Episode 26: Dr. T. Sloane Guy Explains His Robotic Unroofing Procedure and Process for Acceptance.

SPEAKER_02 0:00

I think surgeons that don't do robotics underestimate the value of robotics, but I think patients overestimate the value of doing it minimum evasively, even totally endoscopic, like myself and Dr. Balkey does. I think there's value to it. But again, our first two priorities are safety and efficacy, right? Safety and effectiveness. The most important reason to go to someone is that they're experienced at this problem and they know what they're doing and they do a good job that gives a durable result. And that's more important than the incision that they use.

SPEAKER_03 1:09

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 this episode is somebody I know many of you are anxious to hear from. He practices at Northeast Georgia Medical Center in Gainesville, Georgia, north of Atlanta. Dr. Thomas Sloan Guy is director of minimally invasive and robotic cardiac surgery at the Georgia Heart Institute with Northeast Georgia Physicians Group. He has a broad range of surgical capabilities, but is very experienced and nationally renowned as a leader in robotic mitral valve repair and is one of the few surgeons in the country doing robotic unroofing of myocardial bridges. He grew up in North Carolina, played varsity football, and graduated Magna Kum Ladi with honors and a distinguished military degree from Wake Forest University. As a trauma surgeon, he also served twice in Afghanistan and one tour in Mosul in Northern Iraq. He was awarded the Bronze Star among many other medals, completing his service as a decorated lieutenant colonel. Dr. Guy has also been named a New York Top Doctor, a Philadelphia Top Doctor, U.S. News World Report Top Doctor, and Castle Connolly Top Doctor. Dr. Guy, welcome to the program.

SPEAKER_02 2:36

Well, thank you so much for having me, and I'm I'm honored to anytime I have an opportunity to connect with patients and with those that are advocating for patients, you know, I consider it to be of the utmost importance. Very glad to be here.

SPEAKER_03 2:48

Well, first of all, let me thank you for your service. You did three tours in the Middle East. That's an incredible commitment to our country. So so thank you so much for that in the first place.

SPEAKER_02 2:59

No, thank you so much. I appreciate that. In fact, my last deployment, I was actually stationed at the San Francisco VA near where you are. And I I used to actually care for veterans from the Mather VA, which is in the town you're in now.

SPEAKER_03 3:12

So Yeah, correct, not very far away.

SPEAKER_02 3:14

Yep. I used to care for a lot of patients from that VA because they would be shipped into the San Francisco VA. And I was deployed to Iraq out of San Francisco, and then I got out of the Army shortly thereafter.

SPEAKER_03 3:25

What was it that you gleaned from your service overseas that led you to where you are today in the practice of cardiac surgery? Because I'm sure that's not what you were doing over there, was it?

SPEAKER_02 3:34

No, I was doing mainly trauma surgery and humanitarian elective surgery of various kinds. There's a few things that can be learned from deployments. One is the element of teamwork. You know, you're not an individual, your function is a team, and that can be quite challenging. You're you're thrown in the middle of a desert and you're supposed to stand up a high-level trauma center within a week and function with people you may or may not have ever met or worked with before, who have a very diverse set of backgrounds and capabilities, and yet, you know, the mission is incredible, which is to save the lives of injured American soldiers injured in battle, in combat, along with a fair amount of humanitarian work we did. So I think number one would be teamwork. Number two would be the ability to think outside the box, to be outside your comfort zone. When I was in Iraq and Afghanistan, I had to do a fair number of procedures that were outside the specialties of general surgery and thoracic surgery where I was cardiothoracic surgery, what I was trained in. You know, urology, GYN, plastic surgery, pediatric surgery, et cetera. And I had had some exposure to those things, but I had to help people, and there was no one else around. It was me or nobody. And I even had to do in Afghanistan a series of brain surgeries for people that were injured, had injured heads, you know, as a general and cardiothoracic surgeon. And what I learned from that experience was that it's amazing what you can do if you care about patients. Like if you truly care about their well-being, they don't have any other option. You've done everything you can to help help them, maybe get them to another facility where there would be expertise, but you can't do that, so you do what you can. And I was amazed at how generally well the patients do. How the real essential component was not so much a certain knowledge set as it was a desire to do good and to care about the patient, I think, in all honesty.

SPEAKER_03 5:35

It's certainly a testament to not only your skill set, but your consideration. One of the things that I'm know you're keenly aware of is that people are seeking the surgical and roofing of their myocardial bridges. And when they get into this process, they look for alternatives to the sternotomy because the sternotomy scares the heck out of everybody because that's painful, or they've heard it's painful, and it's a visible opening of the chest. But a minimally invasive approach well, and we would all love that because we think it's going to be simpler or easier. It's often not the case where that's an option. So this is kind of a two-part question. You're one of the few doctors in the country that is actually using robotic surgery to unroof bridges.

SPEAKER_02 6:17

Yes.

SPEAKER_03 6:18

Could you walk us through how you got to the point of uh doing the surgery in the first place and then how'd you get to the robotic side of it?

SPEAKER_02 6:25

Yeah, fair enough. So you know, the first thing I I tell patients is You've got to really think through what your priorities are, okay, as a patient. Because my priority should be the same, right? So what do you think the number one priority should be for any kind of heart surgery, in your opinion? What's your answer?

SPEAKER_03 6:45

Successful recovery, elimination of symptoms.

SPEAKER_02 6:49

Okay, I would take it even to a more poignant level, okay? I would say your first priority is to survive the experience, to not die. Okay, and while it may seem hilarious, there are people who die after heart surgery. Yeah. You know, I always tell patients, Neil Armstrong, the first guy on the moon, died after a simple heart operation. You know, had some bleeding afterwards, he ended up dying. You know, heart surgery is no joke. There are risks, and the number one priority has to be surviving the experience, along with, you know, limiting complications, right? As much as we can as human beings. Recognizing that, you know, while many of us are pretty good at what we do, we're not God. Things can happen no matter how good we are, okay, or how much we care, or how thoughtful we are, or how well prepared we are, or how experienced we are, complications can occur. You you shared with me your own experience, and and that can happen. Now your second priority is to fix the problem and fix it as durably as possible. In this case of unroofing, that's adequate unroofing of the myocardial bridge, right? And then your third priority is make it as least invasive as possible without compromising goals number one and two. Does that make sense?

SPEAKER_03 8:00

Absolutely. And I think if I can add, I really appreciate you making that point because the group of us, let's say, that are communicating on the Facebook page, 2300, 2400 some people, the people who interact with me on the podcast, even the doctors, sometimes we take it for granted because we haven't heard of any death as a result of this particular surgery. That oh, it you get the surgery. We forget the fact that correct this is. This is a huge risk. You're operating and cutting the heart.

SPEAKER_02 8:31

And it's not just death. I, you know, I have not seen that or heard of a case. I'm sure it's out there, but from myocardio and roofing, however, it certainly could happen. You know, I have heard of other complications, you know, bleeding, infection, all sorts of things, inadequate myctomy I've heard of. But the truth of the matter is that it's very, very important as a patient, referring cardiologist and a surgeon to understand those priorities and they're in that order. So we never put minimally evasive at the top, which is why in my practice I do a fair number of sternotomies for for various problems, not usually front roofing, but I have done it front roofing when I thought it was appropriate. Because, you know, I'm looking at each patient with that priority list in mind and saying, well, you're a good candidate, you're not a good candidate. And for me, I think it's very important. I just finished just a few minutes ago, finished a coronary bypass grafting through a full strenotomy, you know, old-fashioned full strenotomy. So it's not like I'm, you know, opposed to that when it's appropriate. The now, the way I got into this is fairly interesting. I do a large volume of robotic mitral valve repairs. That's kind of what I'm known for. And I became interested in the robot back during residency and fellowship when we had it at the University of Pennsylvania, the robot system, the first generation of robot. And at some point decided to get serious about it and joined a couple of very famous surgeons at St. Joe's Hospital in Atlanta, Dr. Doug Murphy, who was a mitral guy, and Dr. Sudhir Sravastava, who was a coronary expert, and learned from them during my time there when I got out of the army. And then sort of went about my business, you know, building programs in robotic mitral valve surgery primarily with some endoscopic coronary bypass surgery procedures. Okay. And then at some point, patients with myocardio bridging started trickling in. Because I think that my impression, having learned a lot from the patients themselves, has been that it's a very poorly understood problem. I think there is very much a feeling among many cardiologists out there and surgeons that it's not real, that the majority of coronary blood flow to the heart should occur during diastole. Bridges generally contract the vessel during systole when the heart's contracting, and therefore it should make a difference. And what I've learned from the patients is and the experiences that I've had as I've sort of been dragged into doing this, kicking and screaming, meaning I never, I never sought out a practice in corneary and roofing, okay, nor was I particularly interested in doing that. But patients kept coming to me that were sort of desperate, that had been to lots of different people, et cetera, and they wanted to avoid astronomy. And I have the skills to do that, so I thought, well, you know, we can we can do this robotically, and I started doing them, and I quickly came to the conclusion for me that doing them on the heart-lung machine, with the heart completely still, with the robotic system was the way to go. And there's a couple of nuances to that. For one, Dr. Balke, who's a good friend and colleague of mine, he does them off pump. And to my knowledge, he's the only guy doing them off pump in the world, in part because the coronary stabilizer, the thing that keeps the coronary artery still, has been discontinued by Intuitive Surgical, the robotic company. There's some hopes it'll come back, but that doesn't exist anymore. So to do that off pump, you have to hold the coronary artery still. But even then, you know, there are other ways to stabilize the heart and do it off pump. But I I felt that it was safest to do it with the heart still, that I could get the safest unroofing done with the least likely chance of injury to the coronary and the right ventricle, which sits shockingly close to the to the LAD when that's the vessel in question. That's what we've done. And of course, I'm very comfortable putting patients on the heart lung machine with percutaneous access. I use basically no open incisions. I do it with just needles and ultrasound and fluoroscopy, and and I'm quite facile at that because we do that every day with our mitral valve repairs. And I think it's a nice way to do it. Now, I've learned other things. I've learned a lot about what I call the R's, you know, the RFRs, the IFRs, the various, let's say, more sophisticated measures of coronary blood flow. And I still don't know that I completely understand it. I bet you there's patients that actually understand it better than I do, but as best I can tell, it sort of helps you understand blood flow, not just during diastole, but over the course of the entire cardiac cycle. And I've come to believe that there is a group of, there's a subset of patients with muscle overlying their coronary arteries, who have constriction of that vessel during systole, but who overall have compromised blood flow to their myocardium over the course of the cardiac cycle. In other words, rather than looking at a snapshot of blood flow during diastole, you look more at the area under the curve, if you will, the total amount of blood flow over the cardiac cycle. And that's my theory is that, and you may know more about it than I do, in fact, having interviewed all these smart people, but that that's the case. Now, what I have seen is what I've also seen, in all honesty, is I've seen folks that have various symptoms, including chest pain, fatigue, shortness of breath, all sorts of things, difficulty in school. I mean, you wouldn't believe the things I've heard. And they also have a myocardial bridge or an underlying or a segment of coronary artery underlying muscle that's constricted during systole, and it may or may not be due to that corn, that myocardial bridge. In other words, because no one knows much about the myocardial bridge out there, most people don't, you see a myocardial bridge on your cath report, you have these problems, they're not getting better, you assume it's the myocardial bridge. And what I've tried to do is be ethical and to sort through these things as best I can. So what I've typically done is partner with a cardiologist. In my case, it's a it's a guy named Glenn Henry. Glenn Henry is an interventional cardiologist who was chief of the cath lab at Yale for years and came here recently. And he's just a super smart guy. And he partnered with the cardiologist at Stanford, who clearly have studied this the most, to come up with a protocol here that includes debutamine testing, acetylcholine testing, and various other more sophisticated measurements, including things like IFR, FFR, and RFR, which again, he can articulate that better than me. But for me, you know, I generally will hesitate to do an unroofing unless Glenn says, hey, this is the real deal. He has a very reasonable approach to it. He he has come to me and said, Look, Sloan, you need to do this. This is real. This is causing this patient's symptoms. You need to do this. There's only one time where I did an unroofing when he didn't think it was that real. And I got in there, and sure enough, there really was no muscle over the coronary. I unroofed the coronary from top to bottom of the heart, so there's no nothing on top of the coronary, and the patient still continue to have symptoms. I just saw her in my clinic, and you know, which kind of convinced me that some of these testing is real. At the same time, it's very, it's very tough as a doctor when you really too care about patients, which I do on a deeply personal level, and they come to me and they're just desperate for answers. It's tough to tell that person, no, I don't think surgery is the way to go. Because I want to help them. You know, we're doctors, we want to help them, but we also don't want to do what they used to do in the old days, which is you know, sell snake oil or, you know, do give things to the patient that makes the patient feel better feel like you did something, but don't actually help the patient, but also profits the physician in the hospital. We don't want to do that. I'm not in the business of doing that. I'm not gonna subject a patient to even the tiniest risk of surgery unless I feel that there's at least a reasonable chance that it's gonna help them in their symptoms. But I also spend a lot of time counseling them on this so that they know that about 70% of my patients get better with surgery of those that I agree to operate on, but about 30% don't. And it's not because I'm a bad doctor or you know, Dr. Henry doesn't do a good job. It's because there's limits to what human beings know and can understand. But to the best extent possible, we in our program have tried to maximize appropriate testing to figure out who is most likely to benefit and who is most likely not to benefit, if that makes sense. So I kind of stun I kind of stumbled into it to answer your question. I didn't I wasn't looking to do unroofing, and if there was somebody out there that wanted to do it and I never did another one, I'd be okay with that. But but I I am about I am about taking care of patients that need help. And I do feel that an unroofing can be done just as safely robotically as it can by astronomy, and the recovery can be faster. So why not?

SPEAKER_03 17:32

Well, and that's that's what we need. But you in your description there, you did in that monologue, and I mean that in a really incredibly positive way, you took us through the steps that so many people are trying to circumvent. They want to skip that provocative testing, they want to skip the diagnosis, the proper diagnosis. And to your point of we don't know what causes this. You've unripped somebody and it's uh it was uh no cure, it didn't benefit them. And some people do get the 60, 70 percent better or they get the 50 percent better. But the the truth is that's my understanding that at least one in four people have a bridge. Only one percent of one percent are symptomatic. That's correct. Yeah. So we just don't know what causes those symptoms. So the more testing we can do pre-surgery, which we know is a significant surgery, so much the better. It was one of my questions do you require a full provocative test prior to di uh prior to surgery?

SPEAKER_02 18:28

And it's generally speaking, the answer would be yes, because I want to do the right thing. Look, I'm a very ethical doctor who wants to do right by patients. And again, it's I've been in that difficult position of saying, look, I don't think this is gonna benefit you. I'm sorry, but I I don't think it's the right thing to do. And it's it, you know, it's it's painful for me because I, as a person, I want to help people, but I also don't want to be, you know, that that person that is offering some therapy, knowing it's not gonna work, just to make the patient emotionally feel that, you know, you did something and you're, you know, trying to pass the guy. You're making money off of it, having case volume. I mean, I don't want to be that guy. I I I went into medicine to to generally help people for real. And I don't want to do an unroofing unless I think it's got a chance of working. But at the same time, I'm very humble about it. I I don't know, I don't know everything. I and and there have been times where I've agreed to do it even when I wasn't sure it was going to work. And sometimes it has worked. And again, it's the patients that have taught me the most about unroofing, more than the books. Just listening to their symptoms, their trials and tribulations, things that have gone well, things that have not gone well. But I've also learned other things. There is, you know, a simple phenomenon of coronary spasm, which can very much mimic it. You know, there's run-of-the-mill coronary heart disease, and there's a ton of other things that can cause chest pain: fibromyalgia, you know, musculoskeletal problems, gastrointestinal problems, reflux. I mean, you know, the list of things that can cause similar chest pain is quite large because the nerves that innervate the heart innervate a whole lot else. But my heart, no, no pun intended, my heart is in the right place. I want to, I want to help them, but I don't want to, I don't want to do an unnecessary operation. That's the bottom line. I I don't want to, because there are risk. Yeah, be it uh however small, you know, they're not zero. And I'm never gonna recommend an operation to a patient if I wouldn't recommend it to my own family.

SPEAKER_03 20:33

I've actually spoken to people who you have declined and other doctors have declined as well.

SPEAKER_02 20:38

Yeah.

SPEAKER_03 20:39

What are some of the the criteria that we would use to say this this isn't gonna work? It might save some of the people that the outreach to you.

SPEAKER_02 20:49

Well, for instance, if we look at the you know, the FFR, the IFR, and the RFR, those are kind of the three that I know. And again, I I don't even interpret those by myself. I have Dr. Henry look at those, or previously when I was in Philadelphia, one of the cardiologists there, and I have them interpret those numbers and say, you know, is bottom line is is coronary blood flow substantially impacted by this bridge or not? And that's that's the question. And not to delve into any of the details because there's lots of different opinions about that, but we kind of put the whole picture together, the patient's history, the visual appearance, primarily on angiogram, invasive angiogram. Sometimes we look at the CT cornear angiogram, provide along with the physiologic corneary artery measures, we're really trying to answer the question is is this bridge physiologically significant? Is it negatively impacting corneary blood flow or not? And if those numbers line up in a way that suggests that it's at least possible. And the patient has compelling symptoms, and the patient seems to reasonably understand things, then we'll proceed with it. And if not, I'll usually meet with the patients a couple of times if I'm going to turn them down because I I do feel badly about that. I I mean I genuinely do. And, you know, listen, I I'm sure one day I will turn down a patient, they will go to another surgeon, they will get the operation, and they maybe will have resolution of their symptoms. I suspect that that will happen because again, I don't I don't have all the knowledge. And sometimes there is what we call a placebo effect where a patient can have the operation feel better and it not actually be because of the unroofing itself. You know, there was a study many years ago of something called the Weinberg procedure where they patients with corneal artery disease or blockages, they would take an artery off the chest wall and they would they couldn't do a bypass like an anastomosis or connection beyond the blockage. So what they would do is just dig a furrow into the muscle and they would lay the artery down into the muscle and then close over the top of it. And believe it or not, that was highly successful at relieving angina or chest pain. And we don't know why. Was it because somehow these vessels developed connections? Was it because it denervated the heart, meaning interrupted, you know, uh nerves to the heart? We don't know. But the bottom line is I'm very I am very humble about it. At the same time, I have to look myself in the mirror, and I at this point I I look at those those provocative measures to kind of help guide me, you know, is this the right thing to do? But likewise, I encourage patients to get other opinions. Because again, I I don't I don't know all there is to know about this, and there may be others that have different opinions, and and I I just want what's best for the patient.

SPEAKER_03 23:46

If you were to estimate roughly how many unroofing surgeries have you done and and how many would be robotic?

SPEAKER_02 23:53

Yeah, I've probably done over 100 at this point, and I would say 80% of those have been robotic because early in the beginning I was doing them mostly open. And then occasionally I'll do them open now if there's some other reason. You know, there's various reasons. Maybe they have a valve to fix or they're high risk for robotics, etc. But the majority of them now we do, when we do them, we do them robotically. It's not a difficult operation technically, particularly the way I do it with with it with the arrested heart. Most coronary surgeons that do coronary bypass surgery in any volume are very comfortable with that. There are some nuances. Like I mentioned one, the I learned this early on. One of my early robotic cases, I got into the right ventricle, and it was okay because I was on the hard lung machine, so I closed it with suture robotically and it went fine, but it scared me. I didn't realize how close the right ventricle was to the left anterior descending. Or you can have bleeding, you know, in the bed. So I'm always very meticulous about that. But in general, it's it's not like this is some extraordinarily technical operation that requires just a great technical person, be it open or robotic. But robotics certainly requires a certain robotic skill level, which not many folks have. I think you have actually in Sacramento, Bob Kiyai is there. He may be doing them. I don't know. But Dr. Dr. Kiyai is an excellent robotic surgeon. That would be an example of a robotic surgeon with the kind of skill set it takes to do it. But it the operation itself is not technically difficult. And I would say that most surgeons could easily do astronomy unroofing if they were thoughtful and had a lot of experience doing coronary surgery and you know really wanted to get the get the thing unroofed. It's more in my and I think you can tell by the by the percent of discussion that I'm putting forward to you that most of it has to do with should I do it or not, not with how to do it. The how to do it's actually pretty straightforward, honestly. It's mostly most of the angst that I have is whether to do it or not to do it.

SPEAKER_03 25:53

And it's the same for that patient who's trying to make the decision. They finally got to the point of I'm going to have the surgery.

SPEAKER_02 25:59

Right.

SPEAKER_03 26:00

They've been diagnosed properly. Now it's the decision on what to do. And it goes both ways. Fear of the sternotomy and also fear of the robot. The skills that on the robot is much more recent.

SPEAKER_02 26:11

Rare than obviously than rare.

SPEAKER_03 26:13

Correct. Correct.

SPEAKER_02 26:14

Well, it's actually not that it's actually not that recent. It's interesting because they're getting ready to develop, uh, they've developed a fifth generation of robot. We're on generation number four now. I started doing robotics around 2001. And so robotics has actually been around for a long time. Now, that being said, there are not many surgeons in the country that have the skill level that I would be comfortable with having my robotic heart operation. Okay. And I mentioned a couple of them. Obviously, Dr. Balkey's one for sure. I mean, he's I'm always joking, he's better than I am. He probably is. He's very good.

SPEAKER_00 26:52

He might say so too.

SPEAKER_02 26:53

No, he's excellent, but he's also very humble. Dr. P.I., absolutely you know, fantastic. I also mentioned Dr. Murphy on the micro side, Dr. Sravastava, who's actually in India building a surgical robotic system now. So there, and there, I could go on and on. There are a number of very experienced surgeons in whom robotic surgery is just as safe as sternotomy surgery, but it's not as common as sternotomy surgery. I would say virtually any competent adult cardiac surgeon should be able to do an unroofing. They may not be willing to or comfortable doing it, but the technical aspects of it are that it would be easy. It's fairly easy to do it via sternotomy, honestly.

SPEAKER_03 27:33

Aaron Ross Powell, What are some of the differences in sternotomy versus robot complications and or consequences?

SPEAKER_02 27:41

So if sternotomy is, again, they're both we're both doing the same operation, right? So when you do a strenotomy, myocardial bridge, you basically take a saw and you saw the breastplate down the middle, okay? You put a retractor in and you expose the heart. Again, I just did one of these like two hours ago. So it's not like I'm anti-strenotomy. Sternomy is easy, but I think it is, quite frankly, for at least for my cardio unroofing. I think it's fairly easy to do an unroofing. Now, when I do an unroofing through sternotomy, I will generally put the patient on the heartlung machine and stop the heart. I'm sure there's those. I don't know what Dr. Boyd does at Stanford. I know he's done a lot of them. He arrests the heart. But I like to arrest the heart. It makes it easy. And I can really take my time and really unroof that thing well and drive up any bleeding. Again, if I get into the right ventricle, it's not a problem. And then you put chest tubes in and you close. Now you want to make sure you get the whole thing. And a lot of times what I'll do is pull up the calf film or the CT angiogram and kind of look at it. But generally speaking, it's you can generally tell where it's epicardial, so you can see it, so nothing's on top of it. Now it's diving into the fat and then the muscle. And then when the bridge is is over, and there I've seen them, you know, usually about four centimeters long in many cases, it will then dive back up near the pulmonary artery. And I try to take it as far as possible, and when in doubt, take more and and basically eliminate everything that's over the top of that that vessel. And then you know, you put chest tubes in and you're and you're done. Now, if I do it robotically, I basically do the same thing. The only difference is the patient comes to the operating room, we put some special lines in the neck, and then we will I actually cannulate the patient in the usually the left femoral artery and vein. I do this percutaneously with ultrasound and ferroscopy using the same techniques that cardiologists are using to put in transcatheter valves. And we put them on the heart lung machine. We also put a balloon into the aorta where which we blow up and we deliver a drug called cardioplegia, which which stops the heart, makes and and patients freak out about stopping the heart. Really, I think it's better to say we put the heart to sleep. So and I do it for the same reason that sounds like Dr. Boyd does. I want that heart to be still and under complete control. And then you don't need a stabilizer, you know, the robotic stabilizer. I don't have that anymore because they took it away. And you don't need the stabilizer, you can just use a forceps to bring the coronary artery into view. And then you use a combination of scissors and electrocautery to find your way down to the coronary, starting where you see it, to where it comes up near the pulmonary artery, and you remove everything on top, usually muscle. And I'm sort of struck because I've had many cases where I've been like, you know, I don't know whether I should be doing these unbridging surgeries or not. And is this real? And then I get in there and I see that tight muscle over the top of the coronary. I'm like, you know what? I feel good. I feel I feel like we did some good today. And I literally have told people in the OR that, you know, hey guys, look, look at this. This is tight. This is constricting that coronary. I think we're doing good by this patient today. And you know, you snip it and it's very satisfying. And then you do the same thing. You check for bleeding, you put a chest tube in, and you're done. The only difference is you haven't done it through a steronomy. And I don't see any, I don't I don't see any increased difficulty once you get to the coronary itself, if you're an experienced robotic surgeon. Now, if you're starting robotics for the first time, yeah, that's way too much. If you're using the robot all the time for other things, it's it's not that difficult, especially if you've done totally endoscopic coronary bypass crafting, which I've done. But there's a little more to it, right? You're having to cannulate peripherally, you're using the endaballoon to stop the heart, there's a robotic system, you're a few feet away from the patient when you're doing this procedure, you've got a bedside assistant. So, yeah, that's going to be a bit much for most programs, but the actual on roofing itself is virtually identical to what you would do through a strenotomy.

SPEAKER_03 31:48

How about post-surgery? Any differences in complications? Obviously, there's always the possibility of infection in in either. But it seems uh there could be some myocarditis or different circumstances that could occur post-robotic that are maybe less when it's sternatomy.

SPEAKER_02 32:08

So let's talk about each procedure and what you know unique complications relative. So one complication of sternotomy is a sternal wound infection, and that is actually potentially a devastating complication. It is nasty, you know, sometimes requires removal of the sternum. But in fairness, it doesn't often occur, particularly in patients where you're not removing the internal mammary arteries that are you know supplying blood flow to the sternum. But it it does occur. Superficial wound infections do occur, and those can be annoying because it's a you know fairly big incision, the sternotomy. And and that can be annoying. Pain is a big issue with sternotomies because the sternum it moves. Now, I like to use sternal plates, which reduces the pain, I think, when I do sternotomies, but there's no doubt that you have it can have a fair amount of pain from sternotomies. But a sternotomy is not the worst thing in the world. I just told you I did one two hours ago.

SPEAKER_01 33:00

Yeah.

SPEAKER_02 33:01

And I think that one of the things I've struggled with as a big advocate for robotics and melanin invasive, as much as I'm a fan of it, I do think that patients overrate the value of doing it without a strenotomy. Meaning they think it's like way up here where it's real. I think surgeons that don't do robotics underestimate the value of robotics, but I think patients overestimate the value of doing it minimally invasively, even totally endoscopic, like myself and Dr. Balkey does. I think there's value to it, but again, our first two priorities are safety and efficacy, right? Safety and effectiveness. And I think when I talk to patients, I tell them the same thing I tell my mitral valve repair patients. The most important reason to go to someone is that they're experienced at this problem and they know what they're doing and they do a good job that gives a durable result. And that's more important than the incision that they use to get to your heart. In the end, that's number one. However, we do have this additional benefit. Now, on the robotic side, you know, you're poking holes in the left chest, so you could injure the lung. I guess theoretically, you could injure the diaphragm or the spleen on the left side. I've never seen that. I've heard of people injuring the heart with putting introcars in the left side, but most of us that are experienced know how to, you know, avoid those complications. You're poking a total, when I do these, I have a total of four ports in the left chest, three robotic arms, and then an eight millimeter working port. And then we have one that's sort of sub xiphoid, you know, underneath the rib cage that goes into the right, into the left chest. And you know, these can hurt. I mean, if what I tell patients is, yeah, it's minimally evasive, but if some guy on the street stabbed you five times, you would expect some pain, right? Now I try to mitigate that by freezing the nerves, which is a little more difficult on the left side of the heart than the right. On the right side where I do the mitrals, it's pretty easy and I do it routinely. On the left side, sometimes the exposure's not as good, and and so I tend to not do it as frequently, but I try to because it cuts down on that, you know, intercostal pain. Okay. So I'd say that pain or sort of post-thorkotomy syndrome, we're not doing a thorcotomy where I'm putting holes there, where patients have prolonged pain from the holes in the chest. We see that, and I think we see that less often than when we do a strenotomy, although I saw one study that looked at strenotomy patients a year after, and 50% of them still have pain and discomfort. 50%. So it's not like strenotomies don't have pain. In fact, they probably have more pain, particularly in the beginning. But for me, you know, if I needed my cornea unroofed, putting all those in a bucket, my chances of getting out of the hospital within a couple of days are much higher with an endoscopic robotic operation than they are with either a thorcotomy, meaning a big incision in the left chest, or sternotomy. And my chances of being able to be active in the community are much higher more quickly. Certainly, as a surgeon, that's what I would want in order to be more active sooner. But again, the most important thing is that they have an act that the correct patient gets an operation, that they that we feel that they needed it, that they get a good result and a durable result, okay, with the least complications, and they survive the survived the experience. And if I can do all that with an endoscopic approach that allows them to get out of the hospital more quickly, then I think that's a valuable thing to do. And again, we you and I were talking before the webinar, but I think it's worthy of saying. One thing that I've struggled with in our profession of surgery is, and I think it's important for patients to understand, how can I illustrate it? My grandmother, my grandmother's a wonderful woman. She was the wife of a Baptist minister, Sloan Guy Jr., a Southern Baptist minister, very caring people, and she used to read Reader's Digest. I don't know if people still do that anymore or not, but Reader's Digest used to have this medical section. And one time she sent me an article as I was, I think I was in surgical training at the time, and it said, doctors only recommend treatments that they do. And she was very upset by this. Like, what if Dr. A did it a certain way and Dr. B did it another way, and Dr. B's way was better? And again, we can't always know that, right? We we don't know. Would Dr. A send the patient to Dr. B? And the unfortunate reality is probably not. And to make matters worse, many of these doctors are sometimes affiliated with institutions, right? So maybe the cardiologist is employed by a cardiology group that is owned by the hospital, and the surgeons employed by the same hospital. So they might want to refer you to the person that is in the same rope wearing the same jersey, even if it's not necessarily the right thing. Now, I think that becomes fairly simple when it comes to things we know well, like say a Barlow's valve, which is bi-leaflet prolapse of the mitral valve. You know, that probably I think most people, even surgeons, realize that should probably be repaired by a high-volume mitral valve specialist as an example. For something like coronary bridging, where even the experts admit they don't know everything there is to know about it, and they have doubts about who to do and who not to do, and equipoise in different ways of doing it, you can imagine that that does create the opportunity for one surgeon to say, well, my way is the best way. You know, I and I could do the same. I could say, well, robotics is far superior, and you should only a fool would have it done astronomy. But I'm not saying that. I'm not saying that at all. What I am saying is that patients, number one, should get different opinions. Number two, be very suspicious of any surgeon who sort of badmouths another surgeon, particularly if they're well-known, respected surgeons, or their technique, because in general, there's different ways to skin a cat. And as I said, when you think about the priorities, there's plenty of surgeons, I'm sure, that do sternotomy, myectomies, and do it well and get great long-term results. And frankly, that's more important than using small incisions, right? I don't know if I'm explaining it correctly, but but get you know, get multiple opinions. Realize that there are different ways of doing things. A lot of it has to do with what your goals are. I'm a surgeon. I need to get back to work if I'm having surgery. So for me, anything that gets me quickly back to work, I'm gonna put a high priority on that. But I'm not in any way gonna want to sacrifice goal number one and two, which was to survive it with minimal complications and fix my problem. But if I can do that and get out of the hospital more quickly, then I'm gonna pursue that option, but I'm gonna make sure that it's someone like Dr. Kiyai or Dr. Balkey, or there's another guy, Johannes Bonatti, that does them at University of Pittsburgh, that really knows what they're doing, that does the, that's ethical, that does the right patients, that does it well, that's very experienced at robotic surgery and can provide an equivalent result as for strenotomy. I I hope I'm saying that well because I mean the greatest respect for the other people that do this. And of course, I've heard patients come to me and they say, Oh, we hear robotics is no good. You know, it's terrible, it's dangerous, you know. And I don't think that's true in the hands of good surgeons. On the other hand, that's not the most important element of the patient's care. And I I try not to use, particularly for corn for robotic unroofing, which I just told you, I'm not trying to build some huge practice with. I try to not encourage patients just to come to me just for robotics. But I'm also honest with them. If I think I can do, if I think it should be done, and it could be done just as safely robotically, and I think they may recover more quickly with robotics, and there's some evidence, at least with coronary bypass robotically, that that is true, then then I'll offer them the procedure. But if they want to have it done by a sternotomy, I don't discourage that either. Does that make sense?

SPEAKER_03 41:02

Absolutely. Absolutely.

SPEAKER_02 41:03

And that's part that's part of the medical culture, or you know, in a more negative way, the medical industrial complex that I think patients don't understand. Just keep an open mind. And, you know, again, I I would be very wary of someone who said X is bad, particularly if they have no experience with it. I can't tell you how many surgeons who've literally never touched the robot or maybe dabbled in it and not done well with bad mouth robotics, and they literally don't know what they're talking about. They just haven't seen it. At the same time, it's good to get different opinions. And I think what I've seen from the unroofing community, meaning the patients with coronary myocardial bridges, is that they're pretty, by and large, 80 to 90 percent of them are pretty thoughtful people who are keeping an open mind, looking at different options. And you know, when I hear a patient has decided to go somewhere and have a strenotomy, it doesn't hurt my feelings at all. I'm fine with that because my job is not to do the operation unless they ask me to. My first job is to help them make good decisions for themselves. And if I've done that, if I've contributed to that, even if they get their operation done elsewhere, I'm fine with that.

SPEAKER_03 42:09

Well, I think part of the education or the ability to articulate that you mentioned the amylocardio bridge patients is because of the opportunity to hear people like you speak. And part of that is so much appreciated because that's the only way you're gonna draw proper conclusions. And we know in this condition you have to self-advocate because so many cardiologists dismiss it. And that's that's my next question. I know we're gonna wrap up in just a couple minutes, but this one is important to me. I ask it of all the doctors is it possible that there is a contingent of people who are dying from what looks like cardiac coronary blockage, that it could have been a myocardial bridge. Or in other words, could the myocardial bridge be a cause of sudden cardiac arrest?

SPEAKER_02 42:55

I absolutely believe that is the case. Now, I treat another subset of patients, which is hypertrophic obstructive cardiomyopathy, which is a similar condition, but it's the whole heart that's hypertrophied, and that of course is a cause of sudden death. I think that myocardial bridging is absolutely a potential cause of sudden death. And you know, the problem is is gonna be, you know, the numbers that you gave. It's a very small fraction that are quote unquote symptomatic.

SPEAKER_03 43:22

Correct.

SPEAKER_02 43:22

And yet, you know, a large proportion of people in the population have myocardial bridges, meaning cornea arteries underneath muscular bridges. And of course, we're not gonna, what'd you say, 25% of the comp population? We're not gonna take 25% of the people in the United States and just sort of prophylactically unroof their their cornea arteries. Right. But I think we do need to learn more about myocardial bridging. I mean, I I think a lot more research needs to be done. Not just, I mean, I know Stanford has had a great effort, but I think other institutions need to start to look at some. Of the basic science of this and also looking at coronary spasm, you know, that is a very common cause of heart attack, particularly in young people. But to answer your question, I think it could it is a potential cause of sudden death.

SPEAKER_03 44:16

Your workday is full of life-saving practices. I mean, two hours ago you were just performing a major surgery on somebody's heart. What do you do to relax, Dr. Guy? What what's out for you when you can get out of the high? You're in the OR right now, which you're the first interview I've done in the OR.

SPEAKER_02 44:37

Well, that's a great question. That is important, actually. You know, I was just telling, I was just visiting with a family right before I talked to you, another family, and I was explaining to them that I would not be here tomorrow because I'm not on call tomorrow. And she looked at me kind of aghast. What do you mean you're not going to be here? And I'm like, well, let me put it this way I have to take time off because the last thing you want is a crazy surgeon taking care of you. And if all you do is work, you will go crazy. Okay. I have a number of hobbies. I like to golf. My my newest hobby, which I'm very excited about, is I I moved to Georgia to the Georgia Heart Institute on Lake Lanier. So we have this huge lake, and I have a boat, which is literally just in my backyard on Lake Lanier. And I've been learning how to boat. I'm even thinking about learning how to sail. And I enjoy that a great deal. I used to be a pilot and learn and fly. I mean, obviously, there's a commonality here. Like I like machines, right? And I have a lovely wife and home, and my son's a college football player at Bucknell University, so I like to go watch his games.

SPEAKER_03 45:39

As you were a football player at Wake Forest, if I'm not mistaken, correct?

SPEAKER_02 45:42

I did I did I did play football. Unfortunately, I wasn't very good, so I had to do heart surgery instead.

SPEAKER_03 45:49

Classic underachiever, correct?

SPEAKER_02 45:51

Pretty much. I'm it. Yeah.

SPEAKER_03 45:54

Well, if somebody's interested in getting hold of you now at the Georgia Heart Institute, what's the best way to reach you? And we will put this in the episode notes as well.

SPEAKER_02 46:03

Yeah. So the the number, so our office number is 770-219-7099. And my clinical coordinator's name is Kim. Kim is wonderful. She's very familiar with all this. What our process here would be: I generally like for Dr. Henry to see them first and to review if they've already had provocative testing, because sometimes they've been to the University of Chicago or to Stanford or and gotten appropriate testing. So it's just a matter of reviewing it. Then he'll review it. If not, he'll often go ahead and schedule the testing. And then they'll usually see me after they've seen Dr. Henry. And the reason for that is I'm sort of front-loading what I think is the most difficult part, which is the decision whether or not to operate or not. And I just don't want to do it alone. I want to do it with someone that knows a lot about corneophysiology and corneophysiology measurements. So that's that's the process for us. I do telemedicine visits. I'm a big believer in telemedicine. You know, I hate to make patients travel just to see me. And so sometimes we can do that, although you're certainly always welcome to fly here. Atlanta Airport's not that far away from us.

SPEAKER_03 47:15

And it's a big hub and a lot of people coming to Atlanta now.

SPEAKER_02 47:18

Yeah. And again, this is the one message I would have for your community to wrap it up is I am doing these cases because you have asked me to. You, as patients, have come to me and said, we're frustrated, no one's taking us seriously. Our only option is astronomy, sometimes by people who don't even believe in the problem, and we won't help. So again, this was not a procedure that I went out looking for. It came and found me. But I'm happy, I'm happy to help you, you know, and give you my best opinion. And if I operate on you, do the best job that I can. But it's not like I'm doing this for some sort of selfish reason. I'm not. It's purely, honestly, it's purely altruistic, it's purely, purely for you. And if you want my opinions, I'll give them to you. And even if you don't have your surgery with me, I'm okay with that. If enough people start doing this where you don't need me, I'm okay with that too. But as long as you need me, I'm here.

SPEAKER_03 48:18

I certainly appreciate that. And I have to say thank you for just the discussion. The breadth and depth of what we covered is immense in 30, 35 minutes. So I expect a profound effect from the people who are going to hear this episode because it now compounds on top of the other stuff that preceded you to let them know that this is viable. Hopefully, we we do have a fair number of cardiologists that are hearing it because they're being forced to listen from the patients to say, look, this is real. You can help me. And I thank you from the bottom of my imperfect heart for sharing what's so important to so many of us, and that is our condition and recognition and understanding of it. So thank you.

SPEAKER_02 49:00

Thank you so much for having me. I I am passionate about surgery and helping patients. So anytime I get a chance to hear and learn, I'm I'm I'm appreciative.

SPEAKER_03 49:09

Thank you, Dr. Guy, so much. Thank you for listening to Imperfect Heart. It's my hope that this information help 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 Stuart.