Fresh From the OR, a Heart Surgeon Chats With Users

On Tuesday, October 2, U.S.News & World Report and the Cleveland Clinic presented a groundbreaking event—live surgery, streamed in real time over the Internet. Visitors to usnews.com got a rare opportunity to go inside the operating room for an up-close view of cutting-edge heart surgery.

Dr. Tomislav Mihaljevic of the Cleveland Clinic performed the procedure. A specialist in minimally invasive and robotically assisted cardiac surgery, he repaired a leaky mitral valve using a robotic device, going into the heart through a small incision on the right side of the chest. This type of surgery involves much less trauma to the patient than a traditional operation, in which the breastbone must be divided.

Following the surgery, Dr. Mihaljevic answered questions from users in a live online chat. Here's a transcript of that conversation:

Cleveland Clinic Host (CCH): Today's talk is on robotic heart surgery with a follow-up from this morning's [Tuesday, Oct. 2, 2007] live webcast surgery on U.S.News & World Report's website.

CCH: Welcome, Dr. Mihaljevic, and thank you for joining us today. Let's begin with one of the questions!

CCH: It was very exciting to watch the surgery this morning on the Web broadcast, how is the patient doing?

Dr. Tomislav Mihaljevic: The patient is doing just fine. He is now in the intensive care unit. He will probably be out of the hospital in three to five days.

CCH: Before we start to take questions from the audience, can you tell us who makes a good candidate for robotic surgery?

Dr. Mihaljevic: At the current stage, all patients who have leaky mitral valves and or tricuspid valves can be evaluated as a potential patient for minimally invasive robotic surgery. In addition to patients with leaky valves, robotic surgery can also be used to repair holes in the heart (atrial septal defect, patent foramen ovale). It can also be used in a limited extent for certain types of bypass surgery.

bimals77: I am 30 years old. I have a leaky aortic valve. My doctor told me I have to do surgery. I don't want to put in an artificial valve. Please suggest what I should do?

Dr. Mihaljevic: You should send us your records for evaluation. As a 30-year-old, you are certainly a candidate for minimally invasive aortic valve repair, so that valve replacement may not be necessary.

Send us the records for review. The optimal mode of treatment will be made after careful review of your medical records. This type of surgery is done with a minimal risk.

khome: Which valve and how many can be fixed by this type of surgery?

Dr. Mihaljevic: We most commonly perform repairs on the mitral valve; however, the tricuspid valve can also be repaired using robotic technology.

We can do the combination of both of these valves as well during this type of surgery.

markd: How and when would I know that I am a good candidate for aortic valve surgery? How do I find a doctor?

Dr. Mihaljevic: That depends on the type and severity of aortic valve disease. Most patients have aortic stenosis (which is a narrowing of the aortic valve). Timing of the surgery is mostly determined by echocardiogram, an ultrasound of the heart, which accurately determines the severity of disease.

maryp: My mother has been diagnosed with severe mitral regurgitation and is interested in robotic surgery. What are her options?

Dr. Mihaljevic: The robotic surgery is a valuable option even for elderly patients. The operation can be performed with minimal risk. A final decision is always made after a careful review of the records. We would be more than happy to review your mother's records.

katie: I have been diagnosed with myxoma. Is robotic surgery an option?

Dr. Mihaljevic: Yes, it is. Robotic surgery is an excellent option for removal of myxoma, which is a benign growth in the heart.

peter59: What is the probability of reoperation for mitral valve repair on a 48-year-old?

Dr. Mihaljevic: Mitral valve repair can be performed even after a failed earlier attempt to repair the valve. Repeated operations on a mitral valve can be accomplished robotically in some cases and with very low risk.

Patients who get their mitral valve repaired in their 40s are most likely going to enjoy a lifelong benefit from surgery. The failure rate from the operation is only 10 to 15 percent over a 20-to-25-year period.

michael48: What about a person who has MVP with regurgitation and slightly enlarged LA as well as a history of atrial fibrillation treated with Sotolol? An MV repair has been suggested by the cardiologist with a Maze procedure to control the arrhythmia.

Dr. Mihaljevic: I would definitely agree with the recommendation since the enlargement of the LA and the presence of atrial fibrillation are suggestive of an advanced stage of the disease.

Mitral valve repair and a Maze procedure can be done in the same setting using a robotically assisted approach.

mike: The surgery this morning was amazing. Is there ever a time when you need to switch to a more traditional approach?

Dr. Mihaljevic: There are rare occasions when we need to switch to a more traditional approach. But that occurs in less than 2 percent of operations. The switch to a conventional approach can be achieved in less than a minute or two.

doncarrera: How many CT surgeons in the Cleveland-Pittsburgh-Columbus area can perform the MI mitral valve repair?

Dr. Mihaljevic: I am not really certain about exact number of surgeons who perform this procedure. However, you look at centers that provide minimally invasive options, mitral valve repair options, and the volume and outcomes of those procedures. You can compare our statistics to other hospitals--look at our website for those numbers.

namaste1: My daughter had open-heart surgery when she was 1 year old. Tetralogy of Fallot. She is 20 now and one of her valves is leaking. Her surgeon wants to wait before fixing the valve to see if it can be done robotically, but I'm not sure how that works.

Dr. Mihaljevic: The repair of mitral valves for congenital heart disease can often be complex, and whether we can repair her valve using robotic instruments would require a careful review of her medical records.

Heart surgery should not be done at the same setting of reconstructive surgery.

peter59: During the surgery, they said that mitral valve repair was better than mitral valve replacement. Why?

Dr. Mihaljevic: Because the repaired mitral valve performs better over the short and long term than the artificial heart valves. Keeping your own valve reduces the risk of potential life-threatening complications (such as a stroke) that are often associated with artificial heart valves.

Trudy: I am an 80-year-old male with aortic stenosis and mitral valve regurgitation and I want to know if they both can be repaired at the same time.

Dr. Mihaljevic: Patients with aortic stenosis and mitral valve regurgitation usually require replacement of the aortic valve and a repair of the aortic valve. This operation can be done using a minimally invasive approach at the same time.

jbbrown: I need tricuspid valve repair or replacement due to radiation received 24 years ago to the left breast. Would I be a candidate for robotic surgery?

Dr. Mihaljevic: Tricuspid regurgitation after chest radiation is a difficult problem to solve. Although you may qualify for robotic surgery, you will need to be carefully evaluated prior to operation to insure the optimal mode of operation.

bimals77: I am 30 years old. I have a severe aortic leaky valve. I want to play soccer. I want to get married, do whatever I want. What would be the best option?

Mihaljevic: Leaky aortic valves can oftentimes be repaired using a minimally invasive approach. Repairs are usually performed at specialized centers and can be done with a minimal risk and excellent long-term results.

If the aortic valve repair is accomplished, patients can resume all regular activities of daily life, including getting married.

mary: They mentioned the ring is very important to a valve repair surgery. If I am looking for valve repair surgery, should I make sure they also include a ring in my surgery?

Dr. Mihaljevic: Absolutely. The purpose of the ring is to prevent the later deterioration of the function of the mitral valve.

nnsmith: Can you have robotic surgery after traditional open-heart?

Dr. Mihaljevic: The answer is yes. Robotic surgery is an option for a selected group of patients that had previous open-heart surgery. Whether the robotic surgery is an optimal approach depends largely on the type of surgery that was provided in the past.

CCH: Dr. Mihaljevic, what do you think the future of robotically assisted heart surgery will be?

Dr. Mihaljevic: The future of robotically assisted heart surgery will be an even broader use of robotic approaches that will continue to minimize the trauma to the patient and enhance the chances of early recovery.

Trudy: Eleven years ago, I had a double bypass surgery, and the TE report shows some aortic valve mild regurgitation and the tricuspid valve shows some mild regurgitation pulmonary valve N/D and mitral valve regurgitation moderately severe. Could this be corrected during the same operation? And verify that the bypasses are still in good working condition? And if not, replace them at the same time?

Dr. Mihaljevic: The answer is yes, provided that the severity of leakage through the mitral valve truly warrants surgery. Patients who had bypass surgery in the past may have mild to moderate leakage through the mitral valve—but that does not pose the need for surgery.

Before you get to surgery, you would need a detailed echocardiogram and most likely a repeated cardiac catheterization to assess the condition of your previous bypasses.

michael48: Does a history of AF and PVs with moderate to severe mitral regurgitation complicate the surgery outcome?

Dr. Mihaljevic: This is a common observation in patients who have mitral regurgitation. Atrial fibrillation can be treated successfully by doing a Maze procedure at the same time as doing a mitral valve repair.

CCH: It sounds like robotic surgery has so many benefits. Why wouldn't all surgeries be robotically assisted?

Dr. Mihaljevic: The robotic surgery requires a specially trained surgeon and surgical assistants in the operating room—an entire surgical team. That is the main reason why this is being performed in very specialized centers with a greater experience in cardiac surgery.

There are only certain patients with blockage in their heart vessels who are potential candidates for robotic bypass surgery. We are most likely going to see a greater use of this technology for treatment of coronary artery disease in the future.

bimals77: Aortic valve repair, is this a lifetime solution for a leaky valve for a 30-year-old male?

Dr. Mihaljevic: It is a potential lifetime solution for patients upon whom aortic valve repair can be performed. Based on your age, I would assume you would have a bicuspid aortic valve, which means that your aortic valve is made out of two cusps instead of three. If that is the case, you have a 70 percent chance for successful repair of your valve using a minimally invasive approach (however, without a robot).

liswife: What would cause "heart failure" after robotic mitral valve repair? Prior to surgery ejection rate of 60; after surgery rate of 35?

Dr. Mihaljevic: This is a very good question because decline in ejection fraction after mitral valve repair is actually very common and an expected finding.

The decline in ejection fraction does not implicate a decline in heart function. Patients with severe leakage of the mitral valve have falsely elevated ejection fraction prior to the surgery. So the repair of the mitral valve eliminates this false impression and unmasks and reveals a true ejection fraction, which is oftentimes lower.

hillm: Is robotic surgery ever done "off pump"? If not, how long is the time used on the heart-lung machine?

Dr. Mihaljevic: Robotic surgery can be done off pump—but only for bypass operations. All heart valve operations with the robot are done on pump since the heart has to be stopped and the heart chambers opened in order to get to the valves. The average time required for mitral valve repair is approximately 19 minutes.

hillm: Are there specific complications or concerns with a robotic surgery that are different from a conventional surgery?

Dr. Mihaljevic: There are no specific complications related to robotic surgery. Since the only difference between the two surgeries is the size of the incision, the surgery itself is done in the same way—the only difference is we are using robotic instruments instead of conventional ones.

The risk of death or mortality for robotic mitral valve repair at our institution is 1 in 1,000.

michael48: Do you find that patients with chronic controlled AF who have the repair see correction of the AF from the repair alone, or do they find that the Maze needs to be done no matter what?

Dr. Mihaljevic: In those patients, Maze needs to be done in conjunction with mitral valve repair. Mitral valve in isolation is not a cure for atrial fibrillation.

namaste1: What other minimally invasive approaches are available for leaky valve problems?

Dr. Mihaljevic: Other than robotic surgery, the operation can be done through the partial division of the breastbone or an incision on the right side of the chest. After review of your records and test results, all of these options are discussed with you by your surgeon.

hillm: What are the immediate restrictions after having a robotic heart surgery? Driving? Restrictions on lifting items of a certain weight?

Dr. Mihaljevic There are no restrictions in terms of driving after surgery. We only advise a patient not to drive as long as they take narcotic pain medications, which are usually required during the first week after surgery.

Most of our patients resume their regular activities within two weeks of surgery, including lifting.

hillm: If a patient had breast cancer, mastectomy with radiation to the chest, and now has mitral valve issues, would robotics still be an option?

Dr. Mihaljevic: Absolutely. Robotics may be an especially attractive solution to patients who had previous radiation to the chest because of a lesser chance of wound infection when using a small incision on the side of the chest instead of a sternotomy, which is division of the breastbone.

CCH: How many robotic procedures are performed at Cleveland Clinic in a year?

Dr. Mihaljevic: We have done 70 mitral valve repairs in the first 10 months of this year and we anticipate to complete 120 mitral valve repairs by the end of the year. In addition, we plan to do other types of robotically assisted heart surgery this year.

CCH: Thank you, Dr. Mihaljevic, for chatting with us today. It was very informative.

Dr. Mihaljevic: Thank you for having me today.

CCH: Thanks for joining us, everyone!