Episode 17: Minimally Invasive Myocardial Bridge Unroofing Explained by Professor Theo Kofidis

SPEAKER_01 0:00

For a myocardial breach patient, I take two hours because they happen to be educated, very clear about their condition, they have tons of questions, and the doctor must take his time to address all those questions. It's even medicalically sound, so no question is left uncovered. No doubts.

SPEAKER_00 0:45

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. If you would have asked me nine months ago when I started this podcast where I thought our conversations with doctors or those with bridges would originate, I would have most certainly said the United States. I never would have imagined I would be speaking with unroofed patients around the globe, and I certainly would not have expected to have had the opportunity to speak with one of the leading cardiothoracic vascular surgeons in Europe or Singapore for that matter. I guess that gives you a hint as to who my guest is today if you're active on the Facebook page. It's none other than the professor who gave us nearly two hours of his time on a Sunday for an interactive Facebook Live presentation. Yes, Professor Theo Cofetis. Head of the Department of Cardioth, thoracic, and vascular surgery at the National University Hospital of Singapore, senior consultant cardiothoracic surgeon, an expert in minimally invasive heart surgery, and an avid researcher. He's a renowned cardiac surgeon and strongly sought-for proctor and surgical teacher around the world, one of only a very few American association of thoracic surgery members in Southeast Asia, he's also an ambassador for the steering committee of the World Society for Cardiothoraci for the same region. He's founder and owner of the company Cardia PTE Limited, aiming at the development of disruptive heart valve and minimally invasive heart surgery technology. He's chairman of Initiative for Research and Innovation in Surgery, has introduced various new technologies and launched new types of less invasive surgery, and over the last 12 years in Singapore, has established the most complete, pioneering and advanced minimally invasive and endoscopic heart surgery program in the region. He's also set up the most advanced hemodynamic research laboratory and cardiovascular surgical research group in Singapore. Professor Grafitas has trained in some of the world's leading institutions, including Rochester, New York, Texas Heart in Houston, Hanover, Germany, and one we're most familiar with, Stanford, California. He's decorated with various international awards and carries various offices and commitments internationally. He has lectured for the American Medical Association, the FDA, the Bill Gates Research Institute, and more. As an academic teacher, proctor, and consultant for a number of companies, he is holding events and workshops in various countries around the world, bringing minimally invasive know-how to doctors and patients alike. He resides in Singapore with his wife and daughter, has a passion for flying airplanes, and enjoys photography, exercising, and reading. Welcome to Imperfect Heart.

SPEAKER_01 4:04

Happy to meet the audience as well.

SPEAKER_00 4:07

You happen to have the distinction of being my first international guest. So we've never had anybody outside of our United States time zones. I know it's nine o'clock here. What time is it in Singapore?

SPEAKER_01 4:20

Well, it's 12 noon the next day. We have 15 hours of difference. Singapore is ahead.

SPEAKER_00 4:25

Wonderful. You know, one of the things that we see from the Facebook group, and and thank you so much for the participation on that Zoom session that you did for everybody that participated with you. Europe seems to be slower in acceptance of myocardial bridges and certainly the subsequent surgery process or surgical process to repair a bridge. Why might that be the case?

SPEAKER_01 4:47

Well, first of all, there is this global phenomenon of the myocardial bridge not being duly recognized and acknowledged as a disease entity. There is a lot of confusion. We must also remember that Europe is not one thing, one healthcare system. It's like 35 or 40 different healthcare systems. There is no continuity or common philosophy on all kinds of diseases. Myocardial bridge, being more or less at the edge of this spectrum, is not really duly recognized oftentimes. The other reason may be that every country has its own healthcare coverage as well as medical-legal system. And there are quite a few countries in Europe where doctors, out of fear of failure or fear of medical-legal persecution, exercise defensive medicine or defensive surgery. Myocardial bridge being a not so well recognized entity, many surgeons will think twice before they go into something like in the gray zone, as myocardial bridge is. That's how they may view it. And that would be the best answer, I would imagine, addresses your question.

SPEAKER_00 5:51

It does. And I saw in your training that you spent a fair amount of time in the United States at some phenomenal hospitals, including Stanford and Texas Heart. Do you think that gave you a little bit different perspective taking it back to Europe and Singapore?

SPEAKER_01 6:08

Yeah, well, absolutely. That was in my earlier years, my formative years as a scientist and surgeon, so to speak. And definitely the United States has impacted the way I think, you know, the way I strive for the best possible outcome for the patient and innovation. So the open-mindedness, the grandeur of, you know, the hospitals I had the privilege to train helped me think big and pursue my goals with the utmost dedication. That's pretty much American, I would say, and that stained me in a good sense for the rest of my life.

SPEAKER_00 6:41

Let me ask obviously, you're Greek, and Greece is home. Why Singapore? How do you tie those two together?

SPEAKER_01 6:50

That's a very good question. And I'll keep my biographical part short in a nutshell. I left Greece when I was 18 years old, born and raised in Greece. That's where they say home is where mama is. So mama is in Greece, definitely. So I then went to Germany. I did my medical studies in Germany. I did my internship in Rochester, New York, and Texas Heart, as you mentioned. Then back to Germany for the main specialty training. And then I got an award which financed my training in Stanford as well as my research. So this done, I had to go back to Germany to get my PhD defended. So I defended my thesis, finished it, and out of nowhere, I had an offer from Singapore. I found myself at a dinner with a very significant Singaporean leader around the table who got very interested in my pursuit of innovation, research, but mainly minimal invasive and endoscopic heart surgery at that time. So he invited me for a lecture in Singapore, and the rest is history.

SPEAKER_00 7:47

One of the things that you just mentioned there with the minimally invasive is a very hot topic with the Facebook group and certainly amongst all of us with myocardial bridges. As I hear from those conversations, and having recently had Dr. Balkey out of Chicago on, and certainly Dr. Boyd out of Stanford, two very different perspectives. One's sternotomy predominantly, one's robotic. You fall somewhere in between in the middle as the minimally invasive doctor and professor performing. Can you explain a little bit first about the minimally invasive procedure? Yeah. And then secondly, why you segment yourself in that space? Okay.

SPEAKER_01 8:27

So the minimal invasive procedure means that we avoid median stenotomy. We avoid basically chopping the chest bone open. That's the main difference when you do minimal invasive. And minimal invasive is a broad term that includes endoscopic, also, that means guided by cameras, or robotic, which means done by robots. Robotic is also a form of minimal invasive, truly very minimal invasive. We must understand that the premise in the treatment of myocardial breach is the thorough unroofing. Now, whether you are a median stenotomy surgeon or a minimal invasive surgeon or a robotic surgeon, as long as you don't take any discounts and you do a proper unroofing on the arrested heart, I believe, you are good to go. So now the minimal invasive perhaps is a marriage of both worlds and gives you both the tactile feedback of the human own hands, the versatility of changing direction and going to the other artery as well, which the average robotic surgeon may not be able to give you. And at the same time, it saves you the median synotomy. As I said, the number one requirement, however, is to do a good job. Not every patient qualifies for a minimally invasive or robotic procedure. Every bridge is perhaps different, and every unroofing may end up being a slightly different procedure. So, and there are patients who don't qualify for a minimally invasive or robotic procedure. So, in a way, minimally invasive, robotic, or median stenotomy, they are customizable solutions for the best interest of each and every individual patients. We just have them around quiver and we pull out the right thing for the right person. We, and I personally cover the entire spectrum, it may be any of those. And you will have heard that some of the patients I operated in Greece had to have immediate stenotomy because they didn't qualify for minimal invasive. The myocardial bridge may have been very, very high up close to the aorta or the pulmonary artery. And this is something you don't want to risk trying to reach from a small keyhole on the side.

SPEAKER_00 10:35

Perfectly understood. And I think it's important that our listeners know that you speak with our other surgeons that we've actually had on the program. And you're familiar with them, Dr. Balke especially, who is predominantly robotic. He works on a beating heart as opposed to yourself, who arrests the heart, and Dr. Boyd, I think, is predominantly arresting the heart. What is it that helps you determine whether you're going to accept a patient or not accept a patient for unroofing surgery?

SPEAKER_01 11:06

Well, unfortunately, as we all know, there is little science behind the causation and the progress of myocardial bridging. Let's face it. So people around the world have controversial views as whether it's really a myocardial bridge, whether it's vasospasm, what it is in the end of the day that causes the patient the symptoms. And accordingly, we take the appropriate approach. What I've learned is that when the heart is beating, and I've seen a lot of myocardial bridges, they can be so fine, so thin, almost invisible, just fibers crossing over the artery. And I believe the Stanford group goes, you know, follows the similar principles. It can be so fine. I've seen too many doctors injuring the LED, the underlying coronary artery, when you try to do it on the beating heart. So, right up front, I learned to respect the myocardial bridge and go on it very, very thoroughly and rather conservatively in unroofing it, trying to unroof beyond the actual myocardial bridge, well into the healthy area of the vessel. So, and I've seen so thin arteries, partially calcified arteries, arteries that you can easily destroy if you really don't pay attention or if the heart is beating. Now, coming back to our colleagues, particularly Sam, Professor Usambalki of Chicago, there are many robotic surgeons out there. And I know Sam very well. I'm privileged to call him a friend. We are talking about potentially the top robotic cardiac surgeon on the planet. Okay? So if there is somebody amongst those surgeons who believe to be able to unroof a myocardial bridge robotically, he's somebody who can land a helicopter on Everest. Okay? So the normal rules perhaps don't apply for him. All right? I have the utmost respect for Sam. But I do, having said that, retain my own views that I've seen so versatile, so diverse, so dangerous, and so thin and undiscoverable myocardial bridges, that I'd rather give my, you know, retain my own fingers, super fine, tactile feedback that a surgeon has, which the robot may not give you. My all due respect to the robotic surgeons out there. And let's not forget that the way I've come to see myocardial bridges and started knowing and learning about this issue was from the medical-legal point of view, because I was senior reviewer in some court cases of arteries that were destroyed, myocardial bridges which were not unroofed properly. So that's what got my interest to study and understand this entity very, very well and see what is out there, do a thorough research and customize what for me is the adequate surgery for those patients.

SPEAKER_00 13:52

It's interesting that you say it was a court case that you got you interested in the myocardial bridge. Right. Same situation for Dr. Schnitger. She was involved in a court case, had no understanding what it was, and she was almost embarrassed because she didn't, because the attorney knew more about it than she did. And so that caused her to investigate, and she realized this is really a place where I need to do a lot more research.

SPEAKER_01 14:15

Absolutely. And to this day, the disease is very often not objectifiable by the cardiologist. That means that they look at the controversial angiography, they look at eventually a CTCA scan, which looks like so and so, and they still cannot make a 100% diagnosis because the consequences are severe, right? The patient must go for surgery and all this. And then they put the patients on the treadmill and it doesn't show up. They do all kinds of ibus tests and the usual half moon sign doesn't appear. And yet the patients are suffering from symptoms. So to this day, Jeff, we don't have clear guidelines as we do for bypass surgery or heart valve surgery. We have recommendations in the form of a flowchart that tells us in this case, if the patient continues to have pain, severe pain, his life is compromised, and medical therapy with the usual, you know, calcium channel blockers, beta blockers, nitrates failed for six months at least, then the discussion is open for surgery.

SPEAKER_00 15:20

You just teed up three questions that I have to ask you.

SPEAKER_01 15:23

Yeah.

SPEAKER_00 15:24

The first one is what is the process you use to identify the bridge for the patients that you're actually going to operate on?

SPEAKER_01 15:33

Yeah. So, well, all the aforementioned, I would say. So the the main diagnostic method is the angiography, and they're ideally the DFFR, which is a diastolic flow measurement of the vessel. We'll come to discuss a bit about the background of these examinations. I appreciate having a CTA, a CT scan, a CT angiography that is then reformatted by the radiologist or cardiologist in a 3D fashion that has a high likelihood of showing you the course of the artery, not necessarily the bridge itself, but the very exact cost of the artery. And indirectly you get hints of where the bridge is or may be. Of course, the more you do like exercise tolerant tests, usually by the time I get to see a patient, the patients are so knowledgeable, they've been suffering for years. They have done all these tests. They've done all these tests, but this latter-mentioned test, for example, is very unstable. It may come out positive, it may turn out negative, but the patient still has a breach and still still has symptoms. IVUS, which the Stanford group is using, is also can add value to the diagnosis. But my last word on that is that many of those techniques are supplementary in the diagnostics. They may not be the diagnostic cell test itself, which we 100% rely on. So the least I expect is to see the bridge in the angiography. That means you see the squeeze as the heart muscle squeezes and let's go. And then the CTA scan, which will show me the geography within the chest and the arteries on the heart. So I can adapt the technique for the particular patient.

SPEAKER_00 17:08

On the CT scan, if I can ask, the ability to read that scan.

SPEAKER_01 17:14

Yeah.

SPEAKER_00 17:14

And I know Dr. Schnecker at Stanford really relies only on one or two particular professionals to read her diagnostics off those CTs. It is, I want to say, almost somewhat commonplace that we're seeing people, oh, I that's a bridge, that's a bridge, that's a bridge. And I know it's causing some people concern on the Facebook group because they see it and they know what it's supposed to look like, and they see three or four or five of these on their CT, but we're we're not trained people. We don't know specifically what we're looking for. And I want to maybe get it from your perspective, from somebody who really knows what these are about, what to watch for and what to be careful not to be fooled by.

SPEAKER_01 17:53

Right. Well, first of all, I would discourage any of our friends on the Mayo Cardial Bridge Facebook group to make conclusions on their own. I would equally discourage them of panicking, because I'm watching the group, I'm part of the group, and there is so much panic, and on a lighthearted note, sometimes also a bit of nonsense, meaning that uh patients are so confused and so stressed that they project other problems onto the heart and the myocardial or other symptoms that may be unrelated. And I feel so compelled to jump in and answer, you know, to relieve them of their panic. But you know, I must respect the PDPA, Patient Data Protection Act. If I answer to your case particularly, Jeff, that will trigger an avalanche of reactions from two other thousand patients who may not have what you have, and that is against my hypocratic professional principles. So, anyway, so I would discourage them to make conclusions for themselves. There are in our profession, as in any other profession, there is a whole range of professionals. Some experts in looking at the knee and telling you exactly what you have. There are cardiac CTA professionals who really have the eye, the expertise, and the 10,000 hours, so to speak, behind their back that can make better 3D reformations and better diagnosis of myocardial bridges. One of them is Dr. Khalifati, for example, in the St. Luke's hospital in Greece, where I'm unroofing some of the patients.

SPEAKER_00 19:21

One of the things that you mentioned in the conversation on the Zoom call was as you go through the process of unroofing and you are making that slight incision, I'm assuming very delicate incision with a lot of haptic feel. You also denerve.

SPEAKER_01 19:39

Yeah.

SPEAKER_00 19:39

And I think that was a new word for a lot of us. Can you explain what that means?

SPEAKER_01 19:44

Okay, I will start with a disclaimer, if you permit me, Jeff, that this theory of denervation is just a, it doesn't have scientific foundation under it yet. It's just our theory in our team because we often see that the myocardial bridge is very, very small. People target the myocardial bridge, unroof the myocardial bridge, but then patients turn out retaining their symptoms. There is no difference. I'm sure you can tell there are hundreds or thousands out there who went through unroofing and their symptomatology remained the same. It's all for nothing, basically. So in our practice, as I said, in order to not miss any potential thin fibers that are crossing over, right from the beginning, I was unroofing all the way, basically over a long stretch of the LED or any other vessel. And so then I realized how come our patients turn out to have almost excellent results? I mean, at some point we need to gather them and publish them with long follow-ups. And I realized that, and I did some thorough search, and I'm working with a university professor in Greece as well and a larger team who are doing a thorough search. Now, there is a mechanism in the LADN, any coronary artery, that is affected by the surface nerves on top of the artery. It's the outer layer of the artery. Those nerves can have impact on the constriction or the dilatation of the coronary artery. Usually, what they do is they release a hormone, a substance, which is called acetylcholine. This acetylcholine infiltrates through the wall and causes impact on the endocelial cells. This is the inner lining of the vessel, and normally causes the vessel to constrict. Now, in myocardial bridge, there is enough literature out there that proves that that interaction is disturbed. And instead of causing dilatation of the vessel, it causes constriction of the vessel. Add on a second physiological impact, which we found. After the squeeze, there is a massive acceleration of the blood because of the squeeze. So it's like the Bernoulli effect in the pipe in a vessel. You know the the Hose in your garden. If you press it at the exit, then the water will jump farther away. So there is an acceleration of blood right after the bridge or at the middle of the bridge already, causing this blood to accelerate towards the end of the vessel. And so the branches, the preceding branches right after the bridge, don't get enough blood. So we call this a steel phenomenon, steel as in robbery, stealing. So these two physiological phenomena seem to have an impact on the symptomatology as the bridge itself. So and by unroofing thoroughly on the arrested heart all the way up and not just going desperately for a one-centimeter bridge seems to affect that denervation process. That means these nerves on the outer layer probably are cut or made dysfunctional. In many cases, I do see the vessel beautifully blowing up basically, becoming bigger and more round. You know?

SPEAKER_00 23:04

You mean immediately after you unroof it?

SPEAKER_01 23:06

Yes, immediately.

SPEAKER_00 23:08

That quickly?

SPEAKER_01 23:09

Yeah. Not in all patients, but in many patients where this eventually takes effect. And in order to keep record of this, when I do my unroofings, I use an additional device called high frequency ultrasound. The market name, the branch name, the brand name is Medistin. And it has a special epicardial probe, a little probe which you put on the vessel, and you can see right under the surface of the heart, you can assess the artery. It's the MEDISTIM MiraQ, Mira as in M-I-R-A-Q, and I'm using this before I start cutting and afterwards to compare before and after. So our quality assurance is there. It helps me guide and find the bridge, but it also shows me the improvement of the flow right after that. Again, it's not always the same in every patient, but it's an additional guide.

SPEAKER_00 24:03

Well, and I'm sure that also gives you some sort of tangible evidence of change in that artery.

SPEAKER_01 24:09

Right, right. The most telling evidence is the symptoms of the patients we'll see afterwards. Remember, unroofing a myocardial bridge may not result in immediate total relief of symptoms. It may be an ongoing process of recovery. In a certain percentage of patients, we're not sure, 20%, 30% may not experience a symptomatic relief. But what in our patient group, call for it, what basically confirms that our strategy is perhaps right, is the fact that the vast majority of our patients experience asymptomatic relief.

SPEAKER_00 24:47

If I can take just a little bit of a step back, because it's a question I've asked of all of our doctors, professors that we've had on, is we know that the condition causes a starvation of blood to the heart, which in some cases causes a myocardial infarction, or even worse, you know, a full-on heart attack with damage and everything else. I personally had a heart attack, fortunately, no damage, but it did cause an MI as much as we all hate to say, no, that wasn't. It was we just had an incident. But is it possible if the estimates are that there's 25 to 30 percent of the population, global population, just humanity, has a myocardial bridge of which a small, small percentage are symptomatic, we understand. But is it not possible that some of them may be asymptomatic until one time and they actually die?

SPEAKER_01 25:43

Well, there is this quote: there is nothing in medicine that there isn't there. So that means everything is possible, in other words. We have seen all kinds of borderline situations. But, Jeff, the reality is unlikely. We have to distinguish at this point a myocardial breach, a true myocardial bridge with an element of vasospasm, with a post-breach acceleration. We must separate this from an intramyocardial cause of a vessel, which we surgeons see during the bypass surgery all the time. That means the best the vessel gradually dives under a thin layer of muscle and then disappears. That's a very frequent situation. That's not equal myocardial breach. So you are right, indeed, even of all those patients, you throw them in a pot, only a small percentage will have a symptomatic myocardial breach. Now, this the myocardial breach, other than causing severe and debilitating symptoms, is also known to cause earlier onset of coronary artery disease. I mean, real atherosclerotic disease with blockages of the coronary arteries. In fact, in many of the patients I unruve, even though they are young people, I do see a premature thickening of the vessel wall, like the starting process of atherosclerosis, the true disease that causes bypass later, bypass surgery. Yes. Right in front of the myocardial ridge. As for this, the muscle damage, the ischemia you mentioned, this is also the reason because of the acceleration of the flow and the steel phenomenon. You see, the LED is running right over the septum of the heart. The septum is the muscle that separates the left heart chamber and the right heart chamber. And there the LED gives rise to a lot of small septal branches that feed this septum. So because of the acceleration, the blood doesn't have the time to go into those septal branches. So what is the end muscle, the end organ that feeds from these branches? Is your septum. And therefore it bulges and because it swells, it's stunned for a little while. And this phenomenon, the septal stunning or the septal bulging, is well described in myocardial breach patients. So it's a temporary relative ischemia caused by the breach.

SPEAKER_00 28:03

I think that's a wonderful explanation. And it leads me to believe that while the bridge directly isn't the cause of a potential heart attack, but it could be the cause of another symptom it creates or another condition it creates. Right. And then it has to be either rerectified or you could you could die from it.

SPEAKER_01 28:24

Absolutely. I mean, very unlikely though. I mean, I haven't, it may have happened somewhere in the world where patients have not been followed up. From the myocardial breach patients, I know nobody thankfully has died ever. But there is a likelihood of a heart attack. There is also a likelihood that the coronary artery disease, which is a two-degenerative disease of the vessel inner wall, will set on earlier in life compared to incotation marks, normal patients.

SPEAKER_00 28:54

Yes, and our other doctors have explained the same situation where the artery thickens or occludes, could be both, where it enters that uh you know, that heart for a variety of different reasons and in some cases necessitates a bypass. Yeah. Certainly the older you are, the more likely you are to have an incident or an issue where there's a problem there. A lot of your cohorts and peers, I mean, in the professional medical world, the greater professional medical world, not your cardiac thoracic surgeons, but cardiologists for sure, still are not on board with these myocardial bridges. If you could say something to them as a result of your experience and what you've seen and what you've done so far, what could you say? What would you say to help move them along to better diagnose people who really are symptomatic who are just being dismissed?

SPEAKER_01 29:45

Well, number one, take the patient seriously. The reason I joined this group is because I suffer with the patients, meaning that I see how much confusion and desperation is there. And the solution is an operation that, my goodness, takes 30 minutes. It's not a big deal for an experienced heart surgeon. So take the disease seriously and don't send the patients to the psychiatrist. I know hundreds of patients with myocardial breach, because the breach itself is not objectifiable in the existing diagnostic methods, they are sent to psychiatrists. Definitely, the patients may need some psychological consultation who wouldn't with a chronic condition. But my advice is take them seriously. Number two advice would be to study. Study deeply and understand the mechanism of this disease. And don't wait until the head drops off the shoulders of the patient to initiate definitive treatment, which is unroofing. Number three, regardless of your background, whether you're a cardiologist, general surgeon, thoracic surgeon, cardiac surgeon, study the outcomes and results so far and don't go and offer the patient a bypass surgery or a stenting. I recommend against stenting. We don't need to turn a non-endothelial disease into an endothelial disease. I've seen also enough myocardial breach patients who have been stented because they presented in some emergency department. All the preceding diagnoses were ignored, and the patient is sent in for stenting, which turns the young patient into a coronary artery patient, and then the stent broke. And then they went in and put a bypass distal to the stent. So the right treatment for this disease is the proper extensive arrested heart and roofing and to address both the breach and eventually vasospasm as good as we can. So educate yourselves. Take the time, that will be my last advice. Take the time to talk to these patients. On average, again, on a cordial and lighthearted note for our audience, a normal consultation of a patient in my busy schedule takes me about 15 to 30 minutes. For a myocardial breach patient, I take two hours. Because they happen to be educated, very clear about their condition, they have tons of questions, and the doctor must take his time to address all those questions. It's even medico-lecally sound. So no question is left uncovered. No doubts.

SPEAKER_00 32:05

And I applaud you for not only participating in the Facebook group because that's one of the best sources and resources for people to get information. I'm sure that's causing some of the greater discussion because they're learning so much. And as a result of the participation in a program like this, where people really get to hear the doctors and the professors speak specifically about the condition, which again educates and they hear it in words versus other people's stories, that they actually start to begin to formulate the questions that are appropriate for themselves so they can better present it to their own cardiologists. And I just can't thank you enough for that participation. You know, you mentioned a little bit earlier when we've seen it from the group, you now have a small cadre of Americans who have headed over to Greece to have the surgery performed. And I don't know that we would call those, you know, destination surgeries or any sort of a vacation. Right. You know, it's it's certainly much more for the cause and the concern of the condition. But do you have any idea or understanding how the insurance in these situations plays out? If somebody's leaving from the United States to come over to Greece to get the care because they just can't find it in their particular city, it's going to cost them just as much to go across the country as it is to go across the ocean.

SPEAKER_01 33:25

Right. Well, now I'm going to get slightly political, but I must be sincere to our audience and the myocardial breach group. As I said before, my practice is in Singapore. I had the department here in Singapore. So after COVID, however, Jeff, and that's the humane reality of it, my father got sick. We lost our father just three months ago. And so after COVID. Thank you. Thank you. After COVID, I had to travel to Greece very frequently to ensure his home nursing and his treatment and all this and whatever comes with that. So these visits had to be more frequent. I went there since 2022, maybe 10 times. Now, whenever I go there, they know me in Greece. They know actually I'm an endoscopic and minimal invasive heart surgeon as my sub-specialty. And so they grabbed me and said, Can you give us a workshop? Or can we do a little conference? Or can you operate those VIPs and so forth? And that's how it started. So I didn't have any intention to go and operate there, coming from one of the top 10 universities in the world in Singapore. However, I was surprised, Jeff. I was surprised that this little two, three private hospitals in Greece, particularly the St. Luke's one, the level of care, it's a family business, it's an American-funded foundation, basically. And with an amazing team, high-tech, you can't even imagine, and no waiting times. So whenever I go to Greece, I just simply thought that look, all those American patients who have to wait for I don't know how long to get a diagnostic scan done. You know? Months and months. And since I'm there, I guess it's easier for them to travel to Greece rather than travel to Singapore, which the which is the antipod of the planet for them. And Singapore is a very high-tech, very advanced, but very, very expensive country. So it's easier and better to just cross the Atlantic, go to a beautiful Mediterranean environment, you literally stay in front of the waterfront, and it that contributes to the healing process. It's a bit of a burden to get on the plane and come over, but on the other hand, it's much, much cheaper for the insurance or the patient themselves. All of South Europe is ridiculously cheap. I don't know the exact numbers, but somewhere about the one-fifth to one-tenth of what an average American patient had to pay for his treatment in the United States or his insurance. So that is a very, very important factor for those patients. I do know from knowing the healthcare systems around the world, all have their advantages and disadvantages. In many ways, Greece ticks certain boxes that other places do not. And if the hospital itself, I know the CEO, I know the guys, they all train in the United States, they assure me that I can have the slot I need for the patient I'm bringing from the United States at the utmost high-tech level, with a family approach to it. They literally take you by the hand at the entrance and lead you to your single bedder for a very reasonable total package. Then I said, okay, I'll do it.

SPEAKER_00 36:25

Well, and the response has been exactly that: that they've been extremely well treated, they have been blown away by the service and the attention and the care that they got. So I I again compliment you for doing that. That's a it's just such a plus because this, you know, that weight is is devastating sometimes for people. Right, right. If you went in mentally healthy, by the time you're getting tested, you're beginning to become unwell because you're anxious and you're not feeling well, you can't do anything, and you don't know what's going to happen. The uncertainty is it's horrific. Right. You know, let's let's take it just a little bit of a detour here, if we can. Everybody likes to know what people do in their downtime. Yeah. And you guys are saving lives, and you have an incredibly high pressure career. And and also an emotionally personal one too, because I'm sure that there's a patient interface that you want to do the best you can for that patient. So it it just drains. I did have a chance to read a little bit in your bio, some of the things you do, but I'd like to hear it from you. What do you do when you get a break and you actually get to go out and enjoy yourself?

SPEAKER_01 37:34

Well, unfortunately, Jeff, my downtime or break time or meet time, as they say, is becoming shorter and shorter and uh more rare, so it would be.

SPEAKER_00 37:43

Based on the stuff you're doing, I would absolutely expect that.

SPEAKER_01 37:46

Yeah, now nowadays I'm a frequent to the United States as well because I'm starting a company. We're developing new endoscopic tools and uh new hard valve implants. So I'm frequently in Minnesota as well as Irvine, California. But okay, what do I do? I'm a pilot. I love flying airplanes, I have a Californian license. So that gives you a kick in a very short period of time, basically. Okay, so the the recovery effect is very, very intense, basically. If you do something unnatural that engages all your senses. So I taking a heavier than air vehicle and bringing it down safely is quite a feat, I thought. So I am a private pilot, obviously. And the other hobby of mine is photography. That quietens you, you uh indulge really, you force yourself to be silent, and you learn to see the way you should see without a camera. It sounds strange, but with a camera, you learn to see the way you should see when you're not carrying a camera. But what we do nowadays in our fast-paced life is we just go by, we look, but we don't really see. There's beauty everywhere.

SPEAKER_00 38:57

I can concur wholeheartedly because I was running at a pace pre-surgery, pre-conditioned, pre-symptom of just go, go, go, go, go. Yeah. Until I couldn't. Yeah. And you make every deal in the world to say that if I get to stick around for a while, I will slow down and appreciate the things that I miss. Right. And when I go out and exercise now, it's not for the pace or the time or the win. It's for the pleasure and the experience. Right. And I'll stop and take pictures. I would never do that. Right. So I I thank you for that. And I can appreciate that. And on that that flight, now, you know, Irvine to Sacramento is close. So you are welcome anytime to take that flight to Sacramento and experience what we have here. And you know, you're welcome.

SPEAKER_01 39:44

Oh, yeah, absolutely. The flight to Sacramento from California, where I usually rent out, is beautiful. You pass over these huge, very high antennas you have just southwest of Sacramento. I don't know if you know about them.

SPEAKER_00 39:56

Yeah, I absolutely know those antennas over TV towers. Right. And you also get to come from over the Sierras and Lake Taro and it's spectacular.

SPEAKER_01 40:05

It's spectacular checkpoint. And then uh there is anecdotally, I once tried to take off from Sacramento, but I was so upset because I was put on hold waiting for the governor's airplane, Arnold Schwarzenegger, to take off. And so that was a nice memory I have. I was in awe when he pulled ahead of me.

SPEAKER_00 40:25

I think he pulled rank.

SPEAKER_01 40:26

Yeah.

SPEAKER_00 40:28

If somebody wants to get hold of you or your nurse Maria, what's the best process? How do they reach out to start a conversation?

SPEAKER_01 40:40

The best way is usually by email because then they can usually attach images, CT scans, and geographies, so we can have a Zoom consultation for which I don't charge, by the way. And so best is email. The most immediate first point of connection is usually the messenger behind the, you know, there's this function under Facebook where you can send a message. Most of the patients send me a message, and then I encourage them to send me an email because I can't obviously disclose everything everywhere using an email which I can have access to from everywhere in the world. So they shouldn't be waiting too long for my response.

SPEAKER_00 41:17

Okay. And is that email the one that I've been working with you on?

SPEAKER_01 41:20

Yeah.

unknown 41:20

Yeah.

SPEAKER_00 41:21

I can post that on the show notes for wonderful.

SPEAKER_01 41:24

And now the good thing about the small boutique, private hospitals in Greece, is that waiting time is basically zero. You get your two hours, not in two months.

SPEAKER_00 41:34

Yeah, that's just unheard of. Even to get a provocative test at this point is going to take, you know, three to six months in some cases, depending on where you're going.

SPEAKER_01 41:43

Right. And I'm I'm sad to hear that, but this is the situation. This is where our advanced healthcare systems are going. Probably we need a reset there on a political basis.

SPEAKER_00 41:54

Professor Cafidas, I I can't thank you enough. I think you shared so many things that not only reinforced, but also brought some new explanations to the conversation that I hear so many people asking. And I think it's just a compounding effect. The more information we can get out there from competent, qualified professionals who really care about what's happening in the condition, it we just can't do it enough until we get 100%, 99, 98% of the cardiologists to at least be able to diagnose appropriately that this is a real condition. Is there anything else that you'd like to add before we before we close?

SPEAKER_01 42:31

Well, I hope that our conversation today aids our patients and helps our patients further. We're always at their disposals. A lot of doctors around the world who are able to help. My advice for the Facebook group is don't panic. This disease can be a chameleon. It changes colors and faces. In me may be different than in you, than in yourself, Jeff. So please don't panic and don't derive conclusions from yourself when you read the Facebook post of another patient. The most tempting thing for me is to engage in the discussion and resolve all the panic on the spot. But for the reasons I mentioned, is I don't consider it, you know, ethically sound. But do reach out if you need any help.

SPEAKER_00 43:15

Thank you so much. And I think to your point, the novelty of humanity is the fact that we are all unique. We are individual, and there are no two cases that are the same. So we have to take that into account, whether it's healing or symptom. And that couldn't have been stated any better coming from a source who has seen so much of it. Professor Graffitas, thank you so much. I appreciate it. Thank you, Jeff. Thanks for having me. 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. The views and opinions expressed in this program are solely those of the host and the guest and are not intended to provide, nor are they a suitable substitute for professional care by a doctor, therapist, mental health professional, or other qualified medical professional. Imperfect Heart is a production of Hear Me Now Studio.