Atrial Fibrillation

  Atrial fibrillation is the most common sustained heart rhythm disturbance.  During this rhythm the atrial (upper chambers of the heart) are quivering instead of contracting (beating).  Roughly 6 million people are affected by this problem.  Patients with this rhythm have twice the risk of death and 7 times the risk of stroke compared to people in normal sinus rhythm. Since the atria are responsible for about 10% of the heart's output many people notice a significant drop in their energy levels when this occurs.  One key risk of this rhythm is that since the atrial are not beating,  the blood flow thru these chambers can be sluggish allowing clots to form.  These can then be ejected into the circulation causing occlusion of vessels to the brain (with subsequent stroke) or other organs.  Atrial fibrillation can be intermittent or continuous.  

      Initial treatment is aimed at controlling the heart rate (since it can commonly reach 150 or higher) and thinning the blood to avoid clot formation.  In situations where patients are either intolerant of medical therapy, the medicines are not effective or they continue to be symptomatic, invasive treatment to reverse this rhythm may be indicated.

     Dr James Cox developed an operation known as the Cox Maze procedure.  This ingenious operation was carefully designed to form a series of scars in the heart to re-route the electrical signals into a more controlled and regular pattern.  Although quite complex in its original design a modified method has been successful in treating many patients with intermittent atrial fibrillation.  Additionally the full Cox Maze III procedure can now be performed thru minimally invasive approaches for many patients.

Angina (Chest pain)

Angina: officially Angina Pectoris, from latin and greek meaning 'squeezing of the chest'.  Chest pain characteristic of ischemia (lack of blood and oxygen) to the heart muscle.  Frequently described as a tightness in the mid chest with radiation to the arm or neck.  The actual symptoms can vary  widely, and in fact many people (especially diabetics) can have 'silent' angina and have ischemia or even a heart attack and just feel 'bad', with no specific chest discomfort.  Angina is most often caused by a narrowing in one or more of the coronary arteries.  These vessels supply the blood to the heart muscle itself.  Prolonged lack of blood and oxygen to an area of heart muscle leads to the death of muscle cells (think permanent irreversible damage) = Heart Attack.

    Angina itself is not a heart attack.  The pain is usually relatively short in duration and with cessation of the inciting activity will subside and adequate perfusion to the involved heart muscle cells return.  Stable angina is characterized by a repeatable set of symptoms, typically chest discomfort that occurs with physical exertion and will be relievable with rest.  It may progress to occurring with less activity and in severe cases may even occur at rest or wake one from sleep.  Symptoms that are progressive are then referred to as "Unstable" angina.  Rest and especially nocturnal angina are most concerning since they frequently are characteristic of severe coronary artery disease.

      The important 'take away' is that any chest pain should not be ignored.  In the case of a heart attack "time is muscle' and the sooner attention is sought and perfusion restored to the heart muscle in jeopardy (via drugs or mechanical treatments) the less permanent damage occurs.

Minimally Invasive Heart Surgery

Most heart surgery is performed via an incision known as a 'median sternotomy'.  This incision splits the breast bone (sternum) longitudinally.  The main advantage is exposure.  The heart is entirely visible and the surgeon can literally get both hands around it.  A disadvantage is that the resulting two long strips of bone must, at the end of the procedure, be wired back together.  Bone is slow to heal and significant upper body activity must be strictly curtailed during the healing time, about 3 months.  This means no heavy lifting, pushing, pulling or reaching.  Therefore, no golf, tennis or swimming.  More importantly no work if your job entails lifting, painting, digging or hauling.  Thus, a manual laborer is out of work for about 3 months.  Now, considering that heart surgery is only done for serious, frequently life threatening, conditions, it is a price that must often be paid for the multiple and significant benefits.  Most patients do very well with this incision and it remains the standard approach today.

But.............what if we could achieve the same life saving, heart improving benefits via an approach that does not require the physical limitations post operatively?  This is the goal of minimally invasive approaches to heart repair.  The same work done on the inside, with, at least, equivalent results and safety, but with a mode of entry and exit that heals faster, with less pain and little to no physical activity restriction.

 A variety of approaches to heart surgery can be considered minimally invasive:

Mini sternotomy: this can entail an incision thru just the top or bottom of the breast bone, sometimes with a 'T' off to the right or left.  Advantage: smaller incision, half sternum remains intact.  Disadvantage: still requires bone healing, smaller field of vision.

Mini thoracotomy: an incision into the chest thru the space between two ribs. Advantage:much more rapid healing, minimal or no activity limitation, lower infection risk.  Disadvantage: smaller field of vision, limited access.

Endoscopic or thoracoscopic approach: utilizes small ports, usually 5-8mm incisions between the ribs, thru which a scope and a variety of instruments are passed. Advantage: scope increases field of view and magnification, very small incisions, rapid healing with minimally or no restriction, shorter hospital stay and recovery. Disadvantage: 2D vision, visual motor misalignment as surgeon is looking a scope away from operative field, instruments are long and not suited to very fine work.

Robotically assisted endoscopic approach: adds a powerful computer interface to enable introduction of wristed instruments, 3D vision magnified 10-15x, tremor elimination (tremor is exacerbated by long endoscopic instruments), motion scaling and hand eye alignment is restored compared to traditional endoscopic approach.  A variety of instruments and fine motion control make this amenable to fine reconstructive techniques.  Disadvantage: not available everywhere, longer procedure time.  Advantages: small port incisions, rapid healing, shorter hospital stay, rapid return to full activity, less infection risk.

      Each approach has advantages and disadvantages.  Some lend themselves to specific procedures more than others.  Aortic valve replacement surgery, for example, is not currently approachable via endoscopic or robotic approaches, but in many instances can be well suited for a small thoracotomy incision instead of the standard sternotomy.  Mitral valve repairs, atrial septal defect closure, maze procedures for atrial fibrillation and removal of left atrial myxomas can often be done via an endoscopic or robotic approach.  Some coronary bypass surgeries can be performed robotically or via a small thoracotomy.  The bottom line is, if you are in an elective situation and have the opportunity to do some research before a planned procedure, ask about all of your options.  A minimally invasive approach might be possible which could cut your hospital stay in half and allow you to return to full activity in as little as a week or two.

Participatory Medicine

For hundreds of years, the physician-patient relationship has seen the physician as the authoritative, sometimes dictatorial, healer — the unquestioned expert on care, protocols and medical regimens. The patient assumed the role of a passive receiver of information, taking orders and instruction from the doctor. Today, there is a movement afoot — one that is welcomed by me and many of my colleagues. It’s a change that I hope will become the norm when it comes to the physician-patient relationship. It’s all about partnerships between patient and provider.

Participatory medicine, as noted by the Society for Participatory Medicine (S4PM), is “a movement in which networked patients shift from being mere passengers to responsible drivers of their health and in which providers encourage and value them as full partners.” The society further states, “Participatory medicine is a model of cooperative health care that seeks to achieve active involvement by patients, professionals, caregivers, and others across the continuum of care on all issues related to an individual's health.” I encourage my colleagues and medical professionals across our region to embrace the participatory medicine movement.

My introduction to participatory medicine originated with Stanford University’s Medicine X conference. Medicine X is a Stanford School of Medicine initiative that explores how emerging technologies will advance the practice of medicine, improve health and empower patients to be active participants in their own care. This past fall, I was invited to speak there about the interconnected lives of patients and doctors. These interactions have inspired me to further pursue the concept of empowering patients as active participants in their own care. I believe that when health care providers empower patients to do so, we can achieve the best possible outcome for each individual. The participatory medicine movement can document these improved outcomes, such as reduced medical errors and increased patient satisfaction and empowerment in their health and wellness.

As a cardiac surgeon, I have become aware of how intimidating surgeons can be to many patients, because of both the high impact we have on their lives and the invasive nature of surgery, even minimally invasive surgeries. Because of this, many patients feel they cannot question me about their treatment plan or discuss information they have discovered while researching their heart condition. I have recently been part of a “flip the clinic” project, which endeavors to reimagine the medical encounter between patients and care providers (along the lines of Khan Academy’s “Flip the Classroom”). Included in this project are materials that help patients focus their questions during a visit so they can be sure their message is delivered. It also includes “knowledge” prescriptions as well as a “farmers market” prescription to aid in starting on a better diet.

Physicians and the entire medical team need to shift to a patient-centered focus and approach patient interaction with the goal of understanding what matters to each patient. Basically, we need to become much better listeners and teachers. A primary function of the physician should be to deliver the knowledge, resources and skills that will enable patients to make informed medical decisions, thereby empowering them to become active participants in determining their own outcomes. By playing central, meaningful roles in their medical care, patients are far more likely to establish — and accomplish — their health and wellness goals.

One great message I received at Medicine X was an encounter with an e-patient who was concerned that frequently she would leave a physician visit with the feeling that the doc did not “get it” regarding her fears and concerns. I now ask all my patients, at the end of our visits, “Did I get it? Did I successfully answer your questions and address your fears?” My hope is that they can now leave the appointment comfortable that all questions and concerns have been properly addressed.

I supply references, both text and web-based, all in an effort to help my patients become better informed and more active and engaged in their health. I also encourage our academic medical centers to embrace the participatory medicine movement and to introduce courses in medical schools to ensure the next generation of physicians enters practice knowing the benefits of forming partnerships with their patients in their health care journey.

Have Heart (havhrt)

   Welcome.  In this blog I will try to decipher some of the confusion and controversy in the world of heart care.  I will attempt to explain, in layman's terms, what some common conditions are and review some of the available treatments.  In addition I will try to pass on some relevant cardiac medical news updates.  I will be glad to answer some factual questions but, for obvious reasons, cannot dispense personal medical advice in a forum such as this.  In that line, nothing in this blog should be considered as medical advice simply an adjunct to understanding the often confusing world of medical care.

    Some times I will give you an insight to the world of my cardiac surgical practice, obviously without compromising any specific patient confidentialities.  And from time to time may share some of my other passions, such as photography.