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.

7/28/16

Today was my first day back in the OR, and I picked a good morning to come. All the while, I had company in some interns from UT, and got to chat with Dr. Nguyen for a bit before he scrubbed in. It's interesting to see how calm and collected these surgeons can be before cutting someone open, but I suppose a lot of the pre-op excitement dies down when you're performing multiple operations each day. One great thing about today was that one of the performing doctors decided to use a headcam, which is perfect for giving us lowly students some insight into the surgery; a fiberoptic cable links whatever they're seeing to suspended TV screens around the room, displaying footage in real time. Otherwise, the only good view in the house is from the anesthesiologist's corner of the room, which can get a bit crowded. Today's case was a double bypass, and was pretty standard fare- sternotomy, saphenous vein harvest from the left leg, interior mammary harvest from the left breast, etc. At this point, unless I see a new procedure or surgical method, I can sit back and enjoy the surgeons' work instead of tapping away at my phone taking notes. But, I did find out about one thing: why the saphenous vein harvests are done endoscopically (within the leg), instead of making an incision along the length of the leg and opening it up completely. When I wrote about the first surgery in which I saw a vein harvest, I didnt know what it was (formally) called, and looked it up to find out. Most of the picture results displayed a long incision spanning the length of the leg, which seemed ridiculously excessive. Turns out that the latter method is is much more traumatic, and takes much longer to recover from. Here's a picture of endoscopic vs. standard vein harvest techniques below, to give an idea of what I'm talking about:

  I also watched one of the doctors prep the saphenous vein for the graft, which is something I've never really paid attention to. The vein gets flushed of blood, the leads going to the venules (smaller vessels along the vein) are sutured shut, and the vein segment is dyed purple to distinguish it as foreign tissue when the time comes to graft it onto the myocardium. 

Update 7/26/16: I'm back (plus Heartwell info)!

 Wow, it's already been three weeks since I gave my "I'm leaving" announcement. I'm really getting tired of the word hiatus, or any of its synonyms,  so I'm going to go after things a bit more aggressively in the next two weeks before I have to use it again- I was thinking two blog posts a week, which is what I should've been doing since the beginning of the summer, but hey- Junior year was hard (can I still get away with that excuse?). Joking aside, with the exception of the past ~21 days, I'm really happy that I've been able to keep up the momentum of The Heartwell Project. "Understanding Aortic Stenosis" almost has 20,000 views on Youtube, something I definitely didn't expect to ever happen. People have learned from something I've created, and I really can't say enough about how awesome that feels. The TV appearance only stoked the forge there, and made our goal seem even more tangible; I'd like to keep that going. I'm currently laying out some plans to continue the project, which basically hinges on one thing: how much money we'll be able to put into it. So, I'll reach out, see what's available, try to organize some fundraising events, and see where things go. Maybe even set out a timeline for different videos and topics- which I'll consult Dr. Nguyen for- and get an idea of which diseases are most worth attending to. This is more than a high school student's "hey, look at me!" project for colleges, it's an extremely potent educational tool. And I want to see it through. More to come soon, in regards to The Heartwell Project and my experiences in the OR.

7/1/16

 Back again with a double-header blog post: an HVI visit and a (rather unexpected) talking segment on TV. I made it on Good Day Houston in the end, and got to talk a bit about my involvement with the Heartwell Project. Besides those two things, I wanted to inform everyone that this blog might be dormant for the next two weeks- I'm on vacation and visiting with family in South Carolina. I might do an update for something, but it probably won't be as meaty as what I've been putting out in the past few months. I expect to return to a regular blog schedule around the week of the 24th- I'll try to make it something special! But, without further ado...

Valve conference was fairly standard today, except for a few critical AS cases- those patients had multiple stenosed valves, showing themselves to be presumptive wildcards for the OR teams. The comorbidities (additional factors that increase the risk of surgery failure or death) were easy to pick out for these patients, and as a result, almost all of the recommended procedure options were minimally invasive. Many were TAVRs, simply because that procedure would solve the first of many problems that needed to be addressed for these people. Did I ever mention that the aorta is the largest blood vessel in the human body? Well, it's pretty important that this super-artery (and its accompanying valve) stay functioning correctly. Healthy blood outflow is always nice to have. 

Two commercial MitraClip candidates were discussed near the tail end of the conference- one with mild aortic sclerosis, mild tricuspid regurgitation, and moderate/high mitral regurgitation; the other another with severe mitral regurgitation, mild tricuspid regurgitation, aortic regurgitation, prolapsed anterior and posterior leaflets and a few other issues. As these patients were fairly high-risk, they were definite candidates for the MitraClip procedure, which stands as the only percutaneous (non-surgical) way to repair the mitral valve. It's pretty neat. A part of the discussion hinged around the decision of how to approach the second Mitraclip patient- the choice between transeptal and transapical entry points. Judging from the CR scan, both approaches were viable, but there were other things that weighed on the doctors' decisions. If the transeptal approach was chosen, it would be the first procedure of its kind, utilizing a new kind of catheter delivery system. It has only been tested on pigs so far, and because of that, some doctors were cautious about using it and wanted one or two successful cases to be available for reference. The patient's roomy left atrium would make the transapical catheter's entry easier, but Dr Nguyen voted transseptal- saying, 'we need to start [using the transeptal approach] sometime.' Transeptal was chosen in the end.

                    
 So, remember when I said I wouldn't be going on TV, and was relegated to an audience position with Matt? Well, that was true. But we got to do a lot more than we expected with said audience positions. When I arrived, Dr. Nguyen was still a few minutes from going on, and we had time to get comfortable; but, just as I was settling in and making small talk, a woman approached us- clip-on microphones in hand- and asked us to put them on. We did, and sat to watch Deborah Duncan's exchange with Dr. Nguyen on the stage in front of us. Soon enough, the topic of conversation turned to patient education, providing Matt and I with quite a foothold in the discussion. We both got to speak about what we had done for the project and how it had impacted us, and it became a really valuable experience. We were no longer just spectators, but a real part of the show. They also recruited me to do an Australian accent as part of another segment, which I'm glad none of my friends saw. Being on TV is a blast. 

I hope everyone had a happy 4th of July! 

6/20/16

Last week, some scheduling conflicts arose and Dr. Nguyen was out of town for a few days. making me unable to go to MH. I also had to reschedule a presentation of the Understanding Aortic Stenosis video at The Gardens of Bellaire, a senior community here in Houston. That's pushed it awfully close to another presentation I'm doing at the Elmcroft senior community, but I'll be able to do both. I'm interested in seeing how much the seniors will contribute to the discussion; many of them just want to get to bingo. I'll see how the presentations go and report the details here. Anyways, here's the case from June 20th.

Today was a single CABG (coronary artery bypass graft), a procedure that I haven't exactly seen yet. It's really just half of a double CABG, if that makes sense, since only one new vessel is being grafted on. So, in this case, only the saphenous vein got taken, while the interior mammary artery (which gets used in a double CABG) is disregarded. I forgot to mention (last time I talked about CABG) that the saphenous vein grafts that I've seen have all been harvested endoscopically, meaning that a probe was inserted into the leg to extract them.  I recently learned that there is an "open" method that requires the leg to be cut open length-wise, giving a clear view at the tissue and veins. Today's endoscopic vein harvest could've gone better, as some problems arose with getting appropriate vein segment lengths- I'm not sure if this was a technical issue, but I'd really like to see if the open method is any easier. This seemingly simple misstep made the surgery much longer than expected, delaying bypass and all of the "interesting" parts of the surgery. Nonetheless, the graft placement went rather well, and was definitely the highlight of the case. Grafting the saphenous vein onto the coronary arteries is a lot more complicated than dealing wth the interior mammary artery. With the saphenous, both ends are being attached to the heart, rather than just one with the interior mammary. Interesting instruments are brought in to support the graft placement- my favorite is this gray-colored device with two prongs that encircles the graft area. It has two sets of gears that seem to be used to tighten or loosen the grip on the myocardium, and is really cool to see in action. I still don't know what it is called, though, and "gray rotator tool for CABG" yielded no results on google images. I'll keep looking. 

I’ll have plenty of interesting stuff to report about early next week, including the Elmcroft visit and (possibly) another case. I recently learned that the producers of Great Day Houston won't be able to fit Matt and I onto their TV spot on the 27th, but Dr. Nguyen will still be on that morning to talk about our project. It won't be as cool without us, but hey, things happen. I definitely recommend that you all tune in and see what he says about it!