Touching the heart
By: Roi Tzur and Dr. Gil Bolotin, Director of the Department of Cardiac Surgery, Rambam Health Care Campus
Bypass surgery and catheterization have become routine procedures, and some people even claim that the number of procedures currently performed is exaggerated. Claims are also heard stating that some of the patients could have continued feeling well if they had received treatment by medication only…
Dr. Gil Bolotin: "There are clear indications when to carry out bypass surgery and when to carry out catheterization; the advantages and strong points of each of these procedures are quite obvious, and in most cases, there is a consensus. Sometimes, a cardiologist who is present during catheterization may tend to do rather more than he had planned when performing a procedure that perhaps should have been performed by surgery, while the patient, quite naturally, prefers a non-surgical procedure."
What are the indications?
"If there is significant disease in the three coronary arteries supplying the heart with blood, and especially if cardiac function is reduced, this is an indication for bypass surgery. If there is stenosis in the left main coronary artery, there is a clear indication for bypass surgery. The same is true for cases of complete obstruction, which cannot be opened by catheterization; surgery is preferable in such cases."
Aren't you a bit too ready with the stent or knife?
"Although I am a cardiac surgeon and not a catheterization specialist, I don't think this is true. Statistical data show that we don't perform catheterization without a good reason. It must be remembered that we are discussing a fatal disease, which can be effectively treated if discovered in time. Indeed, many people die because they haven't undergone catheterization. Perhaps it is better ─ so long as the procedures are performed in a controlled fashion ─ to carry out a few too many catheterizations or even to catheterize some people unnecessarily, than to miss any of those with coronary artery disease, who may die due to a wrong diagnosis. In this respect, as a cardiac surgeon, the ethical problem I face is less than that of the catheterization specialist. I don't run after the patients with a knife. The cardiologists who perform catheterizations determine who comes to me."
Some people claim that there is no statistically significant difference in life expectancy between patients who underwent cardiac surgery and those who were not operated on…
"Cardiac surgery extends life expectancy! This has been proved by controlled studies. In extreme cases, such as aortic valve replacement, the surgery dramatically extends the patient's life expectancy. Similarly, bypass surgery has been proven to extend life expectancy, and I am not only talking about people who were approaching death, but surgery on people who were in good condition.
If we use cardiac surgery wisely and appropriately, then the bottom line is improvement in the patient's condition."
What are the currently common surgical methods – how do you reach the heart?
"The regular, conventional, classical method is the well-known incision. That is, sawing and opening of the sternal bone. Most surgery is performed using the heart lung machine. However, some operations are performed today without connecting the patient to the heart-lung machine, and our doctors at Rambam are trained in both methods. Surgery is performed using advanced instrumentation, enabling fixation of a specific region of the heart, while the surrounding heart regions continue working and supplying blood, and only the area where the bypass is being performed is stabilized. This procedure enables us even to turn the heart over and to perform the bypasses in the posterior region of the heart, entirely without the heart lung machine. The main advantage of this method is reduction in the blood loss caused by the machine, so that patients require fewer blood transfusion units, if any, and they have an easier recovery from surgery. This procedure reduces mortality and the incidence of strokes in high-risk patients.
"There are already some types of surgery that can be performed without opening the sternal bone. We've recently started practicing at Rambam a method for which I have received specialist training in the US and the Netherlands. This method, called the "Mini-Mitral", is a minimally invasive procedure for repair and replacement of the mitral valve. In this method, the mitral valve is reached through a small incision made on the right-hand side of the patient's chest, without opening the sternal bone.
Many possibilities are currently available, but the most important aspect is good communication between the surgeon and the cardiologist, so that together we can find the best method for the patient."
Is the era of heroic major cardiac surgery over?…
"No. Ascending aorta replacement operations, which are considered major surgery, are being performed today (including here at Rambam). In certain cases, the entire aorta is replaced. Heart transplants are performed worldwide; I myself have had the opportunity to perform many heart transplants, in Chicago. However, the number of transplants is small, due to lack of donors. I assume that instead of heart transplants, the field of artificial pump transplants will be developed. However, this process is very expensive, and the rate of success is not high, as yet. I believe that in a few years, such operations will become common."
Has the success rate increased in line with technological advances?
"The current rate of success is very high, having significantly increased since the introduction of cardiac surgery. In the past, the risk of mortality associated with cardiac surgery was very high. There is still a mortality risk today, but for a 50 year old man, for example, without special risk factors, the chance of having a good surgical outcome is 99%, which is undoubtedly an amazing figure. Of course, the risk increases for a patient over 80 years of age, who has additional risk factors."
"We have to consider that, in the last 10-15 years, the age of patients undergoing heart surgery has increased, but in spite of this, the mortality rate from surgery has remained unchanged. Today, we dare to operate on patients whom no one would have dared to operate on in the past. Surgery on 80 to 90 year old patients, even patients with severely reduced cardiac function, is not exceptional today. And despite the fact that we are operating on patients who are more seriously ill, the results have remained good."
What is the contribution of the patient's optimism to the success of the surgery?
"I think that hope is important. The placebo effect is well known, and has been proven in clinical studies. It is known that, in many illnesses, the patient's condition is improved even by the administration of a placebo, just because the patient thinks that he is receiving efficient treatment. This demonstrates the power of the mind. I observe such situations in daily practice: an active patient, who does not stay in bed even at an older age, will survive surgery with a much better outcome. I think that the motivation and optimism of patients who undergo cardiac surgery contribute a great deal to their fast recovery."
Doesn't this sometimes create a dilemma ─ whether the whole truth should be told to the patient?
"My profession is highly optimistic, because, in general, the results are very good. In contrast to the past, the current policy is to tell the whole truth to the patient, even if his condition is serious. The advantage is that medicine is not a precise science. Therefore, even if the patient's condition seems hopeless, I know that there is still a chance that we may be wrong. Even in the most serious illnesses, there is a small proportion of patients who survive against all the odds ─ this is a fact; There is no need to deceive the patient; it is possible to tell the truth without destroying their hope."
Will all of us eventually come to you?
"Not necessarily. It is true that heart diseases are very common in the Western world, and their prevalence increases as the age of the population increases. However, most patients do not need surgery, and can have quite a good life without cardiac surgery."