Surgeon has Completed 5 Robotic MVP repairs - Should I be the 6th?

[Mooney]

Hi everyone,

I am hoping you can help me select a surgeon and a hospital. I am 43 years old and was diagnosed with MVP and moderate MR in 2011. Last month, my symptoms took a real turn for the worse and I went into heart failure with fluid build up on the longs. I've since had a CT scan, an echo, a TEE, and a heart cath. In a nutshell the mitral valve has worsened and it is time for surgery.

I've been looking at options which started with the Cleveland Clinic, but the more I researched the more I feel like I want to stay close to home for any pre/post surgery follow up. I'd hate to be experiencing some weird symptoms a couple weeks afterwards and having to seek guidance from Cleveland over the phone or email.

My local options in Reading, PA are Dr. Kirk McMurtry at S. Joseph's, or Dr. Christine McCarty at Reading Hospital. I have met with both and each said pretty much the same thing however there were some differences:

Dr. Kirk McMurtry at St. Joseph's:

- he THINKS the valve is repairable based on the imaging - but wont know until he gets in there
- he's done about 150 valve operations, including 75 mitral valve repairs/replacements in the past 24 months. About 20 of those were minimally invasive. He thinks mine looks good for minimally invasive.
- 93% of MV repairs are still intact after 10 years
- I will have to choose mechanical or tissue valve in advance - as he will go ahead with replacement if he gets in there and cannot repair (that's a whole other discussion)
- says I am young and good health, risk factors and minimal, 1% mortality rate, 1% chance of stroke
- he does not use the robot, says he "prefers the tactile feel of standing over the patient and working with his hands"
- to use the robot he says you sit in a corner of the room at a console and manipulate the robot
- both procedures are about the same he says, it's mostly surgeon preference - if you're used to the robot then that's what you do - if not, then you use your hands and instruments, himself, he says he and the robot "do not get along"
- suggested robot might be better for surgeons who do not have steady hands
- uses same team of anesthesiologists and heart/lung machine operators
- their hospital does NOT have dedicated cardiac ICU - it has cardiac, pulmonary and something else I forget
- he can fit me in end of Feb/Early March

Dr. Christine McCarty at Reading Hospital:

- she also thinks my valve is repairable, but will not know until she gets in there. She said she felt about 80% certain that it could be repaired. As with McMurtry she would go ahead with replacement if needed.
- she would plan to do minimally invasive using the daVinci robot
- daVinci robot not a walk in the park however - long discussion about technique, how the heart and lung machine is hooked up - basically they go through your veins for this (groin and neck) for the heart/lung machine. If for any reason the heart and lung machine is not working to their satisfaction (maybe bad veins, kink in veins, I don't know...) they immediately stop with the robot and perform conventional OHS
- same thing even if the heart/lung machine working fine - if for any reason she does not feel like things are going right - stops the procedure and goes full OHS
- says the robot is not quick - anticipate 7-8 hour surgery
- repair could and should last a lifetime, but so far the data is 10-20 years
- we also had the discussion about valve replacement selection - however she differed from Dr. McMurty here saying she could ONLY counsel me to select a mechanical replacement valve as the tissue replacement is really only good for five years. Given my "young" age of 43, she felt it crazy to select a valve that might again need replacement in as little as 5 years. Dr. McMurty provided similar information but clearly left it up to me to select one or the other, whereas with McCarty I got the impression that she would not install a tissue replacement even if I wanted it.
- she says my chance of dying on the table is about 5%. That's up from McMurty's 1%. I am not sure where they get these numbers from, I guess they are both low enough not to be statistically significant
- they do work as a team as well - same anesthesiologists, nurses and heart/lung operators always
- they always have a cardiac physican or PA on staff 24/7 (unlike St. Joseph's which puts their Dr's on call)
- they do NOT have a dedicated cardiac ICU - it's divided into cardiac, disease, trauma.
- they DO have dedicated cardiac nurses
- now for the part that is most concerning for me...her mitral valve experience with the robot. Six operations in total, she just started doing them last fall. Of those six, she had to abandon one and revert to traditional OHS. Now, she's done about 50 of them the conventional OHS way. And with the robot she says she is "very comfortable" having done over 300 heart bypass surgeries with it. So I think her robot experience is excellent, and I think her mitral valve repair experience is also good, but six tries and five successes with the robot, what do you guys think about that? I guess she has to start somewhere, right?
- next step for her is to do a CT scan to look at veins and circulatory system - to help determine whether robot or OHS is warranted
- surgery date would be latter part of February

What do you guys think, are my local options any good or should I be looking elsewhere? Any feedback or comments appreciated!

all the best
Richard

 

[Midpack]

Hi!

I am 45 and a mitral valve repair/replacement is in my future, as a consequence of mitral valve regurgitation (resulting from mitral valve prolapse). I have only talked to cardiologists for the moment, because surgery is not already suggested. In case repair is not possible, they allways talked about mechanical replacement. it seems (to me) that tissue mitral valve, in relatively young patients, is not much considered.

5% for surgery mortality seems too high. For someone your age, and supposing that no other risk factors are involved, the risk should be around 2%.

Have they estimated the probability of being able to repair YOUR valve? I beleive it is an important point.

Minimally invasive means faster recovery, because your sternum is not split. But it also means more time in the heart-lung machine. And no tactile sensation and direct lookup of the heart. So it has pros and cons.

Anyway, you are taking good care of yourself and asking the right questions. whatever you choose, you will be fine!

 

[Tirone]

Both surgeons seem to have quite some experience. 150 is a lot of repairs. At the end you need to trust your surgeon and have a good feeling.

I think it's important to be careful with numbers from individual surgeons. Consider this: An exceptional surgeon might end up having a higher mortality, just because he operates really complicated cases other surgeons are not capable of doing. Another very untalented surgeon might have a lower mortality, because he picks out the young and otherwise healthy patients... In my opinion the number of cases per year is more important. If a cardiac surgeon ends up having more complications or worse outcomes than other surgeons, the cardiologists will soon realize and stop referring patients to him. Then his numbers drop.

Is there any advantage in using the robot over conventional surgery? I would be very hesitant to let someone operate on me who has done only 5 operations before. You really need to trust this surgeon a lot. 7-8 hours is almost double the time needed without robot. The probability for complications rises with every minute on the heart lung machine...

In cardiac surgery, more than any other field, there is no room for errors. As I've written in another thread: Cardiac surgery isn't about the scars you see on the outside, it's about what was done in the inside. I wanted my surgeon to only concentrate on the repair, the main reason for the operation and not on the minimal exposure, technical problems, bad light, and maybe even some anxiousness because there isn't much routine yet. Before surgery I was very concerned about sternal pain. I was surprised by how good the pain was managed in the ICU and I was off pain killers within 1 week.

 

[Lynlw]

Hi, First I think it is really good you got so much info from both doctors.
From what I know, most doctors, recommend repairs for Mitral valves and IF one is not possible, then I think for someone your age, most would rec a mechanical valve, altho a tissue valve wouldnt be ruled out, depending on the patients preference if everything else is equal, a tissue Mitral valve could be a good option for a 45 year,

Personally, I don think I would be comfortable being the 6th mitral valve repair attempted w/ a robot. I also really prefer hospitals tht have their own dedicated Cardiac ICU and then floor to recover on when you get out of ICU. Altho I know that isnt always feasible with "smaller" hospitals or ones that do NOT have a large volum of heart patients or only a couple heart surgeons on staff where having a heart floor r CICU isnt "needed".

I also personally feel IF, you can find a hospital, that is ranked well that is closer to home, it might be better to stay a little closer, even an hour or so as apposed to 6. for the reason you mention, alot of the "complications" pop up in the first couple weeks home, so IF you need readmitted quickly you will have doctors and staff that don't know you at all and sometimes surgeons dont like to touch another surgeons patient right after surgery. Hopefully you will have a great reovery with only a small bump if any but it is good to plan ahead.. How close are you to Philly? here are some very good, ranked Nationally heart centers in philly, I' guessing you are about an hour or 2 from Philly it might be something to consider. US news does a vry good ranking of top hospitals every year. They have alot of good info a couple years ago they started to rank hospital in Mero Areas, by hospital over all and each specialty. http://health.usnews.com/best-hospitals/area here is Philly's top heart hospitals. http://health.usnews.com/best-hospitals/area/philadelphia-pa/cardiology-and-heart-surgery thats just the chart, but you can see which are also ranked high nationally. they also show Harrisbug or Lancaster, but there are only 2 hospital listed

Also 1 thing to think about for either robotic or many min invasive valve surgeries, as you mentioned how the heart and lung machine is hooked up - basically they go through your veins for this (groin and neck) for the heart/lung machine, Some times the doctors dont really have a real preference and they get good results either way, but sometime when you have multiple 3-6...OHS having to use the groin or neck for bypass is a possibility, for Justin's 4th and 5th OHS during the preop testing they did echos of all the areas they might need to access to see if there were any places better, Justin decided for HIM if possible he rather have an extra scar (2-3 inches) in the femoral area than neck. During the 5th they did use his groin area for the machine.

 

[Mooney]

This is great information and feedback, thank you! I almost feel more confused after talking to both surgeons. I had thought that my meetings with them would bring clarity and comfort but this decision is stressing me out even more. I suppose Philadelphia could be an option for me too. I had not thought of that but do not really have any contacts there.

Richard

 

[Agian]

5% mortality sounds like I lot. Given what you've written, I'd be squeamish about the low number of robotic repairs the lady doctor has performed. The other fella seems to have more experience with and without using the robot.

 

[Lynlw]

This is great information and feedback, thank you! I almost feel more confused after talking to both surgeons. I had thought that my meetings with them would bring clarity and comfort but this decision is stressing me out even more. I suppose Philadelphia could be an option for me too. I had not thought of that but do not really have any contacts there.

Richard

If you are ntersted, altho there are a couple I believe U of Penn, is one of the best in the Nation. Pretty much you just calland ask to speak to the cardiac surgery dept, then let the reseptionist know you need Mitral valve surgery and that you would like to get a second opinion from there and what do you need to do. They most likely will ask to have all the discs and dvds or whatever they recorded all your recent test on and set you up for an appt.If you dont have a special surgeon in mind, it is always good to ask for the surgeon who has the most experience in what you need done. They are pretty good at taking care of people who want 2nd opinions since many people request them

 

[dornole]

Just want to wish you a great outcome from surgery. Pulmonary edema stinks. I hope you are able to get at least some rest without coughing all night in the meantime and that you feel 100% better after you get through your surgery.

 

[tom in MO]

I would take the guy with the most experience. But then I'm a guy with experience

If you can talk to people who've been at the hospitals, you may get a better vibe for one over the other.

You don't say how far you are from a hospital with a dedicated cardiac ICU. If it's within your grasp, I'd look there. The only reason being is that more patients means more experience and overall better chance they will be able to take care of any problems.

I do agree that staying local is good...for you and your family. I'd have no trouble going to either one of your choices.

 

[Lynlw]

This is great information and feedback, thank you! I almost feel more confused after talking to both surgeons. I had thought that my meetings with them would bring clarity and comfort but this decision is stressing me out even more. I suppose Philadelphia could be an option for me too. I had not thought of that but do not really have any contacts there.

Richard

I forgot to mention this.

they always have a cardiac physican or PA on staff 24/7 (unlike St. Joseph's which puts their Dr's on call)
- they do NOT have a dedicated cardiac ICU - it's divided into cardiac, disease, trauma.
- they DO have dedicated cardiac nurses"

IF a all possible, I would feel better being in a hospital post op that HAS Heart doctors on site 24/7. I dont know off the top of my head if either center is a teaching hospitals w/ Cardiac Surgery and Cardiology Fellows, if that was the case I would feel better about "attending" docs being on call as long as a good fellow was there to take care of immediate problems. BUt I certainly wouldnt feel that good about having a complication and them calling the doc on call and waiting for them to drive to he hospital and on days like today, hope here isnt a snow storm or something.. Its probably just a coincidence but with ALL of Justin's heart surgeries and different complications he has had while still in patient or after he got home, it seems MOST of HIS problems happen in the middle of the night or weekends.

Also about a back up plan, I now the vast majority of Mitral repairs are successful, so hopefully you wont need a valve replaced, but there have been some good studies released lately on Miral tissue valves lasting longer in younger (under 60) people still doing well 15 years out (YES NOT everyone will have great results, things happen) and there already is good results replacing tissue valves that need replaced w/ percutaneous valves. I know most of the discussions here are about Aortic valves and Aortic valves replaced by cath (TAVI) since the majority of people needing valves replaced are Aortic, but there is a lot of good things being done for Mitral valves too, including replacing a native valve by cath or a older tissue valve.

 

[AZ Don]

Hi,
It seems like you are asking good questions but I know what you mean about the information being overwhelming. Sometimes I think they just make up the %risk of dying, I've seen numbers all over the place. It might be worthwhile to talk to the 2nd doctor and ask her what the risk would be with OHS, or if it were minimally invasive but manual. Then at least you can get a sense for which has the higher risk, in that surgeon's opinion. My 1st thought was I wouldn't want to be the 6th operation but given she is experienced separately with the operation and the robot. While not a plus I wouldn't necessarily rule it out just because of that but the length of the surgery might also be a concern. The thing with some of the newer more minimally invasive procedures is that although the recovery is typically much better, the risk of the procedure is not always lower - something else to ask about.

If you do consider other hospitals, there are a number of top hospitals within 100-200 miles. Here's the list of top Cardiology hospitals at 200 miles from Reading: http://health.usnews.com/best-hospi...alty_id=IHQCARD&city=reading,+pa&distance=200. US News no longer provides a list of top Dr's, but this site does, and I believe it used to be the source for US News (it was on the US News website that I found out about it): http://www.castleconnolly.com/doctors/

I am not clear how well the ratings truly reflect the Dr's skill, or the Hospital's, but it's a good place to start. Another factor you have to keep in mind is that you need this surgery very soon. Getting an appointment with a new Dr and getting on their surgical schedule may take longer, especially for a top Dr. at a top hospital.

You have two experienced surgeon's and hospitals locally, it is likely they would fix you up well. You can see how patients rated your Dr's on Healthgrade. Here is the 2nd: http://www.healthgrades.com/provide...rhood=&locType=|state|city|zip&locIsSolrCity=

The 1st Dr. had less reviews a higher rating, but Healthgrades also shows that he had a malpractice claim.

Good luck.

 

[Mooney]

Thanks all for the replies, your feedback REALLY is helping me here! I am reaching out to and talking to anyone I can think of for feedback and advice.

Can we talk for a moment about the "dedicated cardiac ICU". I like the concept, anytime they dedicate their expertise to one type of patient sounds good. But what advantages would it offer over a shared ICU where you still have critical care cardiac nurses overseeing things?

Richard

 

[Lynlw]

Thanks all for the replies, your feedback REALLY is helping me here! I am reaching out to and talking to anyone I can think of for feedback and advice.

Can we talk for a moment about the "dedicated cardiac ICU". I like the concept, anytime they dedicate their expertise to one type of patient sounds good. But what advantages would it offer over a shared ICU where you still have critical care cardiac nurses overseeing things?

Richard

In my opinion there is a big difference, especially if you are havng one of the surgeries that are not as common. FWIW almost all the patients operated on at Adult heart centers (for lack of a better word, with patients that have aquired not congenital heart problems are having bypasses, then Aorta Aortic valve surgeries, then Mitral.... In a Surgical ICU the staff has to learn /know about every possible kind of surgery patients, from brain, to heart, stomach GI etc and what is common /usual for each kind of surgery what to watch for what are common complications and what to do if they happen, meds used etc. Its possible to be an expert on everything, but IMO a staff that only takes care of heart patients day in and day out and and focuses on just hearts for the most part would be able to know alot more about hearts, what meds do what, different heart rhythm , what is common post op for different heart surgeries ir what to watch for.

Local or smaller hospitals do a very good job aking care of all kinds of patients, and for the most par there isnt a problem, BUT if you have a complication, I like knowing that the staff knows what to do and doesn have to stop and look things up as much.

 

[scott.eitman]

It never hurts to get 2nd opinions. Yes, I am a little biased towards the Cleveland Clinic, so I will try not to lean that way too much. Lyn's really is an excellent summary of the difference between a dedicated ICU and a shared ICU. I will take it a step further and say the same holds true for a cardiac step down unit vs a shared one. If there are problems, places like the CCF have the resources and experience.

Even though you want to stay close to home for the procedure, You may want to consider going to the CCF to get their opinion.

 

[epstns]

I took the approach of trying to find the highest ranked of the regionally available surgeons. The one I chose had been one of the top guys at Cleveland Clinic (see my signature for info). His opening comment was "While I am not the top man in the country for this procedure, I am DEFINITELY number two." Not the kindest bedside manner, but when the stuff hit the fan, he was the man.

With respect to the robot, I'll use an airline analogy. If you're on a jet airliner, do you want the pilot to be the guy with 5 flights under his belt, or 500?

 

[tom in MO]

When it comes to a cardiac center vs. a regular hospital, the cardiac center is definitely better. I've had 4 operations in the same hospital, but my AVR in their cardiac center was the best experience, the most integrated care and the highest quality service and response from attendants, nursing, doctors, therapists and janitors.

 

[Mooney]

I think I am getting close to making a decision. I've been able to speak to a number of people and get feedback from many sources, including a current cardiac critical care nurse who works at St. Joseph's and just happens to live down the street from me. One thing she said was that I would stay in her ICU unit the entire time until discharge, there is no discharge to a general floor. She said at Reading, I would probably be discharged from ICU after 24 hrs. I like that I would receive the higher degree of specialized care for the entire duration of my time in hospital at St. Joseph's.

As I mull things over I find that I am ranking, in order of importance:

#1 - Surgeon's experience with MY specific situation (mitral valves)
#2 - Surgeon's experience with internal heart operations (other valves)
#3 - Surgeon's experience with any heart surgery (bypass etc)
#4 - The length of time I'll be on the heart/lung machine
#5 - The Hospital's recovery, ICU and nursing capabilities
#6 - My gut feeling

I think I'll have a decision made in the next day or so.

Thank you for all the input, it has really helped me focus on some facts. The whole thing about time spent on the heart/lung machine was something I never considered until I came here. THANK YOU.

Richard

 

[neil]

looks like you have got good advice richard

 

[epstns]

Richard - The only point of caution I can offer on your option to stay in ICU is that when I was in CICU, I didn't get much sleep. It seemed that although there was always one nurse per patient and I was constantly watched, they always had a constant stream of little things to do to/with/for me, since there was no "off" shift. Yeah, you may be sedated, but it still was a disturbance.

 

[Lynlw]

Richard - The only point of caution I can offer on your option to stay in ICU is that when I was in CICU, I didn't get much sleep. It seemed that although there was always one nurse per patient and I was constantly watched, they always had a constant stream of little things to do to/with/for me, since there was no "off" shift. Yeah, you may be sedated, but it still was a disturbance.

Good points..One thing that makes it tough to make recommendations is so many hospitals are set up differently so unless you know about the hospitals being considered, its tough. For example many hospitals ICU?CiCU is a large room, either w/ curtains or partitions separating them or bigger rooms with a couple beds. usually nurse to patient is 1 to 1 or 1 nurse to 2 patients, depending on how the patients are. They can be VERY loud.. Other hospitals might have some large wards, but also have private rooms in CICU/ICU.. Which are so much nicer (as far as if you need to be in a intensive care unit can be nice)

Then different hospitals step down are also different, some leave CICU when you can walk, talk etc and go to a heart 'floor" which is just for heart patients, surgical or medical with 1 -2 patients rooms and usually 1 nurse to 2 patients. It is just a little more pleasant usually, than CICU also might make it easier to have visitors

But Other hospitals when you are "well enough" to leave ICU you go to a floor that is all surgical patients from car accident and gunshots to brain and heart patients which is like he differences between dedicated Cardiac intensive Care Unit to surgical I care units.

Mooney I agree with your list, if anything I would move gut feeling a little up the list. I often found when I had to make choices, I often felt at peace when I decided , if I kept requestoning myself, I thought it was time to rethink things.
St Jos's sound like tyou feel the best about, my only question would be to ask who is there in case of complications if the docotors are on call? I they have Cardiology or CT surgery "fellows" who will be "attendings" in a few months and have been residents for years, I would feel better than just nurses on staff as good as they are there are things they can not do