Minimally invasive heart surgery driving long-term health benefits
Sturgis St. Peter will always remember the day a cardiac surgeon at Cape Cod Hospital told him about his planned course of treatment for his heart problem.
“Dr. Dan Loberman, MD came in and said, ‘we’ll take good care of you. We’ll do this procedure that’s called the mini mitral valve surgery. Instead of doing a midline incision of about six to eight inches in the front of your chest, we just make a small cut of two to three inches underneath your right breast and use some micro tools to repair the valve.’”
St. Peter’s response: “That’s cool.”
St. Peter, 67, of Barnstable, can talk about it in a light-hearted way now, but when he had the surgery in May 2016, he was in dire shape. He had a torn mitral valve, which had left him feeling weak and sick for months.
The mitral valve is the “inflow valve” for the left side of the heart. It can need surgical repair or replacement because of stenosis (narrowing) or regurgitation (leakage). Traditional mitral valve surgery requires a median sternotomy, an incision of 6 to 8 inches in the middle of the chest. In minimally invasive mitral valve surgery, an incision of 2 to 3 inches is made in the right side of the chest.
Mini mitral valve surgery has a number of advantages, according to Dr. Loberman. Approaching through a mini thoracotomy instead of a median sternotomy benefits patients in three main ways:
- Less need for extra blood products
- Less time in the hospital post-operatively
- Less pain after surgery
“It has been proven that approaching through a mini right thoracotomy instead of a median sternotomy has saved patients from receiving extra blood products, shortened length of stay post-operatively and reduced the pain level after surgery,” he said.
Mini mitral valve patients typically stay in the hospital for three days after the operation and take two to three weeks to completely heal, versus a five-day stay and a six- to 12-week recovery for median sternotomy patients. Cosmetic results are also better.
“Women can wear a bathing suit, and no one will ever know that they had mitral valve surgery,” Dr. Loberman said.
There’s an advantage for the surgeon, as well, because the approach to the mitral valve through the minimally invasive incision gives them a better view of the mitral valve.
“The mitral valve lies in such a way that when you go from the right side of the chest, you just fall on it and you don’t look at it from above, as happens with mid-sternotomy patients,” he said.
“Whoever reads surgical books for any reason, one of the main phrases you see is that the thing that facilitates good surgery is exposure.”
Dr. Loberman and his team have performed more than 100 mitral valve surgeries at Cape Cod Hospital (CCH) over the last three years, including about 50 minimally invasive mitral valve procedures, mostly repair.
“We have had very good results as demonstrated by one-year post-operative echocardiograms to look at the valve function. When you repair a 50-year-old’s leaky mitral valve, you’re moving from one survival curve to the general population survival curve.
“It’s no longer a new procedure. It’s something we can do any day, any time for whatever patient comes in needing the procedure.”
It is, however, still heart surgery, which means that the operative risks are there, and should be discussed and clarified prior to proceeding with surgery. Also, prudent patient selection is crucial for success.
Affiliation and Training
The Cape Cod Hospital Cardiac Surgery program is part of the Cape Cod Healthcare Heart & Vascular Institute, a partnership between the healthcare organization and cardiovascular physician specialists on Cape Cod. The CCH Cardiac Surgery program has been affiliated with Brigham and Women’s Hospital in Boston since the program started in 2002. The partnership has allowed the Hyannis hospital to expand its cardiac surgery services to include the latest procedures using cutting-edge technology.
CCH was where the program started, and remains today, one of just three community hospitals in the state to be licensed by the state health department for cardiac surgery. Dr. Loberman and Paul Pirundini, MD, who is cardiac surgery medical director, are the two cardiac surgeons in the CCH department.
Dr. Loberman was taught how to do mitral valve repairs and replacements by a physician who learned it from French surgeon Alain Carpentier, MD, PhD, who is known as the father of modern mitral valve repair.
“I was lucky to have my old boss, my professor in Israel, who was Alain Carpentier’s student. Mitral valve repairs were his little baby, his hobby. I used to watch him operate and I think I saw him do 500 procedures before I laid a hand on a patient.
“The heart is a three-dimensional structure, and you really need to know the anatomy to know the implications of every movement you make,” he stressed.
When Dr. Loberman wanted to add the minimally invasive technique to his surgical repertoire, he took his surgical team to Miami three times to study with Joseph Lamelas, MD, FACS, an expert in minimally invasive heart surgery, who is now affiliated with the Baylor College of Medicine.
“This is not a one-man show,” Dr. Loberman said. “I took my perfusionist and physician’s assistants with me to see how Dr. Lamelas’s team works.”
Which Patients Are Chosen
The best candidates for mini mitral valve surgery are those whose heart structure is not yet frail or too damaged.
“We want to identify patients when they are not yet symptomatic, the patients who have not yet developed the sequalae or the natural history of mitral valve leakage, like atrial fibrillation, embolic events or congestive heart failure,” said Dr. Loberman. “The best results are with patients who don’t have symptoms yet.”
Patients with mitral valve regurgitation or leakage have a heart murmur, he said.
“That shows up in echocardiogram or in a simple check-up in a cardiologist’s office or in a primary care physician’s office,” he said. “Once you identify a murmur, you need to define it better by an echocardiogram. If you find mitral valve regurgitation, that patient needs to be monitored. If the regurgitation gets to be severe, it needs to be treated surgically.”
The echocardiogram results indicate whether repair or replacement is indicated. For patients over 65, replacement is usually the answer. The assessment process of the heart structures then begins and the surgeon decides how to go about the repair, he said.
Replacement mitral valves can be mechanical (carbon fiber), which last for a lifetime but may require long-term use of Coumadin (a blood thinner), or biological (typically from a pig’s or horse’s pericardium), which lasts for 10 years, possibly 20.
“After the surgery, sometimes patients feel better and stronger. They breathe better,” said Dr. Loberman. Sometimes, if there were no clinical symptoms before surgery, there will not be any change in a patient’s general feeling, but as we know from multiple studies, their long term health benefits from the procedure.
“With the minimally invasive mitral valve procedure, if the patient is recovering without any complications, after two to three weeks he can be back to work, even if it’s a physically demanding job.”
St. Peter, who is a building contractor, is the first to tell you he made an impressive recovery from his mini mitral valve surgery.
“I felt so good that about two months after the surgery I went out and bought a 70-mile-per-hour jet ski,” he said. “I’ve been terrorizing people ever since. I still do my high-speed go-kart racing. I’m still very physical, swinging a hammer. I’m doing better now than I did 10 years ago.”