Robotic and Minimally Invasive Heart Surgery: Expert Q&A

Mitral valve repair and coronary artery bypass surgery are procedures generally performed through open heart surgery, which requires the chest to be cracked open. Now, using robotic devices, sophisticated thin instruments, miniature cameras, and hybrid techniques, surgeons at UChicago Medicine are able to repair the heart without having to make a long incision and cut through the breastbone. This approach is only available at innovative and highly specialized cardiac centers. Dr. Husam Balkhy, a pioneer in the field, will join us to discuss the benefits of robotic and minimally invasive heart surgery. You'll also hear from a couple of patients and your questions will be answered, coming up right now on At the Forefront Live.

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And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Dr. Balkhy, we're going to start off, first of all, welcome to the program. You've been on before. It's a delight to have you back.

Thanks, Tim. It's great to be with you.

So let's just start off with having you kind of introduce yourself to our viewers and tell us a little bit about what you do here at UChicago Medicine, because you have a very unique area of expertise.

Yes, that's for sure. So I'm the director of the Robotic and Minimally Invasive Cardiac Surgery Program here at the University of Chicago Medicine. And we specialize basically in doing heart surgery in the least invasive way. And the unique thing about our program here at the University of Chicago Medicine is that it's extremely comprehensive in terms of the different types of cardiac surgeries that we perform with a totally endoscopic robotic approach, meaning little holes, the largest of which is about 12 to 15 millimeters in size. That's less than half an inch. And the way we're able to do that is basically by leveraging some advanced technological aspects of robotics and wristed instruments. And we can get into a little bit of about the different types of procedures that we do using that technology.

Absolutely. And we're very fortunate today, we've got a couple of patients that are going to be joining us throughout the program. We want to remind our viewers, if you have any questions for Dr. Balkhy or one of our patients, just drop them in the comments section. We'll try to get to as many as possible over the next half hour. Let's start off with just kind of a-- you gave us a real brief explanation of what you do, and we have a graphic that I want to run and have you kind of talk us through, Dr. Balkhy, if you can. So let's do that if we can now, John, bring up the graphic and have Dr. Balkhy kind of talk us through what we're seeing here. The one side, we have kind of the traditional open heart surgery, and then the other side, it looks like what you do.

Yes, exactly. And this is a very kind of rough schematic as to what things look like, but on the left, there's a picture of a heart, which is being exposed using a long incision through the breastbone. The breastbone is actually sawed with a saw. If anybody's gone through that procedure, they know what that feels like. And usually, the whole breastbone is opened with the saw, and then a metal retractor is placed and spread apart, as you can see here, to show the heart. And then the surgery happens on to the heart.

On the right-hand picture, on the other hand, is a picture of a heart that is not fully exposed. You can see it's kind of covered. And the sternum is fully intact. And the instruments that are operating on the heart are coming in from these small little ports on the right side there. And things are reversed when we look at images of the human body, so these are actually ports coming into the patient's left chest cavity through the left ribs. So in between the ribs, there are these small little ports that I mentioned.

One of them has a camera, and the other three have arms that are fitted with the different instruments. And so we're able to do the surgery because of the dexterity of the arms and the high definition and magnified view of the camera. That's really what it boils down to. And so in this case, the camera and the arms are coming in from the left side. We operate on the coronaries through this approach, and we do coronary bypass procedures. You'll meet a patient today that had that operation.

And in the other types of procedures, sometimes we'll come in from the right side, which is opposite to what you're seeing on this image. And the most important thing to note, if you're the patient, is the two time frames on the bottom of each of these panels. On the left-hand side, you see that the time in hospital is about five to seven days, and the time to return to normal activities and work can be as long as six months. On the other hand, if you don't have your chest cut open and you have an early recovery mindset, then basically you're in the hospital for sometimes one day, but anywhere from one to three days, and then you'll return to work, as you'll see in the patient conversations that we're about to have, you can return to a physical job within two to four weeks, usually, because there's really no restrictions.

It's just amazing, the technology and the work that you do. I was fortunate enough to actually get to view one of your surgeries at one point in time. You were nice enough to invite me in the OR, and I got to kind of watch you at work and what you were doing. And it just is really incredible. And John, I guess we could roll a little bit of that surgery, and maybe Dr. Balkhy could even talk to us a little bit about what we're seeing here, if we can. But it's pretty amazing.

Yeah, so this is probably-- OK, so this is footage from the outside of the patient's chest. And you just saw the instruments there. This is us moving the console controllers, if you will, these are the masters of the instruments that are inside the chest. So every move that I make underneath that console-- so that's me sitting at the console, away from the patient. Every move that we make is registered and translated into a similar minute, if you will, and very accurate move inside the patient's chest.

And what I'm looking into here, I'm immersing myself into a 3D view of inside of the patient's chest. And obviously, if the camera was in the abdomen, it would be the abdomen. Wherever the camera's positioned is what I'm seeing. And I'm moving these quote unquote joysticks, some call them, to effect the movement on the arms. And I have an assistant or two at the table who are responsible for exchanging those robotic arms and/or troubleshooting if there's any issues there.

Yeah, I tell you, the video doesn't even do it justice. You were nice enough to let me look through the other side of the robot, too. And the three-dimensional effect that you talk about, and just the dexterity and the skill that obviously you have to be able to do what you do is just stunning. I do want to bring in one of our patients. And this is David Nicholson, who was kind enough to agree to join us today and talk to us a little bit about his situation. David, welcome. You look great, first of all.

Thank you. Good to be here.

And David, we were talking before the program, you just had your procedure just days ago, right?

It was February 2nd, the day after my 60th birthday.

That's great. Tell us a little bit about your situation. First of all, why did you come to see Dr. Balkhy? What did you need to have done, and how did you find Dr. Balkhy?

I had no symptoms whatsoever, but there's a family history, my dad had a double bypass when he was 64. And so due to family history, my doctor said we should go take a look at some things. And so I went through a series of tests, the calcium tests, the heart scan. And eventually, they ended up saying I got a 75% blockage. And they immediately scheduled for three days later a triple bypass. And I asked them to slow that down a little bit, and I went online and googled alternatives to chest hacking for cardio surgery. And interestingly, Dr. Balkhy's name popped up at University of Chicago. And that launched me into the conversation.

That's great. And so you came here for the procedure. Kind of walk us through the process. How long were you actually in the hospital? And then I think the most impressive part is tell us after you got out of the hospital what you did, and how soon you did it.

Yeah, it was truly amazing to me. I was scheduled for February 23rd, but I told him, if anything came up earlier, please let me know. And they ended up calling me several days later, says we got an opening on Tuesday the 2nd of February. If you want it, it's yours. And so I cleared the decks. I checked in at 5:30 AM on Tuesday, February 2nd. They did the surgery a couple hours later.

I checked out on Thursday morning with an all clear, no restrictions. And the people wheeling me out basically said, if you want to lift weights tonight or shovel snow when you feel like it, feel free. You're good to go. I will say, I didn't feel like shoveling snow that evening, and I did not, but I was back at work on Friday morning. Now, granted, I don't haul bricks for a living, I work at a desk, but I worked a full day on Friday. I felt great. And I was off pain meds completely within three days.

So two points you have to make about that. I don't think I ever feel like shoveling snow, and Dr. Balkhy may not suggest that you go out and shovel snow the day of, I would imagine. But you look great, and clearly this has been a tremendous advantage to you. Dr. Balkhy, can you talk to us a little bit-- this is something also that I thought was quite interesting before we started. A lot of times, when you were saying that people will tell people that they had this procedure done or a procedure done, and they think that they're mistaken, that it must have been something much more minor. Can you talk to us a little bit about that?

Yeah, absolutely. Yeah, that's happened on occasion for some of our patients, where they are told by family and friends that you really don't understand, you did not have surgery, you had a stent, because you look too good, you're able to move around, there's no restrictions, you have a full ability to do whatever you want physically. And so we have to clarify to them yet, yes, indeed, they did have the surgery, but we didn't open their chest.

And that's kind of the big deal here, is that the restrictions that we put on patients after open heart surgery are not because of what we do inside the level of the heart, it's because of this cracking of the breastbone that has to then get put back together with wires, and sometimes now we're using plates, actually, when we put them back together because, technically, it's a fracture. So the majority of the patients, especially at our hospital here, that get a sternal opening will get it put back together with plates and screws. And that does tend to bring down the time of recovery a little bit compared to the wires, but not as much as if you leave it intact. And so that's kind of the reason for restrictions after surgery.

Now, I did promise that we would get to viewer questions, so I'm going to get to a couple of those, and then we'll kind of rejoin the conversation with David here in just a moment. One of the viewer questions we just received, "I have minimal mitral valve regurgitation. At what point does it become a problem?" And I guess probably the question would be, when would they come to see you?

Yeah. So good question, and the answer is when it becomes severe. There's good data to tell us that, even if you have no symptoms, your cardiologist will be following you with a yearly echo. And once that mitral valve leak becomes severe-- there's four grades of mitral valve leakage, grade one, two, three, and four. You probably have one or two at this point, which is what we call mild to moderate. And then once it becomes severe, regardless of symptoms, surgery is recommended to fix that problem so that you can get back to being on a normal curve of survival based on heart function. And so that's kind of been shown in multiple longitudinal studies, that if we catch it even before the symptoms start, then it will not have a long-term effect on you.

So Dr. Balkhy, how did you get started on this? Was there just a time years ago where you thought to yourself, there's got to be a better way?

Yeah. I mean, I tell the story a lot, is that I trained to do heart surgery the normal way. Take a saw, open the chest, and the bigger the incision, the better the surgeon is, what we used to say, because big cuts mean that you have all this exposure and you can do whatever you want. And that's me operating on somebody close by on the chest, I guess. I'm not sure if we're opening the chest, but it's something that I did for a long time.

But every time I opened somebody's chest, there was a nagging feeling of are we causing harm that we can avoid causing by doing this. And so my goal in life was to try to find minimally invasive ways to do the same thing that we were doing with the open procedure. And we eventually kind of found our way to the robot. It took me about seven or eight years of doing less invasive sternal-sparing non-robotic surgery until I got my hands on a robot around 2006.

And ever since, I've been gradually increasing the number of procedures that I do with the robot, and gradually decreasing the number of procedures I do with the sternotomy. And for the last, I would say, five years my practice has been pretty much fully robotic. Maybe even a little bit longer. But that's kind of my passion.

And I think it takes dedication, it takes a team, it takes somebody who does it every day. And so I get a lot of questions of, should I ask my surgeon to do the surgery with the robot or do it without opening my chest? And the answer is absolutely not. If you're happy with your surgeon, you're happy with your physician, you do the surgery the way the surgeon is trained and expert at doing it. And that's what will lead to the best outcome.

That brings me to my next question for David. You know, David, we were talking to you before the show, and you were talking about advocating for yourself and doing research. And clearly, that was important to you. What would you tell somebody that's facing a procedure like you faced?

You know, I think that in every industry, when big changes come along, there's a tendency for people who have been established to want to keep doing it the way that they've always done, and not be as open to learning new things and leaping into new technologies. And so what I've kind of discovered here is that, in the absence of me being an advocate for myself and doing the research and looking for those other alternatives, it's going to be really hard for me to find a referral to someone like Dr. Balkhy. And I mean, I found an article from 2006 where Dr. Balkhy was quoted extensively saying the technology is here, but the humans aren't ready for it yet. The doctors haven't jumped in and embraced it yet. And obviously, from that point on, he jumped in full force.

I would say to anybody who's been told that they have this kind of issue, go start doing the research. Have the conversation with your cardiologist. Have it with Dr. Balkhy, and figure out what's best for you. But this seems, in a lot of cases, like a no-brainer. With the recovery being what it is, the risks being so much lower, I love it. I think it's great.

We do have a few sound bites with another patient, Lorenz. And John, let's play that first one, where he talks about how he found Dr. Balkhy, and how that worked for him.

I'm a law enforcement officer, and every year, I take a physical test. You know, running, bench press, sit-ups, just a general test to see your physical fitness each year. And about a year and a half ago, I started struggling with the breathing part, where I was having trouble recovering. I felt it was an issue. I passed the test, but then went to visit my cardiologist, and he put me through a battery of exams and procedures and determined that I had a leaky valve that didn't need attention right now, but it needed monitoring.

Then this year right now that we're in, 2020, I went for a recheck in January. And at that time, my cardiologist told me it's time to look into surgery, I need. It was at that point where I needed attention on it. And I had an option of choosing a surgeon. And one thing that scared me about the procedure was it's been historically open heart surgery. And still being active in my career, it kind of scared me a little bit.

So my wife and I were looking into options and trying to research. And then this year, on my actual birthday, there was a wraparound section on the Chicago Tribune that spoke with and was described by Dr. Balkhy and his robotic procedure for the actual surgery I needed. Seemed like a sign to both of us that, on my birthday, what I actually needed at this time. So we decided we were going to be contacting Dr. Balkhy and go through this procedure.

That's great. So a couple more viewer questions, Dr. Balkhy, this one from a viewer asking, "are there restrictions to which patients can undergo robotic heart surgery?" I guess if there are certain restrictions where they cannot do it, I suppose.

Yeah, no, that's a good question. And I'll just comment on Mr. Burkert's clip there. It's important to note that Mr. Burkert had a different operation than Mr. Nicholson. And that's one of the very unique things about our program, is that we do totally endoscopic surgery on multiple indications in the heart. So what Mr. Nicholson, David here had was a coronary bypass procedure, which we specialize in. And there are really not too many centers worldwide that do a total endoscopic approach, as we do.

But also, in Mr. Burkert's case, his mitral valve was problematic. And that's an operation that there are a couple of centers in the US that do robotic mitral valve surgery, and that's still growing, but it turns out that the robotic approach is probably the best approach to look at the mitral valve. And Mr. Burkert had a very complex valve. He had two leaflets that were-- or both leaflets of the valve that were collapsing and sick. And we ended up repairing it, doing a complex mitral valve repair with eight neo cords, and then putting a ring around it. And he had a perfect result.

And I don't know if you're going to be able to play some clips afterwards of his talking about his post-operative recovery, but we ended up doing a very complex repair that I think a lot of patients who have mitral valve surgery through a sternotomy, the vision, the view of the valve is not as good as what you get with the robotic approach. And those patients will have what we know in heart surgery is an inferior operation. And that is a replacement.

So if you have a mitral valve that leaks, your best bet for long-term survival and long-term efficacy is to have a repair. And the only way to get a 95% repair rate is to go to a place that does a lot of repair. And in my view, and many of us who operate using scopes and through the right chest, getting a view from that side is the best way to view all of the components of the mitral valve.

Now, talking about people who are not candidates for robotic surgery, in my mind, there's not too many. You can't do a heart transplant through the robot, and you can't today put in a ventricular assist device robotically. But every other cardiac pathology I think is to be considered. And there are patients who, for example, need three valves and six bypasses.

To do that robotically would take a very, very long time, and we don't advocate for that. But I don't think that the decision on what type of surgery should be done is final. And what I mean by that is, if you are told that you need to have six bypasses and a valve, the reason that we do six bypasses many a time is because we're under the hood, and you really don't need to have six bypasses.

Some patients will come in, and they'll have two valves or they'll have a valve and a coronary problem. We can treat the coronary with stents, and we can do the valve without opening your chest. So I guess what I'm trying to relay is the fact that, when you have a minimally invasive mindset, there are things that you can do in collaboration with other colleagues in cardiology that will, quote unquote, spare the sternum. And we belong to what I jokingly refer to as the sternal-sparing society of the world. I think I'm the president of the sternal-sparing society, at this point.

That's great. So talking about recovery, you mentioned Lorenz's recovery. We do have a sound bite that we're going to play. And then David, I also want to hear a little bit about your recovery and the pain associated with this kind of procedure. Let's go ahead and play Lorenz's recovery sound bite right now, John, and then we'll come back and I'll ask that of David.

I feel great. Able to work out. I literally-- well, here, I actually-- after I went full-duty, I actually ended up getting a new career offer, still in law enforcement. So I retired from the department I was at, and now I'm an investigator for county government. And in that meantime, I literally cut down seven trees and removed seven stumps manually, which couldn't be done with the way my heart was. And now it's like that, it's incredible. I mean, I have done some serious physically intensive work, and am able to complete it.

The recovery time, the pain management time, I literally wasn't taking any pain medicine after the second day. I didn't need it. It's an incredible surgery. The pain goes away quick. Your recovery is fast. Again, like I said, the scarring, there's some scars, but it's not like, oh, you were opened up. It's just a couple of marks on the side of my chest. I would definitely recommend it. Young or old, whoever needed it, this is the way to go to live a normal life and have a great quality of life.

That's great. And David, could you talk to us a little bit about issues with pain and how significant that was?

Yeah. Obviously, coming out of sedation, out of the surgery is never fun. You know, you've been in a significant trauma to your body. University of Chicago did a great job with pain management relief for me over that first 12 hours. But once that was done, during the daytime, it's almost immediately at the hospital, I wasn't on pain medicine. They had me back on at night, but during the days, I was fine. As soon as I got home, within a couple of days, I also was off the pain medicines all together. Again, only took it at night for a couple of nights, and then I was done. I've been amazed at the recovery period.

Last weekend, I was on stage with my bass playing for an hour and a half. I'm scheduled to play in a Frisbee golf tournament with my son on the 28th, and I'm all ready for that. Been outside, you know, walking, doing the treadmill inside, lifting weights again. So the recovery has been great, and there really is no residual pain. Obviously, as the other gentleman said, there are some holes, but those are healing relatively quickly. And there's nothing that stops mobility or from doing anything that I want to do. So it's really been great.

The other thing I would throw in there is that the other cardiologist, based upon the angiogram, wanted to do a triple bypass. And what Dr. Balkhy had said is, well, once we're able to take a look at those. And what he discovered when he was in is that the second one wasn't needed at all, and the third one was a maybe we'll talk about something like a stent later. So it's wonderful for him to be able to get in there and see what's really going on, and not have to go in and do a whole lot more than is really necessary. So I think that saved some pain and recovery time, as well.

And Dr. Balkhy, can you talk about that a little bit? Just when you are looking inside of a person like that, that really gives you, when you're using the robot, a unique vantage point to really see what's actually wrong, if there's more that potentially is wrong. Do you find things when you're in there?

Sometimes we do. Sometimes we find masses or tumors that have to be addressed. Recently, we had to resect something from somebody's lung tissue because we were right there. But in terms of understanding the pathology of, say, a mitral valve, I feel that the robotic scope really does allow us to analyze the valve and do the different types of maneuvers for repair significantly better than the naked eye.

The naked eye in surgery is magnified about two and a half to three and a half times with the special loops that we wear on our glasses when we're doing traditional open heart surgery. The robotic magnification, on the other hand, is 10 to 12 times. And so you can bring that camera all the way up to the structure, and you can look at it very carefully, analyze everything, and get a really, really granular view of the tissue that you're talking about, that you're dealing with.

In terms of what David was saying regarding the number of bypasses, I think that's a very, very important issue to bring up because we make those decisions by looking at the angiogram and deciding what arteries are really, really necessary to get bypass, and is it justifiable to crack somebody's chest to do a small little branch of an artery or to do an artery that's only about 40% blocked, which is what we end up doing when we crack somebody's chest. When I take a saw to somebody's breastbone and cut it in half, by golly, I'm going to do the twig branch, I'm going to do a 40%, I'm going to do everything because I'm under the hood. And if I don't have to be under the hood, then you do only what's necessary, and you do only what the patient really needs.

And so in David's case, he needed a graft to his anterior blood vessel, the one in the front, which is the most important one on the heart. And he got a nice bypass. It's strong. His other artery, which is major, only had about a 40%, 50% blockage. That one, we're going to follow. We're in touch with his cardiologist. And so if he needs to have that one stented, it will be stented in the future. If he doesn't, then he doesn't. And that's the kind of customization, the tailoring of the therapy that we do, not only for each patient, but for each coronary artery. And that's just in the coronary realm. So that's just two examples of the expertise that you can get by using this type of technology for the different aspects of cardiac surgery.

We're about out of time, Dr. Balkhy. There's one more question I wanted to get to with you, though, because I think there are a lot of people that have probably had surgery in the past. If you've had open heart surgery, can you have robotic heart surgery in the future?

Yes. Yes, absolutely. When you're at an experienced center like University of Chicago Medicine, and the team is facile with the robot and we do it every day and it's not a novelty, then we take on redos, which means somebody who's had previous surgery, we take on frail patients, we take on obese patients, which are actually harmed more than others by having their sternum cut open, we take on patients who have complications like diabetes sometimes, and end-stage renal disease on dialysis. These are the types of patients that you don't do with the robot when you're first embarking on it. Your first 50 or 100 patients cannot be of that. But now that we're close to up to 2,000-- this is in my own experience, and at the U of C, I think we're up to 1,200, or getting there-- we're very facile with doing these things.

I just want to add one more thing, Tim, if I can, before you sign us off, is that this return to work and the lack of using opioids that both David and Lorenz described is something that we see in our patients. We just presented a paper at the CSC, the annual cardiac surgery annual meeting, national meeting. And we showed, in 600 patients who underwent the same operation that David went, we showed that the return to work, on average, was about 14 days.

This is a return to full activity and return to work. And we also found that fully a third of the patients that have the surgery do not fill their prescription for pain medication after they leave the hospital in one or two days, sometimes three days. And then by 7 days, about 3/4 of the patients are not taking pain medications anymore. So it's real. And I think the two experiences that we heard today really reflect that.

Well, we are out of time. Dr. Balkhy, thank you very much for sharing your expertise and time with us. I know you're in demand, you're a busy guy, it's tough to book you, but we really appreciate you doing this. And David, thank you for joining us, because you have a wonderful story. I'm glad things are going so well with you, and have to listen to your band someday.

Thank you both very much. Dr. Balkhy, amazing stuff. Appreciate everything you do.

Thank you.

This is great. And to our viewers, please remember to check out our Facebook page for a schedule of programs that are coming up in the future. To make an appointment, go online at UChicagoMedicine.org, or you can give us a call at 888-824-0200. Thanks for being with us again today, and I hope everyone has a great weekend.

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