Episode 10: Stanford’s Dr. Jack Boyd Explains Myocardial Bridge Surgery. The Unroofing Process.

SPEAKER_01 0:00

20 or 30 percent of all human beings have an intramyocardial LAD, or you know, what we call a myocardial bridge. How common it is to have a bridge and have it be pathologic or cause symptoms is is much, much more rare. That's really only a small percentage, a fraction of a fraction of a percent of the entire population. So it's very real for the people that have it.

SPEAKER_00 0:56

We'll talk with healthcare professionals, those in related fields that support our condition, and others just like us with stories of their myocardial bridge experiences. It's my intention for this content to inform, educate, entertain, and even motivate or inspire you in your personal journey on dealing with a myocardial bridge. Most importantly is to have you leave each episode with hope, knowing you're not alone and that what you're experiencing is real. There are some guests that get you really excited to speak with, some that make you really anxious, even nervous to speak with, and yet others you cannot wait to talk to simply to enjoy the conversation. The guest for this episode actually transcends every emotion for me. He earned his medical degree from Indiana University School of Medicine and completed residencies in general surgery and thoracic surgery from Indiana University School of Medicine. Following his residencies, he commenced robotic cardiac surgery and minimally invasive cardiac surgery fellowships from Good Samaritan Hospital in Cincinnati, Ohio, and Hospital of the University of Pennsylvania. He was on the faculty at Indiana University for five years prior to joining the Department of Cardiothoracic Surgery at Stanford in 2014. He's a recognized authority in performing the majority of coronary bypass grafting surgeries at Stanford Medical Center, is one of a handful of surgeons in the world who regularly performs minimally invasive and or robotic coronary artery bypass grafts, and he is likely the preeminent surgeon for myocardial bridge unroofing procedures, having performed nearly 250 surgeries to date. He serves many leadership roles at Stanford and is a clinical associate professor in the Department of Cardiothoracic Surgery. Personally, he's the surgeon who performed my unroofing and bypass procedures that have restored my life and allowed me to create this podcast. Excited, anxious, humbled, and with an overwhelming amount of gratitude, I'm pleased to introduce Dr. Jack Boyd. Dr. Boyd, welcome to Imperfect Heart.

SPEAKER_01 3:09

Thank you, Jeff. It's an honor to be here.

SPEAKER_00 3:11

I can't tell you how excited we are to have you on the program. You are without doubt the foremost authority on unroofing surgery in the country, having done more unroofing procedures than any other, possibly all other surgeons doing the procedure combined. When did you do your first unroofing procedure and what was it that led you to believe that what you were doing would become such a successful procedure at reducing and in some cases eliminating symptoms of a myocardial bridge?

SPEAKER_01 3:37

I first was coming to Stanford in the fall of 2014. And as that was developing, I was coming as a coronary surgeon to do bypass surgeries, all the different types, on pump and off-pump, with the well bot, minimally invasive varieties. And there was another surgeon here, Scott Mitchell, had been doing these surgeries and had teamed up with England Schnicker. And I think they'd been doing them for about three years and had done, I don't know, 20 or 25 of them. It just temporarily correlated that he was, you know, moving on when I when I was coming in. And they asked, because it was a natural segue from coronary surgery to this, if I'd be willing to come out a month early to watch him do a couple. So I made an extra trip to Stanford over the summer and watched him do two of them on a single day to see how he did it. That was the end of July. And then I came and joined the group in September. And I think probably in October was the first time that I did the surgery. You know, I wanted to make sure that we did them as they'd done them before. It was something that was unfamiliar to me, but they started to develop an experience with it.

SPEAKER_00 4:38

I know many of the people joining us in this conversation today are trying to decide on whether the procedure is right for them. What are the criteria that you take into consideration before the option of surgery becomes valid?

SPEAKER_01 4:51

I rephrased the way that I think about it just a little from how you did in that. We looked, do we have the appropriate indication for surgery? Is it valid? It's a different way of trying to say the same thing. But in our language, it's what's do you have the right indication for surgery? And so the first thing is the symptoms, right? Someone has generally has chest pain with it. There are some symptoms that potentially can be bridge-related. You know, we see it's fatigue, you know, weakness, some other things that we can't necessarily directly attribute to bridges, but sometimes we think are associated, but chest pain being the main driving factor. And then if there's been nothing else to explain that, right, they've generally been to the emergency department or through the primary care and onto a cardiologist. It demonstrates they haven't had a heart attack or they don't have reflux or there isn't another obvious explanation for their chest pain. Frequently they'd have a stress echo. And when it's done here, we have some expertise in seeing some objective but very subtle changes in one of the ventricular walls that can be suggestive of it. And in our program, that would probably warrant you medical therapy for it. We would just try some beta blocker and see if that takes care of the symptoms or a specific calcium channel blocker to see if that helps. If the symptoms persist or are, you know, the medications don't really cover it, then we look for the anatomic presence of a myocardial bridge. And we usually do that with a CT scan, coronary CT scan. And our radiologists can identify the bridges, they quantify the length and the depth from the CT scan. We start to get more suspicious, the medical management is ongoing, adjustments there. If really it gets to the point where we say if you have symptoms in a hemodynamically significant LAD myocardial bridge that's not tolerable despite maximal medical therapy, then we think surgery could be an option for you.

SPEAKER_00 6:56

I'm going to take that one step further now after the diagnosis. As the most sought-after surgeon, as a result of your experience and familiarity with the entire process of the unroofing procedure, can you share, for the benefit of those who are just learning the details of the procedure, the steps taken prior to surgery and then exactly what's done once you're in the operating room?

SPEAKER_01 7:19

Jeff, I just want to recognize one of the points you made. I have this surgical experience because of the team that we have here. Dr. Schnicker on the echocardiographic and medical side, and Dr. Trumell on the interventional cardiology side, and our IVIS fellows, which rotate every couple years, and chest radiologists that allow us to put this program together and look at so many patients with this medical condition that isn't universally accepted as being the medical condition. So skip ahead to when they get in the operating room, right? So they've been through this whole process, they've met with our team, they've been studied, they've met those criteria. And we decide on surgery, we always decide the approach prior to surgery. The two options are a strenotomy, which is what people think of as traditional open heart surgery through the middle of the chest, or a minimally invasive anterior thoracotum, a small incision between the ribs in the left chest. So the patient goes to the operating room, goes to sleep, we get the breathing tube placed, we put in the appropriate moderating lines and catheters, and then we'll make the incision to look to the heart. When we get there, we position the heart such that we can see where the LED should be. We can usually see it where it exits the bridge and the distal or the farthest out aspect. And then we have an instrument, a stabilizer, kind of a U-shaped suction cup that we can place over a part of the heart that holds the portion of the heart still, and that way we can begin the unlooting procedure. So most people's heart have a little bit of fat on the outside, and so we divide the fat on top first, and then there's some veins that go through there will control those. So we we get down to the muscle that overlies that that is the bridge. And then moving from the farthest point out to the nearest point, we just divide the muscle over the top of the artery. Sometimes a joke that everything you need to know you learned in kindergarten, and mostly here we just want to cut in a straight line.

SPEAKER_00 9:16

So when you actually do that, it's an incision of the heart muscle.

SPEAKER_01 9:20

Yes. So I mean, usually we say incision, we're talking about cutting with a knife on top. The way I prefer to do this, and this was related to how I was trained to do bypass surgery, is I actually take scissors and cut through the muscle like you would a cut a piece of paper.

SPEAKER_00 9:36

I don't want to minimize the significance of the procedure as we're talking about literally cutting of the heart muscle. But fear of the surgery sometimes holds people back from doing what would be in their best interest. Has there ever been a case where a patient did not make it out of the surgery as a result of the procedure?

SPEAKER_01 9:56

No. So we've done close to 250 of these now, and we've had no major complications. My definition of major complications is no death, no stroke, no heart attack, no significant bleeding where they required a reoperation in the short term. And we haven't had anyone that's needed a reoperation because the bridge wasn't done completely either. Now, this is not to say that there's been some minor issues. The most debilitating ones is we've seen a few cases of what we call Dressler's syndrome, or an inflammation of the sac around the heart, or the sac around the lungs, where they get bad inflammation and pain afterwards, or can collect fluid around the heart or the lungs, do that. We've had one or two patients that have required a blood transfusion, you know, received you in the platelets. And we've also had one or two people who's had some healing problems with the breastbone or the skin above that. Very low rates. I think I have trouble completely putting myself in the patient's position. But I think a lot of the concern of it being scared about having cardiac surgery, the risk of major complications, and it's not zero, but for us they've been very low. And then I think the recovery, right? There's a period of time where you're not going to be able to do what you want to do when you want to do it. And that's tough. And getting up that control, in my mind, I don't want to ever coerce anyone into surgery, but I think the right if the symptoms are so significant and the patient's driving it, the cost of the surgery is the risk up front and then the time to recovery. And the patients that we've studied really think there's a very high likelihood of significant symptomatic improvement. That risk is short, and the recovery period in the big scheme of things is short, and then hopefully we'll get you back to doing what you were doing before the way you wanted to do it.

SPEAKER_00 11:53

Well, I want to make two comments on that. First, it absolutely is the team, and it's the preparation of that team that I can attest to having gone through the procedure. So much takes place on the back end that if that doesn't build confidence, yeah, I I don't know what does. But the second part is that people are so concerned, and and what we hear more than anything is the sternotomy part, it's the cutting open part that's the hard part. And oh boy, is it gonna hurt and the pain and well it it's your heart. We're worried about your heart, it's not so much your sternum. And I think that as they hear this, what you're saying gives them some solace that okay, maybe it's not gonna all happen when I want and happen as fast as I want. I mean, we're all impatient, but to your point, the body does take time to heal.

SPEAKER_01 12:49

Yes, and we do offer a minimally invasive option as well. So, I mean, the recovery can be a little bit quicker with that. Sometimes it's actually more painful than the strenotomy. And I certainly understand people's reticence to have their chests cracked open. I mean, we do this regularly every week with excellent results and expect people to be back, you know, to 100%, you know, within two to three months, and really to be 80 or 90 percent within a month if they have the steronomy throat, but potentially a little bit quicker, the thoracotomy approach. But again, yes, as the surgeon, it's easy for me to downplay the surgical approach because it's not being dumb to me. But I am also able to prioritize the long-term results and not as much on the short-term discomfort, inconvenience, limitations.

SPEAKER_00 13:41

Agreed. Can I ask a question? And this wasn't something we actually prepped on, but it's coming to mind as we speak. Do you see more incidences in a certain age range than you do, let's say, in others? Does it tend to be older, younger, middle-aged, male, female?

SPEAKER_01 14:01

Yep. So we're still learning a lot about this disease, right? I mean, if we go back to the most basic aspect of it, is 20 or 30 percent of all human beings have an intramyocardial LAD or you know, what we call a myocardial bridge. For a at least as far as we can tell, it's only a very small portion that have active symptoms because of that. You know, and our when we looked at our first 50, 100, and 150, we found that it was usually women kind of in the 30 to 45 age range. Uh, we haven't, now that we're you know, in the 250 range, and I'm only talking about the ones that progressed to surgery. I think there's a thousand, right, that Dr. Schnicker and Dr. Tremella see, but no, you know, whatever percent come to surgery. So it's my impression now that we're seeing some more males and some people up into 60s and 70s. And then well, yeah. And I mean, there are also we're beginning to see some distinctions within the disease itself, right? So for me, class, what I call classic, isolated, you know, this being the only problem, myocardial bridge, is someone without coronary disease associated with it, right? They're quite young for someone that's gonna go to heart surgery in the 30 to 50 range, and they don't have a fixed blockage from coronary atherosclerosis, but they do have significant symptoms and chest pain when their heart rate gets up and possibly some endothelial dysfunction with it as well. So that's one part of the disease that's just myocardial bridge, plus or minus endothelial dysfunction. Then we've also looked into this and the flow disturbances that come from the bridge. And we do see that all patients have some thickening of the artery before the bridge. And we have a question, this is a hypothesis, this isn't known, if that can progress to a certain form of coronary artery disease where there's proximal LED obstruction from the altered flow dynamics from the bridge that develops farther along in life. So it's not necessarily, you know, your cholesterol is way out of black and you're ate at McDonald's twice a yeah, you know, twice a week, twice a week or smoked or something like that. If there's actually just a mechanical component to the way your heart formed that predisposes you to having significant coronary artery disease.

SPEAKER_00 16:36

And Dr. Schnitter was very clear in her discussion with us 100% of the people with a bridge have some semblance of thickening or occlusion where the artery enters the heart.

SPEAKER_01 16:48

It's not always occlusion, right? The tube doesn't always get narrow, but the wall always gets thicker. And then sometimes also the tube is getting narrower. Is that because of the bridge, or is that because of the more commonly recognized problem of coronary artery disease?

SPEAKER_00 17:04

Thank you for clarifying that because that's an important part. Especially for those of us with bad cholesterol issues. It's like, well, why? How is it how is it compressed like that? I didn't do anything to cause it.

SPEAKER_01 17:16

Yes, yeah.

SPEAKER_00 17:21

So knowing what we know and knowing what we see from so many people who have had the surgery and the resulting reduction in symptoms created by the bridge, and uh for some of us with literally no symptoms post-surgery, and we become asymptomatic. What's your opinion on why this is still seen as such a controversial procedure? What can we do to convince the cardiology community that myocardial bridges are real, they are symptomatic, and we've got all these case studies now, hundreds throughout the country, of people who have been improved as a result of the surgery?

SPEAKER_01 17:56

Yeah, so I think I alluded to it earlier, that the the fact that bridges are so common, right? We suspect 20 or 30 percent of all people have them. But then the surgeries that we've done for our patients have been very important and life-changing positively for most, almost all of them. But that's really only a small percentage, a fraction of a fraction of a percent of the entire population. So it's very real for the people that have it. How common it is to have a bridge and have it be pathologic or cause symptoms, I think, is much, much more rare. So that's one thing. Then I also medications, whether it be a beta blocker, a calcium channel blocker, or you know, a nitrate-based medication, those are generally seen as pretty reasonable. But surgery for something like this seems quite radical, right? I mean, we have you know done lots of planning and had very good results for our patients, but it still is heart surgery. And there is a risk that a coronary artery can be damaged. Sometimes the coronary arteries run through the ventricle, the heart can be opened up. You know, it's not without risk. And so at some point, there likely will be a major complication. And you know, humans have had myocardial bridges for the entirety of history, and we haven't conclusively demonstrated that it causes sudden cardiac death at a lagulate rate, you know, and it's something I understand how people are, you know, slow to accept the medical community, the established medical community, is slow to accept it as a real problem. So I think more than convincing, it's really developing a good relationship with your physicians so that you can have a conversation. Because when I first heard about it in 2014, I was like, maybe I heard about this in medical school, but we certainly didn't pay any attention to it. So I look at it more at developing good patient-physician relationships, being able to have a conversation about it. Our program is really continuing to do quite a bit of research into it. You know, well, what group of people is it most commonly in? What are the hemodynamic factors that you know predisposed to having symptoms? What is the natural history? Can this be a life-threatening condition? Is this a life-threatening condition? Is there another medicine that could treat the symptoms that people could avoid having heart surgery for? I think those are some of the reasons. And then we have still yet to collect beyond symptom surveys, a significant amount of objective data or that hemodynamic data after the surgery to show that the surgery has what it's changed physiologically, and you know, be able to make that connection from the bridge and its squeeze to the symptoms that you experience to well, did those measurements change after the surgery, or how much of this is a placebo component, right? Because Dr. Schnicker cares about her patients and has developed that relationship with them in separate instances, that in itself has been shown to be beneficial. And so I think all those reasons together. It's a common anatomic finding. We don't know if it's a risk for sudden cardiac death. We have seen some you know minor heart attacks from isolated bridges, how it plays a role in the development of coronary artery disease, kind of all those things together can contribute to why it's not universally accepted as a disease male.

SPEAKER_00 21:32

Do you think the information that's being conveyed today is effective in getting more and more cardiologists to understand and at least appreciate the reality of the symptoms?

SPEAKER_01 21:41

Yeah, I would say in the first five years that I was doing this, when patients would come and travel to us, right? The story we received was you know, the cardiac, the physician that they were working with, you know, was not on board with them coming to our program to see it. And sometimes, you know, involving Different group of physicians stress that relationship with their primary doctors. It that seems to be less common now, in that I think, well, your podcast, how many listeners you had, and certainly the Facebook group and the literature that our group has published is bringing it to awareness. Had sessions on this at some surgical meetings, right? So the AHA will talk about it a little bit, the ACC will talk about it a little bit. Our surgical societies are also starting to mention it. So it's gaining critical mass, or like it's becoming more, people are becoming more aware of it.

SPEAKER_00 22:39

And that's certainly the intent here. It's just to make people more aware of it so that more and more people can get treated and live better lives. You know, Dr. Boyd, many people are considering the surgery. They're apprehensive about the strenotomy, and they're hearing about robotic surgical unroofing at this point. And obviously it's less pain, faster recovery times, less trauma to the body. Can you comment a little bit about what you're seeing in terms of robotic unroofing at this point?

SPEAKER_01 23:06

One of the main limitations of robotic surgery is that the main surgical robot no longer maintains the appropriate equipment or makes it for the current additions of the surgical robot to do the surgery. I know it's been done and been done safely. I'm not sure it's going to be universally applicable because coronary travels within the ventricle that opens up. Or sometimes we see just pure muscle over the top that's easier, easily separable. Sometimes there's some scar tissue that doesn't come off the blood vessel quite as easily. And I see that as being potentially problematic with the robotic approach. I certainly recognize its appeal, right? Having your chest cracked open is worse than having a minimally invasive surgery is worse than having a robotic surgery from the from the patient's perspective. Some of that, I guess, perception and marketing than real. So certainly with minimally invasive, if you can perform the same surgery and do it with less trauma, that's a better thing. I agree with that completely. I do minimally invasive valve surgeries, I do robotically assisted bypass surgeries. I think that's the way we should be headed. The equipment doesn't exist to do it for everyone at this time, and there are going to be some people that aren't going to be candidates based on their anatomy. And I also think robot surgery, the perception that it's a quick fix and that you're going to come in one day and go back and be completely normal tomorrow is unrealistic at this time.

SPEAKER_00 24:43

And I do think many people see it as the panacea to the challenges of everything else, right? A lot of people are just waiting, and in some cases, they're wasting quality of life time. Whereas a healing of eight to 12 weeks from a sternotomy really is relatively short when you think about it in the grand scheme of things.

SPEAKER_01 25:00

Yes. But I mean I can understand how, right? I'm not the one that's going through that. So it's a balance of what the symptoms are and how how difficult that is for you on a day-to-day basis, and what your own internal value system is for what costs you're willing to pay to have a very good chance of having those symptoms go away.

SPEAKER_00 25:21

So I'm going to shift a little bit on you. Yours is truly a career of life and death in so many cases. That to me is incomprehensible in terms of the stress. What is it you do to unwind? What does somebody like Dr. Jack Boyd, who's in people's hearts and chests all day long, do to relax and have fun? And I know you do take vacations because I had to wait a week for my surgery while you came back from one. But what is it that you do, Dr. Boyd? How do you relax?

SPEAKER_01 25:51

Well, Jeff, I have a wonderful wife and four terrific children. And so a lot of my time away from work is doing fun things with them or and or driving them around to extracurricular activities. And we do like to take time off when the kids are out of school to go visit family or go see somewhere that we haven't been before. I've also, since relocating to California, I've developed an interest in surfing. So as you say, I'm learning how to surf and generally like, you know, hiking, biking, reading books, the things that uh I don't know, I think most people enjoy doing.

SPEAKER_00 26:25

Yeah, and the values that California brings to us in terms of its topography, its geography, everything else.

SPEAKER_01 26:32

There's there's so much available to do here pretty much any day of the year.

SPEAKER_00 26:35

I appreciate that. Thank you. You know, if there was one thing we could leave everyone listening with, knowing the majority of the people who are paying attention to the podcast have a myocardial bridge, is there a suggestion that you could give as the best thing you can do for yourself? Obviously it's individual, but if you could say something to the effect of, Jeff, here's the one thing I'd like you to consider as you consider the options of how to deal with this bridge, what might that look like?

SPEAKER_01 27:07

I guess I think of it as being their own self-advocate and recognizing that the medical team that they form around them or form with them to work through this problem is on their side or their team. So someone outside of our program may not have a lot of experience or exposure with myocardial bridges, but they're in their profession generally because they want to help people. And so it can be difficult if a patient presents with symptoms and the doctor or nurse practitioner doesn't have a fix for them. And so I guess I would say hang in there, keep your head up, continue to work through it. And certainly by all means, they're welcome to contact us in our program, you know, to help work through this. There's literature available that they can, you know, present in the right manner to the people that they're working with to, you know, help them gain some understanding and know that, you know, if their problems are because of a myocardial bridge, there is a potential solution for them that can make them feel a lot better.

SPEAKER_00 28:09

Thank you. And that self-advocacy is so important, as we know, just because you get told one time it's anxiety, it's stress, you know, whatever, which we know happens quite often, but you just have to keep going and you have to keep asking the questions. And if you really believe and you really feel and you know your body, then that condition is real. There's an answer out there someplace.

SPEAKER_01 28:34

Yep. You you know your body better than we do. You have to give us some time to catch up and figure it out. I think you know mine better than I do inside.

SPEAKER_00 28:45

So I've been blessed to have been introduced to you as a result of my condition, Dr. Boyd. And I have the utmost appreciation for what you do. I'm eternally grateful for the fact that you are my surgeon, as most people know. And I've been asymptomatic since the surgery. So I mean, what a blessing that is. Your surgical skill allowed me to return to the physical condition I was in a couple of years ago. I remember the day that I was leaving the hospital. You showed up, and it was a Saturday when you could have been spending time with your family or hiking or learning to surf. You were very casual, which was really nice to see. And we had a conversation in the hallway, and I said, You know what? I do podcasts for a living. And I'm going to do a podcast about this, and I would love to have you on. And here we are. So I thank you for that. I thank you for your time, for sharing your experience, and for giving so many people the hope and knowing that there are solutions to relieving the symptoms of these crazy myocardial bridges. It's my opinion that the world's a better place because of what you're doing and what your team at Stanford is doing. And I cannot thank you enough. I thank you from the very, very bottom of my imperfect heart.

SPEAKER_01 30:10

Thank you very much, Jeff. It really is a pleasure and an honor. And I can't tell you how much satisfaction I I take from being able to work with you and other people with conditions like yours. It really means a lot to me.

SPEAKER_00 30:24

And this speaks volumes for a lot of the people who are in the space because we have one of the foremost authorities on the literal condition itself, the person who handles the heart. What we're doing in this conversation will give people the confidence and the hope, and I think it'll eliminate some of the fear. So thank you again, Dr. Boyd.

SPEAKER_01 30:46

Appreciate your work. Thank you.

SPEAKER_00 30:48

Thank you for listening to Imperfect Heart. It's my hope that this information helped in some way to improve your situation or will help you better understand this condition. More importantly, that it gives you hope through stories that there is help and you most certainly are not alone. If you've been diagnosed with a myocardial bridge, please be sure to join the private Facebook group, Myocardial Bridge Support Group. For more information about our program or to reach me directly, visit the website, myimperfectheart.com. If you like what you heard today, please give a positive review, thumbs up, high five, whatever your app likes. And be sure to share with everyone important to you so they understand what it is you're dealing with. Please subscribe as well. Welcome each day with gratitude and positivity.