Cardiovascular surgeon at Mount Sinai in New York, John Puskas, MD talks about a bloodless heart surgery that’s saving lives.
Interview conducted by Ivanhoe Broadcast News in 2022.
Could you just give me full context, what conditions would require a heart bypass?
PUSKAS: So coronary artery bypass, grafting, CABG or CABG, sometimes called heart bypass, is the surgical treatment of coronary artery disease. Coronary artery disease is the most common form of heart disease and actually Is the number one killer of human beings.
Traditionally, how are you bypassing the heart?
PUSKAS: So of course, the heart’s job is to pump blood all the way around the body, but it needs blood supply itself to do that work. The coronary arteries are the little arteries that feed the heart itself. When they become blocked with calcium or cholesterol that can cause a heart attack. Meaning that the portion of the heart that’s downstream from the blockage dies, that muscle is replaced with scar tissue. That’s what a heart attack is. So coronary bypass grafting or heart bypass is the surgical procedure in which we create a bridge. We take another artery from somewhere else in the body, and we attach that to the heart beyond the point where the heart artery is blocked. And that provides an alternate route, a detour, a bypass, hence the name, to deliver blood to the working muscle of the heart beyond the point where the heart’s own arteries are blocked.
Are there some people for whom the traditional bypass is either not a good idea or just isn’t going to work?
PUSKAS: Traditionally coronary bypass surgery is done using the heart-lung machine. And this is a remarkable device. It’s really quite a fancy machine. It’s a pump and a heater and an oxygenater. But to use it for the heart, we have to put a big cannula in the aorta and other cannula in the heart. The blood is diverted out of the heart into the machine and then pumped back into the body. We stop the heart from beating by putting a clamp across the aorta and instilling into the heart a high potassium solution that makes the heart lay still. And all of that process makes the surgical procedure quite easy for the surgeon, but that’s a lot for the heart and for the patient. Particularly the manipulation of the aorta, the cannulation of the aorta, the clamping of the aorta that can shake loose calcium or cholesterol that has formed there. The same blockages can develop in the aorta that develop in the heart arteries. And if that calcium or cholesterol is dislodged, it can cause a stroke or go somewhere else in the body. And that’s the kind of complication that we seek to avoid by using this no aortic touch-off pump bypass operation.
Can you describe how you’re able to do this surgery without stopping the heart?
PUSKAS: So the no aortic touch, all arterial bypass operation does not use a heart-lung machine at all. Instead of attaching arteries or veins to the aorta, we actually leave them with their own normal inflow. These are the two internal mammary arteries, they run inside the breastbone. We disconnect those from the breastbone and then use them to provide blood supply to the heart. So they are the two inflows for the new blood supply for the heart. We typically make a little incision in the wrist and put a scope under the skin to remove one of the arteries from the left arm. And with those two arteries providing inflow from inside the breastbone and this transplanted artery from the left arm, we can bypass three or four or even five arteries on the heart. That avoids any manipulation of the aorta. We literally do not touch it. There’s no use of the heart-lung machine. And instead of arresting the entire heart with the heart-lung machine, we use some special devices that mechanically stabilize a portion of the heart. And we move those devices around the heart, doing one bypass at a time. And as we go we restore flow to each of those bypasses because the inflow is available from these internal mammary arteries that are inside the breastbone. And we add a little more blood supply as we’re going around doing each of the bypasses on the heart. And once we’re finished with the bypasses, the operations is essential but we close up. The patient was- the heart was never arrested. We don’t have any issues with restarting the heart because we never stopped it. We have a miniscule of stroke risk because the aorta has not been manipulated. Most of the strokes that occur around the time of cardiac surgery, we believe, derive from knocking loose calcium or cholesterol from the aorta, the aortic manipulation, and we will so we completely avoid that.
How much lower is the stroke risk?
PUSKAS: The stroke risk for patients having conventional on pump coronary bypass grafting is about 2% in our national database. With a No Aortic touch technique avoiding manipulation of the aorta, that stroke risk comes down to about a quarter of 1%. So it’s about a three-quarters reduction from 2% to about a quarter of 1% or half of 1%.
What are the other benefits of doing that surgery in this way?
PUSKAS: It tends to involve much less blood loss and therefore a lesser that- need for blood transfusion. We are especially favor- favoring this procedure. Let me start again. We especially use this procedure for our bloodless patients. We take care of a lot of Jehovah’s Witness patients and they of course will not tolerate any blood transfusion. So in that patient group, once we’ve got their hemoglobins elevated prior to surgery, we never give them any blood products in the operating room or afterwards. And this operation, which minimizes blood exposure to machinery, minimizes blood loss before- during and after surgery. This procedure is much more favorable for patients who cannot or will not accept blood transfusion.
How about recovery time? Is there any indication that recovery is better or is it about the same?
PUSKAS: There have been numerous studies randomized and observational comparing the off pump approach with an on pump operation. And typically the length of stay in the hospital is reduced by one to two days with an off pump approach. Patients tend to wake up a little more sharp, they’re more active, able to get up out of bed and resume their normal activities more quickly.
One technical question just for clarification, when you do the artery grafting, those stay in place then?
PUSKAS: They do. The artery graphs are permanent. And in fact, that’s a very important point. The arteries that we use for this operation, rather than veins in the legs have several advantages. One of them is that we don’t touch the legs. Patients need their legs for walking, to get up out of bed and move on the first day after surgery. And that’s what we expect from our patients. And typically they’re able to do that. So avoiding any incisions in the legs improves the comfort experience, that recovery that returned to normal activities for patients. Using arteries from the arm and from inside the breastbone has another very important advantage. And that is that arteries last longer as bypass grafts, than vein grafts do. Veins are on the venous side of the human circulatory system. In other words, they’re designed to face a low pressure. Veins have a low blood pressure. They return blood to the heart. Arteries have a high pressure. They deliver blood from the heart to the body at a higher pressure. So when we use a vein on the heart, we’ve taken a low pressure tubing. You can think of it as plumbing, if you will. It’s a vessel that’s designed for low pressure and now we’ve transplanted into the heart and it faces a high pressure. And that’s the conventional bypass operation. But those vein grafts react to that high blood pressure and about half of them will have closed within 10 years. The arteries, on the other hand, about 90% will be open at 10 years. And of those that are open at 10 years, about 90% will be open at 20 years. Now at 20 years, almost all being graphs of closed. So for a younger patient that wants to avoid a stroke, avoiding the manipulation of the aorta, avoids that stroke minimizes the risk around the time of surgery and using artery graphs instead of vein graphs maximizes the longevity of benefit of the surgery itself. Those graphs will stay open longer for decades.
Who’s the best candidate for this surgery? You don’t do this on everyone or do you?
PUSKAS: We do, I know Eric touched all arterial operation as our routine default procedure. So there has to be a reason to not do that operation. And those reasons are actually few and far between the vast majority, more than 90% of our coronary bypass operations are done by this technique. Let me back up one second. I just want to make one more comment response to that last question. The patient who benefits most, is that patient who might have a stroke or other complication from a conventional operation. That’s the immediate benefit. But the patient who benefits longest would be that young otherwise healthy person in their 50s with multiple blockages in the heart arteries and for whom a vein operation will lead to another problem in 5,10 or 15 years. We want that patient to live 30 or 40 years. So we want to give them a bypass operation that is their only operation, one and done. Don’t have any other problems with coronary artery disease in their future.
I wanted to touch a little bit about Ms. Busche. Can you tell me a little bit about her?
PUSKAS: is Busche is a very sweet 60-year-old grandmother who’s had a lot of problems with diabetes in vascular disease. She suffered a stroke in 2021, I believe that left her left side weak, she’s had difficulty managing a diabetes and controlling her weight. And those things have led to blockages and heart arteries and of course, in the brain arteries that caused that stroke a year or so ago. She developed blockages in the heart arteries in such a way that stenting was really not going to be a good solution for her. The pattern of blockages that she had were such that stents were going to be very difficult and probably not that durable for her. So she was referred for coronary bypass grafting. But here we have this lady who’s pretty vulnerable. Patients who have had a previous stroke are at risk for another stroke. And again, we’re trying to avoid that in open heart surgery, we want to salvage the heart and not at the expense of the brain. So for her, I know aortic touch operation was essential. We wanted to do the surgical procedure for her heart that would have the lowest risk for her brain. And that’s what we did for her. We did all arterial know aortic touch bypass grafting. She received arterial grafts to the coronary arteries of her heart and actually came to that beautifully. Despite her weakness and her left side, she was able to get back to her baseline pretty quickly. Went from here to rehab, got physically strong and went home and then she’s able to meet with her grandson, which was her real motivator to get herself through surgery and to recover it was her family that was the focus of her desire.
How is she doing? Healthier than ever?
PUSKAS: She’s actually doing wonderfully. I would say healthier than ever and certainly more hopeful than ever. Her symptoms were interesting. Some patients, especially diabetic patients, do not feel classic Hollywood angina pain. They don’t have that crushing burning pressure in the center of their chest. That is typical of how we represent heart disease in the Hollywood scenario. She had a vague tingling and numbness that involves her upper chest and her arms and especially her left arm but it was very disturbing the symptom. But it wasn’t classic here. It’s obviously my heart. It was enough to bring her to the emergency room though. And that led to an investigation that demonstrated this was the cause of her symptoms. I think this is an important message. Not everyone has classic chest pain as a manifestation of their coronary artery disease. Diabetic patients and female patients in particular have what we call atypical chest pain. It’s not that classic scenario that everyone can recognize, see this person’s having heart pain. And that’s an important message because as our society gets bigger, more diabetes, diabetes becomes more endemic and common in our population, more patients who have heart disease will not manifest the classic symptoms. They’ll have a different sensation. It’ll be discomfort but not classic pain. It’ll be a vague burning or tingling. It’ll be fatigue or shortness of breath or sometimes nausea rather than the classic easy to diagnose angina pain.
How often does she come back? Is she back once a year with you now for a checkup or how often will she need to come back?
PUSKAS: So she’s finished her operation some months ago and is now back with her family and living her normal life. She will follow up with her cardiologist at intervals but our goal as a surgical team is to take exquisitely good care of our patients, so that they get well and then they can forget about us and go back to their lives. That’s our goal.
Is there anything I didn’t ask you about the no touch heart bypass that you would want people to know?
John PUSKAS: The all aortic- the all arterial know aortic touch operation is a new procedure that is a very advanced. I think, state of the art way to accomplish coronary artery bypass surgery because it reduces the risk to the patient upfront and emphasizes or maximizes the longer-term benefit in terms of the durability of the bypass grafts. It’s very uncommon. Less than one percent of all coronary bypass surgery in America is done by this technique. But I believe it’s the best technique and I think it’s something that we need to propagate to teach and to disseminate within the surgical community so that more patients can have this. In the meanwhile, I think it’s appropriate for patients at risk or those who are contemplating a coronary bypass operation to seek out a surgeon who can provide that for them.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Ilana Nikravesh
Ilana.nikravesh@mountsinai.org
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