Hello! I did an AMA six months ago and people are still asking questions. So i decided to do it again! I am a cardiac surgeon that is involved in a transplant program and research about VADs and artificial organs. Here we go again AMA!

Have you mastered Surgeon Simulator 2013? It's a great way to practice your surgical techniques.

I saw a video but i haven't played it yet. I want to try it out.

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I have. I really haven't taught about it as a coping mechanism.

My dad had a heart transplant 5 years ago and a kidney transplant last year. Thanks for being a surgeon. Sorry for not asking a question.

Thanks!

Came here last time with the same thing to say: I'm two surgeries out after aortic dissection caused by Marfan's syndrome and doing splendidly. Thanks for being a surgeon, you bunch of goddamn hotdogs.

Thank you very much.

In your honest opinion, do you think we will ever see people replacing their normal fully functioning organs for superior artificial ones? please say yes

Yes

Did you say yes because Edward asked you to, or do you truly believe that?

Yes

Isn't this being done already?

http://www.popsci.com/science/article/2012-02/no-pulse-how-doctors-reinvented-human-heart?page=all

Yes, but they are not superior to natural circulation yet, that was the question of edward1990. continous flow pumps have been in use for a long time as VADs, Not total artificial hearts (THA need the native ventricules to be explanted and the machine to be placed in their place. VDAs do not require removing the native heart and work along side with it). It's a paliation of a disease not a cure or improvement. Continuos flow devices have proven symilar to pulsatile devices and cause less mechanical problems because they have less moving parts wich offers lower risk of component failure, new generations of devices have only one moving part and no axels because they impulse blood with an impeller that is magnetically levitated and has no conection to other parts of the pump, but have shown a higher risk for developing gastrointestinal bleeding secundary to arterio-venous malformations due to the lack of pulse, it seems like the body needs pulse to develop blood vessels. The human heart is an awesome machine billions of years in the making. Maybe we will be able to make something better than nature, nature just has had more time to develop it.

What animal organs can work in a human body?

I have a fully functioning pig valve in my heart.

Thats actually made from the pigs pericardium, not the heart valve.

Why is that?

Because tha actual valves aare smaller than human valves.

Medic here. How the fuck should I work a code if my patient has an LVAD? We all just stood around and pushed drugs at the last one and it didn't seem right.

You should start the same way, do a abc while someone else calls the number. Connect the defibrillator to see if he is in a defibrillatable rhytm, sometimes if the patient is on a LVAD and starts fibrillating, the machine will still be able to give a small amount of flow, but because the right ventricle is fibrillating, the LVAd can not fill properly. Defibrillate the patient to set them back to normal functioning. If it is due to a mechanical problem and the patient has no cardiac reserve, its really serious, intubate and call the number.

I concur.

do you concur doctor? i concur.

No CPR but I believe you can intubate still. Call the number on the device if it comes up again; the doctor will know absolutely everything about LVADs and that patient specifically.

I understand the mechanics of an LVAD and why dislodging the pump is near instantly fatal. But without compressions and assuming the arrest doesn't happen on the surgery table, is there really any survivability for a PT with an LVAD going into arrest? Are drugs even helpful?

You can compress, all the tubing is ok, its the motor thats broken.

Edit: you should compress if there's a mechanical problem with the vad. If the problem is an arrhytmia you should treat that without compressions.

edit2: compressions come after everything else has failed and the patient is going to die most surely. it's like saying all in in a poker game and should never be the first response.

How has your job changed your diet ?

I cook with almost no salt, only vegetable oil and mostly olive oil, a lot of vegetables. I don't eat french fries :( i love yougurt. And mostly eat birds and fish.

Edit: unless i am at the hospital... there i eat whatever i can at that moment. at home i behave better.

No salt? Is it really that bad? What are some other ways to prevent heart disease? Im 29 and my diet has been not the good.

If you don't have a heart condition not really, but i lived with my grandfather after i was born and he couldn't eat salt. So after he died i just kept eating the same way. Of course, on a busy day i would eat what ever i can get.

edit: i use salt, butter and all the big guns on the christmass dinner... fuck it! jesus was born! (suppousely)

A lot of salt is bad, but isn't little to no salt also bad for the body?

All the salt you need is already in the food, you don't see monkeys adding salt to their meals...

Hello, A little while back I became really sick & ended up with an infection on my tricuspid valve. The infection was a growth(?) about a quarter inch diameter. I also had septicemia & a pulmonary emboli. Treatment ended up being Vancomycin. As the "growth" died it scarred the lung tissue causing extreme difficulty breathing at one point.

Q1) Why did everyone think I was an IV drug user?

Q2) Why did the cardiologist decide not to replace the valve?

Background - 35 yo Male. Never smoked, never taken any kind of illegal drugs (smoking or IV). Minimal alcohol consumption (3-4 drinks 4 or 5 times a year). Suffers eczema, asthma. Allergic to penicillin. Long term user of prednisone/prednisolone (30 mg daily) to treat eczema. I'm in Australia if that makes any difference.

It's a type of endocarditis that is only common in I.V drug users. Because the bacteria bacteria goes into the veins from the dirty needle and the first valve they find is the tricuspid valve. It is theoretically possible to get the the infection from any infection in the skin. Drug addicts just get it more often because they constantly pierce their skin with contaminated needles.

No every case of endocarditis needs surgery, it depends on different factors or you were probably too sick at that time.

Is performing surgery fun?

Yes! A lot... It's awesome.

http://qkme.me/3u0i5p

Both. Sometimes i am like: La la la la!

I missed your previous AMA so sorry if this question has already been asked/answered, but what do you think is limiting the development of artificial hearts being used for people waiting on donor organs? Is it a lack of research? Or is it an unwillingness from patients/doctors to use them? I only ask because I remember seeing an article about a Czech man who lived for 6 months without an actual hear and only died due to complications of a separate disease.

Because ventricular assist devices and artificial hearts still have lots of problems. Like the need for anticoagulants (some devices more than others) bleeding, emboly, infection, mechanical problems, chronic wounds where the canulas and wires go inside the body, limited autonomy, limited biocompatibility, close medical follow ups, etc.

They are making progress, better devices, more compatible, Smaller. people are living for years conected to them, as much as 90 months or so. Stay conected for over a year without having serious problems.

My dad has an LVAD device and he usually ends up back at the hospital about twice a year for internal bleeding. They still can't figure out where it's coming from. They just adjust his meds until it's controlled. They adjust his meds a lot and it seems like a never ending roller coaster ride.

Is it a continous flow device? Cause those cause intestinal arteriovenous malformations due to lack of pulse

What does plaque feel like? Also, can someone reduce plaque by changing their diet, or are they stuck with it forever? Thanks!

Theres a hard plaque and a softer one, you only feel it with the gloves on but it feel hard but kind of juicy if you crush it. Plaque usually grow with time. Having a healthy livestyle can reverse it a little like rosuvastatin can also do.

When can I expect to be an immortal cyborg? What will it cost me?

2050 or before! I hope.

Pardon my ignorance but what does VAD stand for?

I'm doing an MSc in Regenerative Medicine next year and I have a real interest in using gene eluting stents to try and regrow cardiac cells damaged due to ischemia and using upregulation of particular genes to block ischemic damage. In your opinion where is the field of cardiac regeneration heading towards and what's the next big development?

EDIT: Spelling

Ventricular assist device.

That sounds like a great thing to develop. Althuough it comes off as quite the contrary to what current stents do now, wich is slowing down the regeneration of endotelium that could stenose the stent. You probably will try to target myocytes specifically and avoid endotelial cells.

I think what could probably reach the patients first would be decelularized human homografts seeded with the patients own steam cells, smaller and better VADs and better total artificial heart.

I'm studying to be a doctor, and I'm sure as you remember, it sucks. Any tips to help myself stay in high spirits, or keep my grades up?

Sex

I could not have asked for a better answer. Thanks!

Yes... Sex can help you get throught a lot my friend.

I just want to thank you for your work. My father's life was saved late in 2011 by a kidney transplant and I just think the world of all of you in the transplant community.

Thanks.

This is amazing. I work in SD county in California and recently was trained on the strange properties this device can cause... Like having no palpable pulse or diastolic BP, but have circulation. Our whole county had to be trained with the device for a Single pt that would be moving into our county. Is there any complications you see this device could cause to first responders in case of an emergency?

Probably the patient will take anticoagulants that will make every little bleeding into a real problem. As you said, the cardiovascular examination varies from device to device.

How old were your oldest and youngest patients, and what differences in procedures does age make?

I'm totally inept when it comes to medical jargon, so if you could explain simply, it would be much appreciated!

Thanks for what you do!

Oldest patient 90 and assisting someone else a 600 grs, 26 weeks of gestational age girl. Children are quite different, congenital heart diseases have such a different physiology it's like they are aliens.

Would you ever work whit doctors without borders? And what do you think about those who do?

I would work with them, i think it's great when you can help someone in need. I live in europe now but i know how things are in latin america for example, since i lived there. I remember that the first thing i did when i finished the university was go for two weeks to a navel base where they were doing free consults and giving out antiparasitic drugs and hypertension meds and stuff like that, U.S marines were there for two weeks.

MSF (Doctors Without Borders) doesn't take cardiac surgeons. Unless he also works as a general surgeon, they wouldn't even let him apply.

There are other organizations that do accept cardiac surgeons.

Have you ever done a heart and lung transplant? Just asking because my mum had one.

No, we don't do that at my hospital. Those patients go to another hospital in madrid

Do you think at one point we won't have those long waiting lists for organ transplants?

Do you feel that producing synthetic organs is going to be something much more common in the future? If so, how much longer do you think it'll take to rely on such technology?

Yes i believe so but it is hard to put a number on the date, i certainly think i will see it in my lifetime.

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Artificial limbs seem to be the faster growing sector. With robots that can be controlled directly with your brain. Progress is being made in the total artificial heart mostly in germany and the US. Basically a lot of artificial organs already exist, they just have to be perfected and made intracorporeal. Artificial lungs are proving hard to make this shift. We already have have liver dialisis and some machines are incorparating hepatocytes into their system.

There's also the line that tries to grow organs, decellularization and recellularization of organs is showing progress.m

Artificial limbs seem to be the fastest growing sector.

So....what you're saying is automail is being developed?

That's one of my favorite series.

Was it hard to become a surgeon? What was your average in school?

I was an A student

I had 24 hour incident of A.fib in my early 30s but no further problems in the intervening 8 years. Why would that have happened?

When paroxistic atrial fib appears in young adults it usually starts somewhere oround the pulmonary veins in the left atrium. It can be influenced by alcohol, stress, intense physical activity, fever, anemia, etc.

Hi! Can you tell me about the effects of getting a heart transplant? After the surgery, I mean. I met someone who had a heart transplant and they said that they can no longer do strenuous activity. What other physiological effects does heart transplantation have?

Depends on how good it works, if you are left with a normal ventricular function or not, if you have rejection or not. How old you are. If you had good results you can live a near normal life. Theres the down side of taking inmunosupresive drugs that have a long list of side effects and can damage other organs or present a higher risk of opportunistic infections.

I had my heart transplant when I was 16. I have no restrictions. The hardest part is getting your heart rate up is harder so it seems like there is more fatigue.

yes because the transplanted heart lacks a conection to the nervous system and has to make all the changes it needs to make based on the information it finds on the blood, wich takes longer that the nervous stimuli.

My mother had her aortic valve replaced last week (severe stenosis). Tell us all about cutting someone's sternum in half, installing rib retractors, and exposing a beating heart. Tools, steps, time per step, tricky bits, noises, smells?

After surgery, when the surgeon shook my hand following the "went great" talk, my thoughts fixated on fact that his hand had literally touched my mother's heart just an hour earlier. Wizards of the magic of modern medicine.

Ok first you make a superficial incision with the scalpel. Then you cut throught all the fat with the electric scalpel til you get to the sternum. After that you carve a line in the middle of the bone using the intercostal spaces as a guideline for finding the middle. You have to remove a tendon thats on the base of the bone so the saw fits. After that you cut the bone with the saw and coagulate the parts of the bone that are bleeding. Then you remove or cut throught what is left if the timus and open the pericardium in a T shape and place sutures on the edges that you later attach to the skin so it gets out of the way. Then you put in the rib spreader in the incision you made and open it. After that you conect the patient to the extracorporeal circulacion using a cannula in the aorta and one in the right atrium or two cannulas, one on each vena cava. You place the cannulas using circular sutures called tobacco bag sutures. This sutures are not knotted til after the cannulas are removed, so we actually place this sutures on the vessels and make a whole inside the circules you just made, that way we place the sutures before we make the wholes, so we can close them up fast when needed and with almost no blood pouring out.

I have tetralogy of fallot and had my second surgery a couple years ago. I was told that it's a relatively new surgery, since the 70s?, and was wondering if you new about recent advances or that sort of thing?

You had a pulmonary valve implanted?

Please keep up the good work. My dad recently passed after heart surgery. We really thought he was going to make it. I don't really have any questions. I just wanted to say thanks for your work. I know that you probably lose patients from time to time. It really hurt that none of the transplant team came to the memorial or anything. They all acted like they really liked him. He was such a joker, always joshing with folks and hitting on the ladies :) I really miss him. I guess I was just wondering you ever went to your patients memorials or funerals.

On a side note, my dad's doctor said that the next generation VAD will be rechargeable and all internal. Do you see that being a reality any time soon, as in a few months?

Well i am surprised! i never taught families would like to see us at the ceremony if had no previous relationship with the patient.

There are already completely internal devices with charge transmision throught the skin

I am a high schools student interested in going into either cardiac surgery or biomedical engineering. I used to just want to be a cardiac surgeon but became unsure because I've heard surgery is becoming more machine-based. I also heard that doctors in general are limited to drugs/treatments/etc they can prescribe due to regulations. Is this true and how hands on is surgery still?

Other surgeries have become very machine-dependent. But cardiac surgery relies mostly in the old cut-n-sew. Automatic suture machines a good for suturing stumps of blood vessels when you just want it not to bleed out, but when that vessel needs to keep funcioning, nothing is better that string and neddle under expert hands.

Hey,

First, thanks for doing what you do. I had a heart attack a couple of years ago and the stents I got made a HUGE difference in my quality of life. You guys are frigging awesome.

I don't really have a specific question, I'm just kind of curious about the equipment you use for angioplasty and putting in stents. (For those who haven't had the pleasure, they cut a small hole in your leg at the groin and run a probe up through the vein into the heart.)

Like, how do you control the probe, or whatever its called? A wee little joystick, or something? And how do you train to work with something like that? The first time you do something like that isn't on a live person, is it? Are there practice mannequins or something?

Oh, and what's the piece of equipment called? I'd like to google it. Tools are really interesting to me, but the one time I saw it live didn't seem like a good idea to be asking a lot of questions.

Stenting is mostly done by cardiologists. There are hybrib ORs were the surgeons are starting to do it aswell, but it is not common practice yet, i am looking to do a rotation in germany on one of those ORs. And yes the first time is on a live patient, taking baby steps, and being stuck in one step for months before you get your turn to move up the steps.

ER nurse here, can you offer any suggestions for ER nurses on how to verify proper functioning of the device and any troubleshooting tips you may have? I'm primarily conerned with a patient who arrives with a tangential complaint and as a matter of course we would need to verify the VAD is functioning, charged, etc.

Thanks for all you do. ;-)

It depends widely on the device. But in general you should evaluate the general condition of the patient, mental state, color, temperature, breading, search for any signs of low cardiac output. All the VADs have an external console that will tell you the basic info of charge, and amount of flow. The patient will tell you the last time he was checked and charged the device, and will tell you when he needs to charge it again if any doubt, patients that get discharged of the hospital are usually well know of the device.

Check the INR and APTT to make sure the patient is properly anticoagulated.

These patients are in an out of the hospital all the time so he probably has a ton of reports on his file that you can check for clues when in doubt.

Hello there, 2 questions here.

• Is the chance for failure ever a high possibility? If so, how do you cope with the stress and likelihood of events?

• How did you become interested in the field? Most people I know are overburdened with the duties and studies that are required.

Thanks for this IAMA, I have a close friend whose planning on becoming a surgeon.

Best of luck to you!

In standard patients the mortality doesn't usually go up from 5%. More complicated patients can have mortality rates super high.

I have learned to accept death and not blame myself for the patients problems. Complicated patients like aortic disections and people in need of a VAD, were dead when they got to my hands. If things go well and they live we won, if they die even if we tried our best well then bad luck, but you were premorten when you got here... If all i could do was give you a few extra hours, days, weeks, well thats it sorry.

Einstein's Anomaly patient here with a porcine valve and a pacemaker.

In your opinion, what do you think are the chances of me being able to get a stem cell grown tricuspid valve in the next 20 years?

Edit: EBSTEIN'S anomaly. I have no cardiac issues with relativity.

Pretty good.

What is your stance on stemcell research?

I wish we had started sooner.

How did you get into your current specialty?

What is your favorite part of your job?

How old were you when you decided to go into medicine?

I am a pre-med student and always love to hear the answers to these quesetions- thanks for doing this AMA!

It was a combination of 3 factors. I love cardiovascular physiology, i love working with my hands, and you see little cancer in my area.

The OR.

Since i can remember, my father was a doctor

Thank you!

As we now have TAVI's and newer methods via Vascular Surgery/Interventional Cardiology with more PCI/EVAR procedures occuring inside the heart, what do you see as the future of a CT surgeon (considering the PCI vs CABG debate)? Cases that require fellowship to train in minimally invasive, a career focusing on transplants, both or something completely different?

We also implant TAVIs, they are used mostly in aortic and pulmonary valves, the technique is not quite developt yet for mitral and tricuspid valves., they are implanted in patients of too high risk for conventional surgery, mostly patients older than 80. Tavis can not be impanted in patients with endocarditis. Or in most patients with previous prosthetic valves. Tavis also have a lot of problems because it is like implanting a valve with one eye closed, you are looking at a 2D image and that presents a high risk of technical failures. Tavis can get detachted and become emboli. Also cardiologist can not implant tavis unless there's a cardiac surgeon inside the hospital and an available emergency OR able to perform open heart surgery.

Surgeons fix cardiologist complications.

Coronary patients wit diabetes, low LVEF, disease of left main or left main equivalent coronary artery, also lesions in the anterior descending artery are better treated by BYpass surgery.

Congenital surgery is highly dependant on surgery. It is the biggest pilar of treatment.

An like you said transplants and VADs.

Hi and thanks for doing this AMA. I am a physical therapist at a very large hospital that does a lot of LVAD surgeries and I see a good majority of these patients POD 1.

Which of the VAD's do you perform more often (heartmate, heartware, ambiomed, ect.)? Have you seen the new LVAD by Jarvik and what are your thoughts on all the things it offers?

Also how many TAH have you performed and what have their outcomes been?

We implant mostly abiomed, levitronix and berlin heart excor.

The jarvik 2000 looks like a very promesing pump. Its one of the smallest and i hope it turns out to be everything they promese.

I was told that instead of sewing together parts of the heart that super glue is used instead. Is this true?

In some cases, mostly aortic disecctions and endocarditis. We also add stiches to the superglue.

I've worked in the operating room for a couple years now and was wondering why you think most of the doctors have a "God complex"? Also, do you have it?

PUNNY MAN! HOW DARE YOU IMPLY I AM ARROGANT?

I'm a perfusionist working for a private surgical group, and I don't see this group lasting much longer. Do you have any openings for a good, young perfusionist? :)

I wish, there's a couple of old omes i would love to get rid of.

I recently read a book called The Undead by Dick Terisie, talking about the transplant industry. There were several interesting questions raised on priorities of the transplant industry, and several cases where patients who were not dead or probably were not dead had their organs harvested anyways. (Failed apnea test, most notably) In another case, a transplant surgeon admitted to having successfully used pain killing anestethics during a harvest to control blood pressure several times. Have you ever harvested on a patient where the death was in question? Do you feel like there is pressure in the industry to hasten harvesting?

I don't think doctors feel the need to push for organs sooner than acceptable. We really don't get paid more or anything if we get more donnors. There has been no case reported on the litarature of a false negative of brain death using the current guidelines. I don't feel like i have harvest organs from a patient who wasn't brain dead.

Maybe science could make us look like fools in the future when tecnologies that can heal patients that we now declare dead under current knowlage. But the truth is that with current science, there's nothing more to do with a brain dead patient.

This is a rather broad question.

How has the process of transplanting a heart changed over the last decade? Has the equipment been changed or have better practices or alternative means of performing the procedure started? Also, has there been any luck treating congestive heart failure?

Conservative Treatment of heart failure has been kind of stucked for the last decades. A lot of good drugs Were developt in the 20th century that still hold their place as first line treatment of heart failure. New lines of investigation had look promesing for a lot of years but without really having the impact predicte for them. What has changed a lot is the last line of treatment (VADs). Better devices, longer times of use, better results, ect. The timing of the therapy is also changing. We are implanting them sooner than before, making the results better.

How resilient is the heart? Or in other words how true is the movie flatliners? How difficult is it to stop and start the heart?

I had no idea how strong the human body is til i saw a cardiac surgery gone wrong...

What advice would you give to people with artificial valves in terms of lifestyle? I'm 26 with st judes mitral valve

Take care of that INR, really! Allways use antibiotics when undergoing any procedure, even if "normal" people don't have to.

What do you think about the recent shift towards minimally invasive procedures? It seems like a lot of cardiologist are now taking over the jobs of Cardiac surgeons doing bypasses and valve replacements. Do you think the cardiac surgeons should be retraining to do those procedures as well?

Cardiac surgeon have to get training in the cath lab for sure. But there are somethings that cardiologist won't be able to take away from us. Like mitral and tricuspid surgery, congenital surgery, highly complex patients with policalvular or multivessel disease, endocarditis, sicker patients are better of with surgery. And what most people don't realize is that cardiologist are not able to do any of those new procedures unless they are in a hospital were cardiac surgery is available, because we are the ones that fix their fuck-ups.

Hi,

My mother passed away about two years ago after a long history of heart problems. In the end she had suffered about 7 heart attacks had had many stints put in place, ended up with terrible circulation problems, she had been admitted to hospital a few days before she passed and doctors found another clot developing that could pose a risk for another heart attack. When she finally passed the doctors told me that she had not suffered a heart attack but rather her heart had gone into a strange rhythm and was simply too weak and damaged and stopped working effectively.

I've never really understood this properly. I'd been told by other doctors years ago that when there's a blockage to the heart new pathways form to carry blood out or something to that effect.

I guess my question is, did my mothers heart strangle itself? Is that possible? Had there been time would a VAD have helped or is there a point when it's not worth the procedure as the heart is too damaged?

I thought I'd pick your brain since the opportunity arose.

Thanks in advance.

the bad may have been a possibility depending on your moms characteristics (age, asosiated conditions.) new vessels form over a period of time with a chronic illness, not in acute conditions, your mother's heart probably started fibrillating due to hipoxia