Episode 19: Inside the University of Chicago OR for a Robotic Unroofing Procedure. What It’s Like.

SPEAKER_02 0:13

Welcome to Imperfect Heart, a place for you to join me, Jeff Holden, in conversations, discussions, and dialogue about our hearts and the impact myocardial bridges have on them. 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. After we aired the Dr. Balkey episode, a few weeks later I got a call from Ruth Buckner, Dr. Balke's scheduling assistant. And it was a call I could never have imagined, and it was something that I had hoped would always happen. Dr. Balkey invited me to attend an unroofing procedure robotically. My heart was beating as fast as I recall it, ever beating, thinking I'm gonna have a heart attack. I had never expected anything like this to happen so early in the process of what we do and the discussions with the doctors that we have, but I always had hoped it would be an opportunity that I would get to experience. Now it was the next steps of what do we do. And as I went through the process of evaluating what it was that was going to happen, it was really ironic because I felt the emotion of my own surgery recurring. And in a discussion with my wife, she said, you know, Jeff, this is PTSD. You're reliving the experience. And I thought, how could I relive my own experience through somebody else's? But it really was, as I thought about it, I'm going to now watch from the outside in something that I experienced from the inside out. And what an incredible, incredible opportunity. So now it's just up to the details to get everything squared away. Ruth Buckner called me, we got our schedule taken care of. She says you need to be there early, make sure you get in on time, because you don't get the option to to revisit, you know, if you screw something up. And I recall as we went into the process first meeting Ruth upstairs on the seventh floor of University of Chicago, and then the walking through into the locker room, and like, what lo what locker room? But you're gonna hear the actual audio of this process coming up in just a few minutes. It is so surreal and and and so exciting for me to even share it again. And I've talked about it you know so many times already that I I just I just don't know how to express myself appropriately on this one. What you will hear is attached to video. So if you get the opportunity, it's gonna make a lot more sense in some of the discussions that are taking place if you're watching the YouTube channel. It's the Imperfect Heart YouTube channel, and you'll see some of the things that we're we're discussing. Anyhow, I I recall I I get to the hospital, I meet Ruth, I'm upstairs on the seventh floor, and she goes, We need to get you, you know, gowned up. And I'm like, I'm like a doctor, I'm gonna get gowned up like a doctor. Of course I would be. You know, what was I thinking? I was thinking I was gonna be in some gallery elevated looking down in this surgical procedure. And it was anything but it was totally, totally different. So we walk down the hall, and I get into this locker room. For those of you who have been in the locker room, whether it be at a high school or a you know country club, whatever, it looks the same. It's lockers, orange lockers, and shoes underneath the benches. And I said, Are those the doctor's shoes? These are the surgeons' shoes. Shoes, yes, of course. And it was just such an experience to start that way. As we left the locker room, then we went into the hallway of where the operating room was. And I'll let you listen to the episode because I have live audio of me going through that process. I got to meet an incredible doctor who was going to actually be attending as well in the OR for the unroofing procedure. And it was Dr. Kumaran Mangalam from India, Bangalore, India, and he is a practicing surgeon who does myocardial bridge unroofing procedures in India, Bangalore, India, with the healthcare system there. And I'll have that information at the end of the episode show notes. I'll have his information on the episode show notes in the event anybody wants to reach out and connect with him. He did give me both a cell number and an email. So for those of you who are in India, this may be an opportunity to connect with somebody who can help you. And it's Nariana Health is the healthcare system that he works with. So he and I got to be friends that day. And what an experience to be able to share and ask questions as Dr. Balkey was going through the process of the surgery. So let me get started. I'll pick up where I'm entering the hospital with the live audio, and again, to just share the gratitude I've got, the thanks for this opportunity to literally attend an unroofing procedure robotically with Dr. Balke. So I bride in Chicago a little bit tired after a 5.30 departure out of Sacramento. And you may be wondering why are you in Chicago, Jeff? Well, I've been given the incredible privilege and opportunity to attend a robotic moving surgery. So tomorrow morning I will head over to University of Chicago and about one o'clock I will be in the operating room in some capacity observing whatever it is that happens during surgery process robotically with Dr. Balk. I can't express the emotion because it feels like I'm actually reliving my own experience as I prepped for my surgery a little under two years ago. This is really going to be quite the experience coming from a layman and being able to share what happens during the process robotically. Heading up to the elevators to the seventh floor, which is where the journey starts. And up we go. And here we are at the Sky Lobby coming in. What a beautiful facility. Okay, it's time uh into the locker room, gotta change into a set of scrubs and uh be heading out. So here I am with Dr. Kumaran Mangalam, my new friend for the day from Bangalore, India. And yes, he is a myocardial bridge unroofing surgeon in India. For those who are in India looking for a surgeon, Bangalore, India is where he performs. And again, his name is Dr. Kumaran Mangalam. If you would help me understand a little bit better what it is we're going to be seeing today and some of the people well to actually be in the uh the OR, even though I won't be taking pictures.

SPEAKER_04 8:03

Sure. You'll see Dr. Kitahara, hero. Kitahara is Dr. Balkie's assistant surgeon. Um, you'll also see Caitlin Grady. She is the senior physician assistant. She'll be assisting him in the OR. You will not see the two nurse practitioners there on the other side of the hospital. That is Shiraka Coleman and Brooke Patel. The nurse practitioners um do the pre-op. They also do uh see the patients after surgery to pull their chest tubes, and they medicate the patient after surgery. They follow the patient until discharge.

SPEAKER_01 8:38

So at this point, all is quite calm. I'm just waiting for surgery to begin. Kind of like the green of the concert where the celebrations come in.

SPEAKER_02 8:50

So, what we're looking at here is the Da Vinci XI machine from a couple of different angles, as it's in the hallway. It's not the machine Dr. Balkey can use because the arms don't work appropriately with the stabilizer. As we get into the room, we'll notice that it's a Da Vinci SI machine that we're working with. Operating room number four is Dr. Balkey's home away from home, where all his surgeries are done robotically for those patients with myocardial bridges, as well as those patients where he is operating on coronary artery bypass graphs. The devices that attach and extend into the portals that go into the patient's body are what we're looking at here. And you can see that they have a different platform that Dr. Balke is going to explain for us. These are the platforms that soon to be dated that are for the Da Vinci SI that we need to desperately get to accommodate on the DaVinci XI machines.

SPEAKER_03 9:54

And the XI system, which is this guy, the XI. This is the XI, the newer generation robot. It's not really new, it's been out since 2014. But it's the newer one. The arm comes in like this, and it clicks down, and the instrument is like my forearm down onto the into the patient's body. With the SI on the other hand, let's walk over to the SI. The arm fits in kind of longitudinal parallel. It's not like the right angle that you saw. And that is the difference between how this one works and how the other one works. The end effector is what you see inside when you're watching the screen inside the patient's body. But here's where the attachment happens. And the uh stabilizer that we have fits on this arm. It doesn't fit on that one, unfortunately.

SPEAKER_02 10:51

And clearly that's a different platform.

SPEAKER_03 10:52

It's a different platform. And all they have to do is take that effector, end effector which we have, and fit it onto the uh this platform. The the XI platforms. That's all we have to do.

SPEAKER_02 11:06

I'm now walking into the OR, the operating room, and I'm I'm shocked at the fact that I'm not in some sort of a gallery. I'm in the OR. I'm literally in the OR with the surgeons and everybody that's there attending the patient. And I'm looking around, what is this? I'm I'm amazed at not only the size of it, but how much is going on in there in every way you can imagine. There's equipment, there's machinery, there's emergency equipment in the event that something should turn in what was expected. There's video screens all over, and then of course there's the robot. And the robot is positioned over the patient with all the portals, which are the rods, so to speak, that enter the patient's body. The patient's there, and the patient is blown up with the carbon dioxide so that there's room for the tools and the cameras and the lights to take place inside the chest cavity. The anesthesiologist team is behind a screen, and there are screens all over the room. There's screens on a wall, there's screens above the patient, and there's these two machines, which are the Da Vinci machines, not the robot itself, but the machines that both Dr. Balkey will sit at and a guest can sit at. And the guest is an observance machine only. It doesn't have the arms and the extensions that operate the robot, but it does have the visual that you can watch. And Dr. Balkey did at some point during the surgery ask me to go take a seat and experience what he experiences. What I learned in the process of sitting through the surgery was the first thing is the magnification is incredible. And you heard that in Dr. Balkey's episode, but the magnification is ten times what is actually taking place inside the cavity. So the visibility of detail is phenomenal. And that's what's up on the screens as you're sitting in the OR, you're watching the screens, because obviously there's nothing to look at other than the flesh of a patient. You can't see anything because everything's taking place inside anyhow. So it's all video. And the arms and the articulators, the effectors, I believe is what he calls them the forceps, so to speak, or the way that the tissue is cut is actually cauterized in most cases, so that it's always getting sealed instead of bleeding internally. And the tubes, the portals, deliver everything. So if a cotton swab is needed, the cotton swab comes down to true not down the tube into the cavity, the forceps grab it and it dabs around whatever it is that it's looking to absorb, and then it gets sucked back up. It it is just amazing. And the first part I see is Dr. Balke is explaining to me, and the way he's explaining it to me, not just me, but everybody in the room is mic'ed up with a headset and a microphone so that the communication can take place all the way around is the first steps of the procedure, and that is to cut the pericardium of the heart, the sac, so to speak, that the heart sits in. And we're all familiar with that because we've heard of pericarditis and some of the effects of side effects of the surgery. But that pericardium is just a tissue sac, and when it gets cut, there's fluid that leaks out of it, and that's the fluid, so to speak, that the heart floats in for protection. And the first question I ask through the surgery is, well, okay, well, what happens with that fluid? When you close it all back up, it just comes back, right? And well, the answer is no. We don't get that fluid back. If we've had open heart surgery, we don't have any fluid. We have our pericardium closed back up, but there's no fluid, it never replaces itself. So a little bit less protective if we've had open heart surgery. That pericardium gets cut and it's it's cauterized as it's being cut and it opens up, and inside there is the beating heart. And it's an amazing thing to see. It's surrounded by tissue, it's surrounded by fat, and that fat is a yellow fat. It looks like the fat that you would see when you open up a chicken or a turkey. And the fat gets moved away, and the tools of the Da Vinci robot then go to work, and they start moving everything to identify where that left anterior descending artery is, the coronary artery. Because in a normal heart, you would open that up and there you would see it. It'd be on top of the heart. Obviously, in our case it's an effort in discovery. We have to find where that artery is. Knowing that it's been mapped out to some degree, they know roughly where to start looking, but they have to start snipping tissue away till they find the artery. And in this particular case, the artery was shallow at the lower end of the heart and really probably not very impactful from a symptom standpoint. But as they continued snipping and continued working their way along the artery, it stayed roofed for quite some time. And in effect, this was a relatively long bridge as uh as we get into it. But at the time nobody really knew because they're working their way along the bridged or roofed part. At some point, maybe six millimeters down toward the upper part of the heart chamber, toward the aorta, the artery takes uh almost a nine-degree turn and goes deep into the heart, and there is the compression. And you literally can see the heart squeezing the artery every time it beats. Remember, we're working on a beating heart here with the Da Vinci robot. The other thing to point out here is as I I'm watching what Dr. Balkey is doing, is the stabilizer that he speaks of that's so critical, really just looks like a pair of rabbit ears. And it's a device that opens up and the rabbit ears spread. They can be wider or narrower. It's just a silver metallic-looking piece, and he opens it up over the artery, and then it compresses the heart at that point where he's working. The rabbit ears open and push down and he works and unroofs a particular portion, lifts it, works down, pushes down, uh on roofs, gets the muscle tissue off. Next step, next step, next step. Without the stabilizer, it would be an external device, and that external device would need to be slid each time on a frame of some sort, uh taking so much longer and being much more difficult because it have to be actuated perfectly just to be right, and and for the robot to get the particular point of the artery where the stabilizer is pushing, it it's just extremely cumbersome and uh almost ineffective. So the necessity of the stabilizer to do what's happening here is extremely, extremely clear as it holds the heart from beating at that point where the tissue is being removed, the muscle tissue is being removed from the artery. We continue down the line, and you know, it's just fine, fine snips and cauterizing and snips and cauterizing all the way till the really effective part where the artery is deep into the heart, and then it becomes really, really critical to the unroofing process of removing that muscle tissue all around the artery. And of course, at the same time, making sure you don't nick the artery or hurt the artery in the process. So seeing this, actually knowing what it looks like inside, you may be wondering, trying to visualize what it is. The artery looks like a worm. Once it's uncovered, it's it's a grayish, pretty thick artery in there. And as it gets uncovered, obviously it it opens up and you can see it much more visibly, and it's just resting nicely inside the heart without the muscle tissue over it, all the way through to even where it goes into the depth and then gets released with the muscle tissue being cut away or cauterized away. And all of a sudden now you see this beautiful length of artery that is now unroofed. And the next step in the process is there's a liquid that's dripped on the artery that will allow it to plump. Acetylcholine, if anybody is familiar from their provocative testing, if you recall, when we're bridged, the acetylcholine actually compresses the artery and aggravates the situation for us. Well, when the artery is unroofed, it expands the artery. And in this case, keeping in mind now this is a patient that has a myocardial bridge and prior to the surgery had the same symptoms with acetylcholine that that artery would have constricted. Now that it's unroofed, the purpose of putting the chemical on the artery is to see how it plumps up. And it was really remarkable to see that as the fluid was being dripped on top of the artery, it plumped up. You know, the worm actually got bigger visibly. And it's miraculous to know that that had probably been that effective that quickly for the unroofing process. The next step then becomes surgically putting everything back together and sewing up the pericardium and closing everything up after making sure that every striation of muscle over the top of the artery had been removed. And those were just really fine snips and little pushes with the forceps and the uh stabilizer to be certain that there was nothing compressing that artery since they're in there, while it may have not been much of an effect. It's certainly nice to know that it all got taken care of in the process. And then at that point, the robot goes through its its machinations and the ports are removed from the patient and off we go to recovery. The look of what's happening in the room, I think, is significant. And you'll see on the YouTube channel if you're watching there, this is what Dr. Dr. Balkey's doing about fifteen feet from the patient. And to give you an idea of of space, I'm sitting maybe ten feet from the patient who is behind me because obviously we're not looking at what's happening at the patient. We're looking at what's happening on the screen on the wall to uh to see everything. And it's it's a high def, high-tech supermagnification of everything. I mean the tiniest of tissue you can see the forceps squeezing and pulling and moving, just incredible visibility. What Dr. Balke's looking at, and as I mentioned earlier, I had the opportunity to look at as well, is actually three-dimensional. The gallery, the people who are in the room, Dr. Crumer on myself and some of the attendants, we're looking at it on a screen, and it's it's not three-dimensional, it's two, but Dr. Balkey's looking at it in a three-dimensional sense. If you recall those viewfinders we used to look at, you click, click, click, and they're three-dimensional nature, mountains, whatever it may be. That's what it's like for him as he looks into that viewfinder. And then his hands are operating these these handles and his feet are on pedals that are actuating what's happening inside the patient. And so you can see him doing his thing here with this uh video that you've got on the uh on the YouTube side. But it's just a it's just a big gray machine. He's sitting there with his shoes off so he can feel the pedals and the the music is playing in the the OR, great music by the way. 70s rock, some 80s rock. It was really interesting for me to see how it all comes to play because we've seen it on TV where the operating room has the music playing. It's literally like that. It very, very real. But that's the process of of how the machine works and the the detail that the issue the machine allows the doctor to effect inside the patient is truly amazing. And having had a steronomy myself, I can imagine the doctor is wearing some magnification so they can see better. But what Dr. Balkey's looking at on the screen at ten times in real time and and no hands, nothing getting in the way, just these tiny, tiny devices that are doing what they need to do is amazing. So having been through it now, understanding the process and seeing how the robotic surgery works, for those of you who it is possible, I can appreciate the interest in doing so and not having a sternotomy. Uh, do I have a concern as somebody who's a third party looking in, just a guy, I would say there should be no concern for robotic surgery whatsoever, given what I saw and how it functions. And if you have a condition, if your condition is is acceptable and you are approved for robotic surgery, I I would imagine that's probably the way to go. So it's quite an experience and it's incredibly emotional to visualize yourself there because if you've been through the surgery, you're looking at this patient who now is about to get their life back as a result of the process and seeing literally what happens to our hearts, how it looks that close, that visibly close, I I just I I can't explain it enough. Um it it's amazing. And in robotic surgery, only one lung is collapsed in most cases, because we're only working on that part of your chest. So they don't have to collapse both lungs. You're not on a heart-lung machine because your heart's beating the entire time. And to see that life from inside and what it's like and how the heart functions is an experience I will never, ever, ever forget. And I hope I can convey to all of you who have the opportunity to be on roof, whether it be robotic or astronomy, the process is real. You can identify and see what's happening and why it causes the symptoms that it does once you've been through this process. And I hope that this discussion uh gives you a little more insight into it. And having seen Dr. Balke, you'll see the pictures, you'll see the arms, the tools that are are clamped onto the machine and how the robot functions. All those are going to be on the YouTube video, as I explained. And then as the pericardium is being stitched up, you can see the robot arms doing their thing. It it's it's amazing how it all works and how the SI functions, the Da Vinci SI functions for us, and how it works to allow us to be unroofed robotically. And and again, I I I hope this episode allows you the opportunity to help make better decision, but also to give you some confidence that if you've been scared, you've been afraid of the strenotomy, and you're a candidate for the robotic surgery, I highly, highly, highly recommend moving forward. Don't suffer with the symptoms of a myocardial bridge when there's an answer out there for you. So we've completed the surgery, I've got my clothes back on. Uh, I'm I'm in the hallway of the of the hospital waiting for Dr. Balkey to come out, and in in the meantime, I'm talking with Dr. Coomran, as we're both marveled and awed at what we've just seen, not only by the professional that Dr. Balkey is, the specialist that he is, the technician that he is, the skill set that he possesses, but the entire process of what we got to see inside that chest cavity and the unroofing process uh of the artery. Obviously, as a lay person and uh you know just somebody who was fortunate to participate and to see this in the operating room, I believe that Dr. Qumran was every bit as amazed, and he sees it on a regular basis back in India. But I the marvel of today's medical technology handled by one of the best in the world is uh just incredible. So uh Dr. Balkey's working walking up. Uh I'm gonna get a few words with him, and then I've got a few words with Dr. Qumran coming up next to the U.S. Dr. Balkey, thank you. I just had the most incredible experience and privilege to sit through a myocardial bridge unroofing procedure robotically with you. Can you tell us what it was that I experienced?

SPEAKER_03 29:03

Yeah. Well, first of all, great to have you here, Jeff, in Chicago at the University of Chicago. And uh what you just witnessed basically was a robotic, totally endoscopic myocardial bridge unroofing of the left anterior descendant, which is where these bridges happen. They don't happen in any other blood vessel, uh, and they're never of significance if they happen anywhere else. So that's what you saw. Uh it was a uh fairly deep one at the very top, but relatively less deep at the bottom. It measured in its whole to total length about nine centimeters uh in length, which is a fairly long disease. The patient was very fairly symptomatic, and on provocative testing had significant changes that indicated that the area of muscle that was fed by that LAD was ischemic. And it went along with pain, which was consistent with myocardial ischemia, meaning chest pain radiating to the arm, radiating to the neck, so fairly classic symptoms, and so we're hoping that this unroofing procedure is going to completely eliminate all of that.

SPEAKER_02 30:09

Well, what you are doing for us and those of us who have the symptoms, who have the condition, who have been unfortunate yet to be unroofed, is giving a tremendous education to the benefits of robotic surgery. And I thank you for all that you're doing, especially for your time. You've been so generous with us.

SPEAKER_03 30:26

Yeah, well, thank you very much, and and uh I'm very happy that you're able to come and visit and see it. And I also appreciate the work you're doing in kind of educating folks about this condition and really helping people understand, you know, not only how it can be treated, but why it should be treated and who should get the treatment or the surgical intervention for it. Uh and also helping us make you know other partners in surgery aware, like industry, who can facilitate getting some of the instrumentation that we need for us to be able to do this robotically. Because that's kind of the big thing that I'm facing right now is that we need to continue to be able to do this with the robotic approach, and um and and your work is is hopefully gonna help us do that.

SPEAKER_02 31:10

Well, we're gonna do what we can to find and you're referring to the stabilizer to refer to the stabilizer. If we have some producer for the XI machines.

SPEAKER_03 31:23

Great. Light sticks came on, so that's good on that notion.

SPEAKER_02 31:26

Yeah, we just have the benefit and the opportunity to participate in an unroofing procedure done robotically. And a lot of people with myocardial bridges get dismissed.

SPEAKER_04 31:41

Yes.

SPEAKER_02 31:42

I'm thrilled to know that you're a believer in myocardial bridges. If you had to say something to the cardiology community at large about the reality of these bridges, what might you say to them?

SPEAKER_00 31:56

This myocardial bridge is very interesting and a very unique uh condition. Where patients they come with the symptoms of angina or chest pain, what we call. And most of the time, like investigations when you do for these patients, all the investigations are within normal. Like ECGs, echocardiograms, you do, it's all within normal. And you find this myocardial bridge only when you put them to stress. So when the patient comes with the symptoms, half the investigations can be omitted if you listen to them. They have a problem, they come to you, they talk to you, listen to them, do the investigations, and if you still can't figure out there is something wrong, then you have to think of myocardial bridge because the myocardial bridges, almost 2% of the patients have myocardial bridge. So when routine investigations are normal, you have to think of myocardial bridge.

SPEAKER_02 32:44

Is it possible that a myocardial bridge could cause sudden cardiac arrest?

SPEAKER_00 32:49

Yeah, that's a good question, Jeff. Like see, myocardial bridge can cause sudden cardiac death. There is not much of literature about this, but there are sporotic cases reported that sudden cardiac death can happen in myocardial bridge. See, the myocardial bridge can give symptoms of angina. That means the myocardium is not getting any blood supply when the patient is put into stress. When he doesn't know that he or she is having myocardial bridge and they were having a hard workout or severe exercises, that time the myocardium is under stress. That time they will have a symptom of angina, and if coexisting lesions in any other coronary arteries, yes, it will cause sudden cardiac death. There are sporadic cases reported in the literature that myocardial breach can cause sudden cardiac death. So if you find a myocardial breach, that is an indication to get treatment. He's an amazing man, he does everything through robotics. What I can do with sonotomy and a minimum is a cardiac surgery, he does everything with robotics and it's it's replicable. It's not replicable, it is easily replicable. Only things you should have a mindset. Future it's going to be all technology driven, and future it's going to be a robotic.

SPEAKER_02 34:01

When I do suspect at some point in the not too distant future, we'll hear that Dr. Qumran in India is performing robotic surgery. Absolutely, you will hear. I want to be sure to thank Dr. Balkey, Ruth Buckner, University of Chicago, everybody that was in the room, the operating room, Dr. Coumran, what a what a blessing for me to have met and had shared experience with him. The emotion that is present not only in the room but after the opportunity to sit through an unroofing procedure is is truly overwhelming. Knowing that it worked for me, knowing that it's going to work for this patient is not only an exhilarating experience, but an overwhelming one as well. And for the opportunity, for the experience, for the blessing, I'm I'm eternally grateful to Dr. Balkey for the invitation, because it's nothing I can compare it to. And I get now the ability to share this with you and with others, that this surgery is so real, so necessary, so valuable, and it's now incumbent on us to see what we can do to talk with, persuade uh intuitive the Da Vinci machines to help doctors like Dr. Balkey continue the process of unroofing robotically by using the stabilizer that needs to be modified for the Da Vinci XI machines. So one last time, Dr. Balgey, thank you, thank you, thank you. 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.