Episode 45: Robotic’s Revolution in Cardiac Care. Dr. Johannes Bonatti Shares Myocardial Bridge Unroofing From the Operating Room.

SPEAKER_01 0:00

One advantage of robotic surgery is as compared to a mini thoracotomy approach. In a mini thoracotomy, you have a keyhole view of the intrathoracic structures and the heart. With robotics, I'm completely immersed into the chest. It's like being in a dome or whatever, and I can look to the left, to the right, up and down. I see all the structures.

SPEAKER_03 0:50

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. I want to share a little bit about our guest this episode as he completes the three-part series with David Vomer's journey. He's a world-renowned cardiac surgeon and a pioneer in robotic heart surgery. With over a thousand robotic heart surgeries under his belt, he has revolutionized the field. He's been instrumental in establishing robotic heart programs at prestigious institutions worldwide, including Innsbruck Medical University, Austria, the University of Maryland, the University of Pittsburgh Medical Center, UPMC, the Cleveland Clinic, and the Cleveland Clinic, Abu Dhabi. He has published over 300 papers that speaks around the globe and is involved in multiple professional organizations. One of his most significant accomplishments is performing the first ever robotic quadruple bypass surgery. This groundbreaking procedure demonstrates the precision and effectiveness of robotic surgery in complex cardiac procedures. Beyond his surgical expertise, he's a leader in minimally invasive cardiac surgery and has now added robotic myocardial bridge and roofing to his expertise. He's held key positions in major medical societies and continues to shape the future of the field. Dr. Johan Bonatti is currently a cardiac surgeon at the University of Pittsburgh Medical Center Heart and Vascular Institute and professor of cardiothoracic surgery at the University of Pittsburgh. What he's going to share with us today in this third episode of David's Journey is something every myocardial bridge unroofing candidate should be certain to listen to or watch, as the video is exemplary to the unroofing procedure. It's my privilege and pleasure to be able to introduce him to the Imperfect Heart community. Dr. Bonatti, it's my privilege to welcome you to Imperfect Heart.

SPEAKER_01 3:11

Thank you very much for having me here.

SPEAKER_03 3:13

Boy, we are we are so excited about the conversation today. We're also joined once again by David Vollmer, whose surgery we'll be referencing in this episode. David, welcome back.

SPEAKER_00 3:24

Hey, thanks, Jeff. Looking forward to this.

SPEAKER_03 3:26

And just prior to hitting the record button, we were talking about this is probably and confirmed the first time that we've had a cardiac surgeon on with not only a patient, but another recipient of the similar surgery. So this is going to be a wonderful conversation.

SPEAKER_01 3:46

This is definitely unique for me as well. A first, if you wish.

SPEAKER_03 3:56

Dr. Banani, this is the third part of three-part series. And it's our first that we've ever done this where we've had the patient process all three steps. And we started with David's story and how he's doing post-surgery now and what caused him to recognize the need for the surgery. And then we had the incredible privilege of speaking with Dr. Fowler, who walked us through the provocative testing, which to date, in a little over a year of programs, we have not been able to get a very, very good and articulate interventional cardiologist to explain the provocative test, even though we see a lot of it on the Facebook page. We talk about a lot, surgeons talk about it a lot. And so he did an incredible job of not only discussing and demonstrating the need for the provocative test, but also gave us some of David's tests so that we could see what it actually looked like to the interventional cardiologist and what they present to you as the cardiac surgeon to know what's going on. Now we have you. Could you tell us, maybe set the stage of what brought you to the point of saying, okay, David, we are going to perform surgery.

SPEAKER_01 5:33

It was definitely the provocative testing that made me take the final decision. Okay. The first things we look at usually are an angiogram or a coronary CT scan with the myocardial bridge, but we would really like to see proof of the functional impact of those bridges.

SPEAKER_03 5:54

And as one of the leading robotic cardiac surgeons, I'm I'm going to say probably in the world, yes.

SPEAKER_01 6:03

I'm part of the small group of you know internationally connected surgeons that do that surgery.

SPEAKER_03 6:10

You made the decision that his situation was one that was capable of being remedied by robotic surgery. He didn't need the sternotomy.

SPEAKER_01 6:21

Yes. So I had done sternotomy myocardial bridges before, and my focus in robotic surgery was coronary bypass surgery from the very beginning. And at some point I thought, hey, we are doing bypass surgery here. If a patient shows up with a myocardial bridge and is otherwise suited, why not offering this in robotic, totally endoscopic, as we call it, fashion? And I went for that.

SPEAKER_03 6:55

To date, how many of these have you done as the unroofing procedure?

SPEAKER_01 7:01

So, as the unroofing procedure, my experience is, to be honest, still limited with less than 10. But all those cases went very well, and I'm very confident that we can offer this to many more patients.

SPEAKER_03 7:19

And on the flip side of that, for coronary bypass surgeries, I know that that's going to have probably another zero or two behind it than 10.

SPEAKER_01 7:29

Yeah. So my my overall experience with robotic surgeries is more than a thousand, okay? And two-thirds of those were coronary bypass surgeries. The rest are mitrovalve repairs and replacements, closures of atrial septal defects, myxoma resections, some electrophysiology procedures, most recently also parts of an left ventricular assist device implantation. So but I think the bridge is really a very elegant solution to the problem because, and I think the audience should be aware of that. So this traumatic approach to that operation.

SPEAKER_03 8:20

And David, you you would attest you healed relatively quickly from the actual surgery itself, correct?

SPEAKER_00 8:26

Yeah, I'm almost three months post-op, and I'm I'm back to 100% physical activity that I was doing, you know, pre-surgery.

SPEAKER_03 8:36

And for those of us that had the sternotomy, you know, three months post-op, we're just starting to get back to what could be considered normal, and it's still a process because you have to gradually work yourself back. Dr. Banati, in performing the surgery, there are a variety of different ways that other doctors can do it. You're performing on a still heart, correct?

SPEAKER_01 9:04

I did procedures so far on the on the still heart, yes, under cardioplegia, as we call it. Okay. My preference for this comes from the fact that splitting, unroofing a myocardial breach is really delicate work, okay? Where you also have the right ventricle close by, you have a lot of fat with veins above the myocardial breach that can bleed. And I just feel more comfortable doing this procedure when the heart is really still and I have a quiet local operative field.

SPEAKER_03 9:47

I know a lot of patients get very concerned about somebody stopping their heart. Could you maybe walk us through the procedure on that? And the to maybe give them some security and and comfort knowing it's it's okay. This isn't a very uncommon experience. We know how to do it.

SPEAKER_01 10:05

Sure. I have to maybe say also, I I'm also doing some procedures on the beating heart. Okay, I do bypass surgery on the beating heart if the patient is suited for that, best suited for that. But to stop the heart, you have to have a few prerequisites. The patient needs to be put on the heart lung machine, cardiopulmonary bypass, as we call it. This is a pump that circulates the whole body volume while we are working on the stopped heart. Okay, the blood is taken from the right heart with large tubes, goes into a reservoir, is oxygenated, okay, with oxygen essentially insuflated into the blood. CO2 is also taken out, and then a very strong pump sends it back into a major vessel in open heart surgery, in steronomy heart surgery, usually the aorta, in less invasive surgery, robotic surgery into the femoral artery.

SPEAKER_03 11:23

So by doing so when it's less invasive on a B on a still heart, it's almost a little bit easier because you don't have everything opened up.

SPEAKER_01 11:33

Yes. Let me maybe go back to the question how we stop the heart then. So the first of all, the patient needs to be heparinized. So blood thinning therapy is injected so that the blood doesn't clot when it is sent through all these tubes. And once we have adequate what we call ACT levels, we start the pump, yeah, and the heart lung machine takes over the circulation. To stop the heart, then it is important that we interrupt the blood flow to the coronary arteries. That's why we put a clamp on the ascending aorta and then inject a potassium-rich solution into the aortic root. That's what makes the heart stop.

SPEAKER_03 12:28

I don't think I ever know knew how it stopped it.

SPEAKER_01 12:33

Yes, so that that's how this is done. And the heart tolerates cardioplegia again, stopping for about three hours very nicely. Three to four hours we get a little nervous.

SPEAKER_03 12:51

Okay. And and how long was David's surgery?

SPEAKER_01 12:55

So we had a little bit more than one hour of cardiac arrest, which is absolutely well tolerated, right, David?

SPEAKER_00 13:04

You are in the thing.

SPEAKER_03 13:09

Yeah. He seems he seems to be doing okay. So whatever the resting time was, he's just an hour younger now.

SPEAKER_01 13:16

Yes, okay. Now, again, so of course, I understand that our patients out there may be scared of that, but really for us as heart surgeons and for heart surgery teams, the cardioplegia is a we can call it a routine process.

SPEAKER_03 13:37

Which is great to hear.

SPEAKER_01 13:38

Yes.

SPEAKER_03 13:39

So you you get to the heart, you've used the provocative test to identify where you need to go. You're you're now there with the robotic tools, and I know we have a special presentation, but let's walk through it first and then we can we we can get there. Is everything already mapped out for you? Do you already know pretty much where you need to go with the tools inside the chest cavity?

SPEAKER_01 14:04

Yes. So the the approach to the inside of the chest is through what we call ports, yeah, metal tubes that are inserted between the ribs, okay, and those tubes are docked to the robotic arms, and then robotic instruments and the robotic camera are inserted. That's how we approach that. And concerning orientation, we it's a pretty standard approach of these ports. The one for the camera goes in more or less in the middle of the chest. It's usually the fourth or fifth intercostal space, okay? And the right and the left instrument port are four finger widths of the camera port. That is pretty standard. And when you go in there, usually you have the left ventricle contained in the pericardial sac and a little bit of fat up above right in front of you. And I was very much used to that view through the experience in coronary bypass surgery. So, and identifying the LAD, for example, is something you have to learn a little bit. You have to open the pericardial sac, of course, to get there. But I would call also that nothing very special for us anymore. We we are now used to that approach. We we use that one on a very broad basis.

SPEAKER_03 15:41

Is there a reason that you might say no to a patient for robotic surgery?

SPEAKER_01 15:48

Yes. So some prerequisites. Redo operations are something where we we are not so excited at this point. I've done some, but even in open surgery, going through the these adhesions through all the scars makes it very hard. Okay, not a contraindication, but difficult. Patients with very severe lung disease might not tolerate the single lung ventilation. So the anesthesiologist inserts a special breathing tube for these operations, a so-called double-lumen tube or regular tube with a bronchial blocker, as we call it. And so for me to have good access to the pericardial sac and the contained heart, the left lung needs to be dropped, deflated, is of course re-inflated after the surgery. But patients with really severe lung disease might not tolerate that. That's why we also in David did a lung function test and he had super values, everything above 100% predicted, so he was extremely well suited for the operation. Another difficulty for us might be the presence of severe atherosclerosis on the aorto iliac level, because the cannulation for the heart lung machine is done in the groin, and we pump the blood from the groin upstream. You can imagine if there's a lot of plaque on the femoral iliac or arteries or the order, we could pump pluck into the brain. So we have some workarounds for that, but that might be an issue for candidacy for robotic surgery as well.

SPEAKER_03 17:53

Now that we've set the stage for the opportunity, would you walk us through the steps once the patient is in the operating room?

SPEAKER_01 18:06

And you know, if this is a good opportunity now to actually show us, yeah, I will that might even be my my great pleasure. I had a chat uh with David this morning whether he would still be okay that we show that, but yeah, you are well on board, right, David? Um 100%. I'm super excited.

SPEAKER_03 18:26

And so what we'll actually be seeing is a video of the robotic process inside the cavity of David's body.

SPEAKER_01 18:34

Sure. I let us start. Does this work for you? Do you see everything?

SPEAKER_03 18:40

Yes, everything looks great.

SPEAKER_01 18:41

All right, okay. Maybe a definition again. So the procedure in robotic surgeons' term is called robotic totally endoscopic unroofing of an LAD myocardial bridge. Okay, and so if we have a look at our operating room, we have the luxury here of using a hybrid operating room for those procedures. We also use it for robotic coronary bypass surgery. So you have a usual surgery environment. You see all the instruments that we need in addition. You see the hard lung machine here. I will come to that a little later. A lot of other devices, the anesthesia setup here with transesophageal echocardiography, OR lights, of course, and uh especially here also it's also a cath lab. Okay, this is a combination between an operating room and a cath lab. We call that hybrid OR OR, and ours uh here is a robotic hybrid operating room. That's the the patient card and the robotic arms already docked to the patient. David, that's you, okay. And uh, but you can appreciate that the robot is covered with sterile drapes, that's very important, of course. And the this patient cart has four arms, okay. The now I sit behind this console, as we call it. It is by the way, I think I can name the type of robot we are using. It's the classic Da Vinci robot, which uh we use in its fourth iteration, the fifth generation is soon coming up. I look into a binocular as you see here. Do you see the arrow by the way?

SPEAKER_03 20:40

Yes, we do.

SPEAKER_01 20:41

Okay. I have masters as we call them, or joysticks, if you wish. I can my arms are leaning on these pads here. I have a small control unit here on which I can control things like the electrocordery level, a few things that I can control from here as well. Early on, the OR team had to do these functions. Now I can control that from here. I also have foot pedals, the yellow and the blue ones here, control the electrocordery for cutting tissue. And with this pedal here, that's a clutch between control of the robotic instruments and the robotic camera. Yeah, so that's the console. You see me here looking into the binocular. It's uh I must say that if you look into such a robot console for the first time, this is just amazing. At least I felt that when I was first sitting behind that. You you enter the chest, a bodily cavity, and you have a view like say. Looking into call it a cathedral or a big dome or whatever, you have a beautiful 3D HD view into the chest.

SPEAKER_03 22:09

And if I understand correctly, it's it's 10x, it's like a 10 times magnification.

SPEAKER_01 22:15

You see the three ports here? Okay. By the way, we insufflate CO2 here to get more space inside the chest, and we dock, as we call it, the robotic arms to this metal piece on the robotic ports. Okay, we hear a sound blip, and then we know that the robot, the computer of the robot, has recognized the port. So, and for port insertion, I mentioned it is very important that the anesthesiologist drops the left lung. And after insertion of the first port, we insufflate the CO2, we get more space, and can insert the other ports safely as well.

SPEAKER_03 23:06

And Dr. Banati, for the benefit of the naive listener or observer, by using the CO2, what that does, it inflates the chest cavity, correct?

SPEAKER_01 23:18

Exactly. It we do that at a pressure of eight millimeters of mercury that inflates the chest, and I have enough space to work in there. So what you see here is the insertion of the robotic camera. Again, this is a 3D HD camera, digital camera, of course. In the back, we have already a look into the thoracic cavity and a port here. It is very important that the team at the table, we call it the patient side assistant and the scrub tech all have a good view on what is going on as well. Okay, and there is also speaker communication between me who's who sits behind the console looking into the binocular. Okay, then it needs to be a microphone and a speaker at the robotic device so that we have good communication. All right. So again, the heart lung machine, our pump that we are using, it's usually on the patient's right end. Just let's recap the principle. So we have the heart with a venous side and an arterial side. The left heart chamber here, the right heart chamber. Deoxygenated blood, blood without oxygen comes from all body areas into the right atrium and then into the right ventricle. With the heart lung machine with cardiopulmonary bypass, we take that venous blood off, put it into a reservoir, yeah. The venous blood, oxygen is insuflated and makes the blood bright red again, arterial blood, is then with a very strong pump that can pump five liters per minute, pumped back into the ascending aorta. And then it goes into the whole body and also into the heart. Yeah, that's that's the support, and that one is slowly started until it circulates all the blood volume. Next step: we do that in less invasive surgery through the groin, and you see that quite long a tube is going in to the right heart here, okay, and into the big veins. This is for drainage of the dark blue, deoxygenated blood. We as surgeons had to learn from the interventional cardiologist a little bit here how to gently introduce these cannulae. So we put in the the venous one first, and you see here the arterial one. Let me also show you that. That one is also inserted over a what we call guide wire into the femoral artery. Okay. Now let's recap how we stop the heart. We are now under, and and the cannula that I just showed are connected to the tubing of the extracorporeal circulation. We are on full support, okay? So everything can be taken over by this pump here. And then we can put a clamp here across the ascending aorta. The blood flow is still going into the body, okay. All organs are nicely perfused except for the heart. Okay, there is no blood going into the coronary arteries anymore. And what we do then is we infuse potassium-rich solution, so-called cardioplegia, into the coronary arteries, and that gives us a flat line on the EKG asystole, if you wish. Yeah. So if we want to do that in robotic endoscopic unroofing of a myocardial bridge, we do not clamp the ascending aorta, but we use instead a balloon, okay, which is inflated here. Okay. This is the catheter that goes through the sidearm of the perfusion cannula in the groin, is positioned under transistophageal echocardiography, has the balloon here at the end, has several pressure lines. We measure the balloon pressure, we measure the aortic root pressure, and here is the infusion piece for the cardioplegia. You can see here antegrade cardioplegia, and the cardioplegia solution, the potassium solution, comes all the way from the groin through this whole catheter into the aortic root. Okay, that's the original picture. Uh the balloon that we used in David's operation, the PA is testing it for leakages, make sure then that all the air comes out of the balloon. We then pushed this catheter up under TEE, transesophageal echocardiography guidance. Again, with a guide wire, the guide wire has to go up just above the aortic valve. And once we are there, we position the uh the catheter and connect it to all the pressure lines and cardiopigen line that I showed you before. Good. So this now comes the point. We go on pump, and my assistant, Dr. Hess here inflates the balloon. I position it properly just above the aortic valve. He injects, we measure the pressure in the balloon, then give a shot of adenosine. Okay, you know what adenosine is, okay, from the testing that you have undergone. Adenosin in this setting immediately stops the heart so that it doesn't eject anymore, and then the potassium solution follows, and we get cardio carried, cardio silence, if you wish. I think we are coming close to what we then definitely did. Let's go here. Just a last look again. This is what we see on the echo. This is the balloon inflated here, and this is the aortic root with the aortic valve, and we see the injection of adenosin, like a snowstorm there, and then the cardioplegia comes in. You see here now, insertion of our robotic instruments. We have seen the camera before. We have to always have a good camera view. Here's the right instrument, here's the left instrument. And what is very important in robotic surgery, the surgeon must never lose his view on both instruments. Okay, that's what we learn to always follow with the camera that we see the tip of both instruments all the time. Shall we go for the splitting of the bridge now for the unroofing? Or are there any other thoughts at this point?

SPEAKER_03 30:59

So the purpose of maintaining visual sight of those two pieces of the robotic arm are because if you're not aware of where it's at, something could happen.

SPEAKER_01 31:11

It may exactly damage.

SPEAKER_03 31:14

Okay.

SPEAKER_01 31:14

That's exactly the reason. So you must not lose the view of an instrument inside the chest because you wouldn't know what it's doing.

SPEAKER_03 31:21

Yes.

SPEAKER_01 31:22

Maybe for our patients out there, this machine is a robot, yes, but it's not an autonomous robot. It's always under the control of the surgeon who controls these instruments with the masters with the joysticks from the console. Good. Okay, so we open the pericardial sac, okay, and the apex of the heart comes into view. We do this with a this is the LED here, and I mark the LED with a clip, as you see here, and we start first of all to divide the fat that usually covers the myocardial bridge. And you see here we have accessed the LED in David's case here, and this is the upper edge of the myocardial bridge. And this this is very fine work. Very, very gently, you go underneath the bridge and split it with these robotic scissors. They are called pot scissors, and what you also see is a ruler, right? On on that, this is five millimeters, and you can appreciate how thick that bridge was, two to three millimeters. And underneath we have the LED, and we split a length of five centimeters here.

SPEAKER_03 32:46

So I I have to ask in some of the presentations I've seen done, you all use a visual tape measure, so to speak. Yes, and it just seems so traditional with all the technology we have that you use something that is so basic.

SPEAKER_01 33:08

That's by the way, something I'm sure that can be integrated relatively easily. You you have that on the iPhone, even, right? That you measure distances, okay. Thanks for that suggestion. I will carry it forward to the appropriate people. But uh, you are right. I think uh that is would be a very nice aspect if you had a quick electronic way to measure that distance, yes. But in that case, I brought a ruler in and measured it by by hand or by robot, if you wish.

SPEAKER_03 33:49

That's the material that you've moved. That's the muscle tissue that you opened up.

SPEAKER_01 33:53

The muscle tissue is exactly here, okay. And remember, in the provocative testing, David, you had a little bit of spasm at the lower end of the myocardial bridge. Okay, that's what Dr. Fowler described. And and see you see how thick it it was, it was most prominent at the lower end here. Okay, again, as I said, so this is three millimeters here. I think it was almost three millimeters in thickness.

SPEAKER_03 34:21

And that would be also indicative of if that's the part of the LAD that was getting the most compressed, it would explain why maybe there was some of that vasospasm and or endothelial dysfunction in that portion.

SPEAKER_01 34:37

Absolutely. And what is also interesting to me, also in coronary bypass surgery, if we sometimes see myocardial breaches or myocardium coverage of coronary arteries on the back wall of the heart. Underneath such a bridge, the coronary artery is usually completely free of atherosclerosis. Okay, has been discussed many times what the reason for that is probably some mechanical restraint that prevents the atherosclerosis uh process to proceed there. But also underneath David's your vessel was completely healthy.

SPEAKER_03 35:21

Yeah. So, David, as you're looking at this, knowing that that's your heart, uh, how do you feel as you look at it?

SPEAKER_00 35:29

I just it's surreal. Yeah, you know, because it's seeing seeing the technology that was used in in all of those steps, I had no idea until right now. So this is you know, me seeing this for the first time, and it's it's it's insane. I mean, it's it's super excited. I can't wait to show my family this video.

SPEAKER_01 35:49

Okay, good. And it is important also. I mean, one advantage of robotic surgery is as compared to a mini thoracotomy approach, okay. With in a mini thoracotomy, you have a keyhole view of the intrathoracic structures and the heart. You appreciate here also with robotics, I'm completely immersed into the chest. Okay, it's it's like like being in a in a dome or whatever, and I can can look to the left, uh, to the right, up and down. I see all the all the structures. And some people say, Yeah, you are sitting a few uh meters away from me. Where are you? I think I'm yes, away a little bit from the patient, but virtually closer than anyone can be.

SPEAKER_03 36:40

I don't think you could be any closer from the visual of what we're looking at, which is the same thing you see in your viewfinder.

SPEAKER_01 36:50

Yeah, that's a mean, and and and and the important thing is I mean, this was all done through these four holes, okay, as compared to the midline sternotomy or as compared to a mini thoracotomy, which is usually also more that length, probably. And this is by the way, the chest tube that we need after this surgery to drain uh the rest of air and blood that is uh collected inside the chest. Comes out usually after two or three days.

SPEAKER_03 37:26

Now that chest tube looks very small by comparison to the sternotomy chest tubes, where there's actually two, one under each side of the chest. Yes. Much more robust. That's amazingly small.

SPEAKER_01 37:39

One chest tube, the the sternotomy ones usually come out of out here. It's uh mostly a mediastinal drain here in the front, and a a pleural drain going from here all the way down to the pleural cavity.

SPEAKER_03 37:57

Yeah, that looks much less uncomfortable than the uh than the other process.

SPEAKER_01 38:04

Yeah, that's what I wanted to show you.

SPEAKER_03 38:07

That is amazing, Dr. Bonatti. There's so many people who are concerned or fearful, and and I know people get a little bit uh queasy sometimes, but I don't think there's anything there that's showing us uh any reason to be concerned or you know, even overly messy. You're you're inside, there's not a whole lot of blood because the heart's not beating. Boy, that's that's just an amazing, amazing video. So post-surgery now, David goes to ICU, the patient typically would go to ICU for recovery and then back into uh into a hospital room. What are some of the uh concerns and or potential risks with robotic surgery?

SPEAKER_01 38:55

Okay, good. So in any type of surgery, uh bleeding can happen. Okay. If it is so the the bleeding from the veins in in that fat patch above the myocardial breach, that that can be relatively nasty. And I uh it can be controlled, yeah, with with clips or electrocautery, but one advantage of doing it with cardio pleacher is that you don't have that while unroofing the bridge. What you can do is instead of using a scalpel or or scissors to split the fat here, is use the electrocautery that burns the small vessels right away. But usually that bleeding can be nicely controlled with the methods I just mentioned or with hemostatic agents. Okay, there's several different ones. One is one is called tachosyl. We have also something that is called arista, that's a sort of it's it's made from potato, it's it's potato power, okay? Powder, potato powder that you spray on on these diffusely bleeding sites, and it would stop with applying that that arista. That's manageable. If if you and that can happen also in open surgery, I don't know whether this was, I'm sure it was discussed with you, the the right ventricle is closed, okay. And sometimes in these operations you enter the right ventricle, okay, and you can with a stitch control that. If that happens, only in cases where we had a major problem. Yeah, I mean, we mentioned earlier that if you lose an instrument and god forbid, enter the the right heart wall, okay. That's that's a situation where the hard lung machine is your big friend because then go on pump again and fix the problem robotically. Should you drift into something that is really not controllable anymore, then you convert to a sternotomy and fix the problem that way.

SPEAKER_03 41:28

And you see, the good the good news is you are aware of a the potential and b the solution.

SPEAKER_01 41:35

Exactly.

SPEAKER_03 41:36

In worst-case scenarios.

SPEAKER_01 41:37

Exactly. I mean, and and we discussed this with our patients, of course, that and that applies for any less invasive surgery, be it the heart, be it the lung, be it uh anything in the abdomen, the less invasive surgeon has to tell the patient that if things become very difficult, it's best not to try to fight this through, but open and do the most standard uh procedure available.

SPEAKER_03 42:04

And then, David, if I can ask you, post-surgery, I see you into your hospital room. We wish it was a hotel room, not a hospital room, right?

SPEAKER_01 42:12

At UPMC, the patient rooms are hotel rooms. I teed you up for that, Dr.

SPEAKER_03 42:17

Bonatti. I teed you up for that. Yes. David, how did how did you feel after that experience? You know, if if you can recall the the most the fresh experience just out of surgery.

SPEAKER_00 42:30

Well, well, the best experience was when Dr. Benatti was shaking me in the ICU, waking me up and telling me how good it went and that you know everything looked really well, that the surgery went really good, and he was very pleased. Like his enthusiasm really made it better for me because you know, the the support I got from him on that really helped my recovery because I I was reassured many times on the big success that it was. And my wife appreciated those words too, as she was you know, sitting beside me and I was just wanting to get an ice cube in my mouth because I was so dry.

SPEAKER_03 43:08

Well, and and Dr. Bernatti, your enthusiasm in the presentation and just your willingness to do this is uh it's effusive. It's it's it's reassuring and it's uh extremely exciting for me, and I hope for everybody else as they watch to say this is a surgeon that really uh cares about the process and is excited about the process. And so it's it's amazing. What are some of the downside or I should say downstream risks? I know occasionally there is some pericarditis, maybe I it could happen with any of the surgeries, but it seems that maybe it's a little more prolific in in the robotic surgeries.

SPEAKER_01 43:52

Yeah. So uh also in the uh bypass surgeries where we place uh uh lema bypass to the LAD. Okay, there is a little bit of a higher incidence in in pericarditis. Okay, we see that on the EKG with some ST7 changes in all leads essentially. There's no real scientific explanation for that, but it happens. Usually that's treated with either iboglufen or colchitsin. Those are the drugs of choice. It's not at all a dangerous problem, but it takes a few days to weeks to resolve. Coming to the post-operative things that we have once in a while, a longer chest tube drainage, okay, that some patients just have more fluid collection inside the chest as a reaction to the operation, and that would keep the chest tube a little longer. Pneumothorax, if air is collected there, same thing, the chest tube would stay a little longer for that. And with any heart surgery, most commonly in robotic mitral valve surgery is atrial fibrillation, okay, that appears again as a reaction to the surgical process, but usually can be treated nicely with medication also.

SPEAKER_03 45:25

And that's one that we are most familiar with. Say condition of the uh of the process. This is a question I've asked of all the doctors that we've had on the program. Is it, in your opinion, possible that myocardial bridges could be responsible for sudden cardiac arrest?

SPEAKER_01 45:46

Yes, I think it can be responsible for it. Rare though. I mean, if we compare it to the common incidence of myocardial bridges, I think the proportion of sudden deaths is is rather low. Hard to create data here.

SPEAKER_03 46:06

Understood, yeah.

SPEAKER_01 46:07

Because there are other reasons, um, yeah, more common reasons.

SPEAKER_03 46:12

Well, and and what we we struggle with is it's pretty well known that the myocardial bridge where the artery enters the heart, there always tends to be some narrowing of the artery, whether it's through occlusion or if it's just from compression of the heart over time, but it's narrower going in. And if there is atherosclerosis as a result of plaque buildup over time from that particular condition, and that patient passes, and it looks like a widow micer was blocked. You know, the LAD was clogged and over. So we see the situation. But in fact, if he didn't have the mariocardial bridge, it may not have been like that.

SPEAKER_01 46:56

Yes, I completely agree. Yeah, yeah.

SPEAKER_03 46:59

So that's going to lead to the next question. If if if and this is not an if, this is we we hope other surgeons do see this because you did such an exemplary job of showing us the condition in the cavity. But we still get dismissed. I would say we probably have half the cardiology community still doesn't believe that myocardial bridges are symptomatic. What would you say to those doctors, the medical community about myocardial bridges? That in fact, yes, they are real, and we we have to address them.

SPEAKER_01 47:34

I would point out to them the huge importance of provocative testing, okay? That it's not only the artery, the LED that you see on the angiogram, you know, with the with the squeezing, with the with the systolic compression and with the milking phenomenon, uh, not only the bridge that you see on the CT, but it's uh it's the tests that Dr. Fowler has so nicely explained. I would tell them, yeah, send the patient to Dr. Fowler, let him do these tests, and then we have more clarity about the importance of the of the bridge.

SPEAKER_03 48:10

And I do appreciate that we're starting to see centers of excellence communicating with each other. And Yale has a a study going for ENOCA, and of course, Stanford has the myocardio bridge research team. UPMC is now entering into the repair and diagnostics of myocardio bridges amongst some other big systems. So we're really excited to see that and and the fact that now people will have access, an access point in the greater you know Pittsburgh, but certainly in the state of Pennsylvania and the surrounding areas, wherever is most convenient, they have a place to go. I want to touch just a little bit on the Da Vinci machine because there is some concern about some of the machines. And now we're going into another iteration of that machine. I think it was the SI was the first one with the stabilizer to work on the beating heart. The then the XI came along, no stabilizer, and and they changed some things for the better in the grand scheme of it all. And then now with the newest machine, is there anything that is uniquely different that allows you to do something different? We look at the technology of the machine moving forward.

SPEAKER_01 49:23

Yeah. I think one of the features of the fifth generation, Da Vinci, it would be called or it is called the DV5. Okay. They the company has integrated force feedback or tactile feedback. I would think that specifically the work uh you have seen today, that that might be something where tactile feedback might help. I grew up without without tactile feedback, and I'm so used to it that I I test drove the DV5. First sight I didn't feel much difference, but when I did my first total endoscopic bypass surgeries, the part where I really struggled a little bit without the tactile feedback was splitting the fat above the coronary artery. Okay, that I had to learn virtually or with visual sensation. And I think if you have tactile feedback from the very beginning in these new machines might help for the operation we are discussing today.

SPEAKER_03 50:28

Sure, I can see that you can have that haptic feel of pressure or tension to give you the understanding of what it is that you're uh you're dealing with in terms of either density or exactly.

SPEAKER_01 50:40

Want to point out though that tactile feedbacks is something the lack of tactile feedback is sometimes used as an argument against robotics. You can learn that. Okay, you learn how to use your visual sense to compensate very well for the lack of tactile feedback. If you think about the old BlackBerry that had tactile feedback, and everyone used an iPhone that's I think an appropriate which has no tactile feedback for the key. So that's an appropriate comparison.

SPEAKER_03 51:09

I think that's a perfect comparison because we all said, Oh, I hate it, I hate it, I hate it. I can't I can't use this iPhone thing. It's terrible. And look where we are today. You know, before we wrap, I have uh a question for you. People like to know their surgeons are human. You present so very, very comfortably. I don't even question, but what is it you do to relax? You have such a high stress job. You're working on people's hearts every day. What does Dr. Bonatti do in his downtime?

SPEAKER_01 51:40

Okay, so coming from Austria, I grew up on skis and I love skiing. Okay, that's I went uh last weekend here at the small ski area in Seven Springs. We had super snow and it worked very well. In summer, I mountain bike, I play tennis. Concerning reading, I like to read into history, philosophy, and at times astronomy, cosmology. That's what I like.

SPEAKER_03 52:09

Well, you're welcome to join us in the Sierras this year. It looks like we're gonna have some snow, so anytime you come out, just let us know.

SPEAKER_01 52:17

We'll do. Okay, thank you for the invite.

SPEAKER_03 52:20

Dr. Banani at the University of Pittsburgh Medical Center, you guys are really moving forward now into a proactive approach for myocardial bridges. And I thank you on behalf of the audience for that. How does one go about getting a hold of you to learn a little bit more about what the center is offering as well as learn more about their particular conditions?

SPEAKER_01 52:43

A very easy way is to Google minimum invasive heart surgery at UPMC. Then you will land at the UPMC Heart and Vascular Institute website. A phone number, which I have, by the way, put on the presentation at the beginning on the title slide, is 412-648-6200 option seven.

SPEAKER_03 53:06

Okay, and I will put this in the show notes for the episode as well. David, this is three episodes. So we started with you. We went to Dr. Fowler to learn about how they got to the next decision to work on you. And we just had an incredible presentation from Dr. Benatti. Any any thoughts for the audience before we re-wrap?

SPEAKER_00 53:27

Well, I just want to say thanks to Dr. Benotti and to you, Jeff, and to Dr. Fowler for all being willing to get this story out and to show people that, you know, just because your doctor doesn't say, you know, says no and dismisses it, you know, there's these centers of excellence. Like Dr. Binotti and Dr. Fowler did Zoom calls with me. You know, I had some basic testing done and we were able to communicate, you know, over Zoom, being, you know, 300 miles apart. And he made me feel very comfortable that it was going to be worth the journey then to go out there. And that was one of the most reassuring things because I was being dismissed at the local cardiologist like everyone else does. You know, they and then as I presented more information, they're like, we don't know how to help you. We don't know what to do. And as soon as I got a hold of Dr. Bernotti, you know, he was on time, even one day he was early. So that that that showed me that this team and his his team that surrounds him, all the girls in the office and the other doctors that work with him really provided literally every answer or every answer that I had a question to, and it made it really easy to go through the process. So it's these guys are exceptional in what they do from the customer service side and all the way through to the technicality of doing the unroofing.

SPEAKER_03 54:48

Well, and now on the outside of it, you're three months out, and you're how how are you feeling for those who have not heard the first episode yet?

SPEAKER_00 54:55

Oh, I'm feeling great. I mean, I'm back to do full workouts. Dr. Bernotti and I talked this morning, you know, I'm getting my heart rate up into the 120s, you know, and pushing hard and and and no issues. I feel amazing. There's been no symptomatic, you know, or post-symptomatic that I had pre-surgery. There, there's no none of that anymore.

SPEAKER_03 55:14

And if I'm not mistaken, you did have a little bit of AFib that now seems to be under control.

SPEAKER_00 55:19

I did. And I did a lot of blood testing, and it was more of a mineral deficiency. And once we got that fine-tuned, you know, it's been almost four weeks now with no AFib or anything else.

SPEAKER_03 55:29

That's great to hear. Well, Dr. Bonatti, this has been a first for us, first for me, a first for the three of us. I I cannot thank you enough from the very bottom of my imperfect heart. And I know I speak for the audience when I say that what you have just given us is going to instill the confidence in them to continue to pursue a solution to the symptoms that they've got. And I hope it allows a lot of the other cardiologists, the cardiology community, the medical care community to recognize that there is a procedure. We now have the steps you take, you know, from the provocative testing to the actual procedure of the unroofing procedure, to know that this is a condition that can be remedied and quality of life can be restored. So for what you guys are doing at UPMC, I again thank you so much, and I appreciate you for taking the time with us today.

SPEAKER_01 56:25

Let me thank you both very much for the kind invitation to this podcast. I enjoyed the conversation very, very much. I learned a lot as well. And all the best to you and your initiative and to the patients and colleagues you're helping. Thank you very much.

SPEAKER_03 56:42

Thank you. Thank you for listening to Imperfect Heart. It's my hope that this information helps 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.