The Practice Pulse April 2019

Welcome Dr. Richard Proia!

In this issue of the practice pulse we will discuss coronary revascularization and the importance of appropriate recognition and treatment of the disease. Recall from a previous issue of the practice pulse that coronary artery disease and myocardial ischemia may present with atypical symptoms requiring a high degree of vigilance by clinicians.

The Florida Heart and Lung Institute has continued to grow both in our hospital and across the division. The progressive development and growth of the cardiac and thoracic surgical procedures at NFRMC has spanned from robotic thoracic surgery to minimally invasive valve surgery and a burgeoning collaborative structural heart program with our cardiology colleagues. We envision ongoing growth and best in class performance across the spectrum of services.

The entirety of the Florida Heart and Lung Institute joins me in welcoming Dr. Richard Proia to the practice. As many of you know, Dr. Proia arrived at NFRMC to join Dr. Snyder after completing his general surgical training and cardiothoracic fellowship. He has been a NFRMC ubiquitous presence for more than a decade. We all agree that the future is bright for cardiac and thoracic surgery at NFRMC, and we share a common goal of patient centered, evidence based, highly effective and efficient while compassionate care for every patient.

We strive to make each patient not only live longer, but live better. While we have collaborated very closely with Dr. Proia since the inception of FHLI, we believe NFRMC is best served by a unified group. This vision has been fully embraced by the entire team and we take great pride in welcoming Dr. Proia to The Florida Heart & Lung Institute.

Charles T. Klodell, MD

Current Trends in Coronary

Artery Bypass Surgery

Coronary artery disease continues to be a major health problem in the United States and worldwide in the current era of healthcare. Coronary artery disease, or CAD, is the leading cause of death in people over 35 years of age in the US. There are roughly 15.5 million Americans with known CAD, and because of this, every 42 seconds someone in the US suffers a myocardial infarction.

Due to the ubiquitous nature of CAD, various methods of treatment have been developed and utilized over the last century to treat this condition. Surgical treatment of CAD with coronary artery bypass grafting, or CABG, is the most common cardiac surgical procedure performed worldwide. In the US alone there are over 300,000 CABG procedures done annually. First performed in the early 1960’s, there have been significant improvements in the way the procedure is done and in the overall success rate in the last 50 years.

Patients with complex multi-vessel CAD, and those with severe left main coronary disease, are often best served by CABG surgery. Recent advances in technique include the use of endoscopic vein harvest, or EVH, which limits the incision on the leg for obtaining saphenous vein bypass conduit to less than one inch. This technique is employed on over 98% of CABG cases at North Florida Regional Medical Center (NFRMC). EVH has significantly reduced post-operative leg complications for patients undergoing CABG, specifically reducing leg wound infections from 5-10% with open harvesting techniques to 0.5% with EVH.

Use of arterial conduits during CABG surgery has steadily grown each decade and the use of the left internal mammary artery, or LIMA, has become standard of care. The LIMA graft has shown the best longterm patency rates with roughly 90% remaining open and functioning well 10 years after surgery. Radial artery grafts are used as an alternative to saphenous vein when the quality of the vein is felt to be poor. At our institution, the radial artery is harvested in a minimally invasive manner utilizing similar endoscopic techniques that are used for the saphenous vein.

Recently there has been increased interest in using percutaneous left ventricular assist devices such as the Impella to allow patients with poor ventricular function to undergo CABG surgery more safely. Patients with low ejection fraction prior to surgery are at increased risk of morbidity and mortality.

In the RECOVER I multicenter trial, the Impella was placed intra-operatively in 16 patients who were in cardiogenic shock after being weaned off cardiopulmonary bypass. 94% of the patients survived and were discharged from the hospital which represents excellent outcomes given that the average pre-operative risk of dying for these patients using the EuroSCORE prediction model was 34%. In addition, the average pre-operative ejection fraction in this group of patients was low at 23%.

At our institution we have recently used the Impella device on three patients who were high risk and needed CABG surgery. All three had the Impella placed preoperatively and kept the device in place intra- and post-operatively to assist with left ventricular function. Once the patients were felt to be stable post-operatively their device was removed and all three were eventually discharged to home or to a rehab facility. Without the Impella device these patients most likely would have never even been offered surgery due to their prohibitively high predicted surgical mortality risk.

In each of the past two years at NFRMC we have performed over 500 cardiac surgeries annually, and in more than 250 cases each year it included CABG as part of the procedure. Our use of LIMA grafts was 100% and our results have shown excellent outcomes, with risk adjusted 30-day mortality rates of 2 to 2.5% which compared favorably both with national averages and risk adjusted predicted risk of mortality (PROM) using the Society of Thoracic Surgeons predictive model. Using a collaborative approach, our team of three surgeons at NFRMC continues to strive in our quest to offer the best care possible for the surgical treatment of coronary artery disease.

Richard R. Proia, MD

For insights, answers to questions, or to share commentary contact: Aubrey Hall, NP and Publisher of The Practice Pulse, at