Transcription:
Innovations in Minimally Invasive Heart Surgery

Melanie Cole (Host):   Over the past decade, minimally invasive cardiothoracic surgery has grown in popularity and is, in large part, due to the benefits for patients such as decreased pain and reduced surgical trauma. My guest today is Dr. Gorav Ailawadi. He's a board-certified cardiothoracic surgeon whose specialties include minimally invasive heart surgery and treatments for heart valve disease with UVA Health System. Welcome to the show, Dr. Ailawadi. What are some of the newest breakthroughs? What's going on in the world of minimally invasive heart surgery right now?

Dr. Gorav Ailawadi (Guest):  Melanie, first, thanks for having me on the radio. I think this is an exciting time for cardiac surgery. Things are really changing and have changed pretty dramatically in the last 3-4 years with so much more new innovation coming down the pike that we haven't seen before, and especially, since probably the 60's or 70's. So, much of the types of surgery that we have performed for the last 50 years are steadfast and true. Things like valve replacement surgery, valve repair surgery, or bypass surgery to try to improve blood flow to the heart. Those are really tried and true techniques that work but patients have long been asking for less invasive options to help them get back to recovery. That really is the benefit both for young patients who need to get back to work, provide for their families, as well as for elderly patients who are worried about what is the biologic toll that a big open-heart operation is going to take on their life and recovery and pain. So, really, approaches to minimally invasive span all types of patients. Where we started with this is we learned to perform similar types of operations that we do through an open chest, through the breastbone, through less invasive approaches, typically, through the side or through partial incisions to try to mimic the same operation, or do the same operation. Now, if a patient needs a lot of things done to their heart, they need more than one valve, they need multiple valves, they need bypasses plus valves, then it's not really feasible often to do that purely through a minimally invasive approach. But, if it is an isolated thing like a valve or a single vessel bypass, then most of those patients often can be evaluated an often can get a minimally invasive approach where we're doing the same operation through a smaller incision. What that means for the patient is, typically, the pain can be a little bit less but the recovery is dramatically less with often no broken bones. They get back to driving sooner; they get back to their normal life; they get back to work sooner. If they're elderly, they oftentimes don't even need to go to rehab or they can get out of rehab sooner, as well. Now, where we're headed is, really, in the last 3-5 years, we have been involved in a number of new trials, new valves, where we can replace the valve with no incision, or we can go through the groin. This is particularly true with the aortic valve. Each of us have four valves in our heart. The most common valve that is affected is the aortic valve. With the wear and tear, that valve becomes tight and narrow. It's not related to our diet or smoking. It's just wear and tear on the heart valve similar to our knees and our back. It gets bad. So, what we can do is go through the groin with a wire up to the heart using x-ray and a new valve is collapsed on a stent. We blow up a balloon which pushes the old valve out of the way and then we go ahead and blow up the new valve on a stent. The stent stays in place and the new valve starts working immediately. Now, those valves have been approved for very high-risk patients who cannot get open heart surgery and we've been performing trials in low-risk patients. We have a very new trial coming out in the near future where we'll be looking at any patient, regardless of how young or old they are, who could potentially get this type of approach. The benefit for that is, they often leave the hospital in two or three days with no incision and get back to the routine far quicker than with any open heart or even minimally invasive surgical approach. So, this same type of technology is now expanding beyond just the aortic valve. We have ways to repair the mitral valve. The mitral valve is the valve between the lungs and the heart, so when the heart squeezes, this valve is supposed to close to keep the blood from going back to lungs. This valve often can leak in certain types of patients and when it leaks, the blood goes back to lungs and the patients feel short of breath. So, we have ways, not only to fix it with open surgery, a common way is with minimally invasive surgery where we go through the side and we can repair and replace the valve. A third option now is also to go through the groin and put a small clip called the “mitral clip” that can clip the parts of the valve that are leaking. It's a good approach for the right type of patient and the beauty of it is that it is very minimally invasive and the patients often go home the next day or two days after. That is also approved for high-risk patients who have the right type of leaking valve anatomy that they can get that. Now, there are many new devices that are coming out, many of which that we're a part of at UVA, like devices that can replace the mitral valve .We can put rings on the valve to cinch it up. We can put new cords so the mitral valve actually is like two parachutes, side-by-side with little strings, or “cords” we call them. Those cords, in some patients, can become torn or elongated. There are new devices coming out where we can place a new cord through a small incision on the chest without the heart-lung machine, using ultrasound to guide us. So, there are lots of new things and this is a really exciting time in our field.

Melanie:  Wow, that is absolutely fascinating and how well-spoken you are, Dr. Ailawadi. There are such interesting innovations that are going on today. Are there certain people who would not be candidates for minimally invasive type surgeries? Then, in which case, for them, they have to have what? The full open heart?

Dr. Ailawadi:  Yes. I think there are multiple things that we're looking at when we're evaluating patients for any of these devices or approaches. I think one of the biggest benefits is that we do see patients as a team. So, oftentimes, we'll have multiple different specialties, not just a heart surgeon but also a cardiologist that specializes in valve disease. Oftentimes, we'll have a specialist cardiologist who focuses just on the imaging, see the patient together and decide together what's best for each individual patient. So, it's really a team approach kind of like you hear about for cancers--there's a tumor board. We literally have a valve board. Every week we meet and talk about all patients considering any of these options. So, for the aortic valve--I think we ought to split it up into the aortic and mitral valve. For the aortic valve, we traditionally had only been able to offer this for patients that are higher risk with new trials that we're going to be a part of. We're going to be able to offer this for lower-risk patients through a clinical trial. Essentially, some of the anatomy is important, meaning the size of the valve, the size of the arteries in the groin. We need a road to the heart and we have multiple different ways to get there. The groin artery is going to be the easiest for patients to recover but we have other approaches where we can go in between the ribs and go into the heart directly, if the groin arteries are too small. So, we're looking at a lot of things in terms of the anatomy, as well as a lot of things in terms of the patient, if it's a suitable candidate. There are subtle things, like how much calcium and things like, that that may weigh in on our decision one way or the other. For the mitral valve, it’s actually a bit more complex because the valve can leak in multiple different ways. For the aortic valve, it's pretty straightforward:  it gets tight, we replace it, whether we do it with surgery—and we have multiple different ways to do it with surgery. We have valves that don't need stitches and we also have the valve through the groin called the TAVR. For the mitral valve, it's a bit more complex because the valve can leak in different ways and depending on how it's leaking, that will dictate how we want to fix it--whether we want to repair it, whether we want to replace it, how we would want to repair it. And so, those things all weigh into the decision as to what that patient can get ranging from traditional open heart surgery, to minimally invasive surgery, to the percutaneous through the groin, mitral clip or the new devices that are coming down the pike. Certainly, if their anatomy is suitable for a mitral clip, for example, and they meet the patient criteria, meaning they're typically high-risk and not good candidates for surgery, we can oftentimes offer that. That's also true with all the new technologies. In terms of minimally invasive, pretty much any patient that has just a valve problem, we really consider strongly for a minimally invasive approach and there are just a few things that may weigh on us and change our decision that we need to do it in a traditional approach. That's if they have a very weak heart or a lot of calcium around their heart, or calcium around their arteries in the groin--those types of things. Or, if they have more than just the valve, like if they have multiple valves or are needing a bypass plus a valve. Those things traditionally can't be done through a minimally invasive approach alone. Now, sometimes we do combinations or hybrid approaches where we may have our cardiologist stent some of the blocked arteries and then we would fix the valve, or vice versa. That's where that team approach is really important to figuring out what's best for each patient.

Melanie:  So, Dr. Ailawadi, in just the last few minutes, and even if we're talking about the transcatheter aortic valve replacement, the outcomes for these, do they have to be replaced? Does minimally invasive surgery affect the outcome as far as how long they last or any of those kinds of benefits?

Dr. Ailawadi:  Well, I think we probably need to probably compare two things. So, if we compare open heart to minimally invasive and then open heart to the percutaneous approaches. So, when we talk about open heart to minimally invasive certainly the goal should be we provide as good a correction of the problem, whether it's replacement or repair than through an open approach. It's just that it's done through a smaller incision and potentially without breaking bones, or breaking less of the bone, to help with recovery. So, really the goal should be the exact same type of operation. Sometimes, honestly, the procedure is better for the patient through minimally invasive because I think we do sometimes do a better job with repairing the valve in that approach. When we compare surgery to percutaneous approaches, I do think, right now, the bar changes meaning, patients and physicians will accept less effective therapy, meaning we don't get as good a result with a valve repair, with a mitral clip as we do with surgery. However, for the type of patient we're talking about, if they're just not a good candidate for surgery or have other things going on, that's probably okay. We don't want to put them through an operation that needs a lot of recovery if they're very frail. So, the bar does change depending on the approach but I think the team approach really will help guide the patient and, ultimately, the patient's decision as to what they think is best for them.

Melanie:  Thank you so much. It's absolutely wonderful and fascinating information, doctor. Thank you so much for being with us today. You're listening to UVA Health Systems Radio and for more information, you can go to UVAHealth.com. That's UVAHealth.com. This is Melanie Cole. Thanks so much for listening.