Douglas Murphy, MD, Chief of Cardiac Surgery at Emory St. Joseph’s Hospital and Head of Cardiac Robotics talks about mitral valve issues and the robotic surgery approach that is treating them better.
Interview conducted by Ivanhoe Broadcast News in May 2018.
Valve issues with the heart and mitral valve prolapse, some people have heard of it some people have not heard of it. Is this a common issue in the United States, do we know how many people are affected by this?
Dr. Murphy: You see different numbers but about forty thousand mitral valves are operated on a year in the United States. The most common problem is degeneration of the mitral valve. The mitral valve is like an opening with two half parachutes and they open and close like this. And if the strings on one of the parachute halves or both of them stretch or break then the parachute halves flip up like this and blood goes backwards. And if it goes backwards and it kind of backs a little pressure in to the lungs so people get short of breath. But the main problem that we worry about mostly is the main pumping chamber under it. That if the main pumping chamber has to do a lot of extra work because it’s pumping forward and backwards in time It weakens. And we want to repair the valve or occasionally replace it but usually repair it before that weakening occurs.
Can this happen to anyone at any age and what are some of these symptoms including the shortness of breath? Are there other symptoms people should know?
Dr. Murphy: We’ve operated on people in their late teens or as late as their late eighties. But the majority are in their fifties. It depends if you have a predisposition to it you might come in earlier. It can occur anywhere from late teens to late eighties. The majority of people are in their fifties to early sixties. That’s probably the most common age we see it. And it’s a wearing out process, degenerative. So if you have a predisposition you come in earlier, if you have a normal valve that just wears out from wear and tear you come in later. You can have one parachute totally loose like this and no symptoms. And that’s why it’s a dangerous disease because it can creep up on people. The most common symptoms really are shortness of breath on exertion. People who used to play tennis and now they get short of breath. Sometimes people come in and say, I can’t go up two flights of stairs. Sometimes they simply go to their primary care doctor and a heart murmur, a sound is heard and then that’s the clue that causes us to look in to this.
Does everyone who has this issue need surgery?
Dr. Murphy: No, we only operate on people who have severe leaking. And we have parameters that we measure on the echo cardiogram. And ultrasound of the heart that tells us if the leaking is severe. If it’s severe then we usually have to do something before the heart is permanently damaged.
Because the heart can be permanently damaged if this is not repaired. What are the options then for this procedure? The valve I know can either be repaired or replaced, is that correct? It depends on the case.
Dr. Murphy: Well for degenerative disease which is the most common kind of leaking of the mitral valve we always try to repair. If it’s the most common forms of degenerative the repair can be as likely as ninety nine percent. It’s basically parachute repair work. If you’re floating down in a parachute with twenty strings and five of them break you can either cut out that piece of the parachute and sew it up, now you’ve got a smaller parachute. Or you can put in new strings which are made of Gore-Tex and restore it to the way it was before.
So leading up to the robotic surgery up until this point did you have to do open heart surgery or what was the standard?
Dr. Murphy: Well first of all one confusing thing to a lot of people is this is open heart surgery because in order to work on a heart valve you have to make an incision to open the heart to get at it. The idea of repairing the valve and how to repair the valve we’ve known that for thirty some, forty years. What is new is how to get in there, relatively new. Traditionally it’s been saw the sternum in half and operate from the front of the chest. One of the advantages of coming from the right side of the chest to get to the mitral valve is that the mitral valve is in the back. So a surgeon, can I show you on this model?
Yes.
Dr. Murphy: If we open up the heart to see the mitral valve over here between the left atrium and the left ventricle, and what’s happening when the valve leaks is blood goes backwards this way. We only want blood to go this way. If too much goes back then several things can happen. This chamber dilates and you get short of breath because it’s backing up in to the lungs or you get atrial fibrillation. That’s a common sequela of this problem. Or you can have the left ventricle, the main pumping chamber which is what your life is depending on, this ventricle is doing extra work it can enlarge. So that’s why we want to stop the blood from going backwards. Now this is a model you can’t make these incisions in a regular heart so the way we get to that valve is here. If you come from the front you have to retract the heart up like that and spread the two halves of the breast bone a lot. If you come from the right side, it’s a straight shot to the valve. So, that’s why one of the main reasons why we started to come from the right chest, to come straight across. We use the heart/lung machine to rest the heart and then we come across. Now we used to come across with hand held instruments and from about the mid-nineties to the early two thousands we would operate through by spreading the ribs a little bit and we would operate with long instruments kind of like chopsticks. And then fourteen years ago, really sixteen years ago now we started to come with the robotic instruments. So now we just make little holes between the ribs and it’s what we call an endoscopic approach. And we’re looking right, we make a little incision here, we just lift up a little and we’re looking right at the valve.
How many incisions do you need to make?
Dr. Murphy: We make one for the camera, we have three robotic arms. We have two right arms we click back and forth between which one. And then the key is a fifth incision because now the surgeon is no longer standing at the patient’s right side where they normally do. We go over to the console so now an assistant stands here so we make a fifth hole so now the assistant can now get access to where we’re working. Unlike a regular heart operation where you have two hands now we now have four. Two robotic and two of the assistant.
Describe how you are at the console and what you are doing because you are directing the procedure but robotically.
Dr. Murphy: The way the sequence of the operation is, is that as a surgeon I make little incisions like in the groin area and attach the heart/lung machine. And then we poke five little holes here for the robotic instruments. Then we hook the robot up to those five little holes and then I go ten feet away to the console. Now the thing that a lot of people don’t understand is the robot is a high tech machine that’s a computer that basically takes our vision and puts it inside the heart and then our hands inside the heart. So over at the console everywhere I move my hands a computer reads the motion of my hands and then digitally sends a signal to the patient side where little motors move the instruments. And then also I can look in and I have 3-D high definition ten magnification vision. I can see things I’ve never seen doing regular heart surgery.
Is this why this a benefit, does it benefit the surgeon and the patient as well to do this procedure robotically?
Dr. Murphy: Well we’re interested in benefitting the patient alright. The value of what we do is directly related to doing the actual technical operation. And I think most people, most surgeons who have mastered robotics would say they’re better surgeons because of the exposure and the ability to make tiny little stitches with the robot. The value also varies inversely with what we have to do to the patient to fix the valve. If we can just make five little holes, the patient what they notice is fast recovery. What we see is lack of more serious complications. So for example, the number one complication of heart surgery is stroke. We see less than one percent stroke with this. And the national average is pretty much about three percent. So that’s a major advantage. We use less blood, the patient is up and around faster, and we’ve never had a chest wound infection. We’ve done twenty seven hundred of these. So that’s been the driving force. And then now a lot of times we can do an operation like that by hand, in thin healthy people. But with the robot we’re hitting ninety seven, ninety eight percent we can do a minimally invasive or what we call endoscopic operation. So it’s higher value and we can apply it to more patients. And especially the more high risk older fragile patients. They’re the ones that benefit most.
The risk to this would just be any risk you would have with surgery. There’s nothing more specific than that?
Dr. Murphy: We operate on almost everybody with this approach. And our death rate with this surgery is less than one in a hundred. And that is the best results that we’ve seen with any approach and that’s been the driving force to continue doing it.
And once the patient has this procedure just like Susan did, and the valve is repaired is the patient generally okay, are they fixed?
Dr. Murphy: Yeah. I don’t remember how old Ms. Watkins was.
Sixty.
Dr. Murphy: Sixty, okay. We’re fixing something that is sixty years old. But it’s roughly with what she had about a ninety five percent chance that she won’t need anything else on that valve. I mean things could happen, the repair could fail, she could break a new string on another part of the valve, she could get infection on the valve. There’s different ways that in that five percent that she could come back and need surgery again. It’s interesting that of the about fifty five patients over the last sixteen years that have had to have surgery again by us, in over ninety percent of them we went back in through the same holes and re-operated on the valve and repaired almost all of them, re-repaired them. It’s not a perfect thing but she’s less likely to need another operation than if we had replaced that valve with an artificial valve.
How long generally does the procedure take? And how long does the patient have to stay in the hospital?
Dr. Murphy: It depends on what you mean about how long it takes. If stopping the heart quite short. In her case it was about an hour to do everything we needed to do. On the heart/lung machine seventy five minutes, seventy minutes just a little more than how long the heart is stopped. The operation itself takes a little over four hours because the anesthesiologist play a big role in this. They put in little special catheters and then we stay in the operating room, I think she was awakened in the operating room and went upstairs already with the breathing tube out.
You told me how many of these procedures do you do a year?
Dr. Murphy: About two hundred.
And the success rate obviously has been very good.
Dr. Murphy: Correct, that’s the driving force.
So in summary you are teaching this to other surgeons, the robotics part of his.
Dr. Murphy: Right. Right now in the United States only seven percent of mitral valve surgery is done this way. There’s numerous reasons, it should only be done in big centers by highly dedicated people. There’s actually a negative financial aspect for physicians because they have to spend a lot of time training and you have to be in the room the whole time, you can’t have assistance doing part of this you have to do it yourself. It does reduce surgeon productivity a little bit that may be one great limiting factor. What’s interesting is some of the countries with socialized medicine where you think they’re not getting the state of the art like England and Japan and Canada are aggressively pursuing this because the overall cost of the care is less because the complications cost money and we have very few of them.
So you hope to see this being done more widespread in the United States is really the case?
Dr. Murphy: What I would hope, the ideal scenario, would be that everybody lives say one tank of gas away from a center that can do this okay. What we’re seeing is when you can do something through five little holes people will come a long distance for it. And they won’t do that for another place that’s going to divide the sternum. They end up getting a good repair at a low complication rate and a fast recovery. I mean you’ve already seen that they’re active really, you know go back at work and swing a golf club in three weeks.
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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