Mount Sinai Morningside cardiovascular surgeon, Dr. John Puskas, MD talks about a new procedure that allows the heart to continue beating during open-heart surgery.
Interview conducted by Ivanhoe Broadcast News in 2022.
What conditions would require a heart bypass?
PUSKAS: Coronary artery bypass, grafting, CABG or cabbage, sometimes called heart bypass, is the surgical treatment of coronary artery disease. Coronary artery disease is the most common form of heart disease and is the number one killer of human beings.
In layman’s terms, how are you bypassing the heart?
PUSKAS: 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. 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. 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 coordinated bypass surgery is done using the heart-lung machine. This is a remarkable device. It’s a pump and a heater, and an oxygenator. In order to use it for the heart, we have to put a big cannula in the aorta, another cannula in the heart. The blood is diverted out of the heart into the machine and then pumped back into the body. We stopped 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. 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 is formed there. The same blockages can develop in the aorta that develop in the heart arteries. If that calcium or cholesterol is dislodged, it can cause a stroke or go somewhere else in the body, and that’s the complication that we seek to avoid by using this no aortic touch off pump bypass operation.
How are you able to do this surgery without stopping the heart?
PUSKAS: 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 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. 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. 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 do not touch it. There is no use of the heart-lung machine. Instead of arresting the entire heart with the heart-lung machine, we use some special devices that mechanically stabilize a portion of the heart. We move those devices around the heart, doing one bypass at a time. 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. We add a little more blood supply as we’re going around doing each of the bypasses on the heart. Once we’re finished with the bypasses, the operation is essentially over, and we close. The patient was net, the heart was never arrested. We don’t have any issues with restarting the heart because we never stopped it. We have a miniscule stroke risk because the aorta has not been manipulated. Most of the strokes that occur around the time of cardiac surgery, we believe, derived from knocking loose calcium or cholesterol from the aorta, the aortic manipulation. We completely avoid that.
How much lower is the stroke risk when you do the procedure this way?
PUSKAS: The stroke risk for patients having conventional on pump coronary bypass grafting is about two percent 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 one percent. It is about a three-quarters reduction from two percent to about a quarter of one percent or half of one percent.
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 need for blood transfusion. 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. In that patient group, once we’ve got their hemoglobin is 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. Typically, the length of stay in the hospital is reduced by 1-2 days with an off-pump approach. Patients tend to wake up a little sharper. 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, they stay in place then? They are not moved back to where it came from first time?
PUSKAS: Correct.
Does he go back in, or do they deserve?
PUSKAS: The artery graphs are permanent. 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. Typically, they’re able to do that. Avoiding any incisions in the legs improves the comfort experience that we’re 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 too. Veins are on the venous side of the human circulatory system. In other words, they’re designed to face low pressure. Veins have 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. When we use a vein on the heart, we’ve taken a low pressure tubing. You can think of it as plumbing. It’s a vessel that’s designed for low pressure and now we’ve transplanted it into the heart and it faces a high pressure. 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 percent will be open in 10 years. Of those that are open at 10 years, about 90 percent will be open at 20 years. Now at 20 years, almost all vein graphs have closed. 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 and maximizes the longevity of benefit of the surgery itself. Those graphs will stay open longer for decades.
Who’s the best candidate for this kind of surgery? Do you do it on everyone?
PUSKAS: We do. I know Eric touched all arterial operation as our routine default procedure. There has to be a reason to not do that operation. Those reasons are actually few and far between the vast majority, more than 90 percent of our coronary bypass operations are done by this technique. 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. The patient 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 years. We want that patient to live 30 or 40 years. We want to give them a bypass operation that is their only operation, and don’t have any other problems with coronary artery disease in their future. about
Can you tell me a little about Ms. Boucher? I think she’s HIPAA cleared we’re going to go see her tomorrow.
PUSKAS: You’re going to enjoy meeting her. She’s a sweet lady, very human, warm, emotional, frightened, but hopeful. She’s human. You’re going to like her. Yvelisse Boucher is a very sweet 60-year-old grandmother who’s had a lot of problems with diabetes and vascular disease. She suffered a stroke in 2021, I believe that left her left side weak. She’s had difficulty in managing her diabetes and controlling her weight. Those things have led to blockages in 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 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. She was referred for a coronary bypass grafting. But here we have this lady who’s vulnerable. Patients who have had a previous stroke are at risk of another stroke. 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. 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. That is what we did for her. We did all arterial know aortic touch bypass grafting. She received arterial grafts on 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 quickly. She went from here to rehab, got physically strong, and went home to meet with her grandson, which was her real motivator to get herself through surgery and to recover her. It was her family that was the focus of her desire.
How is she doing healthier than ever?
PUSKAS: She’s 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 involved her upper chest and her arms especially her left arm. It was very disturbing the symptom. But it was a classic It was enough to bring her to the emergency room though. That led to an investigation that demonstrated this was the cause of her symptoms. This is an important message because not everyone has classic chest pain as a manifestation of their coronary artery disease. Diabetic patients and female patients have what we call a typical chest pain. It’s not that classic scenario that everyone can recognize see this person is having heart pain. That is an important message because as our society gets bigger, more 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? How often will she need to come back?
PUSKAS: 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. 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?
PUSKAS: The all arterial no aortic touch operation is a new procedure that is a very advanced and 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. 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
(347) 852-3382
Ilana.nikravesh@mountsinai.org
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