Teamwork Makes Heart Procedures Less Invasive

Surgery

Marc Katz, MD speaking with his staff
Dr. Marc Katz, chief of the Division of Cardiothoracic Surgery, talks with medical student Chelsea-Ann Patry. photo by Sarah Pack

Helen Adams | adamshel@musc.edu | December 7, 2017

A second hybrid operating room is in the works for the heart team at MUSC Health, a sign of how successful the first one has been for a group that emphasizes teamwork, less invasive procedures and shorter recovery time for patients. Hybrid rooms are packed with high-tech imaging devices that allow surgeons to see in great detail the area they’re focusing on and make sure they’re as precise as possible.

The new hybrid room will be built with the help of a $50,000 donation made in honor of Marc Katz, chief of the Division of Cardiothoracic Surgery at the Medical University of South Carolina. He’s considered a pioneer in minimally invasive heart surgery and also specializes in heart transplants.

Katz is a key player on a team that includes more than 30 cardiologists, 5 vascular surgeons and 4 cardiac surgeons. “It’s the largest interdisciplinary team in the state,” he said.

“MUSC has really become incredibly collaborative, in part because of the people we have here. There are world experts in a variety of disciplines we’re talking about: cardiology, vascular surgery and cardiac surgery. And we now put our heads together and say, ‘OK, here’s a different way of doing things. What’s the best way for this individual?’”

Aortic and Thoracic Aneurysms

That collaboration is leading to new ways to treat heart problems at MUSC Health. A prime example: changes in how the team treats aneurysms.

Aneurysms are weak spots in blood vessels that cause them to bulge. They can rupture, leading to potentially deadly internal bleeding. When an aneurysm develops in the arch of the aorta, which is the body’s main artery, it can be challenging for doctors to get to, Katz said.

“Usually, we have to use the heart-lung machine and cool the patient all the way down to room temperature. Instead of 98.6 degrees, we cool them down to about 68 degrees and turn off the heart-lung machine. There’s no circulation. You have to work like crazy, because you can’t leave them like that for too long. There’s no way to fully perfuse and get in there and still get blood to the brain. It’s a complicated situation.”

But that’s not always necessary anymore, Katz said. “We did some cases where we replaced the whole aortic arch. There was no heart-lung machine, no stopping the pump, no deep hypothermia, no circulatory arrest. We did it by debranching, moving the branches and then putting an endovascular stent graft in. It was much, much less invasive than it would have been if it had been done by conventional approaches. And you can’t do that without collaboration between services.”

The team can also do endografts to treat aneurysms in the chest and abdomen. The procedure involves using collapsible grafts, which are cylinders made of cloth and metal, to relieve pressure on weakened blood vessels. Katz said he works very closely with the chief of vascular surgery, Ravikumar Veeraswamy, who is a national leader in this area.

Aortic Valve Stenosis

There have also been changes in how the heart team treats patients suffering from aortic valve problems such as stenosis, which involves a narrowing of the opening of the valve.

“We can use transcatheter valves to replace the aortic valve,” Katz said. “In the past, we used the heart-lung machine, stopped the heart, went in, cut out the diseased valve and put in a new valve. Now, it’s a needle stick in the groin to pass some wires up and release a new valve. The patient’s home in two days.”

For these cases, Katz works closely with Daniel Steinberg, who started the MUSC transcatheter valve replacement program, or TAVR. He called Steinberg a world leader and innovator in this area. “TAVR has revolutionized the treatment of aortic valve disease,” Katz said.

In most cases, the valves are placed via an artery in the groin. But the vessels have to be big enough for that to work. When they aren’t, the team finds another way, Katz said.

“Sometimes, if people have vascular disease or blockages down in the arteries, the vessels aren’t large enough to accommodate the catheters. There are other ways to do it. The most outside-the-envelope approach we’ve used is where we go through a vein in the leg and then cross over into a clear area in the aorta.”

Mitral Valve Repair

Katz said robotic surgery is a powerful new way to do mitral valve repair, and the heart team at MUSC Health is the only group in the state offering it. The mitral valve plays an important role in the heart's function, allowing blood to flow from the left atrium to the left ventricle. If the valve is damaged, part of it can slide into the left atrium, a condition called mitral valve prolapse. Some people also suffer from mitral valve stenosis, which is a narrowing of the valve, and mitral valve regurgitation, which causes blood to leak backward.

Katz said using a robotic system can dramatically shorten how long it takes a patient to recover, allowing the person to go home in two days instead of about seven. It lets the surgeons go through muscle via small ports instead of splitting the breast bone to do the repair, with cameras that give them 3-D vision magnified 10 to 15 times.

Katz and Steinberg also use the MitraClip to treat mitral valve regurgitation in people who aren’t good candidates for surgery. This is a trans-catheter mitral valve repair, or TMVR. The doctors send a catheter through a vein in the leg to get to the heart. It delivers a small clip that connects to the mitral valve, helping it close better to reduce the leak. This procedure is done on the beating heart without the need for a heart-lung machine.

Ventricular Assist Devices

Katz said the heart team is also a leader in another area, offering three different ventricular assist devices for people whose hearts are failing: the HeartMate 2, HeartMate 3 and HeartWare. That’s more options than any other program in South Carolina. These devices help provide circulation when the heart is failing either as a bridge to a heart transplant or a destination treatment.

Heart Transplants

Heart transplants are another specialty of the heart team, Katz said. MUSC Health is the only place in the state offering them.

That part of the program has undergone some scrutiny in recent years. Due to concern about improving results, the program underwent a rigorous review in 2014 and 2015, seeking outside consultants to examine all aspects. Having made multiple process improvements, and with the addition of more heart failure and transplant medical and surgical experts, the program is back up to full speed with results equal to or better then national averages.

The Heart Team

Katz, who joined MUSC Health less than a year ago to start the robotic surgery program, said he’s proud to be part of the team. “Our goal is to get our patients the highest quality help through the least invasive means. We want to get them feeling better and back to full activities in a short period of time.”

The team recently took care of a medical student who thought she had a run-of-the-mill virus. It ended up damaging her heart, leading her to wonder if she’d need a heart transplant. She was rushed from Greenville to MUSC Health.