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The Beat Goes on at South Florida Cardiovascular

FEATURED ARTICLE

Originally published in the November, 1999 edition of M.D. News.

A group of local surgeons are offering quality surgical care using the latest medical breakthroughs and minimally invasive techniques. The group, South Florida Cardiovascular Surgical Associates, was established in the early 1980s and consists of Dr Richard Brezing, Dr. Kenneth Herskowitz, Dr.Harold Roberts, Dr. Marwan Tabbara, Dr. Marek Zalewski, and Dr. William Bailey, Jr. The office is located in the medical offices building adjacent to Florida Medical Center (FMC), in Lauderdale Lakes, and the surgeons are on staff at FMC, Broward General, North Ridge, Holy Cross, and several other hospitals in Broward County.

The trend toward minimally invasive mitral valve surgery has been increasing due to the maintenance of operation quality at a lower cost with improved outcomes. Dr. Roberts performs many different types of cardiovascular surgical techniques and specializes in mitral valve repair and trausmyocardial revascularization (TMR).

Mitral Valve Repair
When valve disease occurs, the valve may be repaired rather than replaced. Mitral valve repair can be the treatment of choice for a floppy or myxomatous degenerated valve or ischemic mitral regurgitation and should be accomplished whether or not the anterior, posterior, or both leaflets are involved. Anterior leaflet prolapsed is usually repaired by adding artificial chords (5-0 Gore-Tex) to the area of prolapse.

Ruptured chordae to the prolapsed posterior leaflet is the most common entity encountered in mitral-valve reparative surgery. This is treated by resection of the prolapsed portion of the posterior leaflet. Reconstructive techniques in combination with a prostheic stabilizing ring have been performed since the early 1970s. Most of these techniques were developed by Dr. Alain Carpentier in Paris, France. Many surgeons, including Dr. Roberts, believe that support provided by annuloplasty reinforcement rings or bands is essential for the longevity of the repair and stabilization of the annulus. Dr. Roberts uses an annuloplasty ring composed of silicone rubber impregnated with barium sulfate to enable radiographic visualization. According to the manufacturer, Baxter Healthcare, Edwards CVS division, Dr. Roberts performs more mitral valve repair using the annuloplasty system than any other surgeon in South Florida.

Transmyocardial Revascularization
Another technique that Dr. Roberts uses to improve patients' quality of life and prolong mortality is transmyocardial revascularization (TMR). TMR is a new surgical procedure indicated for patients for whom bypass surgery and angioplasty are no longer appropriate. It was approved by the FDA in May1999.

The TMR system is an alternative treatment that employs high-powered ECG-synchronized C02 laser energy to create small channels in the heart muscle. Instead of attempting to bypass or widen an occluded artery, TMR provides direct blood flow to the ischemic heart tissue. The typical TMR procedure that Dr. Roberts performs takes only one to two hours versus four to six hours for traditional bypass surgery. Because the heart is not stopped in order to perform the procedure, a heart-lung machine is not required.

The procedure involves making a small incision between the ribs to expose the heart muscle. The laser system's hand piece is then positioned over the ischemic myocardium. Approximately 20 to 40 channels (each one millimeter wide) are created through the wall of the myocardium into the left ventricle. The laser is synchronized with the heartbeat and automatically triggered to fire during diastole. The blood acts as a backstop for the laser energy and prevents it from damaging other tissue in the heart. The pulsed-C02 laser does not fire during the refractory period, which contributes to less arrhythmia compared to other laser sources. Clinical evidence suggests that the outside of the channel heals, while the inside of the channel remains patent. Blood is then forced from the left ventricle into the new channels, exposing ischemic areas to oxygenated blood and reducing angina symptoms. Long term, the channels generally close, but they do stimulate arterial capillary in-growth; this is likely due to vascular endothelial growth factor (VBGF). There is gradual improvement in blood flow (6 to 12 months). Dr. Roberts has been successful combining TMR with off-pump CABG without the use of a heart-lung machine.

Dr. Roberts performs TMR procedures at the Florida Medical Center in Lauderdale Lakes so that the patient does not have to travel to a University Hospital where such procedures are typically performed. Post-operative hospital stay is typically one week and Medicare and Managed Care Organizations are beginning to reimburse the procedure.