Procedures

Demonstrating consistent clinical excellence in a well balanced, full spectrum cardiothoracic surgical program is the most important goal of Munson's open-heart program. The Cardiothoracic Surgeons of Grand Traverse customize treatment to meet the specific needs of each individual patient with documented superior results.

Coronary Artery Bypass Grafting On- and Off-Pump

The coronary arteries supply blood to the heart. The most common cause of death for men and women in this country is heart attack which is usually caused by blockages in these arteries. When the condition cannot be effectively treated with medicines or catheter-based angioplasty and stents, a form of open-heart surgery called coronary artery bypass grafting may be recommended. Coronary artery bypass grafting (CABG) uses arteries and/or veins from other parts of the body to bypass the blocked coronary arteries on the surface of the heart. CABG surgery remains a mainstay of Munson's cardiac surgery program, with approximately 700 open-heart procedures performed every year. Although Munson's cardiac patients are somewhat older and sicker than regional averages, patient outcomes are very favorable, with risk adjusted mortality and complication rates regularly determined to be superior (www.healthgrades.com).

One of the most robust discussions today involves the relative risks and benefits of conventional on-pump coronary artery bypass grafting and off-pump coronary artery bypass grafting (also known as OP-CAB). Much of the discussion has centered on possible side effects of on-pump bypass and poor long-term graft patency associated with off-pump procedures. Recently published studies have contributed to better understanding of both issues. A multi-center, randomized trial concluded that although patients treated on-pump may have some cognitive decline three months after surgery, those effects were statistically the same at one year (Van Diij et al. JAMA 2002;287:1405-12).

In addition, a randomized, prospective controlled study comparing graft patency following on- and off-pump bypass showed that three months post-surgery, 98 percent of the on-pump grafts were functioning, while only 88 percent of the off-pump grafts remained functional (Khan et al. NEJM 2004;350:21-8). Another recent randomized trial shows no difference between on-pump and off-pump (though fewer grafts were placed with off-pump) at one year follow up. (Lingaas. et al. Ann Thorac Srug 2006;81:2089-96) The cardiac surgery community will investigate and monitor developments in these areas with great interest. We will no doubt fine-tune our practices as more information becomes available.

It is important to note that there have been important advances in on- and off-pump techniques and technology that make both operations more effective and safer for patients. New technologies including stabilizers, positioning devices, and anastomotic techniques help the surgeon perform off-pump bypass surgery. A number of less-heralded improvements to the standard on-pump cardiopulmonary bypass set up including leukocyte filters, herarpin bonded circuits, soft-flow cannulae, and aprotinin, minimize inflammation and significantly reduce the risk of stroke and other adverse outcomes. (Kapetanakis et al. Ann Thor Surg 2004;78:1564-71).

Like many of the best major cardiac programs in the country, we have concluded that both on- and off-pump bypass have important roles in any comprehensive cardiac surgery program. Appropriate procedure selection is critical for achieving the best clinical outcome for the patient. For most patients, conventional CABG utilizing cardiopulmonary bypass is safe, effective, well tolerated, and provides the best chance for long-term graft patency. However, for frail elderly patients and those with severely diseased aortas, off pump may be the best therapeutic option. The Cardiothoracic Surgeons of Grand Traverse have been performing off-pump bypass procedure in selected patients for over 15 years, and will certainly continue to offer it to appropriate patients at Munson. A similar, carefully selected approach has been adopted by many (if not all) of the most respected cardiac surgical institutions in the nation. (MacGillivray, Vlahakes NEJM 2004;350:3-4 Massachusetts General Hospital, Boston)

   
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Valve Replacement and Repair

Congenital malformations, tissue degeneration, infection and other diseases can cause the valves of the heart to fail. Heart valve failure is usually associated with deteriorating heart function often causing difficulty breathing, chest pain, heart rhythm problems or other evidence suggesting a weakening heart. Open-heart surgery to repair or replace the diseased valve(s) is usually recommended once evidence of a severe abnormality or heart deterioration is present.

The Cardiothoracic Surgeons of Grand Traverse offer sophisticated valve procedures for patients requiring aortic valve repair or replacement. Under certain circumstances the aortic valve is repaired. For those patients requiring replacement Munson offers an array of the best technology available. We typically use a stentless porcine aortic valve graft that is associated with better survival than conventional stented grafts (Luciani et al. Ann Thorac Surg 2002;74:1443-9, J Am Coll Card 2007; 49:790-6). Stentless grafts have superior hemodynamics, with less obstruction and turbulence. Because the valve is nearly completely biologic, patients do not require life-long anticoagulation therapy. The Cardiothoracic Surgeons of Grand Traverse have implanted more than 300 of these devices to date at Munson Medical Center. For those patients who prefer a mechanical prosthesis, a number of state-of-the-art devices with excellent documented hemodynamic performance and durability are also available.

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Mitral valve Munson's cardiac surgeons take an aggressive approach toward mitral and tricuspid valve reconstruction and offer a broad array of complex repair options. Mitral valve repair techniques are often extremely exacting and challenging for the surgeon. However, it is well worth the effort when we make it possible for a patient to avoid valve replacement which would require lifelong anticoagulation. Like the coronary artery bypass grafting program, Munson's valve program shows very favorable clinical outcomes with consistently superior outcomes.

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MAZE

Atrial fibrillation is an abnormal heart rhythm that involves the upper chambers of the heart. Left untreated, atrial fibrillation causes the heart to beat very rapidly and can lead to stroke or other complications including death. Medical treatment is often effective and dramatically reduces most of these risks. Nonetheless, many patients benefit from other therapeutic options.

The Maze open-heart operation was developed to correct atrial fibrillation. The concept behind the MAZE is to create scarring in the atria that interrupts the conduction of disorganized reentrant circuits and restores electrical synchrony. Today, most patients with atrial fibrillation do not require open-heart surgery and can receive a similar but less invasive catheter-based procedure in Munson's electrophysiology laboratory.

For patients who are not suitable candidates for medical or catheter-based treatment, the surgical Maze may be appropriate. The MAZE was originally performed using multiple extensive open surgical incisions, but most cardiac surgeons, like the Cardiothoracic Surgeons of Grand Traverse, now use a modified approach featuring state-of-the-art ablation probes, rings and/or clamps. The latest minimally invasive Maze surgery techniques are available at Munson. For those patients with atrial fibrillation who are undergoing open-heart procedures for other reasons (such as bypass or valve repair) the surgical MAZE can be performed during the same operation.

The Cardiothoracic Surgeons of Grand Traverse have treated many patients using these modalities with excellent results. Follow-up studies at Munson indicate that 87 percent of their patients were free from atrial fibrillation at one year following the surgical MAZE procedure.

Cardiac and Thoracic Aortic Reconstruction

Coronary occlusive disease (described under Coronary Artery Bypass Grafting) results in damage to the wall of the heart. If a portion of the wall is dead it may bulge thus becoming aneurismal and further contribute to dysfunction of a failing heart. The Cardiothoracic Surgeons of Grand Traverse offer the latest techniques in ventricular restoration including TRISVR guided patch reconstruction in addition to other techniques with documented efficacy.

A rare but catastrophic scenario occurs when the heart wall ruptures either within the heart (postinfarction ventricular septal defect) or freely into the space around the heart (free wall rupture). The Cardiothoracic Surgeons of Grand Traverse perform repairs for left ventricular aneurysm, postinfarction ventricular septal defect, and ventricular free wall rupture.

The largest blood vessels in the body reside in the chest. Pathology of the great vessels is often catastrophic and requires immediate aggressive catheter-based or surgical intervention. Munson's cardiac surgeons offer a full spectrum of cardiothoracic reconstruction techniques, including repair of thoracic aortic aneurysms, dissections, and ruptures. An innovative native valve-sparing aortic root replacement procedure obviates the necessity for aortic valve replacement and anticoagulant therapy for selected patients.

Munson internal and external reviews indicate that clinical outcomes in these categories have also been excellent and superior to those published in the literature.

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Ventricular Assist Devices

Ventricular assist devices are innovative external pumps that temporarily support the circulation inpatients who are believed to have reversible heart failure or who are candidates for heart transplantation. The Cardiothoracic Surgeons of Grand Traverse at Munson use the Abiomed BVS 5000 Blood Pump, which can take over pumping action for the right, left, or both ventricles. Ventricular assist devices are used relatively rarely and are very expensive for the hospital, but are mandatory for any comprehensive cardiac program. They provide support for prolonged heart recovery and, in addition, can be an effective bridge to further therapy including transplantation.

Heart Lung Machine
The Munson Heart Center uses the latest, most sophisticated technology for cardiopulmonary support during open-heart surgery. Our new Sorin 55 heart-lung machine is featured.