Live Web Chat Transcript:
Minimally Invasive and Robotic Assisted Heart Surgery - June 20, 2007

Tomislav Mihaljevic, M.D.
Cleveland Clinic Heart and Vascular Institute Surgeon
Cleveland Clinic Department of Thoracic and Cardiovascular Surgery

Cleveland_Clinic_Host: Dr. Mihaljevic was unable to attend the chat due to a complicated surgery, however he did answer your questions below.

Minimally Invasive Heart Surgery

carriemom: Can a tricuspid valve be fixed? Minimally invasive surgery options?

deckcards: If you have minimally invasive surgery and you need surgery again, can you have it minimally invasive the second time?

Dr. Mihaljevic: Patients who had minimally invasive approaches are particularly suitable for repeated minimally invasive surgery if reoperation is indicated. The decision about the best possible approach for reoperation needs to be individualized.

floridasun: I was treated for endocarditis. Now my doctor said I need an aortic valve replacement. I have two concerns. 1. I don't want to be on a blood thinner the rest of my life. 2. I want minimally invasive surgery. What are my options?

Dr. Mihaljevic: Aortic valve replacement in patients with endocarditis can be performed using minimally invasive approach with the use of biological prosthesis, so that you would not need to be on the blood thinners for the rest of your life. Whether you would be candidate for this approach would need to be determined after the detailed review of your records.

Bob72: How long does it take to recover after minimally invasive valve surgery. How much time do I need to take off of work?

Dr. Mihaljevic: Depending on the type of minimally invasive surgery the length of stay in the hospital ranges from 3-5 days. Most patients return to work within 2-4 weeks, depending on their age, overall condition and the type of work they do

richmond: Is it possible to have minimally invasive surgery when two valves need to be fixed?

Dr. Mihaljevic: Minimally invasive approaches are possible even when two or three valves need to be repaired or replaced. The final decision about the suitability of minimally invasive approaches for multivalve surgery can be made only after detailed review of the records.

lizfrompa: I had breast cancer several years ago and have had radiation. I need to have a valve fixed. Can I have minimally invasive surgery?

Dr. Mihaljevic: Minimally invasive approaches are particularly suitable for patients who had previous breast surgery and radiation, since minimally invasive approaches reduce the risk of local wound complications which are common in such circumstances.

mikecal: I had successful minimally evasive Mitral valve surgery in March 05. In Oct 05 echo revealed the surgery reversed with severe regurgitation. Quarterly echo’s and stress tests since indicate regurgitation remains severe, but all heart and atrium measurements remain in safe range. It appears the Medtronic Future Band has fractured. I remain A-Symptomatic. I am 61 years old. What test will more precisely indicate a fracture or other problem? Can a re- repair be done with a more stable device, or is a replacement recommended? Can it be done minimally evasive as before? What device is most effective if a re-repair is performed?

Dr. Mihaljevic: Recurrent mitral regurgitation after initially successful mitral valve repair is a rare phenomenon, that occurs in less than 10% of patients operated in large centers. Fractures of anuloplasty rings are particularly uncommon, and they most commonly occur during surgery. Re-repairs are possible, and can be accomplished in 50 - 70% of patients. The likelihood of re-repair is greater if operation is performed soon after initial surgery, before extensive scarring of the repaired mitral valve leaflets occurs. The operation can be done using minimally invasive approach. However, the choice of the optimal approach should be made after detailed review of the records, and it mostly depends upon the type of the approach that was used at the first operation.

Robotically Assisted Heart Surgery

Patrick: I need mitral valve surgery in the near future. On your website there are many approaches to heart surgery - minimally invasive incisions and robotic. What is the risks or benefits of each - they all say smaller incision? How do you know what is best for you?

Dr. Mihaljevic: There are many choices for minimally invasive approach in mitral valve surgery. The decision of the most appropriate approach is made after detailed review of the case and discussion with the patients. Robotically assisted mitral valve repair represents the least invasive form of mitral valve surgery, since it allows repair of the mitral valve through the smallest incision. Incision is made at the side of the chest, so that breast bone does not need to be divided. The spreading of the ribs is minimal (as compared with non-robotic operations through the side of the chest) which results in less discomfort after surgery. Essentially all patients with mitral valve prolapse can be considered for this type of surgery. The next most common alternative includes partial sternotomy during which the upper part of the breast bone is divided

Frank: I had heart surgery three years ago for bypass surgery. Now I need a mitral valve repair. I was told I may not be a candidate for minimally invasive surgery. If the robot incision is in a different place, why can't I have that type of surgery? Can I have robotic surgery?

Dr. Mihaljevic: You could be a candidate for minimally invasive robotically assisted mitral valve surgery. This operation can be performed through a small incision at the side of the chest, therefore avoiding repeated entry through the previous incision on the breastbone. Whether you would be candidate for this approach would need to be determined after the detailed review of your records.

Jennymae: have a PFO and it needs repaired. What is the difference between a closure device with a catheter and the robot approach. Are there different outcomes?

Dr. Mihaljevic: PFO can be closed using both methods. Closure of the PFO using the device is effective, however it results in potential (although small) risk of blood clot formation with subsequent risk of stroke. Robotically assisted minimally invasive closure of PFO avoids this risk, but is more invasive and requires 2-3 days of hospital stay. There have been no studies comparing the risks of two procedures.

DavidK: Is robotic mitral valve repair a successful procedure? Is it possible to do on an 81 year old man? Does the heart stop during the procedure?

Nancy: If someone has heart failure is there a type of valve surgery procedure that is better? Is robotic surgery or a smaller incision more helpful if someone has poor heart function? I am looking for my dad. He is 75 and has heart failure. He needs a mitral valve replacement.

JillMayock: Dr. Mihaljevic, Can you please address your outcomes for your robotic surgeries?

Dr. Mihaljevic: Our outcomes in robotic surgery have been very good. Our robotic program has in mitral valve surgery has started 8 months ago. We have used robotic surgery mostly in patients requiring mitral valve repair (approximately 40 patients). We have been able to repair the valve successfully in all of our patients. We have not had any major complications (such as stroke or heart attack) in any of our patients. Minor complications (bleeding) occurred in 3 patients. Average length of stay in the hospital is 4 days. We have also used robotic approach for mitral valve replacement, bypass surgery, ASD closure etc.

brenda: My mom needs surgery for valve and atrial fibrillation. Can she use the robot to do this? How long would she be in the hospital. Will she need help when she gets home? We are trying to plan.

Dr. Mihaljevic: Your mom is definitely a candidate for robotically assisted mitral valve surgery, which can be combined with Maze procedure for atrial fibrillation. The length of hospital stay after surgery averages 3-5 days. At the discharge from hospital most patients can take care of themselves independently, and they require minimal help when they come home. Small incisions at the side of the chest allows fast recovery and faster return to regular activities.

matthew82: My dad has triple vessel disease. He needs bypass surgery. Are there minimally invasive options for him? He doesn't want his chest opened up.

Dr. Mihaljevic: They are very limited options for minimally invasive surgery in patient who require bypass surgery on several coronary arteries. One of the possibilities is to combine stent treatment to the less diseased vessels with robotically-assisted bypass surgery to the main coronary arteries. This is called a hybrid approach.

Smdottie 12: Can robotic surgery for mitral valve be combined with the MAZE procedure?

Dr. Mihaljevic: Robotic surgery for mitral valve can be combined with MAZE procedure, and we have done it in several cases. Surgery can be done with the minimal risk (mortality risk of less than 0.1%). Repair can be accomplished in more than 95% of cases, which represents a life-long solution for majority of patients. Minimally invasive robotically assisted operation is performed through the small incision on the side of the chest, without the splitting of the breast bone. Most patients stay in hospital for 3-4 days after surgery, with full return to normal activities within 2-3 weeks. Quality of mitral valve repair using robotic approach is identical to that of "standard" open procedures. MAZE procedure does not add to the risk of the surgery.

jason77: What is robtically assisted surgery?

Dr. Mihaljevic: Robotically assisted surgery is the minimally invasive approach in surgery which uses specially designed robotic instruments and a sophisticated camera equipment. This approach allows us to perform complex operations through the very small incision, avoiding the need to divide the breast bone.

jason77: Can a patient with defibrillator device or pacemaker have robotically assisted surgery?

Dr. Mihaljevic: Patients who have pacemakers or defibrillators can have robotically assisted surgery.

patrick12: How does the surgeon keep control of the operation if they are sitting across the room for the robotic surgery?

Dr. Mihaljevic: Although the surgeon sits at the consol in the corner of the room he controls the movement of the robotic system in the same way that he controls the movement of regular instruments during standard heart operations. Surgeon, therefore never loses control over the operation. In an unusual case that would require conversion from robotic to standard operation, robotic instruments can be removed with seconds, and operation can be continued using the standard way. Bedside surgeon is in standing contact with the operating surgeon.

bernardm: Can a patient with a pacemaker have robotically assisted surgery?

Dr. Mihaljevic: Patients who have pacemakers or defibrillators can have robotically assisted surgery.

geraldine: Are there different risks to minimally invasive heart surgery compared to traditional heart surgery?

Dr. Mihaljevic: Robotically assisted surgery carries similar risk as any other cardiac surgery, irrespective of the type of incision. These risks seem to be lower, due to decreased invasiveness of the procedure.

Mitral Valve Surgery

Glenwood 2: I was diagnosed a year ago with mitral valve prolapse with medium to severe reguritation...More than one cardiologist say that I will need either a repair or replacement in the near future but do not want to do it now..but then on the other hand, they also say that I should do before I have any other health problems. So, I am at a lost as to when to do the surgery..They ask me if I am out of breath which at times I am but can do the treadmill when I go for my echo stress. I am being checked every six month..My question is, do I alone decide when I should do the surgery or wait until I have increased symptoms and if by waiting, can the valve go from repair to replacement?

Dr. Mihaljevic: Mitral valve prolapse is a common disease of the mitral valve which can be repaired using robotically-assisted minimally invasive cardiac surgery. Presence of severe leakage of the mitral valve (severe mitral insufficiency) represents indication for surgery in most patients, even if no symptoms are present. Severe leakage of the mitral valve represents a condition which, if left untreated always progresses to the heart failure. Surgery can be done with the minimal risk (mortality risk of less than 0.1%). Repair can be accomplished in more than 95% of cases, which represents a life-long solution for majority of patients. Minimally invasive robotically assisted operation is performed through the small incision on the side of the chest, without the splitting of the breast bone. Most patients stay in hospital for 3-4 days after surgery, with full return to normal activities within 2-3 weeks.

tammys: I have a mitral valve prolapse, recently I went to the doctor for a lot of symptoms. He said I need surgery, what is the outcome of that surgery? Will I need it again or will that cure me?

Dr. Mihaljevic: Mitral valve prolapse is a common disease of the mitral valve which can be repaired using robotically-assisted minimally invasive cardiac surgery. Presence of severe leakage of the mitral valve (severe mitral insufficiency) represents indication for surgery in most patients, even if no symptoms are present. Severe leakage of the mitral valve represents a condition which, if left untreated always progresses to the heart failure. Surgery can be done with the minimal risk (mortality risk of less than 0.1%). Repair can be accomplished in more than 95% of cases, which represents a life-long solution for majority of patients. Minimally invasive robotically assisted operation is performed through the small incision on the side of the chest, without the splitting of the breast bone. Most patients stay in hospital for 3-4 days after surgery, with full return to normal activities within 2-3 weeks.

Aortic Valve Surgery

Robertl: I am 28 years old. I have a bicuspid aortic valve. Can I repair the valve without a replacement. Can you do this without surgery?

Dr. Mihaljevic: Bicuspid aortic valve can be repaired. However the repair needs to be done surgically. Repairs are indicated in patients with severe leakage of the aortic valve, and in most cases can be done with minimal risk (less than 1% mortality risk) using minimally invasive surgical approach.

Myxoma

nevadatg: What is a myxoma? What makes it grow inside the heart? What type of surgery can cure that?

Dr. Mihaljevic: Myxoma is benign tumor of the heart. Most frequently it occurs in the left atrium. Removal of the tumor is a definite treatment, and the operation can be done using a robotically assisted minimally invasive approach through the small (4-5 cm) long incision at the right side of the chest. Risk of surgery is minimal, with average length of stay in the hospital of 3-4 days.

General Heart Surgery

john76: Can your body reject a new heart valve?

Dr. Mihaljevic: Your body can not reject a new valve. Biological valves (cow or pig valves) are processed in a special way, so that our body does not recognize animal tissue as a foreign object. Biological valves have been in use for decades without a single reported case of rejection

worriedwife: My husband had heart surgery about 4 months ago. He doesn't seem the same. I heard of changes in people like depression. I read about neurocognitive dysfunction after heart surgery. How is that diagnosed? Is there a treatment?

Dr. Mihaljevic: Depression after any kind of major surgery is fairly common, in particular in patients who are otherwise fairly ill. There are number of treatments available, including medical treatment, physical therapy, psychological therapy etc. The most appropriate treatment should be chosen in conjunction with your husband's primary physician.

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