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HEART 3-D technology and robots advance mitral valve repair
3-D imaging and robots allow physicians to detect, diagnose and treat heart conditions before symptoms occur
BY PATTI MUCK
Under Mike Trevathan’s right armpit are four small scars that mark the major heart surgery he underwent last summer. Except for occasional tightness when he first raised his arm, the wounds never hurt.
Weeks after a leaky mitral valve in his heart was diagnosed and surgically repaired at The Methodist Hospital, Trevathan returned to teaching and went on his annual duck hunt near Trinity Bay, Texas.
Thanks to surgeon Dr. Gerald Lawrie, his well-trained team and a robot named da Vinci, Trevathan’s life barely skipped a beat and his heart is ticking like new.
“I feel real fortunate they didn’t have to split me open,” Trevathan says. “I feel as good as I did before I went in. They found my problem real quick. When Dr. Lawrie told me my options, I said let’s try the robot.”
➺ Gateway to the heart
The mitral valve is the gateway into the heart’s left ventricle, which supplies oxygen-rich blood to the rest of the body. When the valve does not shut tightly, blood flows back into the atrium, decreasing blood flow to the body and forcing the ventricle to pump harder. Leakage — or regurgitation — can be present from birth or can develop as a result of damage from rheumatic fever. It also can occur from a ballooning out or prolapse of the valve.
Outwardly healthy and robust at 62, Trevathan had never been seriously ill in his life. Except for having his tonsils removed as a child, he’d never had surgery of any kind or been in a hospital. But when the longtime teacher, administrator and coach had his annual physical last summer, his doctor heard a heart murmur.
Through advanced imaging technology — a 3-D echocardiogram and a TEE or transesophageal echocardiogram — doctors pinpointed the source of the murmur, Trevathan’s leaky mitral valve, and rated its leakage at 52 percent.
Trevathan was lucky. His heart problem was detected, diagnosed and treated before he felt a single symptom. The use of the da Vinci robot to help Lawrie perform the surgery was an added bonus — it substantially cut his hospital stay, recovery time and pain.
➺ Evolving technology
As imaging and treatment technologies evolve, and as physicians learn how to apply newfound knowledge and tools in more innovative and creative ways, Methodist physicians hope to see more patients just like Trevathan.
“Technology is allowing us to detect some heart conditions even before the patient develops symptoms,” says Dr. Miguel Quiñones, medical director of the Methodist DeBakey Heart & Vascular Center and chair of the Department of Cardiology. “Things that sometimes took days, weeks, now can be done almost immediately.
“We’re a center of excellence for several of the leading imaging companies,” says Dr. William Zoghbi, medical director of the heart center’s Cardiac and Vascular Imaging Center and the William Winters Endowed Chair in Cardiovascular Imaging. “Any of the latest and newest technology starts here.”
The use of 3-D echocardiography offers a real-time picture of the heart — almost as if the surgeon is holding
it in his or her hands — says Zoghbi, and this imaging technology continues to develop. “You can even call it 4-D technology because there is a time element,” he says. “You can see clearer images with the help of much faster processing and more physiologic information about how the heart is beating and functioning.”
➺ Leading medicine
Keeping up with the latest developments doesn’t happen overnight, Quiñones says. “Every revolution in medical technology is followed by a five- to 10-year lag time as researchers and physicians learn how to best use that technology to help patients.”
Lawrie followed the medical evolution of the da Vinci robot for nearly a decade before it reached the maturity and the right mix of instrumentation
The da Vinci robot allows surgeons flexibility to perform more complicated surgeries laparoscopically. The surgeon using the robot operates while seated at a console (left), viewing a 3-D image of the surgical field.
for cardiac applications. The enhanced magnification and the need for only tiny incisions made the robot popular for prostate and gynecological surgeries at Methodist and in hospitals nationwide, but not until recently did da Vinci’s instrumentationadvance enough to find its way into a few cardiac suites.
“We spent more than six months training to make sure we could accomplish our technique in an identical fashion with the robot,” Lawrie says. “We’re the only center that’s performing the standard full-scale operation with the robot.”
Lawrie is famous for the “American Correction,” his adaptation of a 15year-old procedure used to perform complex mitral valve repairs. Success rates of near 100 percent attest to its superiority over the predecessor technique — the “French Correction.” Lawrie does not cut out heart valve leaflets and he uses Gore-Tex strings to replace the heart’s damaged chordae, unlike the French version.
The chordae tendonae are the “heartstrings” that attach the valve leaflets to the heart muscle like the strings on a parachute. They can become damaged or elongated, and surgeons found the durability and elasticity of goretex material could replace the damaged chordae and improve function.
Lawrie and his team also developed a series of maneuvers to simultaneously adjust the various components of the complex and dynamic mitral valve.
Dr. William Zoghbi (L) and Dr. Miguel Quiñones
➺ En Garde
At a recent medical conference, Methodist’s “Robot Team” participated in a cordial duel with Dr. Alain Carpentier, developer of the French Correction, to demonstrate the differences between the two procedures. While Lawrie says both showed benefits, the American Correction was the clear winner in time elapsed and patient outcome. Already responsible for training about 20 percent of practicing U.S. cardiac surgeons in the procedure, Lawrie says the demonstration prompted even more interest in his technique.
And now, the American Correction can be performed with da Vinci. Instead of standing at an operating table, Lawrie sits at a console, removes his shoes and works the two hand controls and five pedals with his hands and feet, much like an organ player. A 3-D camera for each eye means a clear and lifelike view of the heart, says Lawrie, and his hands and feet work as if they’re directly connected to the instruments inside the chest.
The dream is to one day perform the procedure on a beating heart — without using the heart/lung machine to stop the organ. That may be 10, 15 or 20 years away, but the conceptualizing has already begun.
The advanced technology tools used in Trevathan’s case — the da Vinci robot and 3-D echocardiography — are among the advanced services that continue to help Methodist’s heart service garner top spots on U.S.News & World Report’s “America’s Best Hospitals” list.
