Working Together: Teaming Up for Safer Heart Procedures

Heart conditions don’t happen in a vacuum. Very often, one problem may be associated with other issues. That’s the impetus behind an innovative program at Baptist Health Miami Cardiac & Vascular Institute that seeks to coordinate the care for blockages in the coronary arteries and problems with the aortic valve.

Joseph McGinn Jr., M.D., the chief of cardiac surgery at Baptist Health Miami Cardiac & Vascular Institute.

“I don't think any other place in the country is doing what we're doing,” says Joseph McGinn Jr., M.D., the Institute’s chief of cardiac surgery.

Dr. McGinn is world-renown for pioneering a breakthrough approach to minimally invasive coronary artery bypass graft surgery. His procedure eliminates the need to cut open the patient’s chest or stop the heart, greatly reducing pain and recovery time. Known as the McGinn Technique, the very advanced surgery is currently performed routinely in only a handful of American hospitals.

Add in the complication of an aortic valve that is not functioning properly, and patients are practically guaranteed that most medical institutions will recommend a high-risk open-heart surgery to address both problems at once.

Dr. McGinn wants to change that paradigm. He and interventional cardiologist Nish Patel, M.D., who specializes in catheter-based therapies for structural heart disease, are initiating a program at Miami Cardiac & Vascular Institute to address the two issues in a hybrid, staged approach that dispenses with open surgery.

Nish Patel, M.D., interventional cardiologist at Baptist Health Miami Cardiac & Vascular Institute.

“By doing this procedure in a staged manner, you give the patient the best result with the most minimalist approach,” Dr. Patel explains. “I don't think there's anybody doing this kind of hybrid approach.”

Why It’s Important

Coronary artery bypasses are performed more frequently than any other major surgical procedure in the United States. Used to treat the narrowing of the arteries that supply oxygen to the heart, bypass is recommended when the vessels are so narrowed or blocked that patients run a high risk of a heart attack.

About 90 percent of the more than 350,000 bypass procedures that are performed yearly still use a technique developed in the 1970s that calls for a large zipper incision in the chest and a heart-lung machine that allows the heart to be stopped.

The alternative, a minimally invasive approach designed by Dr. McGinn, requires enormous skill and experience. Instead of opening up the chest, Dr. McGinn accesses the clogged arteries through small, two- to-three-inch incisions between the ribs and performs his surgery on the beating heart using special instruments.

For almost all patients, this approach is just as safe and effective, in addition to reducing pain and recovery time, Dr. McGinn says. “Why have your chest cracked open and your heart stopped if you don’t need to?”

The minimally invasive approach is used in a greater proportion of procedures to address aortic stenosis, when the valve that pumps blood from the heart to the rest of the body is no longer able to open and close properly.

Transcatheter aortic valve replacement, or TAVR, delivers a folded replacement valve through a catheter without having to open the patient’s chest. Once in place, the new valve pushes the old leaflets out of the way and takes over the job of regulating blood flow. However, when the condition is complicated by the need for a bypass procedure, the open-heart route is typically taken.

Teaming Up to Redesign Care

Addressing both conditions in a collaborative way is in the best interest of patients, Drs. McGinn and Patel explain. Instead of piggybacking both procedures into one high-risk surgery, they team up to determine which condition is most severe and needs to be addressed first, and then take turns doing their procedures about a month apart, with close monitoring in between.

“If you look at the risk of a replacing a valve and doing cardiac bypass at the same time, the risk is extremely high, like maybe five times higher than the strategy that we're using,” Dr. McGinn says. 

Taking this slower and more systematic approach could have a huge impact on a lot of people, they say.

“There are a lot of patients who have a coronary artery disease — it’s a very common disease. There are also a lot of patients who have aortic valve stenosis. It's the most common valve problem in the United States,” Dr. McGinn says. “Having both conditions in the same patient is going to happen a lot, because they're both very prevalent diseases.

“For people who need both coronary bypass and TAVR, which is a pretty common scenario, they should be hunting us down because we have the program.”

The key is doing what’s best for the patient, they agree. “Everyone here has the same mindset,” Dr. Patel says. “We are not just looking for fancy new ways of treating patients; we want to make sure that the patient gets the best treatment with the least invasive approach without compromising the outcome. That's the whole goal.”

Some patients are too weak or have too many comorbidities to undergo open-heart surgery, and this could be their only option. But even for those who are strong enough, taking an approach that reduces trauma, pain and debility can be important objectives.

“We want to create a situation where the patients are actually getting back to life quicker, whether they're retired and golfing, or whether they're a breadwinner for their family and they need to get back to work,” Dr. McGinn says. “Whatever it might be, the goal here is to do whatever we can to get them back to their normal living.”