausted the other options that come before heart surgery, which would be one, medical management.

A lot of times people have chest discomfort or what is known as angina, oftentimes, medications can resolve that for them and they can go for many, many years, treated medically. Additionally, what we have are called percutaneous options, which are, when people get a heart catheterization, sometimes they're found to have blockages in the arteries that supply blood to their heart.

And the cardiologist can place a stent to relieve the blockage and improve the blood flow and alleviate the person's angina or chest pain. When stents are not possible, when medication has failed, then they refer you to us for cardiac surgery or what we call coronary revascularization. And that's when we discuss surgery with the patients and make plans to treat them with operative procedures versus medicine or percutaneous options.

Host: And speaking of which, what are some of the potential risks and complications associated with heart surgery these days and how likely are they to occur based on someone's health?

Geoffrey Cousins, MD: Yes, the risk of most cardiac surgery today include infection, and this is something we give you antibiotics before we start the surgery to cut down on the risk of infection. There's also a risk of bleeding. Bleeding, was very rare that we have to do any blood products nowadays because we've developed procedures where there's not a lot of blood loss, and the Beating Heart Surgery is one of those.

There's also a slight risk of stroke, heart attack. Slight risk of kidney failure or lung failure, allergies to the medications we use. Some people get blood clots in their legs, what's called a deep venous thrombosis, and blood clots could travel from the legs to the lungs, what's called a pulmonary embolism.

Then there's a few people that need permanent pacemaker after this kind of surgery. All those things there, the risk is about 1%. So not likely. The biggest issue we run into after heart surgery is an irregular heart rhythm called atrial fibrillation or AFib for short. And this is a entity that the cause of is unknown, but we see it in about 30 percent of the patients that we do heart surgery on.

And in the population in general, there's a few million folks that have AFib that never have any surgery. And no one knows the exact cause of AFib. And of course the other risk is that of death. And for most of our procedures, now that risk is about 1%, but that depends on the patient and the patient's comorbidities. In other words, what they're bringing to the table with them, whether they have severe lung disease from many years of smoking, whether they have diabetes, kidney disease, or other issues, then their risk varies based on what comorbidities that they present with.

Host: Interesting, but all things being equal, 1 percent death rate, that's exceedingly low, right?

Geoffrey Cousins, MD: That is correct. Surgery is nowadays very safe. The anesthesia is very safe. And the bulk of patients do just fine, and don't have any significant issues with surgery.

Host: Let's address a little bit of terminology here. What does it mean when the surgery is on pump or off pump and how can that impact the outcome for a patient?

Geoffrey Cousins, MD: Traditionally, heart surgery has been performed with what we call a cardiopulmonary bypass machine. But before there was a cardiopulmonary bypass machine available, back in the fifties, we used to do the surgery or they used to do the surgery, with the heart beating continuously. There are some issues with the heart lung machine.

One issue is you have to connect cannulas to the patient's heart in order for blood to be drawn off to the heart lung machine and in order for it to get back into the patient's bodies. And so this is a foreign material. And so when the patient's blood hits the foreign material, the plastics, there's often a systemic inflammatory response that takes place. That causes a patient to vasodilate, requiring more fluid and the displacement of fluid, what we call third spacing, or people become edematous or have swelling in their tissues.

So this is one thing that's eliminated when we do the surgery with the heart beating continuously, because we don't have to hook up those cannulas, prime the machine, increase the volume. And so if a patient is already tenuous, for instance, if they have kidney disease or if they have bad lungs because they smoked for many years, when we eliminate the heart lung machine and eliminate that volume, they have less problems with their kidneys because they're not volume overloaded.

They have less problem with their lungs because they're not fluid overloaded. Additionally, we don't have to give as much blood thinner or a product known as heparin to keep the blood from clotting in the tubing and in the machine. And so we have much less bleeding, when we do the surgery with the heart beating continuously.

And so we don't have to give blood transfusions, which is a great thing because blood is often bad for patients, even though there's no infection, sometimes still people have an adverse reaction to blood. Additionally, since we don't have to manipulate the blood vessels, the aorta and the other vessels to put cannulas in, there's a decreased rate of stroke and indeed since we've been doing beating heart surgery, we almost never see strokes in our patients, which is a big deal. That, plus the off-pump surgery is less invasive and so we typically can get our patients home after three days, after the surgery, which is a huge deal. Back in the day when we were routinely using the pump, it was taking us sometimes six or seven days because the fluid alterations and other derangements that come along with the pump, we eliminate them when we do the surgery with the heart beating continuously and so our patients are able to typically get home within three to four days. so those are some of the many advantages of doing the surgery with the heart beating continuously versus using the heart lung machine.

Host: Understood. So what specific steps should someone take to prepare for heart surgery? Things like dietary changes, medication adjustments, lifestyle modifications, etc.

Geoffrey Cousins, MD: Well, you know, if you get to the point where you need the surgery, you're a little late on making those changes. But things that you can do in preparation, still is if you smoke the less you smoke before surgery, ideally, if you can quit, you're going to do tremendously better. You're going to heal up faster.

You're going to get out of the hospital quicker. If you can cut back on this tobacco use prior to surgery. Additionally, if you could take a walk, cause walking is such a big deal, particularly after surgery. If the patient can't get up and begin to walk immediately after surgery, there are increased risks for infection. That's blood clots in the legs, blood clots could go to the lungs, urinary tract infections, pneumonia, And all those types of things are increased when the patient is unable to get up and ambulate or to take a good walk. So those are things that you can do ahead of time. Often, or actually every time, when you visit me in the office before surgery, we always give you what's called an incentive spirometer.

And this is a little device where you can practice deep breathing exercises to get rid of dead space in the lung where bacteria and mucus could form and cause infection. So that's another thing that you can do. Another thing that's very important is make sure that you have a good bowel movement and that your intestines are cleaned out before you come to surgery, because if you come to surgery and you're constipated and you can't have a bowel movement, and then you get anesthesia, that also slows down your intestinal movement.

And then we have to give you pain medication, after surgery. So narcotics, morphine, and other things further slow down the intestines. So it's a good idea to take a laxative and maybe only drink clear liquids for a day or two before your surgery so that you can have a clean intestine when you come for surgery.

Host: You addressed earlier the mortality rate. What about the success rate for open heart surgery in terms of how often you're able to achieve what you're striving to?

Geoffrey Cousins, MD: Almost always. Surgery, as I say, nowadays is very technologically advanced. Our surgical team here, we have some 60 years of combined experience, and so there's very little that we have not seen or very little that we have not taken care of. The success rate, is very high, upwards of 99%, the success rate nowadays.

Host: How about post operative care? What does that look like in terms of pain management, length of stay in the hospital, you addressed that a moment ago, and when normal activities can resume.

Geoffrey Cousins, MD: Our main restrictions after open heart surgery is related to protecting your sternum or your breastbone until it heals up. And it typically heals up within the first couple of months. But during that time, we ask that you don't do any heavy lifting more than about 10 pounds. Heavy lifting will make the wires that we put your sternum or your chest bone or your breast bone back together with, they will loosen up. You'll drain fluid from that incision, get infection and need more surgery. The only other thing we ask that you don't do is don't drive for one month. Other than that, you'll be able to climb stairs if you need to get up and down to your bedroom. We want you to do plenty of walking and do pretty much what you feel up to as long as you protect your sternum.

 In the hospital, patients are typically here three to four days. To get out of the hospital, you got to be steady on your feet. The pain's under control. You got to have that bowel movement and all your vitals are in order before we let you go. Typically, people don't have, contrary to what people believe, there is not a lot of pain associated with opening of the chest or what we call the sternotomy.

Typically we send people home with 30 pain pills and most of our patients will come back, after one month and say, Hey doc, I didn't take any of those pain pills since I left the hospital. So that kind of lets you know what the pain is. Now, a younger person who still has a lot of muscle mass and a little tighter skin, you know, a person in their forties or fifties, they're going to have a little more discomfort than a person who's in their seventies or eighties, which typically those people don't have any significant pain at all.

Host: Interesting. That's pretty amazing. So a few other things. What can a patient expect in terms of full recovery time once they're home and on their feet?

Geoffrey Cousins, MD: Full recovery, we say usually takes about three months. And it's interesting, entrepreneurs and people who work for themselves and have to get back to work, they're usually ready to go in about two months. People who work for others and have PTO and FMLA and other time off, they take about three months.

So it kind of is patient dependent and what people have to get back to. But typically people are fully healed at about the two month period. They're released, at one month to drive. We encourage everybody to do cardiac rehab because it's like having a personal trainer and you go to a cardiac rehab facility. They monitor your heart rate, your blood pressure, and all your vitals while you're doing some safe exercises with a personal trainer. And that really enhances your recovery and gets you back up to speed much quicker than if you don't participate with cardiac rehab.

Host: And once that full recovery occurs, doc, how about the improved quality of life after surgery? Which is of course, largely what this is all about. What does that typically look like for a patient?

Geoffrey Cousins, MD: Yes, it's amazing. And that is where as a surgeon, we get our satisfaction at that 30 day mark when people come back for their post op visit and they say doc, I never felt better in my life. I have so much more energy. My shortness of breath is all resolved. I have no more chest pain and they're very excited.

And that is truly our reward because, we've been able to get them back to their normal activities of daily living, back to work, back to their families. And, uh, it's a very gratifying situation. And that usually occurs within four to six weeks or so.

Host: That's amazing as well. And speaking of which, in summary here, doctor, what would you say to people that naturally are trepidatious about open heart surgery to say the very least, nevermind trepidatious, maybe just outright scared and understandably so. You mentioned earlier, people have misconceptions about the procedure, but you make it sound like ideally it's pretty quick and easy for both the doctor and the patient.

What would your advice be to people that are worried about it, perhaps understandably, but at the same time unnecessarily, right?

Geoffrey Cousins, MD: My first thing would be to come and see me, because what I find out a lot of times is, when we enter a patient's room, they're very nervous, very upset, they're often very informed, and what's very gratifying is at the end of that meeting, they will tell you that, I was scared, doc, I wasn't going to do this, but you have alleviated my fears, I'm very much more open to doing this procedure now.

They're excited to have met us and our heart surgery team. And then, we set them in the right mind, give them the appropriate understanding and try to set the appropriate expectations. And then people are able to relax, and then we take good care of them and look forward to seeing them back, after their surgery for their post op visit. It is a very gratifying career and opportunity. It's very humbling every day, to be able to do what we do.

Host: Yeah, I mean, to people out there listening, I'm sure what's going through their mind is what goes through my mind talking with a surgeon such as yourself. People literally putting their life in your hands, and that must be rewarding indeed, as you just said. Yes?

Geoffrey Cousins, MD: Yes, yes, it's very gratifying, very humbling, and it's very exciting to be able to participate in. Oftentimes people come in, they've had a big heart attack, they're in shock, kind of facing that bright light, and then we're able to get in and intervene and get them back home to their families. There's no better feeling.

Host: Sure there's not. Well, folks, we trust you're now more familiar with Beating Heart Surgery. Dr. Geoffrey Cousins, keep up your great life changing, life saving work. A pleasure. Thanks so much again.

Geoffrey Cousins, MD: Thank you.

Host: And for more information or to connect with a provider, please visit mhsystem.org/services/heart-cardiology-vascular-services. Please remember to subscribe, rate and review this podcast and all the other Memorial Health System podcasts as well. If you found this one helpful, please do share it on your social media. I'm Joey Wahler, and thanks so much again for being part of Memorial Health Radio with Memorial Health System, Ohio.