No one wants to be told they need heart surgery, even when it’s the best and only course of action. Major surgery often comes with a long recovery period and discomfort, but now the Lankenau Heart Institute in Wynnewood promises state-of-the-art techniques that reduce pain and provide a quicker return to a normal life after surgery.
Minimally invasive replacement and repair surgery on the heart and aorta are now being done at the Institute under the guidance of Dr. Konstandinos Plestis, one of the world’s leading surgical specialists performing these procedures. The new techniques, practiced in very few places around the country and the world, offer less pain, less post-operative complications and a much quicker recovery for patients. Many are back on their feet after only a few weeks.
Recovered heart surgery patients often refer to themselves as members of the “zipper club” because of the long belly-to -neck incision required for the surgery. Dr. Plestis gives his patients an alternative. He can do the same complex surgeries using an incision that typically runs about 2.5 inches, barely covering the chest.
“The amount of pain is directly related with the size of the incision,” he says. A larger incision means more pain, more post-operative discomfort and a longer recovery time.
“Every effort should be made to make the incision as small as possible without compromising the operation,” he says. Make a little cut, you have a little bit of pain, a bigger cut, more pain.
Dr. Plestis was pleased with what they discovered using the minimally invasive approach. “…We saw that a lot of people were doing better than with traditional surgery, much faster than before.”
He talks about one of his patients, an 86-year-old man who needed an aortic and mitral valve replacement.
“If you have major open heart surgery at age 86 you expect he would be bed-ridden for at least a couple of months, recovery six months or something like that. This is what people believe,” Dr. Plestis says.
A video of the patient pops up on a screen. “This guy, three weeks after surgery, is doing stairs. Three weeks after his surgery the man has two valves and he looks great.”
Another patient shows up on the screen, a man who needed an aortic root replacement, one of the most complex surgeries performed. Two to three weeks after surgery, there he is, walking causally down a hallway.
“Traditionally, if you have to have surgery like that it may take you 12 weeks to recover,” Dr. Plestis says.
Up until very recently, surgeons faced a dilemma. There is a problem inside the body, but to fix the problem, to make the machine work properly, you have to cut through from the outside, and that creates a new problem.
“You have to open something which is not a problem to fix something which is a problem,” he says. The trick is to minimize the insult to the body but still do the complex surgeries.
The concept of minimally invasive procedures began with the development of laparoscopic surgery, a technique that puts a camera inside the belly to see. The surgeon, guided by the camera images, uses long instruments to work inside the body.
Traditionally, to operate on somebody in the belly it required a very long incision so the surgeon could see and work. With a small incision and a camera to act as the surgeon’s eyes, the surgeon can look around without having to open up as wide an area.
“It’s like, for example, if you have a problem with your car, you open up the hood wide. Imagine now the hood is open a little bit and you put the camera in and you look around. The concept is absolutely similar,” he says.
If you know where the problem is before surgery you can localize it easily, so a large incision isn’t needed. With special long instruments you can go in, manipulate the organs and find out exactly what’s happening.
Now take those techniques, apply them to heart and aortic procedures and you have state-of-the-art minimally invasive surgery in the 21st Century.
“We’re talking about surgery on the heart of the patient, which is the highest complexity of surgery that can be done on the human body,” he says.
To do the same thing with smaller incisions required new tools and new techniques, many developed by Dr. Plestis and his team at Main Line Health.
“At Lankenau, 70 percent of the [heart] surgeries are being done in a minimally invasive way that allows us to help our patients the most,” Dr. Plestis says. “That is why we believe our outcomes are very excellent. That is why the patients are very happy.”
That 70 percent figure looks impressive when you consider that the average minimally invasive heart procedure is only done 15 percent of the time nationally.
So why 70 percent at Lankenau verses 15 percent elsewhere? The reasons are varied. Special equipment and tools are needed. New procedures have to be learned by the surgeons and, since this is all so new, very few people have the experience under their belts to carry it out.
“If you have a fixed way of doing things it takes a leap of faith and a leap of ability to be able to do it,” Dr. Plestis says. “That is why a lot of people don’t get into that because they are so comfortable with what they do.”
A traditional approach might be comfortable for the surgeon, but it’s not doing much for the patient. If you are so good that nothing will go wrong, it means you are good based on the standards of the decade you are living in and not moving ahead to the next level that may make the patient’s life better, Dr. Plestis says.
“I say, if I’m the patient, what would I like to have myself, and that has to be the guide that allows you to innovate and make the process better and better and better,” he says.
In the 20th century, it was important to be alive after surgery. In the 21st Century, you’re alive after surgery but it is important to have less pain and a faster recovery.
So what kind of minimally invasive procedures can be done at Lankenau on the heart? Right now, they are prepared to do aortic valve repairs or replacements, mitral valve repair or replacement, coronary artery bypass, replacement of the ascending aortic root aneurism, replacement of an aortic heart aneurism, double valve replacement, and double valve repair.
“Of course, there are procedures that cannot be done minimally invasively or it is not worthwhile to do them minimally invasively so we cannot apply this technology 100 percent, but we can apply it to a significant number of patients,” he says. Last year, out of 900 cases, 600 heart and aortic surgeries at Lankenau were done minimally invasively.
The Institute has embarked on a mission to share information on its techniques with others. New, innovative procedures are videotaped for training purposes.
“The reason we do those films is we want to educate others in the techniques that we believe will be having a significant impact on the care of the patients. I think it is our ethical responsibility to indicate to others how to do it,” Dr. Plestis says.
Heart surgery 101
The heart is in the center of the chest. It pumps blood to the aorta, which is like a tube. The aorta extends up and down, begins in the front of the heart and goes to the back. The aorta has branches that go to the right and left brain, the right and left arms, the right and left kidneys and the right and left legs.
The heart pumps the blood through the aorta and into a tubing system which transports it to different parts of the body.
“You have the heart, you have the aorta, you have the ascending aorta, you have the branches of the aorta and that tube has to maintain its integrity because if the blood comes out of the tube, you die.” he says. “Sometimes there is a ballooning of a section of the aorta, an aneurism. The ballooning causes blood to leak and it if breaks, you die.”
Thousands of heart surgeries are performed every day in the United States. In a recent year, surgeons nationwide performed 500,000 coronary bypass procedures.
Sometimes a hybrid procedure, using a stent and minimally invasive bypass surgery is done at Lankenau. “Depending on the scenario we may utilize a variety of factors, a variety of circumstances to fix that problem, a variety of technologies…” Dr. Plestis says.
Fixing an aortic aneurism is one of the most difficult and prolonged operations that can be done on the human body.
To fix an aneurism, you replace the damaged part of the aorta with a plastic tube, and then reconnect the essential arteries going to the plastic tube graft.
A root aortic replacement is even more complex. At the root of the aorta, coronary arteries branch out to provide blood flow to the heart. You not only replace the damaged aorta with a plastic tube, you have to use extension tubes to re-implant the coronary arteries back to the graft.
Many of the surgical techniques to fix an aortic aneurism have only evolved in the 21st Century and only at a few places.
“The aortic surgeries are being done in select places in the United States because of the complexity and experience that they have and the experience that is required by the surgeon to perform the surgeries,” Dr. Plestis says.
In the 1980s and 1990s, there were only two facilities in the United States that did aortic root surgery, in Houston and in New York at Mt. Sinai Hospital.
Today, there are still only a handful of centers. In the United States, a busy aortic program does 16 aortic roots a year, often with multiple surgeries.
“We do 50 a year and we do all of them minimally invasively,” he says. Personally, Dr. Plestis has performed more than 1,500 operations for the aorta since 1999. Even a busy program can only count about 272 aortic procedures in the same amount of time.
Lankenau boasts one of the largest aortic surgery programs in the United States, he says.
“In addition to that, we are one of the few places in the United States that can be measured on the fingers of one hand that do minimally invasive aortic surgery,” he says. “Obviously when you do so many surgeries and you have a lot of experiences with that, you can minimize the surgical incision because now you have a lot of experience with this type of surgery…”
The surgery is so specialized that right now the surgeons have to be at the level of a Picasso.
“Not every guy that paints is a Picasso. The same thing applies to the highly technical thing which is aortic surgery,” Dr. Plestis says.
Other minimally invasive procedures, like the aortic valve and mitral valve replacement and coronary artery bypass, are becoming fairly routine at Lankenau.
The use of minimally invasive procedures for heart surgery has moved to more and more complex procedures. First, there was aortic valve surgery, than mitral valve surgery, than coronary bypass surgery and now minimally invasive aortic surgery, which Dr. Plestis feels is the “last frontier” for advancement in heart surgical techniques.
Dr. Plestis says that it’s time to advance cardio-thoracic surgery to this new frontier. Major medical institutions should be adopting this technology much faster, instead of staying with the way things were done 20 years ago, but they haven’t, he says.
“When you have a successful enterprise, a successful practice, it’s very difficult to change. For us, we believe that if Ford had stayed in the way that he made cars in 1910, we would not have BMW and Mercedes in the 21st Century. In order to improve, you have to be able to innovate in the process of caring for patients because that is a very important thing in the way that medicine evolves,” he says.
He would like to see 10 or 20 centers in the United States that will do the most complex heart procedures over and over so they can become experts at it and develop a tradition in the management of the patients.
From the patient’s point of view, the journey to save a heart begins with a visit to a primary care physician. The patient may be complaining of symptoms like heart burn, pain, or weakness. The doctor evaluates the patient and if they feel it could be a heart problem, they are referred to a cardiologist. Using sophisticated tests, the patient is evaluated and the cardiologist makes a decision on what the next step should be. It could be medical therapy. It could be surgery.
“What we always say to the patients is there is obviously no perfect way—it is not as if you are going on a vacation,” Dr. Plestis says. The intent is to make the experience as comfortable as possible for the patient.
Comfort includes reducing anxiety, beginning with the pre-operative evaluation, a very “patient friendly process,” at Lankenau, Dr. Plestis assures. Thanks to pre-operative testing with CAT scans, MRIs, echograms, etc., the surgeon knows what the trouble is and where it is before he even has to cut into a patient. He can make a smaller incision because he knows exactly where he needs to work.
Dr. Plestis demonstrates with a video of a minimally invasive aortic procedure he performed. “This is the heart but you see only one-tenth of the heart. So what that incision does, it focuses you on the area that you want to operate on without having to open so much to see the entire heart because you don’t need to see the entire heart,” he says. “The area you have to see is exactly the area where I have to cut,” Dr. Plestis says.
On the video, he takes the valve out, measures it, and replaces it with a new valve graft, suturing it in place with a suturing device that places the sutures deep into an area that would be difficult to reach with the surgeon’s hands.
Minimally invasive surgery is often faster thanks to technologies like the suturing device used in the video. “With this device, you just put it down without having to waste time by tying it by hand,” Dr. Plestis says.
A typical open heart patient after the operation feels weak and experiences significant chest pain which requires a lot of medications for a couple of months. With minimally invasive surgery, the pain and discomfort the patients are experiencing is much less. Their ability to get out of bed and move around is much faster and much easier because they have less pain. Consequently, the possibility of post-operative complications is much less because they can get out of bed and move around much faster compared to people with much bigger operations. There is less chance of infections. In addition to that, because the pain is much less, they heal much faster.
Patients do not expect the experience of heart surgery to be easy, he says, but with the minimally invasive procedures, they are dramatically surprised how well they do.
“The point is, can we do the work that we do in the smaller incision? And the answer to that is, ‘yes,’” Dr. Plestis says.
Dr. Plestis recalls one patient, a well-known pianist. He was on the golf course in New York and felt something like a whip across his chest, followed by a loss of feeling or control in his legs. There was no sign of a heart attack. A doctor at the time said the problem was back pain and sent him home, but the ripping sensation across his chest returned.
Turns out he had an aortic dissection, an aneurism, which is usually fatal.
“It was like surviving a stabbing to the chest. Eighty percent die. It claims 15,000 a year in the U.S. It’s what killed John Ritter,” Dr. Plestis says. “He’s a very lucky man that he survived.”
If a heart aneurism ruptures the survival rate is very low, maybe 20 to 30 percent. When the aorta ruptures there is severe internal bleeding and all the organs are shut down.
Aortic disease is a lethal disease because most of the time you don’t have any symptoms. When it hits you, you can die very quickly.
The patient came to a facility in Atlantic City on July 4 and Dr. Plestis performed aortic surgery, saving his life.
Heart aneurisms can run in families. Two men in Russia lost their brother a month earlier to an aneurism. On July 3, they came to the emergency room, both of them with chest pain. A CAT scan revealed they both had aneurisms.
“I operated on the left guy on July 4 and the other brother on July 5 so I had both of them in the hospital,” he says.” Both of them did very well. I fixed their aortas and they did perfectly.”
A commercial truck driver tested for pneumonia and an aortic aneurism. He could have bled to death, but it was caught in time and the aneurism repaired, using minimally invasive techniques.
“The patient said he was up the day after surgery and he hasn’t stopped, “Dr. Plestis says.
Statistics and last word
Lankenau Heart Institute had 513 heart patients in 2011, 555 in 2012, 589 in 2013 and 681 patients in 2014.
With Dr. Plestis now chief of cardio-thoracic surgery, that number has jumped to 946 in 2016, a 30 percent jump. At the same time, the mortality rate for the facility has decreased. It dropped from 3.12 percent in 2011 to 3.08 percent in 2014, to 1.69 percent this year.
“We do more surgeries with less mortality,” he says.
The Society for Thoracic Surgery tracks mortality rates for all the major procedures in the United States. The national rate is 2.5 percent. “We have .8 percent,” he says. For aortic valve replacement, the national benchmark is 2.1 percent. “What do we have? Zero.”
For mitral valve work, the benchmark mortality is 1 percent and Lankenau has zero.
“We have a decreasing mortality rate overall and for individual procedures we have a lower mortality compared to the STS (Society for Thoracic Surgery), which is the benchmark,” he says. “We strive continuously to have the benchmark lowered.
For example, the STS coronary bypass benchmark is 4.9. Lankenau has 2.9 percent.
For stroke rates after aortic surgery, the STS benchmark is 3.8 percent. Lankenau has .6 percent.
Kidney problems following surgery, the STS benchmark is 4.3 percent. Lankenau has 1.4 percent.
“To a degree all this has to do with the fact we do minimally invasive surgery. It’s affecting the outcomes,” he says. “Not only the aorta, you have it in the coronary, everywhere you see our numbers, you see the same kind of response.”
Lankenau also ranks high on the national scorecard for the quality rating of different hospitals in the Greater Philadelphia area.
“Our score is 99 percentile,” he says. “In terms of quality, mortality, complications, patient quality, patient safety, we are better than 90 percent of everybody.”
“I want to make sure that everyone in the community knows that Lankenau is the best place to go for aortic surgery, cardiac surgery in general. I want to make sure everybody knows about aortic surgery and I want to put it out there that we are the place where you’ll have not only the best outcomes for aortic surgery, but in the most minimally invasive way, which is a significant improvement compared to the maximum invasive way.”