Maggie McKay (Host): Welcome to Conversations Like No Other: Heart Care, presented by the Heart and Vascular Institute of Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad, everyday cardiac topics to discuss very real and very specific subjects that impact your heart health. We think you'll enjoy our fresh take. Thanks for listening. I'm Maggie McKay.

Today, we have with us Dr. Juan Grau, Director of Cardiothoracic Surgery at the Valley Hospital, to explain CABG, valve repair and replacement, aortic surgery, and minimally invasive options in plain language. Good to have you here, Dr. Grau. Thank you for making the time to join us.

Dr. Juan Grau: It's a pleasure for me to be here. Thank you.

Host: Absolutely. So to begin, would you please explain what cardiothoracic surgery is and the types of heart conditions you typically treat?

Dr. Juan Grau: Yes. So, cardiothoracic surgery is a field that basically deals with two things, all the organs in the chest, mostly the heart and the lungs. Traditionally, they were together in the United States. That's why it's called cardiothoracic surgery. In other parts of the world, Europe, for instance, there's a clear separation between thoracic, which deals with the esophagus, you know, the food pipe, and the lungs, and then cardiac surgery, which fundamentally deals with the heart and the big vessels, in this case, the aorta. So, this kind of chasm is occurring as well in the United States.

So, I am a cardiothoracic surgeon, but I only do cardiac surgery. I don't do thoracic surgery. We do have a division here, thoracic surgery, that's focus is just on the lungs and the esophagus.

Host: Let's begin with CABG surgery. What is that? And what problem in the heart is it designed to fix?

Dr. Juan Grau: So, it's a complex name. It's very technical name, that I don't think is a good idea to translate to lay audience, because it stands for coronary artery bypass grafting. And what that means basically is recreating a piping system that is not intrinsic to the heart itself, but has been manufactured from vessels that you have available in your body, which those vessels could be arteries, which is the preferred method, or veins. This procedure dates back to the 1960s and has evolved quite significantly over the past few decades.

What we have learned is that inside our bodies we do have arteries that somehow are protected from the atherosclerotic process, from the degenerative process that affects the coronary arteries of the heart. And we use those arteries to bring blood flow over the areas of narrowing to not only bring oxygenated blood to those areas of the heart, but also to keep that bridge open for many years.

So, the coronary bypass grafting fundamentally means recreating a highway system of pipes that are different from the pipes the Lord gave you, that reside inside your heart, to bring oxygenated blood to the areas that require it and stay open for a very long time.

Host: Valve disease is another common reason patients need surgery, could you explain what it means when a heart valve needs to be repaired or replaced?

Dr. Juan Grau: We do have in the heart four valves. We have two entry valves called mitral and tricuspid valves, and we do have two exit valves, which is the pulmonic and the aortic valve. So, what we call the exit valves. These valves are crucial, very similar to the plumbing system in your home. And the valves are supposed to open properly and close properly. So, some of the conditions affect either the opening or the closing or both the opening and the closing.

As you can imagine, if the valve fails, whether it is by no opening properly or no closing properly or both, then the heart is being put at maximum duress because it has to handle this volume that is not being either ejected properly or it is moving volume, in this case blood, back and forth in a very inefficient manner. So, the valves are very similar to the faucets in your home. So if your faucet is leaking water, well, that is going to represent a significant increase in your bill of water, and eventually, that faucet is just going to stop working. You need to change that faucet. If, on the other hand, you have a valve that is not allowing in your plumbing system the areas in the plumbing system to stay in compartments, then you're going to have reflux, if you will, of that water into your piping system.

So, you're basically overwhelming the system, in this case, the chamber that pumps blood, which is the ventricle, both ventricles right and left, from either volume, which is the leaky valve type of problem, or pressure, which is when the valve becomes narrow and the heart has to exert extraordinary pressure to open it.

Host: Dr. Grau, aortic surgery can sound very intimidating. What conditions affect the aorta and when does surgery become necessary?

Dr. Juan Grau: So, aortic surgery basically deals with the great vessels, meaning the pipes that come off the heart itself. And this pipe is called the aorta. It's a big, big vessel that brings blood flow to your brain and the rest of your body.

So, two things can happen in the field of aortic surgery. The pipe itself can dilate and become bigger than where it's supposed to be because the components of the wall have weakened. What that does is put that segment of the aorta at risk of rupture or dissection. So, people with aortic disease can be treated electively if we find out that they do have an aneurysm, which is the dilatation of this pipe or, unfortunately, urgently or emergently if they do have an aortic dissection.

An aortic dissection means that the walls of the aorta have broken down, and the blood, instead of going through the center of the pipe, is going through the walls of the pipe, putting a significant risk for rupture over time. So in the aortic community of patients that we treat, we would love to treat them all electively, so we don't have to face these catastrophic complications, which carry not only a significant morbidity and mortality at the time of the procedure, but you cannot undo that ever. So, those patients become our patients for the rest of their lives.

Host: Wow. A lot of patients hear about minimally invasive heart surgery. What does that actually mean, and how does it differ from traditional open heart surgery?

Dr. Juan Grau: That's an excellent question, and a question that has been somewhat contaminated by advertising and lay talk, if you will. We have moved the entire specialty, towards a less invasive form of cardiac surgery. And when you consider what is less invasive and what is more invasive, when I was in training, patients used to stay in the hospital for a week or 10 days, and it was a very complicated recovery. Right now, the patients stay in the hospital three days, two days, four days maximum. They go home. And then, I allow my patients to drive at that second or third week, and then go to the gym at the fourth week.

So when you talk about minimally invasive, it normally pertains to the type of incision. It means that the incision is smaller than the regular big, open, cardiac surgery. But it's not only that. It also means that you may not use the heart and lung machine. You may do the operation with the heart beating. And it also means less invasive, in my opinion at least. It means the patient goes through the process in a much faster, efficient manner and recovers much, much faster as well.

Within the minimally invasive community, you have now multiple different iterations. You have small incisions, you have small incisions aided with cameras, such as scopes that we call them, that are being used to reach the area that cannot be seen from the outside. Another most sophisticated way or latest iteration, which is called robotic surgery, which means you have a robot that brings the visual aspects of it with high definition. And the arms, basically your arms are not anymore doing the operation. They're being extended through the robotic arms that you are obviously manipulating. So, that's basically the gestalt of the minimally invasive world

Host: How do you decide whether a patient is a better candidate for a minimally invasive approach versus a more traditional surgical procedure?

Dr. Juan Grau: I think the way you pose the question is important to focus on. And what we are all agreeing, I think, in the community of cardiothoracic surgery, is that what matters in this equation is fundamentally the patient. So, you don't tailor the patient to the procedure, you tailor the procedure to the patient.

This is a very binary way of thinking, but it's the correct way of thinking. When I look at a patient today, I saw three new patients, each one needs a very particular intervention. For what reason? The reason is to give them a 30-year outcome. And I think this has not been mentioned until now that I am mentioning it.

Cardiac surgery is supposed to have a very significant longevity in its outcomes. That's why we are called for. We're called to provide a 30-year outcome in terms of survival and freedom from what we call reintervention, or freedom from major adverse cardiovascular events, such as heart attacks and so on and so forth.

So when I look at a patient, I had looked at two patients today. One is fifty-five. What is being asked of me for that particular patient? And this is a good example. This patient is to live another 30 years. So, the way I choose the bypass, conduits, meaning the pipes themselves that I'm going to be using at the time of surgery, will determine how long they stay open and how many years of no concerns are going to be given to the patient. At the same time, in the same patient, I can do the operation with a heart beating without stopping it, which is one of the minimally invasive points you were bringing up before. But the goal is not to do a minimally invasive operation. The goal is to give 30 years without having to see my face again for a re-intervention.

The other patient is a patient that has had multiple heart attacks. The heart is delicate and has a valve that is leaking. And the symptoms that he came in with are clearly secondary to the valve. A very fit person. The goal in that setting is to give a valve intervention, plus whatever else needs, in this case, bypasses. But the intervention is supposed to fix the leaky valve forever, if at all possible, right? So, you kind of see this way of thinking is different from the way people think about it, right? People think, "I want a minimally invasive approach." Well, what you should want is the best possible operation for you as a patient. And then, many aspects of this could be less invasive than they have been in the past. But it shouldn't be that we tailor a minimally invasive procedure for a patient that is going to come out with less than he or she should.

Host: Let's talk about recovery for a minute. What does that typically look like after these types of heart surgeries? And what should patients expect in the weeks and months afterward? I know you touched on it a little bit earlier, but...

Dr. Juan Grau: I was asked this question twice, like an hour before walking in here. Patients think wrongly, that we're going to destroy their body in the process of doing cardiac surgery. And there is nothing more far from the reality than that.

The length of stay of my patients is exactly 3.8 days of all-comers in the past year, meaning they stay in the hospital for no more than four days in any circumstance, right? Unless they come in a very bad shape, in which case, that's an exception.

But the overwhelming majority of patients spend a very short time in the hospitals. They are moved immediately after surgery. They are walked around. They are rehabilitated and prepared for them to go home. Once you go home, any desk work, you can do. I mean, normally people wait about a week, ten days. But all the patients of mine that have been lawyers, accountants, people that work at a desk, they can go back to work without a problem within the seven-day to ten-day window.

At the two to three-week window, I let them drive locally. At the four-week window, I let them drive anywhere. And I put them in the gym at the fourth week mark with, you know, some directives in terms of what to do and not to do, so they don't injure themselves in the process of rehabilitating. When you see a patient a month after surgery, that person is doing really well, completely independent and able to travel wherever they want to travel by plane.

So, in the equation or in the calculation of risk benefits, you are investing a month maybe of being annoyed with a return of investment of 30 years if things are done correctly. And I think that is something that I see myself having to explain every day more and more often.

The last thing you want, unfortunately, and I have seen that, is to undergo a "minimally invasive procedure," and then having to have that redone down the road, meaning in a year or a year and a half. You have to think of cardiac surgery as a resultative situation, after which we should give the patient and the cardiologists that refer those patients a significant window of no troubles in terms of heart function, valve function, and so on.

Host: Well, that's encouraging as far as the recovery. I did not know it was that short. You think it's going to be like two, three months. In closing, Dr. Grau, what do you wish more patients understood before coming in for heart surgery, especially when they're feeling anxious or overwhelmed?

Dr. Juan Grau: Two things fundamentally. Number one, we live in the world of immediate gratification, and very few people want to put the time or the effort to be "healthier."

Heart surgery is very similar to that, you're going to undergo an annoyance or something that has a risk, but most of our operations have a risk below 2%. So, you're going to undergo that with one goal, a goal that you cannot see, that you cannot taste, that you cannot grasp.

That goal is to give you freedom from reinterventions and troubles in many decades to follow. That's what I wish they understood. Because I get questions like, "What if I do this, when can I play golf?" I'm like, "Well, you know, perhaps golf can wait a month or six weeks." And I think that is not the patient's fault. It is the false advertising that this is like a haircut. This is not like a haircut. This is like a forever haircut.

In other words, if you get this haircut, hopefully, you won't have to have another haircut until two or three decades from now. And that concept needs to be understood because there are no shortcuts in life. Equally, if you are in good shape, and you exercise, and if you have a good diet, if you manage your lipid profile, your glucose profile, your insulin profile, if you manage all these things, you're going to be a healthier human being with a longevity that's going to be above the average that will require you do something every day or so to try to maintain.

So, there is no such a thing as not doing anything and being healthy until the age of, let's say, 90. If you look at all these people that live until 95, 93, and I operate on many of them. There is a reason for that. It's this continuous investment on keeping common sense as the leading force of your life. That's what I hope people understand. We don't want to violate your body and do, aggressive things. We do them because the return is such that it's justifiable to do them.

And then, also, the fear of pain is unsubstantiated at the moment. The patients really are almost, I don't want to say pain-free, but they have maybe a day or a day and a half of discomfort after which they are really very comfortable. So, this fear is not supported by the data.

Host: That's amazing. Well, thank you so much for sharing your expertise on this crucial topic. We really appreciate your time, and this has been so informative.

Dr. Juan Grau: Oh, it's been my pleasure. Thank you.

Host: Again, that's Dr. Juan Grau. We hope today's conversation has helped demystify some of the most common heart surgeries, including CABG, valve repair and replacement, aortic surgery, and minimally invasive approaches. While these procedures can sound intimidating, advances in surgical techniques and technology continue to improve safety, recovery, and long-term outcomes for patients. If you or a loved one has been told you may need heart surgery, don't hesitate to ask questions and have an open conversation with your care team.

To learn more about cardiac surgery and heart care services at Valley, visit valleyhealth.com/heart. And as always, be sure to subscribe, share this episode, and take good care.