Tommaso Hinna Danesi, MD, Cardiac Surgeon, talks about how for the first time in the United States surgeons have replaced three ailing heart valves in one minimally invasive procedure.
Interview conducted by Ivanhoe Broadcast News in February 2022.
We’ll talk for our viewers who may not be familiar, when you’re talking about triple valve surgery, what is it that you’re replacing and why do they need to be replaced?
DOCTOR HINNA DANESI: So, usually because you got or regurgitation or stenosis on your valve. It means that the valves are leaking, or they get narrower, not allowing normal blood flow through the valve. So, that’s the reason why you need something to be done on your valves. At that point, you’ll have two options, usually. If the valve is leaking, you can try to repair the valve, if the valve still smooth and well-functioning or you must replace if the valve is stiff net or thick net, usually when you’ve got the stenosis or a narrowing of the valve, you have to replace those valves.
What are the health risks?
DOCTOR HINNA DANESI: So, a not working valve will lead you to heart failure. So, at the beginning, it will harm your quality of life. You will start to experience a heart failure. It means that the heart enlarges it and start to try to put in place some mechanisms to balance the improvements of the valves, but after several months, you start to experience short of breath, swelling, so all these are symptoms of heart failure, and it will compromise your quality of life. The end stage of heart failure is a shortened of your life expectancy.
What causes these problems with the valves?
DOCTOR HINNA DANESI: So, there are several issues that can lead you to have valve problem. Usually, we must divide to acquired disease or congenital disease. Some people are less likely than others, and they are born with abnormal valves. So, they got a congenital problem that get worse during the time and maybe a mitral valve regurgitation, a congenital one. So, they know since their childhood they got a heart murmur that get worse during the years and the valve starts to leak much more and then you must do something on it because there’s an anatomical problem on that valve. Then you got acquired disease, so you may have an infection on your valve. So, you’ve got bacteria or other pathogens that destroy your valves, so you got a disruption of your valve by an external agent, or you may have radiation off your chest and radiation, get your valve thick and over the time the valve get narrower, and stiff and cannot work as well as they were used to or age because we get older. Everybody gets older. So, what I used to say to my patient is that especially the aortic valve does get calcified. So, it’s a normal process during your life that your valve becomes stiffened and calcified and get narrower.
Traditional surgery, this is usually a big deal to either fix a leaky valve or to replace one?
DOCTOR HINNA DANESI: No, usually is not a big deal, but it’s something that cardiac surgeon developed since 50 or 60 years. So, the technique to repair or replace valve are well-established, and we have very good results and durable results over the time.
Is it major surgery?
DOCTOR HINNA DANESI: It is a major surgery not only because of the central incision and you need your chest bone cracked, but because we need a cardiopulmonary bypass, and we need to arrest the heart to work inside the heart.
Talk to me about a new way of doing it.
DOCTOR HINNA DANESI: Yeah, there’s a different way to get into the heart and that’s my job. So, the work I must do into the heart, it’s almost the same because I repair or replace valves. The difference is in how I get into the heart. So, I don’t need to crack your chest bone because I brought all the technologies and techniques from other specialties, like general surgery, think to laparoscopy, thoracic surgery, and endoscopic surgery. I try to bring these technologies into cardiac surgery. So once I can get into the heart, I’m into the heart and I’m able to perform the work. Doesn’t matter the way I get into.
Describe for me how you’re fixing the valves and discomfort.
DOCTOR HINNA DANESI: So, the technique, it’s almost the same used for a standard open chest surgery, because one of my first rule is no compromise. So, the target is to give a patient a perfect job on the pulse, so there’s no compromise between the access I choose and the work I must do on the valve. So, you may have the same good work on your valve, even if performed through a standard sternotomy and then there are several ways to fix a valve. So, I for the mitral valve and for the tricuspid valve, so the left and the right-sided valve between the atria and the ventricles, I use something called physiological repair. So, I don’t like to cut and to modify too much the geometry and the anatomy of the valve because I try to leave the patient its own tissue. So, I use to replace the cords of the valve, I put smoldering inside, but I try to be minimally invasive also in the technique
How big is the incision and where is it?
DOCTOR HINNA DANESI: The incision is barely big, ranging from .8 and 1.2 inches. It depends on the patient. It depends on the valve you must work on. If you must work on the aortic valve, that is the valve between the systemic circulation and the left ventricle, you can use a pre-pectoral incision, so it’s a small incision just in front of your chest here. If you must work on tricuspid and mitral valve, the two valves between the atria and the ventricles, in males you can use a small cut around the nipple, and I like to call it ghost surgery because after one month, you cannot see where I entered the chest or in women a small cut below the breast so its hiding surgery.
What’s the benefit for the patient to have the surgery?
DOCTOR HINNA DANESI: So, I think that everybody could have benefit from this kind of surgery, but the benefits are different because if you think to an elderly and fragile patient, maybe a gentler surgical access might be the difference between being alive or death from an operation, so it’s a big advantage. For a young patient, from a clinical standpoint there are not so much difference. The recovery time, it’s faster in an endoscopic fashion. So, maybe younger patients can get back to their normal life earlier and they don’t feel operated yet and elderly patient could benefit from a more gentle surgical access.
How much faster is the recovery time?
DOCTOR HINNA DANESI: Usually a standard patient can get home after four or five days.
With open surgery, how long?
DOCTOR HINNA DANESI: With open surgery, one week, but the big difference is that an endoscopic patient doesn’t need an external restriction or precaution, so they can go back to work in one or two weeks when they feel okay.
Can you tell me a little bit about the patients? The one patient that you’ve done so far in Cincinnati. You said she had a very quick recovery.
DOCTOR HINNA DANESI: Oh, the triple valve surgery, Ms. Carrie. So, she was so, so sick when she came here because she had two intensive care unit accesses for severe and end-stage heart failure. So, the first time I saw her, it was early March. Then, the heart failure team did its excellent job and try to recompensate her, and then I start to think because she had a triple valve issue, she has got a mitral valve regurgitation, aortic stenosis and regurgitation and tricuspid regurgitation. All these due by rheumatic disease. So, but she was so fragile, especially she was young, she is so young. She was so sick, and she was so fragile, so I was concerned to perform a standard surgery on her, especially for the postoperative period and recovery. So, I started to figure out if she would be candidate for endoscopic surgery, because here I am measuring the patient. So, in Italy, I was used to offer this kind of surgery to 100% of valve repair patients must figure out if U.S. patients are almost the same because the BMI is different, there are different ideologies. So, but barely, I think that the population is almost the same, so we can offer in 100% of the patient this kind of approach, but speaking to Ms. Carrie, I try to lower as much as possible the surgical impact on her, and I start to plan a digital surgical planning with Dr. Rybicki, so he is the vice chief of radiology here, and we start to work on a 3D modeling to increase the precision of the surgery on Ms. Carrie.
I’m going to ask you to show me the 3D model after, but if you could just describe for our viewers, you know, how was that 3D model helpful in planning the surgery? Please talk about that.
DOCTOR HINNA DANESI: So, with a small access, you are trying to preview where the heart will be and you try to be as much closer you can to the heart, but you are looking a patient from the surface, so you don’t know exactly where a valve is a very small structure, is a two centimeter at least structure, so you have to try to guess where this valve will be and the orientation of this valve because they are oriented in a 3D space. So, when you’re facing fragile patient or complex surgery, you want to reduce as much as you can the variability of the relation between your access and the structures you must work on. So, that’s the reason why I asked Dr. Rybicki to make a 3D model and try to segment all the valves, trying to choose the best access to be as much as close as I can to the three valves to reduce the variability of the patient’s anatomy.
Were able to study it and map out how you were going to approach?
DOCTOR HINNA DANESI: Correct. I was able to preview where I had to put my work import to create a more comfortable operating field.
How’s patient doing now?
DOCTOR HINNA DANESI: She’s doing good. Four weeks after surgery she was able to go back to her students and I heard her. She is doing good. She has no complaints. She has started to exercise again. She is lovely.
What’s the implication, Doctor, of having this surgical method available?
DOCTOR HINNA DANESI: If I have a valve problem, I don’t want to have a sternotomy. So why do I have to offer others for something that I don’t want for me? That’s my question and that’s my answer.
Is there anything I didn’t ask you that you want people to know?
DOCTOR HINNA DANESI: A lot of people used to ask me ‘why don’t you use the robot, and which is the difference between endoscopic surgery and robotic, minimally invasive surgery?’ I started with robots, I used the robots, but then I left the robots because of the human touch. I realized that I could perform the same job with my own hands without losing my tactile feedback with a less and smaller incision, sparing time. So, that’s the difference. Because the idea of a robot is something that is very futuristic, but it doesn’t work like the human touch. Not yet.
Do you have any other triple valve surgeries planned?
DOCTOR HINNA DANESI: No because it’s rare and I used to plan high-risk surgical patients first in a hybrid way. What does it mean? It means that I told you the first target is to give the patient a perfect operation on their valve. The second target is to do that with the lowest risk as I can give to them. So, it means that if there is any option to perform on hybrid approach on their valve, it means maybe performing one valve surgically and one valve percutaneously, it means without arresting the heart, I do that because I’m used to also perform this kind of procedure with the interventional cardiologist here.
The heart is still beating. So, you’re working around moving organs?
DOCTOR HINNA DANESI: Correct. So, this is a 3D model, this is a real reconstruction of the patient. So, it means this is a 50% scale of the right chest of the patient. So, what I need to know all these bar’s target a structure that I must take care of. So, from the back, this is the aorta. This is the main vessel exiting the heart that supply the blood flow to our body, and the purple one, this is the left atrium, and inside the left atrium, you got the mitral valve here. So, we made a reconstruction of all the more interesting anatomical part on the part I have to work on, and then we reconstruct the surface of the patient, so I can easily plan where I have to put my working port to be straight on the valve. You can see here the mitral valve in that patient is having posterior, it’s very posterior. So, if I enter the chest from here, I’m 90-degree as far from the mitral valve and it will be very uncomfortable because you must walk vertically. So, I know that probably I must be more lateral. And there’s no way to know this just looking at the patient. So, you need a CT scan and you need to add it. There’s a lot of engineering work on it and a lot of hours, and you’ll have to edit everything from the CT scan, the angio-CT scan.
Is that just a CT scan or is that married with some other imaging to make the 3D model?
DOCTOR HINNA DANESI: No, it is an Angio CT scan that must be synchronized with the heart rhythm, and from this scan, then the engineers with a specific software they’re able to edit all the structures I need because you see here, you don’t have the lungs, you don’t have a lot of anatomical structure that I don’t care because I take just about this part. This is the diaphragm, the orange one. So, I ask them to reconstruct the structure that are interacting with my surgery. Now, we made a step forward and we are not still making this physical 3D model, but we move on 3D PDF. You can look at it on your mobile phone, but these are two or three papers that we are building for next conferences.
How long did the surgery take on this patient?
DOCTOR HINNA DANESI: Time is something, especially in cardiac surgery, because we have several scales to count our time. The most important one is the time you get the heart arrested, because time is muscle, and we must be very quick to reduce the time of the cardioplegic arrest of the heart, and she had a barely shorter rest time, so she had one hour and half of cardiac arrest just to have three valves done. Then you have the time of the surgery, so the skin-to-skin time, and the skin-to-skin time for Carrie took barely four hours, 3.54 four hours.
The heart was beating, except for that one hour where you were actually fixing the valves?
DOCTOR HINNA DANESI: Yeah, I fixed one valve on beating heart in order to further reduce the cardioplegic arrest of the heart.
So, two of the valves you fixed while the heart was stopped and one…
DOCTOR HINNA DANESI: Correct.
Wow. Talk about working on a moving target. You really were working on a moving target.
DOCTOR HINNA DANESI: Yeah. You have to work on a moving target.
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.
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Amanda Nageleisen Matt Martin
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