12/6/16

$3415. Three thousand, four hundred and fifteen dollars-- all raised through the efforts of a good community that I couldn't be more grateful for having. Whether family, friends, acquaintances, or friends of friends, they all took part in supporting our mission by donating. I was very surprised to see us break 20% of our goal. It's been a great and productive three weeks, but fundraising has slowed down; I might send a few more emails, but I believe that this is the majority of the money we'll be able to raise. The next step will be making our way to a series, and we already have one almost through production. This video will explore TAVR a bit more. We might come to the plan of covering only a few diseases, tantamount to (or possibly lower-prioritized than) discussing the surgeries related to them. Surgeries, the operations being performed, are what's important to people-- not general knowledge of information that isn't relevant to them. I'm interested to see how this will evolve; we want to eventually get some more serious investors involved in our idea, or allow it to expand beyond us, but only time will tell.

November Update/ Heartwell Project Fundraiser Launch

The Heartwell Project's fundraiser has now been active and circulating around social media (and in the email inboxes of a few dozen friends) for more than a full day. We've already raised more than $700! It feels great to finally get things moving; a lot of my internship-related work has been subverted in the past few weeks due to school, college apps and other priorities, and this was one thing that I knew I just had to get started on. The fall has sped by-- its already been five months since Understanding Aortic Stenosis was posted to YouTube. I see no better way to end the year than by raising money for the next chapter of this project, and I'm glad things are going swimmingly.

However, before talking more about Heartwell, let's discuss the state of the internship as a whole.

To be completely honest, I don't have much more to say about most of Dr. Nguyen's cases-- he doesn't perform specific ones for his pleasure, he does them because it's a part of his job and he is specialized in a handful of procedures. This limits the kinds of surgery that I get to see, and I feel as though I've covered most of what he does frequently--TAVRs/TAVIs, CABGs, AVRs, MVRs...I've talked about them all,  and extensively so. If I were to go any further, it would be into the realm of serious and verging-on-professional-tier research information; the point of this blog was never to do that, but rather to break down cases so that more people could understand them. It's basically just a more in-depth (albeit written) form of The Heartwell Project, and it was through this blog that I first learned to understand medical information. For my first few posts to the blog, I was learning alongside all those who read it. It's meant a lot to me in the past year, but these case analyses will be fewer in number over the coming months, unless I feel that they're merited.

I'll be keeping the blog primarily focused on project updates for the foreseeable future; provided that we raise the requisite amount of money to carry on into the production of the video series, the blog will then segue into covering that progression. I'm excited to see how things will develop!

Here's a link to the fundraiser, which I encourage any readers to take a look at and consider donating to:
https://www.crowdrise.com/the-heartwell-project

10/19/16

Things have been very busy recently, and it's now more difficult for me to make time to craft lengthy, in-depth weekly posts, or get the OR time to put them together at all. This is a departure from eight or so months of (what I'd call, at least) consistent content, and I hate to be abandoning that. I'll be moving to a bi-monthly schedule proceeding into the winter--save for special announcements and things of that nature. However, there's no shortage of posts on this blog, so if you're new here, feel free to browse around!

Today's case was a redo mitral valve replacement. I'm not sure about the context, or why Dr. Nguyen decided to repeat the procedure, but the patient's condition must have been concerning enough to merit it. Having never seen a redo before, this case was interesting-- the fallout from the previous surgery was very visible. Still-recovering myocardial tissue showed blackened marks from the last case's cautery burns. I arrived before bypass, and progress was still being made to expose the aorta for the start of that procedure. I did a general overview of mitral replacements last post, so I thought it'd be fun to get into the true details of the surgery-- for example, bypass prep (e.g., cardioplegia use). To start on that, Dr. Nguyen usually uses retrograde cardioplegia instead of antegrade-- the difference being cannulation through the right-atrium-feeding coronary sinus, instead of the aortic root's coronary artery. Today was no outlier, and he went retrograde; this was done in hopes of maintaining certain heart conditions proceeding into the replacement. Retrograde delivery arrests the heart more slowly, and generally, antegrade is only safe for all patients (especially those suffering from aortic regurgitation) if administrated in tandem with retrograde. Myocardial damage can occur if it is used alone.

After bypass is wrapped up, the tissue surrounding the heart is held open with lengths of suture thread, pressed against the chest cavity, to make room to maneuver about the myocardium and secure an opening for the pump(s). Saline sprays and a vacuum are used to facilitate the removal of blood, and ensure a clear attachment from the pump to the opening.The draw pump tube, situated at the inferior vena cava's opening into the right atrium, is noticeably wider in diameter than the push pump at the aortic arch; I'm not sure why this is. I found a lot of good information about the more detail-heavy aspects of bypass on this website, so definitely take a look at that. It probably does a better overview of it than I have over the course of my many posts, and is all in one place to boot:

 https://www.openanesthesia.org/technical_aspects_of_cardiopulmonary_bypass/

Jumping further into the case, the mitral entrance Dr. Nguyen picked  was...interesting. Three scoop-like metal supports, ringing the chest retractor and extending into the sternal incision, were used to hold the heart up and rotate it to the left in its cavity. This provides a very narrow pathway from under the right side of the heart to the mitral valve, and it's probably the most difficult-looking task I've seen in the OR (yet). Standard tools can't be used to remove the valve, simply because of how deep down it is-- the task calls for specialized elongated cutting instruments.

The next phase of the Heartwell Project is set up and ready to go, though I'm a bit tired of giving "soon, guys!" updates about it. Early November is our target launch window, and has been for a few weeks now. I might not talk about it until then.  

9/28/16

Despite being quite a standard day at the HVI, I got to see (a part of) a case that I haven't seen in a while-- an open-heart mitral valve replacement. A mitral replacement is performed to counter calcification or other interruptions to blood flow in the mitral valve, and replaces the defective valve with a prosthetic or biological one. This is a fun surgery to watch, as its procedure doesn't leave much to the imagination. First, the sternum is split with a saw in an incision 3-4 inches in length, and underlying tissues are then bisected length-wise to get a decent view of the heart. Cardioplegia is administered to slow the heart and prepare for bypass. The cardiopulmonary bypass machine is used to pump blood throughout the body in place of the heart, and reoxygenate it without the use of the lungs; it does this by cannulating the vena cava or right atrium to draw out deoxygenated blood, oxygenating it outside of the body, and then feeding it back into the ascending aorta. This allows for the attending surgeons to operate on a still heart and chest, which is pretty useful. Going further, an incision is made in the heart's left atrium, exposing the mitral valve. After removing the diseased valve leaflets and annular tissue, there is a long preparation for the new valve's insertion into the mitral space. I like to call it "scaffolding": a ring of sutures is sewn into the tissue, and then used to lower in the replacement valve. I'll include a picture of this (a).

Arriving at the tail end of the surgery, I missed all of this, and saw more of the cleanup process than anything else. The patient soon finished being weaned off of the bypass machine, and the final sutures were performed in the chest cavity. Shortly after, chest tubes were inserted into the mediastinal cavity to help with post-op fluid drainage. In the days following an invasive surgical procedure, a mixture of body fluids will leak from the damage done to the tissue inside the chest-- the chest tubes provide a place for that fluid to drain to, preventing against nasty infections and other complications. Valuable, but a bit gross nonetheless. One might also wonder how the sternum is pieced back together after being sawed in half, which yields a more complicated answer than one would expect. Well, metal wires are looped through the tissues directly adjacent to the center of the sternum, then cut before another loop is made. This results in multiple horizontal lines of wire, running under both sides of the sternum and out through the left and right breast.These lines are then crossed and twisted until the two pieces of the sternum meet. After this, the excess pieces are clipped, and the performing surgeon tightens the twisted wires as they see fit. The wire-ties are then pressed down and into the surrounding tissue. It's almost like heavy duty suturing, but is a bit hard to explain without a picture-- see below (b). A standard sealing/suture procedure reattaches  the tissue above the sternal plate back together, ending the surgery. 

The solicitation letter for the next phases of the Heartwell Project has been finished, but Dr. Nguyen has been rather busy recently, and hasn't had a chance to give any input. We aim to use his minivalve web domain to host information about fundraising, and use as an ancillary viewing platform to our YouTube channel if/when the videos are ready.


Ex. A.

Ex. B.

9/19/16

This afternoon, I met up with Dr. Nguyen a bit serendipitously- we both happened to be walking over the skybridge between Memorial Hermann's main building and the HVI at the same time, and joined up there. It'd been a few weeks since we'd talked in person, which made catching up more interesting than usual. Extending past my conversations with Tom, there was an unusual air of excitement at Memorial Hermann today; it's an unforgettable place that has had a huge impact on the past year of my life, and just a month away from it had fuzzed my memory. The hallways of 2850, the panoramic view of Rice/downtown Houston, the OR and the smell of the cautery (not a positive memory)....all of it had a newness to it that I haven't felt in a while. It's so, so good to be back. 

 After a bit of small talk and brainstorming in Dr. Nguyen's office, we went quiet and did some work. Shortly after, we went to a post-op patient checkup down the hall. He was a MIVR (minimally-invasive valve replacement) recipient, likely in his late 60s/early 70s. With most of the incisions sealed and healing, Dr. Nguyen discussed comfort options for the patient more than anything- remedying small issues, making sure the former patient could get back on his feet (not literally, though, because he was already walking). The man had been prescribed plavix, a standard blood thinner, along with Tylenol 3/codeine phosphate, potassium pills, and a few other medications. He reported being somewhat uncomfortable as a result of the codeine, but was recovering well aside from that. Dr. Nguyen was still waiting for some lab tests to return, but offered to cease most of the treatments if the labs reported a clean bill of cardiovascular health. It’s always nice to see quick patient recoveries.

At around 2:00pm, I joined Dr. Nguyen on the 7th floor of the HVI for a double CABG. We arrived fairly far into prep, as the saphenous vein harvest and sternotomy were thoroughly underway. CABG procedure is something I’ve covered time and time again, so if anyone needs a refresher, here’s a good reference post: 

https://www.blogger.com/blogger.g?blogID=8533419574158229049#editor/target=post;postID=7620191396548475921;onPublishedMenu=allposts;onClosedMenu=allposts;postNum=9;src=link

Continuing on, the saph vein harvest went a bit poorly, which was really no fault of the surgeons. The vein was fragile and almost breaking apart, making it difficult to get a significant length for the graft. They salvaged as much as possible, and it began to go a bit better as they spotted some possible alternatives. Dr. Nguyen set to work on the interior mammary harvest, using the cautery to carve away at bits of tissue lining the artery. I wasn’t able to see any of the surgery past this point, and unfortunately had to head out. If you're new to the blog, I'll be posting more complete surgeries in the future, and hopefully diversifying a bit; CABGs are fun to see, but I might branch off to shadow some other surgeons- getting back into the swing of things with a few new twists, I suppose. More to come soon!

P.S., we’ve got some Heartwell Project updates just around the corner. 

8/18/16

Today was a triple bypass CABG- nothing too out of the ordinary, but still a fun surgery to watch. I still want to see a VSARR (valve-sparing aortic root replacement), but those don’t seem to happen too often, which is a bummer. Digressions aside, before the case started, other surgeons called Dr. Nguyen to inform him of stenosis in the superior vena cava, one of the two venous pathways to the heart. It was a potential risk, but it must not have been serious enough, as they opted to continue. Most of what I saw was standard for CABGs; saphenous vein gets harvested from the left leg, the interior mammary artery gets one end detached, and both parts get grafted onto the coronary artery bed. The triple bypass, however, introduces an interesting twist on this familiar procedure- the saphenous vein is actually split in two for the arterial bypass. Instead of just linking the aortic arch to one artery, the saphenous vein bifurcates and leads to two spots on the heart. This is why the initial saphenous vein harvest is so long. It is divided into two parts, with each segment leading to different blockages in the coronary artery bed. This is all sorta complicated, so here’s a picture to explain it a bit better: 

The saphenous vein, in its two parts, are the two white pieces on the right of the heart.Triple bypasses seem to take much longer than the doubles I'm used to seeing; the third piece of the graft takes some extra work to prepare for. But, I’m not sure how extensive the saphenous vein’s cleaning process is (wish I had seen it!). 

I'll probably have some new stuff coming out soon about the Heartwell Project soon. School has just started, and I have a beginning-of-year retreat going on next week- so, I'll really just have to play it by ear until things get back to normal. I'm not sure how my time in the OR will fit into my new schedule, but my fingers are crossed for any morning but Friday (that's valve clinic/patient rounds, which just isn't as fun). Thanks for reading! 

8/4/16

Last Thursday, I finally returned to the idea of doing live presentations of the Understanding Aortic Stenosis video. In the weeks prior to this, I had been in contact with the event coordinators at The Forum at Memorial Woods, working out a good date to present. We eventually decided that it could be done in tandem with a lunch/dessert event- the seniors got to come for food as well as a health presentation, which is a bit more enticing. I was really excited about this event, and it couldn't have gone any better; all of the audio and video aspects of the presentation worked beautifully. The seniors had a great deal of questions, mostly regarding operations they or their family members had in the past. Some I had to politely dismiss, on the grounds that I'm not a doctor and can't diagnose heart diseases. I still had a great time fielding questions, though, and am looking forward to doing more of these presentations this fall.