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Minimally Invasive Surgery for Complex Coronary Blockages

Posted on Jul 10, 2015 in Heart Health

Mills-Peninsula patient John D. Moore

Seventy-two-year-old San Mateo resident John D. Moore, a retired business owner, felt strong despite a couple of health issues. He had chronic lung disease, collateral damage from a 30-year, two-pack-a-day smoking habit, and rheumatoid arthritis. But Moore quit smoking 17 years ago and stayed active through golf, walking and swimming. He had no reason to suspect that the blood supply to his heart was slowing to a trickle and on the verge of sealing shut.

Last spring, when playing golf or climbing stairs, Moore began to experience shortness of breath. He casually mentioned the problem to his rheumatologist during a routine appointment. Knowing Moore was a former smoker, his doctor recommended a chest X-ray, which led to more tests.

Moore was referred to David Kurzrock, M.D., a Mills-Peninsula interventional cardiologist, who encountered a grim situation when evaluating Moore’s heart. His heart muscle was weak, his right main cardiac artery was completely blocked and his left main artery, which normally supplies about 80 percent of blood to the heart, was 90 percent blocked and now feeding everything. This is a situation that Dr. Kurzrock describes as “100 percent jeopardy.”

Further complicating the situation, the blockage in Moore’s right artery was a chronic total occlusion (CTO), which means not only is the artery 100 percent blocked, but also the blockage is calcified because it has been building for a long time, making it more difficult to break through.

Advanced Techniques Offer New Options

Such a dire diagnosis almost always requires a major open heart surgery. But this would be very risky in Moore’s case because the immune-suppressing medications he takes for his arthritis could leave him vulnerable to an infection. A traditional stent placement procedure, in which a small mesh tube is inserted in the artery to open up blood flow, also was considered dangerous in Moore’s case because the severity of blockages in both arteries meant that his heart could be deprived of blood during the procedure.

Dr. Kurzrock and David Daniels, M.D., a Mills-Peninsula interventional cardiologist who was also involved in Moore’s treatment, both have advanced training in minimally invasive techniques for treating the most challenging and complex coronary blockages, including CTOs. It is a very specialized field; only about 20 doctors in the U.S. have this advanced training. Dr. Daniels is considered an expert in these techniques and travels around the country training other doctors.

The problem of CTOs and other complex lesions is not new, and cardiologists have long tried to correct the condition through minimally invasive procedures. However, the success rate has hovered at only about 50 percent.

Newer techniques are making it possible to open the most complex blockages, including CTOs, through minimally invasive procedures. These new techniques have a dramatically higher success rate, around 90 percent and higher, but are complicated and require extensive training.

“We always go into a procedure with a plan A, plan B and plan C. We are constantly changing our approach during the procedure based on what’s working and what’s not,” Dr. Kurzrock says. “We may try three or four things that don’t work. And it is the fifth approach that works. A lot of decisions have to be made on the spot during the procedure.”

A Team Approach

In Moore’s case, the first problem that had to be solved was to establish adequate blood flow to the heart during the procedure. To do this, Dr. Kurzrock used a device that pumps blood and supports circulation. Then he inserted a stent in the main left artery to open up the blood flow. Once Moore’s circulation was working on its own, Dr. Kurzrock removed the circulation device.

Next, the two surgeons worked on Moore’s heart simultaneously, performing a specialized intervention technique called retrograde dissection re-entry. Entering the body through a tiny incision in the left groin, they inserted a thin wire and tube into the left coronary artery, threaded it across the body into the right coronary artery and through the CTO blockage, moving the wire and tube back and forth to break up the hardened blockage.

From there, they advanced the wire and tube into another catheter coming from the right side, and continued to push all the way through the body and out through another tiny incision in the right groin. Once the blockage was cleared, the doctors performed a relatively straightforward stent placement.

“We worked with two catheters simultaneously and repaired both arteries in a single procedure,” Dr. Kurzrock says. “It’s a very complicated technique. By the end, I was holding both ends of a wire that had been threaded clear through the body and heart.”

Minimal Pain, Quick Recovery

In an open heart surgery, Moore would have required general anesthesia and run the risk of suffering a stroke during the surgery or developing an infection during recovery. He also would have probably experienced significant blood loss, possibly requiring a blood transfusion. For most patients who undergo open heart surgery, the recovery is very difficult and can take months.

“Instead, the whole procedure took only two hours and Mr. Moore went home the next day with a Band-Aid on each groin,” Dr. Kurzrock says.

Before the development of these advanced techniques, certain types of coronary artery blockages couldn’t be opened through minimally invasive procedures. “We no longer feel that is true,” Dr. Kurzrock says. “Between Dr. Daniels and myself, with our skills and tools, we can open almost every type of blockage and give most patients the same results as an open surgery.”

“We are offering new options to patients who previously had to choose between coping with chest pain or having open heart surgery,” Dr. Daniels says. “These are extremely effective minimally invasive techniques that are easier on patients and have a much faster recovery time.”

Moore is breathing easily once again and is back on the golf course. “I’m a lucky man,” he says. “Not many doctors can do this complex procedure. If I had to undergo an open heart bypass surgery I might have lost six months of my life.”

Mills-Peninsula Health Services has one of the top awarded cardiovascular programs in the U.S. Learn more about Cardiovascular Care, Programs and Services at Mills.