At the Forefront Live: Robotic Heart Surgery
February 7, 2019
And welcome to UChicago Medicine At the Forefront Live. This is your chance to ask our expert your questions by typing in the comments section. We'll get to as many as possible in the next half hour. Now remember, this program does not take the place of an actual visit with your physician.
Joining us today is an expert in the field of robotic cardiac surgery. Dr. Husam Balkhy is a pioneer in the field of minimally invasive and robotic cardiac surgeries. We'll also have a special guest, Susan MacLeary. Susan just recently had a cardiac procedure done right here at UChicago Medicine. First of all, welcome to the program.
Thanks for having me.
Let's start off just with some kind of some general information, Dr. Balkhy, if you can. What do you do with the-- or what kind of surgeries can you perform robotically, and what's the big advantage to doing it that way?.
Well, that's a great question, Tim, and thanks for hosting this today. It's not well known in the cardiology and cardiac-surgery community the actual number and variety of cases that can be done with the robot. We can do everything from multivessel coronary bypass to repair of complex mitral valve and replacements to fixing congenital defects like atrial septal defects all the way to taking out tumors, all done with the robot with small little incisions in between the ribs.
Another field that we've actually pioneered here at the University of Chicago is the procedure called pericardiectomy, which entails removing the sac that surrounds the heart during some infectious and inflammatory diseases, and that can all be done robotically as well.
That's interesting. We were talking a little bit before the program, the three of us, and I brought up a story I was telling you about my father who had multiple cardiac surgeries a quarter of a century ago, 25, 26 years ago. But it was very different back then, and he was completely opened up. And I've told him about what you do, and he is very jealous because he wishes he wouldn't have had to have the breastbone open, and that's a huge advantage to the procedures that you perform. It makes it so much better for the patient.
Indeed, it does. It makes for quicker recoveries. It eliminates a lot of the potential for complications that can happen from opening up the breastbone, and it makes for an earlier returned to normal activities and getting back to work, not to mention the psychological aspects of it.
And this is something that we've noticed over the years that I've been doing what we call sternal-sparing heart surgery is that there's a psychological impact from having your chest cut open. And insofar as there are procedures that can be done without that, I think there is a benefit.
Obviously not every operation on the heart can be done that way. You can't do a heart transplant that way. But when you go to a specialized center like UChicago Medicine that has the ability and the team and the resources to do that, it's definitely better for the patient.
Now Susan, you had your procedure just a couple of weeks ago.
Exactly two weeks ago.
So that's pretty incredible. You look great.
And tell us what you had done, first of all, and how did that go?.
I had a mitral-valve episode. It was a problem with my mitral valve, and we weren't really sure what the problem was until the doctor got in there, and it went very well for me. Thank you.
And again, we were chatting about this before the program. You mentioned that you were surprised with how quickly you actually were able to leave the hospital, how quickly you were up, walking around, and how great you felt. Tell us a little bit about that.
Well, I was leaving the hospital less than 30 hours after I actually had the procedure. So I came into the hospital at 5:30 in the morning. I think I was in the operating room by 6:30, quarter to 7:00, and I woke up in the ICU at around 5:00. And the next morning Brooke came in and said, hey, we think that maybe you could go home today, and I was elated. I mean, I actually felt so awesome..
And through the evening the care in the ICU was amazing. They touched my heart. They knew what I was thinking. They knew where my discomforts were, and I thought it was just awesome. And there I was leaving the hospital at 4:30 the next day.
And Dr. Balkhy, one of the things that Susan just mentioned that I thought was kind of interesting, when you get in and you take a look around, you kind of explore and see exactly what's going on, what needs to be repaired, what doesn't need to be repaired. Talk to us a little bit about the procedure and what that entails..
So a mitral-valve surgery is one of the more commonly performed procedures using the da Vinci robot, and it lends itself well to being performed with a very, very minimally invasive approach using small incisions, the largest of which is barely half an inch on the right side of the chest..
And in Susan's situation, we knew that her mitral valve was leaky, secondary to a situation called degenerative mitral valve disease, but we didn't know exactly what we would find in terms of the reason for the leak or the nuts and bolts of what needed to be fixed. And one of the things that we like to do with mitral-valve repair is to repair it as opposed to replace it. And that's a relatively new thing in cardiac surgery for about 15 to 20 years. Prior to that, all we could do is replace the valve.
And the robotic approach is uniquely positioned to be able to explore and evaluate and examine every level of the mitral valve that we have. So the mitral valve, without going into a lot of technical detail, is formed from flaps that basically come together when the valve needs to be closed, and this degenerative mitral valve disease, otherwise known as myxomatous degeneration-- there's various names for it-- leads to a situation where the two flaps don't come together perfectly well. And that can be because the cords that hold them are stretched or they're torn or the frame that houses the two flaps is too dilated and patulous and needs to be tightened up a little bit. And all of those things can be diagnosed very, very well with the robotic approach because we have a perfect 3D superview of the whole apparatus, and we can fix it.
Yeah, that's one of those things I wish we could show video of that. It doesn't translate to video very well, but one time when I was in the OR with you and we were taking some shots, you invited me to put my head in the other side of the da Vinci robot, and it was amazing to see the three-dimensional aspect of it because it's really quite stunning and quite clear, and it allows you to kind of see exactly where you're going.
It does. One of the fallacies about minimally invasive surgery, in particular robotics, is that you don't see as well. And as you witnessed in the second console we call it or the student's seat, if you will, in a driving situation, what you could see is the fact that it was high def, it was very magnified, it was three dimensional, and it was perfect. And it's almost a better view than what you could get with the naked eye because of those things. Well, I was just about ready to say that. I can't imagine you getting a better view, to be real honest with you.
You can't get a closer view, that's for sure. When we do surgery the regular way, we have loops that magnify 2 and 1/2 times, and we're sitting about this far away. So I'm operating on this cup like that. And imagine if I were to bring my eyeball straight down and I could evaluate every little bit of this UChicago Medicine logo and I could look at every letter in a lot of detail and see the complexity of it in the pixels. It's really not afforded by routine, traditional surgery.
And the machine is right there. We're showing some video of it right now. This is you performing an operation on someone. I believe it was a mitral-valve repair, actually. I think what we shot. But your hands are in the little machines.
It's a highly engineered device that allows the reproduction of the surgeon's hand motions into the patient's body using very, very complicated computerized connections. So basically as you can see there I'm moving these what we call joysticks underneath the console. And if you look carefully, you'll see that there's a headset. I'm wearing a two-way kind of a walkie-talkie or intercom communication with the rest of the team because we really need to have very, very tight and accurate communications. So not only am I working a little bit remotely from them, but I'm also able to communicate with them quietly and in a controlled manner.
And that's fascinating as well, and I'll attest to that because you talk to each member of the team and you ask them very specific questions about all of the different things going on, and it does take a large team to do this. There's several people in the operating room that are working at the same time.
Exactly. We're actually part of a study that looks at interposing a machine in the middle of a team in the operating room and how that affects people's behavior and how it affects their experience and the activities, and so it's very fascinating. I think what we've added-- and I've been doing this now-- I've been doing robotics since 2007 or just before 2007, but we've been using the system of communication for only about three years, and it really does change the demeanor of the team, and it changes the ambience of the room and, I think, adds to a lot of the stability that we see.
Now Susan, I'm curious, in your situation, what were your symptoms when you came to UChicago Medicine? How did that work?
Well, I woke up one morning, crawled back in bed, and I had a very difficult time breathing, and my heart was racing. I tried to lay back down again, and I just felt almost as I was going to be drowned.
So I didn't really say much about it to my husband that night. I just thought maybe this was a once occasion, but the next night it happened again. So that's when I informed my husband. And within a few days I was at a general practitioner, and he discovered that my blood pressure was quite high and put me on blood-pressure medicine right away and sent me to a cardiologist, Dr. Reddy.
And after I had a couple more tests, she's the one that informed me that I was going to have to have heart surgery. And she wasn't sure if it would be a repair or replacement, but I started praying that it would be a repair because my symptoms kind of went away after the blood-pressure medicine, most of them. I did have like a crackling sound I would hear when I would lay down, and that was still there.
But then I was on foot looking for the possible surgeon, and she had made two suggestions. The one suggestion I followed up on and learned a lot in talking to those doctors, but one of the doctors had actually mentioned that he had a colleague at this university hospital. And I followed up on that. I found Dr. Balkhy. This doctor sent a referral. And Elise set me up for an appointment the beginning of January, and two weeks later I was in the operating room. Well, you got a pretty good one, I think.
Oh my gosh. Well, the minute my husband and I met him, when he walked out we're going, OK, he's the man. He's the man, and this is the team. We just knew it. You know, you just can feel when you're in the right place at the right time.
Well, I'm glad it went so well for you. And did you know much about the robotic surgery before you came here? Was that a learning process as well?
I didn't know anything about robotic surgery until my cardiologist, Dr. Reddy, brought it up. And then I found out that it is very highly specialized, and you just can't go to an insurance company or go to any types of doctors and ask for them to set you up with somebody or give you some referrals. So that's when I really realized how specialized this was and how important it was to find the right team.
That's great. Well, we want to remind our viewers that we are taking questions, so type them in the comments section. We're already getting quite a few, so I want to get some of those viewer questions. And the first one I want to ask-- it's a statement than a question, but I want to make the statement.
"This patient looks awesome. I never would have guessed that she had heart surgery just two weeks ago. Is this a typical outcome for most patients with this type of issue?"
Well, you are correct, the person who wrote that question. She does look awesome. And make no mistake, she's still within two weeks of open-heart surgery through a closed-chest approach. And yes, patients who come in looking good usually go out looking good, and the outcome is usually this good for patients who don't have a lot of other what we call comorbidities and a lot of other medical illnesses. Obviously each patient has their own situation, but the majority of our patients are usually out of the hospital within the first couple of days after robotic heart surgery.
That's fantastic. So here's another one. "Had a stent placed in in 2001. Should I worry about its age?"
Not if you're feeling great. [LAUGH] That's an easy answer.
Good. I like that. So yeah, if you feel good, but always talk to your physician.
Talk to your cardiologist.
If you do have concerns, make sure you talk to your cardiologist. "I'm wondering what prevents robotic heart surgery from being the norm across all cardiac surgery," is another one of our viewer's questions.
I'm wondering the same thing, but we're working hard. There are many, many centers in the country right now that do robotic heart surgery. They do it in different ways. Our societies have started to actually take up the hard work of creating courses and symposiums and workshops for people to train, teams to train.
It's a thing that basically is a learning curve. And heart surgery itself is not easy to do, and doing robotic heart surgery is also not easy, but we do it. And I think that slowly but surely the technology is catching up with our mindsets, and we are starting to actually invoke some of this technology. And we have a training program at the University of Chicago Medicine, but I'm also involved in national and international societies that are involved in training surgeons and teams around the world, actually, to do robotic surgery. So I think it's a technology that's slowly coming to fruition.
And what you do is still specialized enough that you operate on patients from all over the world as well, don't you?
This is true, yes. I was just reviewing some films of a patient from Kazakhstan. We have patients from Europe, from the Middle East, but the majority of our patients are from the United States. I would say that probably 50% to over 50% come from out of the state of Illinois.
"So Dr. Balkhy, what advances do you foresee or hope to see in the future of robotic cardiac surgery?" I like that question too.
It's a good question I foresee that the instrumentation is going to continue to get better. There are some operations that we can't do with the robotic technology. I think one of the things that robotic systems are working on is something we call haptic feedback, which means the ability to actually feel the tissues that you're working with, which can add some dimension to the procedure. Although those of us who operate with the robot frequently and do it every day, we've developed a feedback that's based on visual appreciation of what happens to the tissues. But the good news is that there are many, many companies that are involved in designing robots for medical use, and that's only going to benefit patients as we go along here.
Susan, a question for you. This is a tough one, but I'm going to ask it anyway. "I'm wondering if you had one thing about your robotic heart surgery experience that you would improve, what would that be?"
Oh, that is kind of a tough--
And maybe there isn't anything. I don't know.
Yeah, that is a tough question.
Maybe it went as well as it could.
Well, I had a few little nightmares, but I don't think that we can improve on that. I think it all depends on how, as a patient, you're coming across. I had a little problem getting oxygen into my blood. So it took a little bit longer for me when I first came out of anesthetic. But the nurses were there. They held my hand. They dried my eyes. They suctioned anything that needed to be taken care of and made me feel very secure. I had never had any fear or any anxiety about what was happening to me. It was just a process I was going through.
So your care postsurgery was pretty positive?
Oh yeah, it was. It was definitely very much so, and I don't know that I have any input as to what could be improved.
Excellent. So here's a question from a medical student. "So what would you say to young medical students who aspire to be heart surgeons and, even more, to do the type of work that you do?" You've got a fan, apparently, out there.
That's a great question, and I think that we're always encouraging medical students and residents to adopt and take on new technologies. First of all, somebody who is in medical school right now is interested in heart surgery, that's a plus right away because we're always trying to attract the good medical students to our specialty.
In terms of what to do to become a robotic heart surgeon, I think you have to go through the training, obviously, and continue to be involved in some of the advances and keep your eye on the ball. I would recommend that you do some rotations, maybe do some clinical attachments, research projects with a robotic surgeon, and attend some cases. I think all those things would serve you well. But great question.
So interesting. So I do like that question because you trained, obviously, as a surgeon. And then robotics came around, and how did you get interested and get involved in that and then learn the procedures? Because a lot of this was a trail you had to blaze.
A little bit, yeah. No, that's a great question. And my path to it is basically the path of somebody who was drilled into me when I was a surgical resident to respect human tissue and to not cut more than what you need to cut to see. And so my whole emphasis in doing cardiac surgery was to try to do it with the least-possible invasion to the human body, and that led to minimally invasive surgery maybe two years into my practice.
And then when I finally got my hands on a robot I said this is the ultimate. This is the highest form of minimally invasive surgery because it allows you to do all of the things that you can do with your hands without making big cuts. And when I was able to finally convince my hospital-- I was actually in practice in Milwaukee at the time. When I was able to convince the hospital I was working at to buy me one-- and these things are not cheap. I'm sure they're not.
It was the sky's the limit. And so I've basically tried to invoke every patient I see, I ask myself, can this situation be taken care of robotically, obviously in a safe manner and without losing any of the efficacy of the care?
Susan, another question from a viewer, and this one is for you. "Was your heart diagnosis a surprise, or had you struggled with any health issues in the past?"
It was a shock, and it was even more of a shock once I started the blood-pressure medicine and feeling good. I thought of every other thing that could be wrong with me at that point. I live on a lake. I was even considering am I inhaling or absorbing algae from the lake? What could possibly be doing this?
So when I went in after having some tests with my cardiologist and she said that you have a mitral-valve prolapse and that it would need to be surgically fixed-- she didn't know whether it would need to be replaced or fixed. So I had to swallow a few tough pills and do a lot of soul searching and just become calm with this is who I am. This is what's happening. Where do I go from here?
And that little word that she said to me about robotics-- and I know of two surgeons-- just never left me. And so we pursued that, and that's how I ended up here. I think it bears mentioning actually, if I can interject--
--that we are in February, and February is Women's Heart Month. Or maybe it's everybody's heart month, but for me it's Women's Heart Month because I'm very interested in how heart disease affects women. And I think Susan's story is somewhat typical. It applies a little bit more to coronary disease where symptoms are not expected, and a lot of women who have heart problems don't get diagnosed right away. I think we're improving and our track record is getting better, but it's not the same as men with heart symptoms. And so I think there's a good opportunity to kind of bring that out when talking about how Susan presented and what the symptoms were and how she got diagnosed.
I think that's an excellent point. And as an educational effort, women do need to listen to their bodies, and particularly if they are having what potentially could be cardiac issues, don't go back to bed. Talk to your physician and get it checked out because it certainly will make a difference.
Another question from a viewer. "Can you please touch upon cardiac tumors, and is that something that you're able to use the robot to help with?"
Absolutely. So cardiac tumors are, first of all, rare. The most common of the cardiac tumors are benign tumors on the inside of the chambers. And we actually have a paper just out on a rare cardiac tumor that we completely removed using the robot. One of my medical students who is doing some research with us wrote this paper and published it recently. It's what we call a fibroelastoma, which is a benign tumor, and it was in a rare position in the heart, in the right ventricle.
And we have a series now of about 15 or 20 over the last couple of years that we've done that we're putting together for publication. So they're not common things, but they lend themselves very, very well to being removed.
Now the other kind of tumor, which is a malignant tumor, is extremely rare in the heart, and those usually require a bigger incision if one is going to do any kind of major surgery for them.
So back to the mitral-valve prolapse. Do all patients need surgery?
No. Mitral-valve prolapse is an extremely common condition. There are millions of people walking around with the diagnosis mitral-valve prolapse. Not all of them have a leaky valve, and therefore not all of them need to have anything done for it.
We do probably about 50,000 mitral-valve surgeries a year, and the majority of those are myxomatous degeneration, similar to what Susan had, and it is the technical term for what a mitral-valve prolapse is.
So the answer is, no, not every patient with MVP needs to have it taken care of, but if that mitral-valve prolapse leads to a leak, then they become a candidate for it to be fixed. We grade the leaks as being mild, moderate, and severe. And if somebody has a severe leak in their mitral valve, then they are better off having it fixed than not.
Another question from a viewer. "How have robotic heart surgeries changed since you started doing robotic surgeries, and how have the procedures changed over time to produce greater benefit to the patient, in your opinion?"
Well, the da Vinci robot's been around-- and this is just in my field in cardiac surgery. There's a lot of different other names of robots that are being used in orthopedics, in ear, nose, and throat surgery, and a lot of the subspecialties. In my field, this is probably the fifth, I think, or almost the sixth generation of robot that we have, and they've continued to become better with better instruments, with smaller openings in between the ribs, with more indications for different types of surgeries to have a lesser impact on the patient in terms of invasiveness, and just better visualization.
One of the things that's happened over the last five years that we didn't have when I was training is something called simulation. And so now for a trainee to learn how to do robotics, they can be on a simulator similar to a pilot. They can log 10,000 hours before they even touch a patient. And so that has added a lot to the safety of the procedure and the learning of it.
And how close is the simulation to the real thing?
Some are better than others.
I understand. I understand. Well, this is fantastic. And Susan, again, you look great. I'm glad you feel well.
And thanks for taking your afternoon and coming over because you certainly didn't have to do this. We appreciate it.
Oh, it was my pleasure. I'm there for Dr. Balkhy as he was there for me.
Thank you very much.
That's great. Anything you want to add? I know it's difficult. You're a busy guy, but you can get an appointment, as you proved. So that's good to know. Yeah. We're open for business. We're actually expanding our robotics program at the University of Chicago Medicine so that we'll have, hopefully, the ability to have a second team, which is not always easy. And we're continuing to expand our indications for the operation. And as I said, we're getting patients from all over looking for a minimally invasive approach to their cardiac problem.
That's fantastic. That is all the time we have for At the Forefront Live today. Thanks to our guests for their participation in today's program and thanks to you for watching and submitting questions. If you want more information about minimally invasive cardiac surgery, please visit our website at uchicagomedicine.org, or you can call 888-824-0200.
Now join us for our next At the Forefront Live. That's just tomorrow when we learn about women's health. We'll have three of our doctors on to discuss fibroids and endometriosis and treatments that are available for those. That's Tuesday, February 5. Also check out our Facebook page for future At the Forefront Live dates and subjects.
Thanks for watching. Have a great week.
The University of Chicago Medicine is home to one of the most robust and comprehensive robotic cardiac surgery programs in the nation. Led by Husam Balkhy, MD, our program helps patients get back to their lives more quickly and with fewer complications than standard procedures, thanks to the use of sophisticated instruments through smaller incisions.
We spoke with Balkhy to learn more about the innovative procedures he and his team offer patients with cardiac conditions. Susan MacLeary, a recent patient of Balkhy's, joined to share her perspective. MacLeary had a robotic mitral valve repair on Jan. 22, 2019, and went home the next day. She joined us just two weeks out from her procedure.
Husam Balkhy, MD
Husam H. Balkhy, MD, is a pioneer in the field of minimally invasive and robotic cardiac surgery. He specializes in the treatment of coronary artery disease, heart valve disorders, atrial fibrillation and other cardiac diseases, using robotic and less invasive techniques in order to reduce pain, disability, and recovery time.Learn more about Dr. Balkhy