Inside St. Luke’s OR: When is open heart surgery needed? Our doctors explain!


My name is Ryan Sundermann I’m
Emergency Department director here at St. Luke’s Hospital and
I’m lucky enough today to be here with Jim Levett he is the director of
cardiothoracic surgery here at St. Luke’s and we’re gonna talk to you a
little bit today about cardiothoracic surgery and what all that entails. First
of all I’d really like to give Jim an opportunity to talk about how he ended
up in Cedar Rapids because Jim I think you’ve been here about 20 years. And he’s been a cardiothoracic surgeon for 40 years and so we were really lucky
to have his level of experience here at Cedar Rapids but Jim how did you end up
in Cedar Rapids? Well, I grew up in Cedar Falls from Iowa and I originally went to high school there and then went to college in Minnesota went to medical school at the
University of Iowa, did all my surgical training at University of Chicago and
had worked there. I took a job at a fairly busy heart-lung Center on the
East Coast when I first so when I was young I first got married and we started
having children wanted to come back to the Midwest for family reasons and and
we liked the Midwest and I was lucky enough to find Dr. Medford and Dr. strong
some years ago the points yeah those are all famous
names around got me started yeah you know that’s kind of something that holds
true around here is that we were just talking a bit ago about a video that we
did for the emergency department so many of the folks that work in the emergency
department are from here and you know that’s the thing is I think people that
are from the Midwest love to be from the Midwest and so it’s always good to hear
that Iowans taking care of Iowans that’s just
such a good feeling how do we know who needs bypass surgery and who doesn’t
need bypass surgery well it’s it’s kind of a it’s an individual decision for
each patient the patient that comes in to see you first through the emergency
department is gonna get evaluated and they have a stress test on there or may
not we have an echocardiogram but if they’re having chest pain frequently
we’ll get a cardiac cath reasonably soon and at that point the cardiologist who
does the cardiac cath is going to make an assessment as to whether or not an
intervention that he could provide would be appropriate for the page should be
like a stent to open up an artery a little to do open that quite rip yeah or
they might be able to stretch and stretch a narrowing in the artery
sometimes they take clot out though it was a little right advice the sections
at Allen or they might determine that the patient would be better served with
surgery in some cases surgery is necessary fairly quickly very urgently
that isn’t the everyday occasion that that does happen but it’s not something
to see if somebody they can’t resolve their chest pain and they just the
stents even if they do them that’s not fixing right and I are in trouble yeah
they’re you know they’re having real problems in that case we would then the
called as urgent bassist I didn’t care of them in other cases they may
determine that the patient’s stable but would benefit from surgery at a more
elective sense why would that be like too many vessels or read disease they
can’t get into them with the static what are the some of the reasons they might
need that well those are some some some some of the reasons are anatomical in
other words that that this the are the vessels would not be amenable to a stem
in other situations there may be a lot of vessels see three or four that are
fairly diseased notice there’s a lot of disease in them and for example in a
diabetic patient we would frequently take those patients to the operating
room but more or less selectively my guys we know that long-term diabetic
patients do do better with surgery than they would have multiple steps right
yeah because you can just keep putting a bunch of stents in but eventually you
kind of run out of room and run out a vessel and you know at some point it
just makes more sense to put new vessels in there right so what goes into that
like how do you like I you’re taking where do you get a vein from and like
where do you take it from and like you get it from somebody else or do you take
it from the person’s body like we’re exactly to get those vessels and what do
you how do you tie those all together well we don’t have any donors for these
kind of vessels so they’re all taped from the from the patient from the lay I
see lots of scars on patients and – is that where they typically get those from
well we basically have three sources of what we would call conduits in other
words vessels or I guess the things we use for the bypass so the classic one
would be a vein those are taken from the legs and those
veins are harvested with an endoscopic technique in other words we use a small
incision usually right at the knee with some very very small additional
incisions high and low in the lake and then the venous hurts it with a skull
and over just a second with the skull so you don’t got to cut the leg all the way
open and take it out of there that’s right we used to do that we had large I
remember those scars yeah yeah so those those are the classic conduits the
second and second two conduits we use are arterial conduits and the most
common one is what we call it an internal mammary artery which is an
artery you normally use the one in the left side which runs underneath the ribs
and we dissect that off the ribs on the underside after we open the chest open
the sternum the breastbone and then that artery is used to come down on the front
of the heart so that’s one that doesn’t normally go to the heart but this is the
one that goes like the chest wall and you redirect it to the rest exactly the
third conduit that we use is actually one of the things that makes our program
so unique and I think of improves our quality and that is that we use a radial
artery frequently and buy that one here and there are no there’s an artery in
the arm we normally use the the non-dominant arm so if I’m right-handed
using the left if a person’s right hand we’re using a left-sided radial those
are also arteries as is a mammary that runs underneath the ribs the veins are
not arteries but in general arteries have a better long-term success or pains
you’re stronger than veins right yeah they just hold up better over time and
then do the veins so we use a radial arteries about 40 to 50 percent of the
time well we’ve been doing that for about 20 years
oh wow the national rate of using radial arteries about six to seven percent Wow
do you have better outcomes when you use those arteries we yeah we think why
don’t other hospitals do that then well either parts more work yeah and it’s
it’s not something a lot of people are used to doing a lot of surgery used to
do and I do I do think that over the last few years
we’ve seen more and more interest in radial artery use there’s more articles
in our journals that talk about using radials yeah and there’s very good
long-term data now on on success rates of raising radials that’s compared to
veins seems like you guys are kind of ahead of the curve and have been for a
long time in that regard well we we’ve been very pleased with it we we’ve tried
to do the best we could and we think patients have done well sounds like it
well the results certainly would confirm that as we’ll discuss a little bit so
what is it like once once somebody what do they have to expect after they’ve had
their surgeries I mean is it a long recovery recovery do they walk out of
the hospital the next day kind of what happens well patients would undergo the
operation normally they come in the day of surgery if it’s an elective case so
schedule they come in the morning of surgery they have the operation normally
we be done with in you know into the morning Nords towards 11:00 or 12:00
1:00 does it take for a surgery use the the actual operation probably two and a
half to four our subconscious depends on what you’re
doing there’s a lot of combinations yeah one vessel three vessels four of us it
was kind of what you gotta do here so so they’d be finished with surgery say by
noon or wrong that time and normally they’d be in the hospital we usually
send them home on the fourth or fifth they just post out of the day
gotcha so Jeff they’re up walking around and you know eating the next day yeah so
it’s not a lot of rehab after that too though cuz they kind of got to get
things reconditioned right right yeah it’s a great point we have very good
rehab people or a rehab group here in the house we do that here right yeah
they get them started and then after they go home they have a second phase
with cardiac rehab that they can undertake and they can also do that at
outside hospitals that they live in out in another community they’re a bit of a
drive to get back to st. Luke’s a good Jones yeah well people come all over
Eastern Iowa to come have surgery here right yeah right so I agree it’s
important yeah well tell you what we’re in the operating room you want to kind
of I mean I’ve kind of know what a bypass machine is I know that it takes
your blood and it puts oxygen in and puts it back India because I guess maybe
we can kind of as we go along we can talk about exactly what happens like
during the surgery as we talk about this you know from coming into the operating
room to putting in the IVs and what we do because I think I mean how do you
operate on a moving heart and maybe you can kind of tell me how all that kind of
works okay kind of walk me through exactly what happens here
well the patient would come in the operating room and it would usually take
our anesthesiologist or the first ones hearing for them so usually it’s going
to take somewhere between 20 and 40 minutes to put a patient to sleep put
IVs in our trio lines neck lines things like that catheter
the bladder and sort of get the patient all ready to start the operation then
the patient is prepped in other words the area that we’re gonna operate on
sterile chest right you have painted with the sterile chemicals and then the
dressings are put on the drapes yeah and at that point then we’d be ready to
start the operation so the patient Dennis
chest is opened the the our assistants are mid-level assistants pas and they
are MPs are helping take the veins out of the legs so they’re kind of doing
that while you’re opening the chest and the arm is already a gotcha after we use
a team approach very much that reduces the time surgery readies the efficiency
of curvature and so the patient then once once we have the conduits prepared
and we have level the chest open we put cannulas in the heart
daniel is like tube jeff and they are used to attach to this heart one machine
like into the vessel like they can’t now it goes like that like a big like IV
line that goes into the vessel there’s a Quran so there’s one that goes into the
the right side of the heart that takes venous blood away from the heart into
this heart-lung machine and then a second cannula is put into the large
blood vessel coming out of the heart the aorta the aorta and that is the machine
here takes the blood from the venous side puts oxygen in it and which is what
the lungs do and then pumps of back to the archery I don’t
like an artificial lung it’s basically I can blow without oxygen put an oxygen in
it right because it’s kind of missing the heart and the lungs so it’s a blood
not even like going my blood not going through my heart and lungs during that
surgery correct it’s bypass in the lungs hence the name
bypass surgery I suppose on exactly and then it’s put back into the order and
Pompton so this is pump function to it so it’s serving the heart and the lung
function ah huh and pumps it down to the body so you’re getting it so while
you’re asleep on the heart-lung machine you’re getting what we call profuse yeah
it’s what’s going around yeah went okay you’re on a blood thinner you have your
heparinized and at that point most of the time what we would be doing for a
routine operation we would stop the heart with a chemical solution which we
sort of infuse into the heart through the blood vessels to the heart and that
would stop the heart and keep it quiet and during that time then we would
moving you’re not operating on a moving car right there that’s right done I
gotcha once it stopped and cold we cool it down we major temperatures we then
can operate on the heart catch and hook things to get put back together prior to
coming to the or we’ve studied the angiograms at the cardiology F we look
at that several times yeah maybe five to ten times behind we study it and then
when we get to the operating room we’re looking at the heart before we stop or
we look at it and draw out areas that we’re gonna
do the vibe justice exact gotcha and once that’s done we stop the heart then
we take one vessel at a time so I take once a conduit say piece of vein and
identify the first vessel I’m going to put that on and open the vessel and then
sew it on uh-huh and then go through the sequence of however many I’m doing sin
to a4 gotcha get all those done that are the ones that are attached to the heart
yeah and then at that point we can restart the heart and so we take our
cross clamp off restart the heart and then we hook those the other end of
those conduits up to the aorta the big blood vessel leaving the heart exactly
so the blood goes from the heart to the orta’s down the vein or the conduit back
into the heart muscle into the heart muscle Wow so the last thing you saw
them into the kind of the other veins of the heart and the very last thing you do
is connect them into the aorta the other thing is the people frequently ask you
it’s whether you know if you have a blockage are you doctor you’re taking
the blockage out yeah and then putting something in it and we don’t take
anything out you’re just going past the block actually it’s a bypass so we’re
going downstream if the blockage is where my knuckle is I’m putting it down
the other side yeah it’s another use bypass machine and your
bypass the blockage I guess that name applies to a lot of different things
there what can you tell like the public what makes us so special one is I think
we’ve had a we’ve ever long-standing program so the program started 1978 by
two very good surgeons and I haven’t be the third fellow that came along in the
80s so so it’s got some history to it we have been fortunate to have a very
experienced group of nurses to help the doctors it isn’t just us is the surgeon
so we have a very good group of nurses anesthesiologists perfusionist there’s
an intensive care unit so even though the nurses have kind of have to be
specialized in this type of this type of surgery right we have them for about 20
years a little over 20 years no we have had a cardiovascular services conference
we have every month that brings together everybody that takes care of our
patients everybody from perfusion to the anesthesiologist to respiratory
therapists to the rehab people right to our office nurses and yeah it’s not just
the surgery itself like you said there’s a rehab afterwards there’s a being in
the ICU afterwards and things like that so we get we get this big group together
it’s probably gosh 25 to 40 people every we know that we sit around talk about
issues process improvement things we’ve developed protocols and guidelines for
managing diabetes preventing infections treating atrial fibrillation at
irregular heartbeats after Sheree basically having a team that’s
experienced that’s done a lot of surgery is a big benefit you know will over the
next year we will probably hit about 14,000 cases and there are 14,000 case
within the next year year and a half or so how many of you done about 5,000
surgeries Wow my five hasn’t hurt wow that’s incredible I’m Nessen I did 5000
of those 14 but over my career I’ve done about 5000 that’s incredible Wow but but
and we’ve also I think benefited from the fact that we have an extremely
collaborative group of physicians in all areas you know I know you’ve mentioned
that you said like even like the kidney doctors a nephrologist and the pulmonary
doctor yeah it’s so multifactorial that it really requires all those and so it’s
you know you have all this experience but it sounds like you’ve had engaged
those other physicians and this whole process so not only do you have this
experience but the kidney divers and the pulmonary doctors and then it’s easy
doctors they’ve all been doing this for 20 years and so they all have that
experience as well yeah we really have very good support study that’s very good
from the ER doctors to the anesthesiologists you know intensive us
yeah I D you know infectious disease infectious disease doctors cardiologists
missing people but you know nephrologist everyone that’s all that we said we got
all this experience do we have any like how do we know that we’re really good I
mean like I see the banner on the side of the wall who determines and what
tells us that we’re good what makes us top 50 Hospital there’s about in the United States today
Ryan I think there’s around 1,200 hospitals that do open-heart surgery and
each year there’s a health plan analytics company that’s owned by IBM
called truven health analytics and they use some very sophisticated analysis
techniques using the IBM Watson system I’ve seen that on TV you do it with
Watson and Watson can like run your elevators more efficiently you know that
it’s a really smart supercomputer right that kind of yeah yeah I don’t know how
they do it but they do an analysis every year in which they look at these 1,200
hard hats goes and each year they they pick 50 as the top top 50 hurt hospitals
so we got selected in that top 50 group six times and lasts roughly 12 years out
of 1,200 hospitals or top 50 that’s impressive that’s really that was nice I
mean I was we were happy about it yeah that’s something to be proud of no
wonder they put a banner on the wall I probably would too yeah I gotta put my
green ribbon from you know YMCA football on the fridge yeah so that’s a pretty
good banner to hang so well that’s fantastic anything else you’d like to
add about our our bypass program here at the st. Luke’s well I think I think that
one of the things that as we as I sort of thought about this I would say is
important for any program and this is true of anything you’re doing
volume and experience make a difference absolutely and we’ve as I said we’ve had
good volumes and experienced people working together but those little the
little details that can be managed by an experienced team of what really can make
a big difference in an outcome and this kind of work because it’s fairly
complicated and there’s a lot of ways you can you can prevent problems and
also create them yeah so we’re very fortunate to have a very busy program
that’s got a lot of good people working in it yeah and you know for most of this
kind of surgery I mean what you need is a comfortable setting you need a good
experienced team you need technical proficiency compassion yeah and you need
good judgement yeah yeah so I’ll tell you what like like any good family you
know team works part of that every was got their role to play and I think
that’s exactly we’re trying to foster here at st. Luke’s it’s kind of that
sense of community family well how would you take care of your own loved ones and
that’s what I think every one of the physicians and nurses and everybody that
works here at st. Luke’s is trying to emulate is what would you do for your
own family members and that’s what we consider every time we do anything
whether it’s in the emergency department whether it’s in the operating room
whether it’s in the clinics so I think that’s a great point and Jim thank you
so much for talking to today people learned a lot today and enjoyed that and
if you have some questions certainly respond to us on our Facebook page and
we’d be happy to get some answers back to you but thanks for joining us today

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