Scott Webb (Host): This is the St. Joseph's Health MedCast from St. Joseph's Health. I'm Scott Webb. And today, we're discussing robotic heart surgery and who's a good candidate with Dr. Charles Lutz. He's a cardiothoracic surgeon at St. Joseph's Health.

Doctor, it's nice to have you here today. We're going to talk about heart surgery, but especially and specifically robotic heart surgery. So, it's great to have you here, great to have your expertise. Let's just start there. Like, what does that mean? I assume a robot's involved, but what is robotic heart surgery in the simplest of terms?

Dr. Charles Lutz: Obviously, it's a pretty broad category. So, I think, we have to start with conventional heart surgery, which generally is performed by dividing the sternum or the breastbone. Conventional heart surgery is really generally done, and that's still the way it's done in most places around the country, is by dividing the breastbone and performing still the most common procedure nationally, coronary artery bypass grafting. You know, despite stents coming out and other less invasive procedures that the cardiologists perform, coronary artery bypass grafting is still the most common procedure nationally.

And then, valve repairs and replacements are the other big category in heart surgery. And that's generally done by dividing the breastbone, generally done by placing the patient on a heart-lung machine, stopping the heart, and performing the surgery, and then, you know, weaning the patient off of the heart-lung machine and closing everything up. And then, so that's really kind of summarizing conventional surgery.

Then, when we think about, you know, robotic or minimally invasive surgery. So, the other big category is minimally invasive surgery. So, there's kind of two things we can vary. One is, you know, using the heart-lung machine or not, so that's one consideration. And then, the other consideration is avoiding the sternotomy. So, performing the procedure through a small thoracotomy between a small incision between the ribs. And that can be done with or without the assistance of the robot. And so, depending on the procedure, we do those procedures with or without the robot.

The advantage of the da Vinci robot is that it allows us to visualize the anatomy better than we can ever really see it with our own eyes. The field is magnified to 15 times, you know, it's a 3D image that we see. And the other advantage of the system is that the instruments have all the dexterity that the human hand has. So, you can perform very precise maneuvers, can reconstruct tissue. You can do a lot of things in a very tight space. And that's where the robotic approach, you know, really offers a distinct advantage even to performing the surgery through a small incision from the side.

Host: Yeah. And in terms of what you can offer, I wanted to have you sort of tell folks like why if they were choosing a place to have any or, you know, let's say at least one of these procedures done, why the Cardiovascular Institute at St. Joseph's Health?

Dr. Charles Lutz: Yeah. So, I think the thing that we can offer that really very few places can compete with is that we can offer kind of a global minimally invasive option for patients. And that's not even, you know, just talking about the robot or, you know, whether or not we use the robot or not. For instance, like for coronary bypass grafting, we can do a lot of heart surgery without stopping the heart. It's a beating heart off-pump approach where we don't go on the heart-lung machine. You know, in certain cases, we can do the procedure without even touching the aorta. So, that's a less invasive way to do bypass surgery. And then, obviously, we can offer all the kind of the full complement of minimally invasive options for every possible disease, basically.

So for coronary artery disease, we can offer off-pump surgery if patients qualify for that. We can offer robotic-assisted coronary artery bypass grafting. We can offer a hybrid approach where we can do a robotic bypass, and then have the cardiologist stent other vessels if a patient has what's called three-vessel coronary artery disease.

So, there's a lot of options in every category for it. And then, for the patients with aortic valve disease, for instance, we can offer a minimally invasive surgical approach. We can offer transcatheter aortic valve replacement. For mitral valve surgery, we can offer robotic-assisted mitral valve repair. You know, so basically for every major disease category in cardiovascular diseases, we can offer a minimally invasive solution. You know, not necessarily for every patient, you know, but for a good percentage of patients, probably 30% or 40% of patients.

And the other thing I think our center offers that few places compete with, we're a high volume, high quality center. So, for instance, in cardiac surgery, every patient's data goes into a national database called the Society of Thoracic Surgeons Database. And basically, you get a report card at the center and the surgeon get a report card back, basically, how you compare to national averages. And in pretty much every category, we beat the national averages by a statistically significant amount, degree.

Host: Yeah, I want to have you talk just a little bit about yourself, just some of your expertise, experience. You sound like someone who maybe, you know, has done many of the old-school open-heart surgeries and are using and embracing the robot. So, just take us through your background.

Dr. Charles Lutz: I actually am from Utica. I went to Hamilton College, went to medical school at Upstate Medical University, did general surgery training. Back in the 90s, basically, it was a traditional—what we call a traditional pathway into cardiac surgery. So, you had to train in general surgery and then do a cardiothoracic fellowship.

So, I did five years of clinical general surgery, two years of research, and then a cardiothoracic fellowship at the University of Utah in Salt Lake. And then, I came back, joined Upstate Medical University for 10 years, and basically started the Robotic Cardiac Surgery Program. I was the first to use the da Vinci system in this town in 2004, and kind of embraced the minimally invasive procedures. And then, moved over to St. Joe's in 2012 and kind of joined forces with the surgeons here. And we've been able to really grow the program here so that in terms of volume and quality, again, there's not many places around the country that can match us.

I mean, there certainly are other excellent centers, but in terms of the global cardiac surgery output of what we can produce. So, I've been in practice for 24 years. Do a high volume of a fair amount of open conventional heart surgery. Not every patient is a candidate for the smaller incision approaches. But certainly, if you look at what the national kind of benchmarks are, we exceed those by a wide margin.

Host: Yeah. You discussed earlier some of the benefits, I guess, from the surgeon's point of view, the one doing the surgery. And my dad had the, you know, old school, open heart, big scar, the whole thing, you know. So, I have a little sense of that anyway. But I'm wondering, like, what are some of the benefits for patients? Is it smaller scars, faster recovery time? What are the benefits for them of the robotic approach?

Dr. Charles Lutz: All of those of which you mentioned. So, benefits for the patient is a much faster recovery compared to sternotomy approach where we divide the breast bone. Basically, we're taking all those issues out of the equation. So, there's no bone healing issues. There's no risk of sternal wound infection. All those potential risks related to the bone being divided are now gone. So, patients recover faster. Generally, it's about a three to four-week time to full recovery compared to two to three months with the conventional approach. So, that's really the major benefit.

I think it is somewhat debatable whether there's less pain or not. Certainly, we're a believer in using all the kind of the adjunctive techniques to minimize pain. Our anesthesiologists do local nerve blocks. And then, for these patients, we do what's called a cryo nerve block to numb the intercostal nerves. And that, I think, really has made a difference in getting patients mobilized faster. There's no question that's the major benefit.

But obviously, you think about heart surgery, obviously, the first thing, you know, because there is still a mortality risk to heart surgery, even though it's low. And I tell patients, you know, 50 years ago, we weren't doing the procedures we're doing today, you know, and even heart surgery didn't really exist like it exists today.

So, the first priority is to get the patient out alive. Second is to kind of address the major pathology and fix whatever problem that we're looking to address. And then, the third priority is performing it through a smaller incision. So, as long as the third priority doesn't compromise anything else, then you're in good shape. You know, and that's the challenge, sometimes the critics of robotic surgery will point out that, "Well, you can't do it as well."

And I think we've shown, and even in our published research, that you can do it as well. You can do it as well as the national standards, if not better. So, I think that point is valid. But it's something that think we've basically shown in our hands at our center with our team, it's not a major concern.

Host: Right. Yeah. And you mentioned that it's robotic surgery. That approach is not going to be right for every patient for every condition. So, who is the best candidate, if you will, or candidates for robotic heart surgery?

Dr. Charles Lutz: If you're looking at, say, coronary artery disease, a patient with single-vessel coronary artery disease involving the left anterior descending that's not amenable to a stent, that patient is going to be probably the best candidate. Certainly, early on, we selected the patients carefully, because the reality is you want good results. It's not a procedure that you necessarily do on everybody right off the bat, you know, especially when you're starting a program.

But I mean, both myself and Dr. Zhou have been doing robotic surgery for over 20 years. So, our inclusion criteria is a lot wider than it was 22 years ago, certainly.

Host: Of course. Yeah.

Dr. Charles Lutz: And then if you have a patient with three-vessel coronary disease, for instance, involving all the major vessels of the heart, then the decision comes in if the patient really wants a small incision, we have hybrid options, multi-vessel, what's called robotic-assisted option. And that's really at the surgeon discretion whether or not that patient is a candidate. A lot of times, the major factor is, are the arteries we're bypassing too big enough to safely bypass? Are the lesions discrete? In general, a patient with more diffuse disease with a lot of blockages is probably better served with conventional bypass surgery. But again, there's subtleties that come up that influence that decision.

And then, for mitral valve surgery, kind of the highlights of our center is that we're a mitral valve repair reference center. There's probably 25 or 30 centers around the country that are designated as mitral valve repair reference centers. And we're one of those centers. And so, that's the other major procedure where the da Vinci robot offers a lot of benefit, in my opinion. A patient who gets sent for mitral valve repair, almost every patient in our center has that surgery performed through either a small mini thoracotomy or robotic-assisted. And that's, you know, and that's something that most centers around the country don't offer.

Host: Of course, yeah. Yeah, and you mentioned earlier that, you know, it could be two to three weeks for most patients in terms of recovery. But I want to get a sense from you, like the before, during, and after surgery and what patients can expect.

Dr. Charles Lutz: So basically, before surgery, obviously, most of our patients come to us after a consultation with their cardiologist, and generally usually symptoms or a new murmur or something that prompts the consultation with the cardiologist. And generally, they have all their testing done by the referring cardiologist. So, they've identified that they have coronary artery disease or aortic stenosis or mitral regurgitation, kind of the three big common things that we treat and that are amenable to minimally invasive and robotic techniques. So then, the patient will see us in consultation. We'll go over all their testing and what the options are.

And, you know, I can tell you that almost every patient comes asking for a robotic or, like, minimally invasive approach, just because we do so many of these procedures. But, you know, not everybody is a candidate. It really depends on the details of their individual case, as well as the surgeon's discretion and experience.

So, you know, that's something we look at. And we discuss a lot of these cases as a team. If it's something that's a little questionable about what the right approach is, we discuss the complex cases at our heart team conference and kind of try to come up with a consensus view, because not every case is completely straightforward. And then, the patient is scheduled for surgery.

In general, our surgeries take in the three to four-hour range. Our patients go directly to the intensive care unit. We have a very highly specialized team. So, there's no rookies on our team. It's a very specialized team at every level. Everybody is dedicated to heart surgery. And that's, I think, the thing that really sets us apart, too. It's not just the surgeons, because I kind of use the analogy that cardiac surgery is like a Division I football team. You need everybody functioning at a high level, you know? So, it's not just the surgeon. In other specialties, it's more just the surgeon and the patient, you know, and some limited team members. But for cardiac surgery, it's a whole different ballgame.

Host: Big team, for sure.

Scott Webb: Yeah

Dr. Charles Lutz: Everybody functioning at a high level, especially to do these complex procedures. So, we're very lucky at St. Joe's, and that's really what sets us apart is the, you know, the nursing care is exceptional. The advanced practice providers, physicians assistants, nurse practitioners, cardiac anesthesia, everything is top-notch.

So basically, for a patient, they generally, if they're a lower-risk patient, generally only a day or two in the intensive care unit. And then, our goal is certainly the patients that can be fast-tracked is to try to mobilize patients quickly and get them out of bed, ambulating, get all the catheters, the tubes and catheters that unfortunately are a part of heart surgery, get that stuff out as soon as possible and get the patient mobilized and home as quickly as possible.

Host: Of course. And then, get them back to pickleball or whatever it is.

Dr. Charles Lutz: Yes. Whatever they want. Right.

Host: Whatever they've been missing, right?

Dr. Charles Lutz: Yes. Golf, gym probably.

Host: Of course, right. Yeah. Hopefully, any and all the things that they maybe hadn't been able to do for a while because of their heart issues. I just want to have talk a little bit about the precision and outcomes, if you will, of robotics. I'm sure it's all improved, especially, you know, in the hands of an expert like yourself. But just give us a sense, like, why is this the thing? Why is this the future? Why is it so right for at least some patients?

Dr. Charles Lutz: Heart surgery, unfortunately, still even though we've come a long way, there is still a mortality risk for heart surgery. So, that has to be as good or better than the conventional approach. And I think it's certainly as good. It's hard to say that it's better. Certainly, some techniques where we don't use the heart-lung machine. There's evidence that it can be better in selected patients. There's less risk of impact to the other organs of the body.

But I think the key thing is the procedure has to be performed well. There's no doubt about that. That's the key, you know. So, we have to do it as well as we're doing the procedure open. You know, that's the challenge for surgeons performing it. You know, you have to be able to do it as well. I think because of the visualization and the dexterity of the instruments, I think, you can do it as well. I mean, you know, I'm a believer in that you can do a mitral repair better with the da Vinci system than you can open. Can I prove that? That's hard to prove. You know, that's hard to prove, because a lot of it is surgeon and center-dependent. But I think our volume has grown. We have very good results. We beat the national averages. So, I think in a lot of ways, patients are voting with their feet and coming to our center. I mean, our volume has grown 20% to 30% over the past three years.

Host: Right. Yeah. Along those lines, I wanted to stay there, the sort of word being out there is I'm sure there are some, I don't know, some myths or some common fears, misconceptions, however you want to phrase it. But what are some of the things that you hear from folks before surgery, and what would be your response to some of those things?

Dr. Charles Lutz: Yeah. Well, I just think a lot of patients come wanting robotic surgery or a minimally invasive approach. So, a lot of our time is spent explaining why that's not the best option. Certainly, the technology has come a long way, but we're not at the point where we can routinely do four to five bypasses through a tiny incision.

I advise patients that in that case, the best option for them is to do a conventional surgery either on or off the heart-lung machine. There's a lot of evidence that, you know, in some higher-risk patients that performing the surgery off of the heart-lung machine and avoiding the ascending aorta completely offers a lot of benefit for stroke risk reduction, lower risk of kidney failure after heart surgery.

So, a lot of it kind of has to be individualized to each patient, you know. So, everybody wants it. I don't blame anybody, everybody for wanting it, you know? But that's part of our job as the experts, is to advise them, you know, that you're just not the best candidate. And at this stage of what we can do, you know, we're just not there yet. That's the advantage of the STS Database of Cardiac Surgery. We could say, "Nationally, 1% of coronary artery bypass surgery is done with the assistance of the robot nationally." So, that's a sign that it's not widespread. Even though at our center, it's 35% to 40% of patients. But both myself and Dr. Zhou, we both proctor other surgeons in other programs, you know, that are starting. And I would say for robotic surgery, you really need the team. For heart surgery, conventional heart surgery, you need the team. But, like, robotic surgery is next level.

Host: Yeah, really good stuff today. I just want to give you a chance here at the end. An exciting time obviously in medicine and science and research and robots, but the future of heart surgery at St. Joseph's.

Dr. Charles Lutz: Well, I think, you know, the future of heart surgery is, you know, definitely very bright because of the team we have, the surgeons, the whole package and the people here. I mean, that's really what makes St. Joseph's Hospital, there's no doubt about it. I look forward to coming to work every day. And that's because of our team.

Host: Right. The team, the experience, the da Vinci, patient-centered care, like, it's all, you know, music to my ears. I just really appreciate your time, your expertise. I'm sure listeners agree. You know, none of us want this. But iif we need something, you know, be it conventional or robotic, folks would be in good hands at St. Joseph's, of course.

Dr. Charles Lutz: Definitely. No question about it.

Host: Well, I appreciate this. Appreciate your time and your expertise. Thank you so much.

Dr. Charles Lutz: All right. Thank you, Scott.

Host: And for more information, go to sjhsyr.org/cvi. And if you found this podcast helpful, please share it on your social media. I'm Scott Webb. Thanks again for listening to the St. Joseph's Health MedCast from St. Joseph's Health.