Cardiac and Thoracic Conditions

The aorta is the main artery that emerges from your heart and carries blood to all parts of the body. The aorta is divided into five distinct sections:

1. The aortic root is the section closest to the heart.
2. The ascending aorta ascends from the heart in the front of the chest.
3. The arch of the aorta is the bend going from the front (ascending aorta) to the back of the chest (descending aorta). This section of the aorta supplies blood to the head, neck and arms.
4. The descending aorta is the part of the aorta that runs in the back of the chest down to the diaphragm, which is the muscle separating the chest from the abdomen.
5. The abdominal aorta runs in your belly before ending as two branches that supply blood to your pelvis and legs.

Cardiac surgeons treat conditions of the first four sections of the aorta, while vascular surgeons care for conditions affecting the abdominal aorta.

The most common condition affecting the aorta is an aortic aneurysm, which is when the aorta balloons and becomes more likely to rupture. This may be caused by high blood pressure and cholesterol, a genetic condition like Marfan and Loeys-Dietz syndromes, or bicuspid aortic valve disease, where the aortic valve has two flaps instead of three.

Treatments

Your care team will monitor an enlarging aorta with CT scans. When the enlargements become aneurysms and reach a certain size, surgery or other intervention will be recommended.

Surgery is currently the only way to treat an aneurysm of the aortic root, ascending and arch of the aorta. This involves the removal of the diseased parts of the aorta, and replacement with a synthetic tube graft. These tube grafts are usually durable and do not require patients to take any special medications afterwards.

These operations are open-heart procedures done through a central chest incision. Some may require other advanced techniques, such as deep hypothermic circulatory arrest – deep cooling of the body to protect the brain and other vital organs during surgery. Your surgeon will discuss this with you in more detail.

Aneurysms of the descending aorta can be treated by surgery, or by a catheter-based procedure called TEVAR. TEVAR procedures involve a graft crimped on a catheter which is then inserted into an artery in the groin and driven up to the point of delivery using x-ray guidance. It is then deployed to cover the aneurysm. TEVAR procedures make for a quicker procedure with faster recovery times. Not all descending aortic aneurysms can be treated this way. Your surgeon will discuss this in detail with you.

Aortic surgeries, while complex, can be done with precision and accuracy, and with relatively few risks. 

Atrial Fibrillation (AF) is an abnormal heart rhythm originating from the upper chambers of the heart, called the atria. AF can occur in isolation or in conjunction with or because of other cardiac conditions, especially mitral valve disease. This disorganized heart rhythm increases the risk of stroke and decline of heart function over time.

Patients with AF can usually manage the condition with medication, which may include blood thinners to prevent strokes. They may undergo catheter-based ablation procedures done by electrophysiologists.

Patients who have failed catheter ablations or certain patients with persistent AF may be referred to surgeons for advanced surgical therapies.

Convergent Procedure

This is minimal access procedure for AF performed through two small incisions. A small central skin incision is made in the lower part of the chest. Through this incision, surgeons use radiofrequency energy tools for AF ablation. This procedure can effectively ablate 75% of the areas needed to treat AF. The remaining areas can be “touched up” by a catheter-based procedure by your electrophysiologist later if required. The second small skin incision is on the left side of the chest to allow surgeons to clip the left atrial appendage.

The convergent procedure can also be done with a surgical robot.

Surgery for Concurrent AF

When AF is present along with another condition requiring cardiac surgery, an ablation procedure called the MAZE procedure is performed. Depending on the nature of the AF and prior therapies, different versions of the MAZE will be performed. The MAZE procedure involves the use of radiofrequency and cryo-energy tools to create ablation lines (electrical exclusion lines) in the atria to allow for return of normal sinus rhythm. All MAZE procedures are combined with the exclusion/removal of the LAA.

Surgery for Left Atrial Appendage Exclusion in Chronic AF

Patients with chronic longstanding AF will not benefit from ablation procedures but will need lifelong blood thinners to prevent strokes. A small cohort of such patients become intolerant of blood thinner therapy and may require isolated exclusion of the LAA to mitigate (not relieve) stroke risk. This can be done through a small skin incision on the left side of the chest using endoscopic techniques or with the use of the DaVinci robot.

Complex and Re-operative Cardiac Surgery

It is not uncommon for patients to require complex operations such as double valve procedures, valve + CABG, Valve + Aneurysm and the like. Lahey Cardiac surgeons specialize in all kinds of complex heart operations.

Patients who have had prior cardiac surgery may need re-operative surgery for new cardiac disease, progression of existing cardiac disease or failure or degeneration of a previous procedure. Lahey cardiac surgeons specialize in the careful evaluation and treatment of patients who require such re-operative surgery.

Coronary artery disease is the most common heart disease in the United States. Various risk factors contribute to coronary artery disease. These include diabetes, hypertension, hyperlipidemia, genetic factors, smoking, obesity, sedentary lifestyle and other environmental factors.

Coronary artery disease is evaluated by your cardiologist, who will perform an exercise stress test, echocardiogram, nuclear imaging and a cardiac catheterization. Your cardiologist will decide which of these tests is appropriate for you.

There are multiple ways to treat coronary artery disease. In each case, your medical team will discuss the benefits and risks, and help you decide on the best option.

Medications

Medications can be used to control your heart rate, blood pressure, cholesterol and lipid levels to improve function of the heart, improve blood circulation, manage diabetes and other risk factors. This care is overseen by your cardiologist.

Percutaneous Coronary Intervention

Percutaneous coronary intervention, or PCI, is the placement of stents – tiny metal jackets that are used to open the blockage. These procedures are performed by a special group of cardiologists called interventional cardiologists.

Coronary Artery Bypass Grafting Surgery

Coronary artery bypass grafting surgery is recommended when patients have multi-vessel coronary artery disease, left main coronary artery disease and coronary artery disease that cannot be treated with the first two options. It is usually performed through a central chest incision. While there are some less-invasive options practiced in several places in the country, these procedures are not considered standard. Lahey surgeons perform both off-pump and on-pump coronary artery surgery.

Coronary artery bypass grafting surgery involves harvesting off the internal mammary artery, radial artery and greater saphenous vein as conduit. Coronary artery bypass grafting surgery can only be done using conduit from the patient's own body. These conduits are connected in a way that allows blood to get to the coronary artery, and therefore to the heart muscle, bypassing the blockage.

Certain genetic conditions, such as Marfan, Loeys-Dietz and Ehlers-Danlos syndromes, can predispose an individual to cardiovascular disease. These conditions can cause weakness in the wall of the aorta that results in aortic aneurysms, and they are also associated with “floppy mitral valve,” producing mitral valve leaks.

Lahey has cardiologists with special expertise in this area to guide you through the process of diagnosis, genetic counseling and early management of these conditions. Our cardiac surgeons have expertise in complex operations to treat these conditions.

Treatments for Aneurysms in Patients with Genetically Acquired Cardiac Diseases

Aneurysms of the ascending and arch of the aorta are managed similarly to those occurring in patients without genetic disease.

Aortic root aneurysms are very common, with the condition affecting the aortic root tissue only and not the aortic valve. The gold-standard treatment is the aortic valve sparing aortic root replacement, where the patient’s native aortic valve is preserved and reimplanted into the synthetic graft used to replace the aneurysm. This procedure is complex and requires special expertise. These operations are always done through a central chest incision called a midline sternotomy and with the heart-lung machine. By preserving the aortic valve, the patient does not have to deal with the issues related to valve replacement, such as blood thinners for mechanical valves and durability issues with the biological valves. However, not all valves can be preserved. Your surgeon will discuss this with you in more detail.

In general, patients with genetically determined aortic disease are treated with surgery. Current TEVAR procedures are not recommended for this group of patients.

Surgery for Genetically Acquired Mitral Valve Disease

Mitral valve regurgitation from a “floppy mitral valve” can occur in patients with Marfan syndrome. While the pathology of the valvular heart disease can be complex, these valves can be repaired. Your surgeon will advise about the possibility of repairing the mitral valve based on echocardiographic images and other tests. Given the complexity of the mitral valve repair, these operations tend to be done in the conventional technique.

There are four valves inside the human heart, each designed for unidirectional flow of blood. A variety of diseases can affect the heart valves and may require surgery or other medical care.

In all cases, your doctor will review options for your care with you based on your medical history, conditions and lifestyle.

Aortic Valve Surgery

The aortic valve is where blood exits from the heart, at the top of the lower left chamber. Calcium deposits may cause this valve to narrow, or the valve may begin to leak.

Aortic valve replacement is one of the most common operations in cardiac surgery. The affected valve is removed and replaced with a mechanical (metal) valve or a biological (cow or pig tissue) valve. While mechanical valves are very durable, they require you to take blood thinners for the rest of your life. Biological (animal tissue) valves are less durable, but do not require blood thinners. Your surgeon will discuss the options with you, considering your age, medical history and lifestyle. You make the final decision.

Other options for aortic valve surgery are less common, but your surgeon may discuss them with you as well. They include aortic valve repair, homograft replacement of the valve (using a human valve from a cadaver) or Ross procedure. 

Conventional aortic valve surgery is performed through a central incision on the chest called a midline sternotomy. Patients are placed on the heart-lung (bypass) machine, allowing the heart to stop so the valve can be replaced.

Aortic valve surgery can also be performed using minimally invasive techniques, such as a small central incision or a small incision at the top of the right side of the chest. Your surgeon will advise if this is appropriate for you.

Transcatheter Aortic Valve Replacement 

In the last decade, new techniques for aortic valve replacement have been developed. Transcatheter Aortic Valve Replacement (TAVR) is one of those game-changing procedures.

In this procedure, an animal tissue valve is crimped and mounted on a catheter which is usually then inserted through an artery in your groin and guided towards your heart using X-ray. This valve is released inside the old worn-out aortic valve with a balloon inflation technique. The new valve pushes aside the old valve and sits in that space.

TAVR technology is advancing rapidly and is currently approved for treatment of aortic valve stenosis (narrowing caused by calcium deposition). There are limited options available for transcatheter treatment of purely leaking aortic valves.

TAVR is done by a team of surgeons and interventional cardiologists who will first evaluate your candidacy and appropriateness for the procedure. While it has broad approval, there are limitations to its application, and your TAVR team will advise you about this during your consultation.

Mitral Valve Repair or Replacement

The mitral valve is between the upper and lower left chambers of the heart. The most common affliction of the mitral valve is mitral regurgitation (leaky mitral valve) due to imperfect valve closure. Various conditions can lead to this problem, the most common being myxomatous disease. Narrowing the mitral valve can be caused by prior rheumatic fever or degeneration. Sometimes, mitral stenosis is associated with mitral regurgitation.

Mitral Valve Repair

Repair is considered the gold standard for the treatment of myxomatous mitral valve disease. Mitral valve repair allows you to keep your own valve, which is best for your heart function, your long-term functional status and does not involve use of any special medications after surgery (like a blood thinner). Repair techniques are complex and require expertise. Our surgeons are skilled at complex mitral valve surgery. Your surgeon will advise you about the possibility of repair and the associated risks.

Mitral Valve Replacement

When mitral valve repair is not possible, replacement is the best option. Mitral valves are replaced with a mechanical (metal) valve or a biological (cow or pig tissue) valve. While mechanical valves are very durable, they require a life-long requirement to take blood thinner medications. Biological (animal tissue) valves are less durable, but do not require blood thinners. Your surgeon will discuss the options with you, considering your age, medical history and lifestyle. You make the final decision.

Techniques for Mitral Valve Surgery

All mitral valve operations are open-heart procedures. Patients are placed on the heart-lung machine (bypass machine), which allows the heart to stop. The upper chamber is opened, and the mitral valve is repaired or replaced by hand. Your surgeon will advise you about the risks of the operation.

There are different ways to approach the valve. The traditional approach, through a central incision on the chest called a midline sternotomy. This incision is about 6-8 inches long and has always been the gold standard for mitral surgery.

Newer, minimally invasive, techniques offered at Lahey include:

• Lower sternotomy, smaller central incisions which are no more than 4-6 inches long.
• Right thoracotomy, a 4-inch incision on the right side of the chest around the nipple area. This procedure involves a second incision in the groin for connection to the heart-lung machine.

Your surgeon will go over these options, and you will together decide on the best option.

Catheter-based Mitral Valve Interventions

Currently, there are no durable catheter-based options for the mitral valve. The only approved technology that exists today is the Mitraclip, which is reserved for patients who are not candidates for mitral valve surgery.

Tricuspid Valve Surgery

The tricuspid valve is between the upper and lower right chambers of the heart. Tricuspid valve regurgitation (leakage) is the most common condition affecting this valve, and it is usually secondary to mitral valve disease though it can occur in isolation. Surgical techniques for this condition are like those of mitral valve surgery.

Tricuspid Valve Repair

Often, the tricuspid valve can be repaired using an annuloplasty ring, a semi-rigid ring that encircles it and cinches it down to prevent leakage.

Tricuspid Valve Replacement

Occasionally, a patient may need tricuspid valve replacement. Tricuspid valves are usually replaced by an animal tissue valve. Patients who have undergone this procedure may need a pacemaker after surgery. Your doctor will discuss the best options with you.