Episode 21: What You Need to Know About the Sternotomy with Thoracic Surgeon Dr. Mark Francis Berry

SPEAKER_01 0:00

The thing that I often get from patients that they fear the most for any chest surgery is this concept of cracking the chest. You know, that just sounds terrible. It sounds painful, but it's a very elegant procedure in the sense where it is a time in the operating room where actually everybody's taking care of the patient needs to be on the same page. The astronomy is to give you access to the heart, and that's it.

SPEAKER_00 0:51

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. My guest today, Dr. Mark Francis Berry, was responsible for the reconstruction of my chest by post-unroofing surgery. In addition to the heart defect of a myocardial bridge, I also was born with a sternum deformity called Pactus excavatum. And while not unsightly for my 65 years, little did I know it was putting pressure on my left ventricle. Enter Dr. Barry to correct that issue before I go into recovery. Dr. Berry joined the Division of Thoracic Surgery at Stanford in August 2014. He came to Stanford from Duke University, where he had most recently served as associate professor. He's a native of Pennsylvania and received his medical degree at the University of Pennsylvania School of Medicine after receiving bachelor's and master's degrees in electrical engineering at the University of Pennsylvania. He completed his residency in cardiothoracic surgery at Duke University Medical Center after performing a residency in general surgery at the hospital of the University of Pennsylvania. His cardiothoracic surgical training included a year dedicated to minimally invasive general thoracic surgery, a period that also included an American Association for Thoracic Surgery sponsored traveling fellowship at the University of Pittsburgh. He practices all aspects of thoracic surgery, including procedures for benign and malignant conditions of the lung, esophagus, and mediastenum. He has a particular interest in minimally invasive techniques and has extensive experience in treating thoracic surgical conditions using video assisted thoraoscopic, surgical, laparoscopic, robotic, endoscopic, and bronchoscopic approaches. He serves as the co-director of the Stanford Minimally Invasive Thoracic Surgery Center and has both directed and taught in several minimally invasive thoracic surgery courses. He also holds a master's of health science and clinical research from Duke University. His clinical research activities mirror his clinical interests and activities in optimizing short-term and long-term outcomes of patients with thoracic surgical conditions. He has more than 150 peer-reviewed publications. His clinical practice and his research both focus on choosing the most appropriate treatment and approach for patients based on the individual characteristics of the patient and their disease process. Dr. Berry, welcome to Imperfect Heart.

SPEAKER_01 3:40

I appreciate being here. Thank you so much for the opportunity to participate.

SPEAKER_00 3:44

Let's talk a little bit about some of the observations I've picked up from what listeners to the podcast are telling me. There are over 750,000 sternotomies performed annually. And that's, I think, unfortunate just because that's an awful lot of open chest something. It's now become a relatively common practice. What is it do you think that's caused this to become so prolific?

SPEAKER_01 4:08

Aaron Powell I think the reason for those kind of numbers are twofold, some good, some bad. One reason that there are so many that are done is kind of a testament to the fact that the cardiac surgery profession and the surgical and medical profession in general can do very, very complex things very successfully. So they can do things for people that in many cases it would be leaving people with a deadly condition if it wasn't addressed. But it can be done with low morbidity and low chance of dying and with a great chance of returning to your normal quality of life. So I think one reason is that there are so many strenotomies done is because it can be done, it can be done successfully, and there are people who have conditions that need them. And then the flip side, yeah, I guess that the not so good sign is the fact that so many people need heart surgery, or so many people need stronatomy. And you know, sometimes you do a stronatomy because someone has cancer, and there are some lifestyle things, such as smoking, that you can do that might lower your risk of cancer, but but there are many things you can't do. You you may get it for just bad luck. In terms of heart surgery, you know, there are a lot of lifestyle habits or medical conditions that increase your risk of needing heart surgery. And some of the things are things like smoking or having diabetes or poorly controlled blood pressure, hypertension. And some things have gotten a lot better in this country, like a lot less people smoke. So a lot of cardiovascular disease may be decreasing because there's not as much smoking. But you know, on the flip side, there's a bit of a health crisis in our country in the sense that many people are obese, you know, much more than what you would expect. And that predisposes you to conditions such as hypertension and diabetes, which then predisposes you to things like heart disease, and then that sets you up for potentially needing heart surgery. So I think you know, going back to the question, why are we doing so many is is is one, well, we can do them, and we can do them successfully, which is great. And but two, a lot of people need them, which is is not so great.

SPEAKER_00 6:20

Aaron Powell I'm gonna make the assumption since heart disease is the number one killer in the country that the majority of the sternotomies are heart-related.

SPEAKER_01 6:28

Aaron Powell Yes, yes, the overwhelming majority of sternotomies are for some kind of heart surgery procedure.

SPEAKER_00 6:37

The second question I've got, and you can probably do this better than than most, is the sternotomy itself seems to create more fear, anxiety, angst amongst the people who are candidates for heart surgery, in our case the unroofing procedure. And I think part of that's because the understanding of what the sternotomy really is is misunderstood. They don't know all the detail and the ease of access and everything else that it provides the surgeon. Could you walk us through literally a step-by-step once they've been prepped and they're in the OR, what happens during a sternotomy?

SPEAKER_01 7:17

Aaron Powell Sure. And you know, that's a very interesting insight that you have. And I actually was thinking about that a little bit when you had kind of prepped me for what we would talk about. And and just before I talk about the steps of the sternotomy, I think the reason why people probably fear that more than actually the heart surgery is because it's easier to picture trauma to your to your body where you break a bone. And it's easy to visualize the scar. And maybe it's also easy in your head to think about my chest is going to be open in this room full of strangers, which I mean I can certainly understand that that can be terrifying. Whereas the fact that someone's actually touching your heart and doing something to your heart, that's a little more abstract. Most people have never seen that, so it's harder to kind of say that's terrifying because it's not something they probably ever thought about before. So I think that that's probably what it is, is that it's easy to picture trauma and and the scar and things like that. It's funny because I've seen so many that I don't even think about it, you know. And if someone tells me that they need heart surgery, I don't even think about the approach, whether it's astronomy or a minimally evasive surgery or a catheter-based procedure. You know, my thought immediately is to the heart. You know, that's an important organ, maybe the most important, or it's tied for top two or three. But I certainly can understand why people worry about that. But basically the steps of astronomy are that you obviously bring in a patient to the operating room, the anesthesiology team will safely and very peacefully get those patients to sleep in a very comfortable way. And then there is a whole flurry of activity done to safely what we call prep and then drape the patient. So you position the patient so they're perfectly positioned for anything that might need to be done during the surgery. And that includes unexpected developments where, if there's any problems with the heart or bleeding or anything like that, that you're ready to take care of that patient with really minimal chance that something bad would happen or there'd be a really bad outcome. But if you can kind of picture a person needing a serotomy, they have to be laying back and their head needs to be extended, meaning their chin needs to be up because you want the sternum to be just maximally exposed. So what that means for the patient is that they're laying on the OR table, which is padded, but then there's usually what we call a little soft bump under their shoulders. So that kind of brings their head back, so their chin is sort of as as far back as it can go. And we're very careful, actually, and that's one of the more careful things at the beginning of the case, is to have the neck extended in a very comfortable way, so not overextended so that they don't wake up with a very stiff neck, but you you position the patient that way, and then you very, very carefully prep the patient in a very sterile fashion, and then you drape the patient, which is where you expose the part of the chest that needs to be exposed, and then everything else is covered by sterile drapes. So the chance of a contamination that could lead to an infection is as minimal as can be. One of the things that now occurs before any surgery in in almost, I think, every operating room, probably in the world, is what they call surgical timeout. So that's where everybody in the room is just focused on discussing what the plan is, what all the critical things that need to be reminded to for everybody, and to make sure everybody's on the same page. And a lot of times people think, oh, that's just to make sure, you know, you don't do wrong site surgery or the wrong surgery on the wrong patient. And that's part of it, of course. But the other part is just to get a team of about 10 people refocused on, you know, we're here for this patient to take care of this. We need all these things, and we need to make sure that they're all available, and we need everybody to be ready to do everything that they do. So that's that's a lot of time, actually. So if you're a loved one of a patient, and and nowadays, you know, you can usually sit in the waiting room and kind of watch an electronic screen that shows what's happening with a patient. For somebody undergoing heart surgery, it can be an hour and a half or or longer between the time the patient actually goes into the operating room until there's a sign that actually the surgical team has has started this the surgery, the actual surgery. But for a strenotomy, you you make a what we call a midline incision. You make an incision over the top of their sternum, down to the bottom of their sternum. Depending on the surgery, and depending on what you need access to, that can be raided up to the top of your breastbone, your sternum, that you can feel it. Sometimes it can be a little lower, so you can kind of hide the scar for some situations. But basically, you cut the skin. We use what's called a cautery device to go through the soft tissue of the chest. So the subcutaneous fatty tissue, the fascia, which is kind of the leather lining of muscle that holds things together. There's not much muscle actually right over your sternum because your pectoralis muscles kind of end just before they they reach in the middle. But then you get down to the bone itself. There are a lot of important things below the sternum, above the sternum, behind the sternum, and you need to make sure that when you're getting ready to actually divide the sternum, that you protect all those things. So we need to make sure that none of the blood vessels on above the sternum in your neck or below the sternum near your heart need to make sure that none of those are at risk of being injured when you're actually dividing the sternum or the breastbone. But then we we use a sternal saw. And I think the thing that I often get from patients that they fear the most for any chest surgery is this concept of cracking the chest. That just sounds terrible. It sounds painful. But really, when when the sternum is divided for heart surgery, I mean, it's a super routine thing. Like an experienced heart surgeon can probably do it in about three seconds, but it is incredibly precise. The world's probably most expensive saw that is used, it just divides the breastbone. It's a very elegant procedure in the sense where it is a time in the operating room where actually everybody's taking care of the patient needs to be on the same page because the anesthesiologists need to stop ventilating the patient, meaning they need to stop filling their lungs up with air so the lungs collapse a little bit, so there's less chance that something could be injured when you're dividing the breastbone. The surgeon obviously needs to be laser focused on what they're doing, their assistants need to be focused on providing them the exposure, and then the nursing staff needs to be, you know, not only giving them the saw, but then also giving them what they need right afterwards. So the sternotomy is probably the quickest part of the surgery, even though it's probably the things that people fear the most. But it just is a matter of sawing through the bone, and then that's it. There's always oozing of blood from the edges of the bone. That's the first step that the surgeons will do. They'll they'll stop that bleeding with cautery and other matters, and then they'll put in a sternal retractor. That again, I think, is something that that patients fear the concept of where you're spreading the chest, and that's what the retractor does. But I mean, that that's what you need. You know, the strenotomy is to give you access to the heart. The retractor holds the bone apart so you can do what you need to do. And that's it. That's the strenotomy. And again, like I mentioned, I think a lot of people fear that. But after that, that's when the real important stuff starts. I mean, that's the reason you're there. You know, whatever the problem is with the heart, that's about to be addressed in in some way. And that's where really the expertise of the team and the surgeon come into play.

SPEAKER_00 15:25

That's a wonderful description and very well laid out for us to visualize. I have a question for you. So as the sternal as the stern is being held open with the retractor, where are the arms? Where are our shoulders?

SPEAKER_01 15:40

In most cases, the patients are laying on the the bed and they have their arms tucked next to them. So they're just laying by their side. They're usually wrapped in foam or other comfortable types of material, but their arms are tucked to their side and their shoulders are kind of just pulled in close to their chest.

SPEAKER_00 16:02

Okay. And then what closes it back up once the surgery is complete? How does that process take place?

SPEAKER_01 16:10

So that process involves obviously going through whatever is involved in the primary surgery, making sure that everything's okay, making sure everything is functioning appropriately. And then it's a matter of bringing the two cut edges of the sternum together. The overwhelming majority of patients that have a sternotomy will have the sternum brought together by putting in stainless steel wires that will bring the two cut edges of the sternum back together. Most patients will probably have eight wires that will be put in the chest. Sometimes, depending on the size of a patient, it may only be seven that's needed. And on the top part of the sternum, that's the part of the sternum that's called the manubrium. It's just the very top part. It's kind of if you feel your chest, that's usually a little bit of a slope to that. If you're coming down from your neck down to your lower body, for most people, their fingers will kind of come away from their body until it reaches a flat point and then goes more flat. Then that's the body of the sternum underneath. When we use the sternal wires to close the sternum, we actually put the wires through the bone in that manubrium, the top part of the sternum. And that's because that's actually a thicker part of bone, and you can put the wires through there and they'll hold very, very well. And then lower down in the body of the sternum, oftentimes you'll just put the wires around the edge of the sternum. And that's partly because the sternum is more narrow down lower, and there is a little bit of a risk that if you put the wires through the sternum, it can actually pull through through the recovery. And for most patients, by putting it around the outside of the bone, it will hold it more snug together. So the process is again a kind of nice choreographed team of assistant and surgeon and the scrub tech at the OR table and then circulating nurse getting all the materials. But it's basically putting in all the wires, so seven or eight wires through the through the sternum. And then one of the most critical parts of the closure is actually then pulling kind of just across the wire, so you bring the sternal edges back together. The reason that's important is because that's essentially closing the chest. So when you bring the chest back together, that can increase the intrathoracic pressure. And if there's anything inside the heart that can get distorted and maybe not function the way it's supposed to, that can display itself in terms of their blood pressure or their heart rate or other vital signs. So most people have a good habit when they're closing the chest, they they tell the anesthesiologist and they tell the room. So if something starts to go a little haywire, then they know we need to release that pressure and figure out like we need to make sure we didn't change something. But once you bring the two edges of the sternum together, it's a simple process of just twisting the wires or the edges of the wires around themselves and then clipping the wires once you have the edges of the bone just nicely snugged together. For most people, we'll will push those wires into the edge of the bone. You then close all of the soft tissue above the bone, and that's in you know, often multiple layers of what we call absorbable suture, the suture that will eventually just go away on its own. And for a lot of people, that's it. Very skinny people can often feel the wire, but m many people don't even know it's there or ever feel it, and that's the end of it.

SPEAKER_00 20:06

Aaron Powell Well, I know I was quite disappointed when I went through the airport. I got nothing. You know, I have these wires in here and nothing. It doesn't set anything off. It's you you want some acknowledgement for what you're carrying in your system. And unfortunately, you guys do such a good job now in certain terms of the, I guess, the gauge of the wire that it doesn't set anything off. The other part that a lot of people are concerned about, obviously, is pain. And I think you addressed why we the scars are minimal at this point. I barely even notice mine most of the time. And certainly from a distance, people wouldn't even pick it up. But pain is the inevitable part of surgery under any circumstance, and you have to be prepared and understand that there's going to be some challenges with pain. However, a lot of the technology has changed today to where the ability to minimize the pain as the procedure is being taken care of, as well as post-surgery, are really significant. Can you walk us through a little bit on some of those techniques now that are capable to minimize the pain?

SPEAKER_01 21:11

Yeah, that I mean that's a super important part of surgery is good pain control after surgery for many reasons. I mean, for one, you you don't want people to be in pain as they recover just because you don't want them to be in pain. But for two, it's super important that people are comfortable through their recovery because that's how you make sure that they recover well with the least chance of complications. If you do a big surgery on somebody and they're in a lot of pain and they're having a hard time getting out of bed or taking deep breaths or coughing, you know, that's a setup for infections such as pneumonia or bed sores or deconditioning, which then sets you up for longer recovery or more complications. So the pain control is super important. And I think for sternotomies, we probably have not made as much progress as maybe many people would hope for this type of thing that's so common. Part of that is because fortunately a sternotomy, I think, does not hurt as much as other traumatic surgeries, even with all the trauma that I just described with the surgery. I think part of that is that when you close the sternum, you end up with a very stable bone. So even though it was it was surgically fractured, when you bring, put the wires in and you bring it together, if it heals well, it's not gonna move. And that's what hurts with a broken bone is when the edges of the fracture rub against each other, that's what will cause incredible discomfort. And you know, anybody that's broken any bone will will know that, you know, that that terrible feeling. And it's also when you have a broken bone and you can feel it move, like that is, I think, a just something that people like just feel a sense of doom, you know, because that's not what your body is supposed to be doing. But fortunately for the sternum, once you wire it together, if it's healing well, it doesn't move, it doesn't really hurt as much as other bones. And because it's stable, you know, even when people take a deep breath, it doesn't hurt as much, like even as like say a small chest tube incision, which which you have experience with, many people have experience with, is can be a very tiny incision, but can hurt like crazy, even though it's like 10 times smaller than the bigger incision. And that's because there's muscle there that gets irritated every time you take a deep breath or you cough or you or you god forbid sneeze. You know, that's one of the most violent things you can do, and it can really be painful. So fortunately, thestronomies are not as painful as a lot of other surgeries. But I think that one advance that we have is that people are much more focused on using non-narcotic pain medication to allow people to recover. So it used to be you would just put them on a pretty strong art narcotic pain medicine like oxycodone or percoset or things that people hear about. But now we'll do what we call multimodality. So you you you'll need a narcotic pain medicine, or most people will need that for a short period of time. But things like non-storidal anti-inflammatories, like ibuprofen or tylenol, even extras and thylenol, can be very, very effective for people and with a lot less of the downsides that can come with the narcotic pain medicine. And then there's also what we call nerve medications, like something like GABA pentin or lyrica is a well-known one, or cymbalta. Those address pain in a little bit different fashion, and they can be much more effective, again, with less downside of the narcotic pain medicines. Where kind of the state of the art is for sternotomies and pain control. There's been a lot of different techniques that have been tried. Like people have tried freezing nerves to try to get them to go numb for a couple months. Occasionally people will put an epidural in a patient's back to try to numb the nerves at the root to try to keep them from feeling it as they're recovering. There's other pain catheters that can be put in the vicinity of nerves that try to gently infuse pain medicine continuously just to keep the area numb. And those have had mixed results. Some people they work great. Other people, it's hard to tell if they do much more than just our standard pain regimen.

SPEAKER_00 25:29

I was gonna say I had that epidural on both sides, left and right. And having only experienced once and hopefully only experiencing it once, I don't know if it was better or worse because I don't have anything to compare it to. But I would say that the pain that I had through my procedure was certainly manageable. And I think I may be two days out, I was able to survive on just the extra strength Tylenol for all the reasons you mentioned on some of the narcotics. Not that it was easy, it wasn't maybe as comfortable as a narcotic might have made it, but it was the preferred choice for me. And once you get through that third, fourth, fifth day, everything gets better for the most part. And and to be sure, not linearly better. There's days that are better and days that are are not as good as you'd like them to be, but the trend line is all positive. You know, fear, just fear of all the uncertainty of the procedure is something that everybody deals with in some way, shape, or form as you're going in for a surgery like this. Have you seen anything that's worked well to help patients minimize the fear or things that maybe you've heard from stories that patients have said, oh, I just did this, and it really helped me accept what was going on?

SPEAKER_01 26:41

I think there's a couple things I think that can be very helpful to people. One thing is just being able to give them a very good understanding of first off, you know, why they need whatever they need, give them a clear but somewhat concise picture of what is going to happen and then what to expect, both in sort of the immediate period after surgery, but then in the next month or two as they continue to recover. And I think by just taking away a lot of the unknown, that can often make people just feel much, much more comfortable. That instead of in their mind thinking about what it could be or what's involved with it, when they actually have a good, nice, clear explanation, that can, in my experience, make people just a million times comfortable. And I've seen many patients who come in for an appointment to talk about surgery, and you can tell they're just a basket of nerves, they're just haven't slept well, they're just super worried. And then they hear about it, and even though, like, I mean, some of it is very sobering, like in some cases, you're just like, well, we're we're gonna stop your heart for a couple hours or for a couple minutes or something, and that's certainly terrifying. But when they they hear about the process and the whole thing, and it's it's you know, it sounds kind of matter-of-fact, I think that can put people at at ease. I think another thing that's helpful and that I'm very grateful that that I have is having a very good team of people that that work with me that can also provide support to patients because a lot of times you'll talk to a surgeon for a period of time and you'll talk about a lot, and most people will not grasp at all. And fortunately, a lot of people will have their family or their loved ones with them, and they're their second set of ears, so they can compare notes at the end. But it's also very nice that if a patient thinks about something and it wasn't clear to them, that they can reach out to the the surgeon's team and then have the team members be able to answer their questions in a very reassuring way. And I think that that can also put people at ease. And I think that that's important for two reasons is is one, it lets them get their questions answered, but I also think it gives them the faith that I'm gonna be able to talk to somebody afterwards, you know, like they're not just gonna cut me loose, like I have this whole team of people that are gonna help take care of me through the start through the finish. And I think that that can be very reassuring for people. And then, you know, I think things like like your podcasts or or support groups are oftentimes incredibly helpful to people as well. And I haven't experienced so much with sternotomies so much. Like we're we're I've I've felt that it's a very important to connect a patient to another patient that's already been through it to give them their perspective and they because they can listen to us talk about it, but I've never had a sternotomy. You know, I mean I I mean I've seen a lot and I taken care of a lot of people, but I've never had one. So sometimes just talking to someone even for I think for a couple minutes can really put them at ease and get it from the patient's perspective. Because sometimes I think a patient may say, you know what, it was pretty miserable for the first couple days, but hey, I'm good now. I got through it and they they helped take care of me and and it wasn't wasn't as bad as I feared, or or maybe it was as bad as I feared, but I'm on the other side of it and and I do it again. And those things I think can be very, very, very helpful for people to just to hear someone like, I I've been through it, I'm on the other side of what you went through. I I had the same fears that you had, and this is what my experience was.

SPEAKER_00 30:24

And I think that's a great explanation because it's certainly the fear of the unknown that people are always challenged with. And as they get educated and they understand a little bit more, and I know for some who are listening, they don't want to know, they don't want to ask that question, but I can't stress enough the necessity to advocate for yourself because you're gonna benefit from that, whether it be emotionally or even in the physical healing, to know that, no, this is normal. We talked about this, this is okay. As you go through it, obviously it's the first time for most of us. It's did I do something wrong? Did I pop a wire? Did I should I not have moved out of my cone, so to speak? And I think that leads us into the next part of that, the the post-surgical procedure that you should, you as the person, as the patient, should really watch. What are some of the things that we have to be careful of once the procedure's been done and now we're working on healing?

SPEAKER_01 31:20

Well, one is you need to advocate for yourself to make sure you're getting good pain control. And and again, going back to the fact that there's no reason to be in pain. I mean, we have buckets and buckets and buckets of pain medication in the hospital and and in the world, and we have many, many different things to do for people. And being comfortable is an incredibly important part of your recovery because not only for your for the like the psychology of being in pain or or the fear of having pain or the fear that if you move, you're gonna be in pain, but you as the patient are gonna recover so much better if you can get out of bed, if you can take deep breaths, if you can cough, if you can sit up in a chair, if you're not just laying in bed and trying not to move, you're gonna be back to your normal self a lot faster and you're gonna feel better. So, so being active, you know, or be being a strong advocate for yourself to make sure that your pain is well controlled. And that can include saying, like, well, I don't want to take narcotic pain medicine. Either like I've had a bad reaction to it, or I've had you know a fear of it, or I know people that have gotten addictions which were incredibly disruptive to their life. And those are important too, because you can take those things into account and you can adjust the the way you take care of people because it's it's not an all a one or a zero. It's not like, well, you can either take this pain medicine or you can be in excruciating pain. It can be, well, we can avoid this pain medicine that you fear, and maybe your pain won't not may not be perfect, but it'll still be good enough that you'll still have a good recovery. So that's that's very, very important. And then when you get discharged from the hospital, I always tell my patients, I want you to be as active as as possible. You know, you can take as many walks as as you want. Can't do anything too strenuous until all the bones are healed because we don't want there to be any healing issues. But the more you do, usually the better you feel and the faster you're back to yourself.

SPEAKER_00 33:19

Aaron Powell One of the things that's prevalent with open heart surgery, I don't know if it's because somebody is working on your heart or if it's because of the sternotomy, or if it's because of the fact that things will be different. You you'll have more memory there because it's going to be visible for the rest of your life. But depression is a part of the healing process. Can you speak to that at all? Is there any familiarity? I know I'm pushing you in a little bit more of a mental health side of things, but I'm sure patients come to you as well and say, you know, Doc, I'm just I'm miserable. I feel terrible. I don't want to get out of bed or whatever. Is there anything you can address to that point of depression?

SPEAKER_01 33:57

Yeah, it's it's an incredibly important topic. I would say that in general, the the medical community doesn't do a great job with it. I think the the kind of the most recognized syndrome that we have is postpartum depression. That took a long time to recognize how important it is and how common it is and how poorly treated it can be. I think there's a lot of reasons for the depression that people can have. I mean, one is just you're you're in the hospital. It's like you're in a fishbowl where you're being watched by so many people and people are coming in all the time. And in some ways, that can be disturbing to people, you know, especially if you're a private person or you want some quiet. But at the same time, I think it's very reassuring that you can think, well, three days ago my heart was being operated on, and like I'm connected to all these monitors, and people are coming in. Like if something happens, they're gonna find it. And I think then people go home and they're by themselves. And they they they, you know, almost always will have family or loved one or friends that'll be at the very least checking in on them. But I think it's a lot quieter and a lot maybe more disturbing. I'm not being watched. What if something is going on? They had me on this monitor for five days. Why did I need it for five days and now I don't need it now? Like, is there something going on? And I think as you're going in your recovery and you're not allowed to do too much, even if we want you to do a lot, we don't want you to be normal in terms of your normal activity. You know, you're you're not ready for work. You know, your concentration's not gonna be back where it needs to be for a little while. And I think you're kind of alone. And maybe people think a little bit about their mortality. Oh my God, like I just went through this. What's gonna happen to me in the future? It maybe their minds go to, well, what if I'm gonna have a complication? Maybe I'm having a complication. Maybe I, as you said, maybe I did something and now I broke a wire and now I'm not gonna recover as well as I should have. And it's it's you know, it's all my fault. I think that those things all can step to putting people into mental health issues such as depression or or just anxiety. I mean, maybe I might simplify it way too much, but like my treatment is let's get them better. Let's tell them they're doing well. If they call us with a problem, don't blow it off. Have somebody talk to them, find out what symptoms they're having. Even if it sounds like, what, this is just totally normal, and I'm gonna reassure you that that's normal pain, that having a cough like that is normal. Show the patient that you want, you're taking it seriously enough that you'll look into it. You'll say, Well, sounds normal, but let's just get a chest x-ray. You know, why don't you just go someplace close to home, get the x-ray, we'll get the pictures, we'll take a look, we'll make sure that it's all the way it should be. Or why don't we have a visiting nurse come out and get some blood, or why don't you just go to the local lab, get some blood work? Let's just check, make sure everything is still on par for recovery, or say, well, you know what, let's if it's not too inconvenient, why don't you come in and see our team? The surgeon might be in the operating room, but our nurse practitioner or our physician assistant or somebody else on the team can take a look at things and just make sure that it all looks okay. I think for for me, that's what I usually focus on with people through their recovery is if they are contacting us with issues, we take it seriously and we try not to just reassure them, but also say, well, we're gonna investigate it and try to reassure you that it really is okay. And if it's not, we'll figure it out and we'll take care of it.

SPEAKER_00 37:36

Aaron Powell I think that was a great explanation. And I think to your point, all this activity is going on when you're in the hospital, everything 24-7, and you are, you're checked on, you're wired, you're everything hooked up, no concerns, because if anything happens, somebody's there to take care of it, and all of a sudden you go to the peace and quiet of your home, like instantly, whatever that drive is from point A to point B, and all of a sudden it's quiet. And now you do have that opportunity to think and process what the heck just happened, especially if it wasn't a prepared surgery and it was a you know a sudden heart attack or something that caused you to be opened up for surgery. That was helpful. One of the things that we've noticed, I've had four women on the program over the course of of this first year, three of the four have had some sort of issue with their sternal wires having to be removed because they were painful. They could feel them. And two of the four actually had a sternum non-union. All of it seems uh fairly easily remedied, although if you're experiencing it and you don't know what it is because you only get to do this once in most cases. Can you explain what that is just for those of the audience who listened and maybe experience something like that? Oh no, knowing what that is, here's what we do, and it's a very s simple process. Because all all of the three women have all had their wires removed, everything's fine, and two of them had some sort of a plate put on at the top of the sternum, and everything's fine. So maybe walk us through what that is that causes it. And they're all small women. They're all fairly petite ladies.

SPEAKER_01 39:15

Yeah, so well first just to address the the topic of the wires and and whether they will ever need to be removed. I would say you know, the the overwhelming majority of people don't have any sensation of the wire there, or or they they don't have an uncomfortable sensation of the wire being present and it doesn't bother them. And the thought of a foreign body in them forever doesn't bother them. But for some people, if they're if they're really skinny, they can feel it. And for some people, the wire may feel more bulky. It may be a reminder to them of a traumatic experience, and that, you know, the the scar maybe doesn't bother them because that will oftentimes heal, I think, in a in a much better way than what they fear, but they can still feel this foreign body. And I I think psychologically sometimes that can be very disturbing for people. And sometimes it can hurt. I mean, it's it's sitting there near the edge of your pectoralis muscle, and it might irritate it when you're doing things. When they need to be removed, it's not too big of a deal. It requires anesthesia so people are comfortable, but usually just a small incision over the wire. And once the bones healed, you don't need the wire anymore. So so it doesn't have to stay in forever. It's just that it's usually not worth it to take it out for take them out for people. But you will just go in and you can cut the wire and just pull it, pull it out. There's luckily, in my experience, a theoretical risk that something could be injured when you take out the wire and maybe cause some bleeding, and then suddenly it's a much bigger deal than anticipated. But for most patients, it's just an outpatient procedure. And for most of the people that I've had who've had uncomfortable wires, it it's usually not all of them. It may just be some of the ones on the upper part of the chest or some other location that bothers them. I've had a few patients that have had chest surgery and then years later get a condition where they lose a ton of weight, and suddenly the wire, which's never an issue for a long time, is suddenly a problem and will take them out in those situations as well. So that's kind of the topic of removing wires. Not too big of a deal, and if they really bother people, they can come out. And not too big of a deal to remove them if that's if that's necessary. The sternal non-union can be a bigger issue. I mean, the goal of bringing the sternum together is so the edges of the bone are right up against each other. Hopefully, within four to six weeks, they've reattached the way any broken bone will. And then once that happens and it's healed, it's not as strong as what it was before the surgical fracture, but it's it's good enough for anything for almost everybody. And really the key is between the way that you close to the breastbone and then the instructions you give patients is you want that bone just to heal perfect the first time. It's one of those get it right the first time types of things. Whereas if if the bone can heal up okay, as I said, for most people, that that they're as good as new, you know, for all intents and purposes. What can happen in some people, and it can either be because maybe they're predisposed to not healing as well, if they have things like diabetes or they have other conditions that predispose to the poor wound healing. If the bone doesn't stay together and heal up okay right away, then you can have a little bit of a gap between the two edges of the sternum. That's what a sternal non-union is. Sometimes that can be because with a little bit of time, the wires actually pull through the bone before the bones actually fuse together. That's where the strict sternal precautions that we give people that that I'm sure you were lectured on several times, where no push-up type move. Let it be. That's part of that. You know, we we don't want to put stress on the bone. We want it just to heal perfect for the first time. That's not to say that if someone has a sternal non-union, it's because, well, they didn't listen to the sternal precautions. I mean, there's all sorts of things that can come into play to that happening, and most of them probably have nothing to do with the patient. And as you said, sometimes it's just a small person, there's not as much bone to sort of wrap the wires around. So there's a little bit higher chance that the bone, the wire could pull through the bone. And that's not the patient's fault. That's not because they didn't file instructions, it can just be kind of the physics of their body. The you know, the worst kind of consequence of a sternal non union is that if it gets infected because it didn't heal together, then then that's a bit of a mess because that's going to require a little bit more advanced reconstruction procedure. Nowhere on the near of the seriousness of heart surgery, but a big deal for sure. But then the other, you know, neck the next step in that is it doesn't get infected, but but it doesn't feel stable to people. So they feel a little click when they do things, or when they're active, it's uncomfortable and they're not doing what they want to do, or they're afraid they're gonna hurt it more. And that's a big deal too. And then that's a case where you know you might need to go back in and close it again, you know, clean up whatever didn't heal perfectly and then close it again. We try to avoid that because if if it didn't heal perfect the first time, oftentimes the same risk factors for not healing might be there the second time. And now you're dealing with something with some scar tissue, which is not as healthy as what your original bone was, and you may run the risk of it not healing the second time around. But there are things you can do differently. As you mentioned, sometimes you can put a plate on the sternum instead of a wire. There's other types of things that can be used to try to bring the sternum together that are different than wires that can be different than what was done the first time around. And for most people, if if something like that happens, it can be fixed in in a way that ends up with a good satisfactory result. But obviously, again, you like to just get it right the first time. You want people if they have to have this major traumatic event that it's just a month to three or four months, and then they're back to their lifestyle and they're not having to address something else down the line.

SPEAKER_00 45:30

Aaron Powell The two ladies that had theirs even repaired with the plate, they're fine. They said everything's back to normal. They're doing everything they used to do, and that was the issue, and everything's good. I want to ask you a question because I think we all get this fear post-surgery. I got COVID two weeks later, and it was upper respiratory, and I coughed and coughed and coughed, and I thought I am absolutely gonna destroy everything you put together in there. I'm speaking with somebody right now who had their surgery in there about a month out and got COVID, and she's anxious and said, ah, you're a month, you're good. I was two weeks and everything held up fine. Can you maybe just give us a little bit of assurance that you're not gonna cough your wires apart?

SPEAKER_01 46:15

Yeah, well, even with all the precautions that we give people, and we really read them the riot act of not doing anything too strenuous with their sternum, you know, at the same time, I'm telling everybody, yeah, I want you walking an hour a day. Like, you know, I don't want you laying down unless you're actually taking a nap or you're going to sleep for the night. I want you coughing. Like if there's mucus in your windpipe or in your lung, I want it out because I don't want it to turn into pneumonia. So coughing is okay. I mean, it is a it is kind of some cruel twist of fate to give somebody COVID after heart surgery. Like that's not fair. But your your body is going to be able to withstand coughing. We we want you to cough. You know, we don't want you to be sick with COVID, and we want you to want you to be coughing violently because you all these things going on. But but your external closure can tolerate those kind of things. You know, we we want to avoid unnecessary stress, but but again, if someone looks like they're trying not to cough, like I'm admonishing them then that they're you know setting themselves up for some trouble. So if you get a cold, you get COVID, you're coughing after heart surgery, it's it's not gonna be the end of the world in almost every case. I mean it's important for people to make sure they they stay up with their surgeon and their team of people taking care of them and just make sure everything's okay. But for the most part, when you get discharged from the hospital, unless there's something really extraordinarily going on, you you're gonna heal well.

SPEAKER_00 47:50

Good. Okay, guys, now you don't have to worry. The cough is okay. And we heard it from a thoracic surgeon, so we're not gonna blow everything apart. There's one thing I'm gonna come back to if you have just a couple more minutes. I wanted to ask, when we were talking about the sternotomy as the access point, you do certainly sternotomies, you also do minimally invasive and even some robotic. How would you categorize the sternotomy versus the other options if they are options for a patient?

SPEAKER_01 48:25

For me personally, and and again, I I I've haven't had any of the surgeries myself, but when I think about what needs to be done, I think about what needs to be done on the inside. So whether it's heart surgery or lung surgery, whether it's a cancer operation or whether it's fixing a valve, whether it's bypassing a diseased artery, for me, what I think about is well, what's what's going to give the best result? And if there's a couple options, well, let's do the least risky or the least traumatic. So in general, like that that's how I think about things. So if somebody needs heart surgery, there are some surgeries that are just they're better done as a traditional open sternotomy. And that's what I would, I think, choose to have if I needed to have that. There's other things though that instead of a sternotomy, you may best access a valve from the side, from the right chest. And oftentimes people will call them mini surgeries. I'm not sure what makes something mini versus maximum. I mean, they're all kind of big and they're all kind of traumatic. But in some cases, coming from the side gives a surgeon better visualization of what they need to see. And they can do a better job, say, of repairing a valve than if they were doing nutritional strenotomy. It may be a little bit more complex in some ways, but for a specific surgeon, that may give them the best access to fix the problem in the best way for the short term and the long term. But I would say if a minimally invasive option is considered an option, then I would investigate that. Like you, if you can't have a minimally invasive surgery, you're probably still gonna do very, very well, but it'd just be a little bit slower recovery, maybe a little bit more pain, a little bit more time before you're back to completely normal. But in a six months or a year, you're hopefully cured of the cancer, whether the scar was big or small, or or your heart is functioning great, you know, whether the incision was big or small. But I think if there's an option for minimum invasive surgery, there's not a reason not to do it. And and it can save people time in the hospital, shorter period of recovery, less pain medicine, lots and lots and lots of good things, and a little bit less risk in a lot of cases. So there's less risk of pneumonia or other types of things. So I think that if people are investigating, you know, having surgery, those are the things to think about. If somebody tells them, I don't think you should have a minimally invasive surgery for this reason, if it sounds like a good reason, then it probably is a good reason. If it is because, well, I'm personally not comfortable with the minimally invasive surgery, that's also a valid reason. And not all minimally invasive surgery is better than open surgery. So if you're interested in a minimally invasive surgery and your surgeon tells you, I don't think it's as good in my hands, and I prefer to do it as an open, that can be a good reason to just go with that surgeon. But it doesn't hurt oftentimes to get another opinion, maybe see someone who's known to be an expert in a certain technique and see what they say. And then that way, at the very least, people will feel fully informed. So they will hopefully not have any regrets later on. Like if things didn't go as well as they hoped, they don't want to look back and say, well, maybe I should have gotten another opinion. I think going in and feeling comfortable with what you've chosen is is super important. I I try to encourage people to not have remorse afterwards because you know, most people they make the best decision they can make with the information they have with a tough problem, and they're relying on people, and oftentimes they make a good decision. Even if things don't turn out perfect, doesn't mean it was their fault they made a bad decision. And then for some people, getting too many opinions can be bad because it can increase your anxiety. Instead of making you feel better that you're doing the right thing, you may hear something and it sounds a little different, and then it can really throw a lot of confusion. Like, wait a minute, even if in at the core people were talking about the same thing, it sounded different and now they're not sure. And then you go for another opinion, and then it sounds even more different than the other two. And I think that can hurt you. But when it comes time to choose your approach, who's gonna take care of you, what you're gonna have, it's super important to feel comfortable with it. And again, once you make that decision, I try to tell people, you know, that's your decision. That's a good decision. You know, you made the best decision you could make, just move forward with it. In most cases, it's gonna work out very, very well for people.

SPEAKER_00 53:11

Aaron Ross Powell We see a lot of that on the condition with the unroofing procedure. Now there are robotic options, not for everybody, but for some. And then, of course, some minimally invasive, depending on the situation, and then of course the sternotomy. And the unfortunate part is some people who we've even spoken with on the podcast become paralyzed by the analysis, paralysis by analysis, and they can't make a decision. And it takes them much longer when if they would have been able to move quicker, they would have been healed quicker and less symptomatic. So wonderful explanation. And I especially like the fact that you didn't take any sides on it. I I was almost going to go leading with it, is you know, is the strenoty the gold standard? And in fact, it really isn't all the time. There are options. One thing I didn't have on the question list, Dr. Barry, is you deal in a very high stress, high-stakes environment on a day-to-day basis. And certainly we're appreciative of what you do. What do you do for fun? How does Dr. Berry relax? What uh hobbies, habits, things you do that you bring me bring you more joy than what you do for patients?

SPEAKER_01 54:21

Well, I have a great family, I have a great wife, I have great kids, I am lucky to go home to them. My day always starts and ends great, no matter what happens in between, uh in in some way. But I I like to I like to run, especially being out in California where I live now. It's almost always nice in some way somewhere, whether it's in the early morning or the later afternoon, it's nice to be be out. I I love music, I love to be an amateur musician, I love to listen to music. And then I I like sports and sort of news as well, so I can jump on and read some interesting story about what's going on in in the in the world, or I can read about what's happened with some of the Philadelphia sports teams. And oftentimes that doesn't bring me joy, but it at least brings me brings me back to my hometown and and back to good memories from when I was growing up.

SPEAKER_00 55:22

What instrument? Is there a particular instrument?

SPEAKER_01 55:24

I like to play the guitar and then I like playing piano also.

SPEAKER_00 55:29

Any final thoughts? Anything you want to leave us with?

SPEAKER_01 55:33

Not really, except I would say, you know, for people that are facing some kind of medical procedure, whether it's something like chest surgery or heart surgery or something maybe even more minor, I would just encourage people to be good advocates for themselves. And if they find that they're worried about something, they should write it down and they should ask somebody about it. Because I think that in most cases, they're gonna be feel better after they get to talk about it and they're gonna have at the very least a better understanding and hopefully a more realistic understanding of whatever it is topic that they're they're worried about. Their answer might not always be super comforting, like maybe what they're worried about is valid and they they should be worried about it. But I think if they can at least talk it over with people, it becomes something that they're actively addressing. And I think it takes away some of the sort of fear of just being a passive player as you're going through whatever medical journey that you need to go through. I think these things like you're doing, these podcasts that are looking at different topics, are a great resource for people because if you've never had heart surgery, you can listen to some people talk about it. And at the very least, you're listening to someone who had heart surgery and they're fine. You know, they sound intelligently like, you know, they're they're they sound healthy, and that's that can be important to start with. And then good support groups out there. You can ask your you know, your medical team if they know of any and sometimes form support groups, and they're not only willing to speak to people, but they're also willing to have them join the support group. And and that's also something that some people find very helpful and very comforting as they're going through whatever it is they have to deal with.

SPEAKER_00 57:28

Dr. Barry, I cannot tell you how much we appreciate what you've just shared with us because it's been extremely helpful. It will, I think, give a lot of people guidance in terms of the steps they need to take and a better understanding of the options when they're evaluating, as well as those who have recently had the surgery and now understand some of the things that they might be dealing with are quite normal. And you just did such a beautiful job of explanation all the way across the board. So thank you, thank you, thank you from the bottom of my imperfect heart. I really appreciate all that you're doing and especially the fact that you came on and spoke with us today.

SPEAKER_01 58:08

Aaron Powell No problem. I mean, I it this is a lot of fun to do. I mean, actually talking these kind of things over with you in particular is very, very rewarding for me in a lot of at a lot of levels in a lot of ways. So I certainly really appreciate the opportunity to participate and and to talk with you.

SPEAKER_00 58:26

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.