Monday, September 3, 2012

"In Our Hands" - Outcomes of Surgery

"In Our Hands"

When surgeons speak about their results, they often use the phrase "in our hands", graciously crediting the entire surgical team. 

Their patients think a great deal about hands also, more specifically about one pair of hands, the hands of the surgeon. 

We wonder if surgeons realize how much we look at their hands when we meet them. Our minds are racing - are these the right hands to open my chest, touch my heart, replace my valve, remove my bulging aorta? Can I trust these hands?

Practice Makes Perfect
Common sayings are rooted in practical life experience, and the phrase "practice makes perfect" is no exception. The more we do something, the better we get!

Outcomes of Aortic Valve Replacement Surgery
In 2003, the New England Journal of Medicine published a special article, Surgeon Volume and Operative Mortality in the United States.  It was a report on the outcomes of 8 surgical procedures in Medicare patients. One of  those procedures, aortic valve replacement, is important to those with aortic disease. There was further discussion about it in this article also, High surgical volume equals better patient outcomes. Looking at a chart in the NE Journal article, (Table 2), the affect on outcome of the hospital's volume for aortic valve replacement was 0%. The affect of the surgeon's volume on outcome was 100%. 

In other words, it was all about the surgeon's hands.  

Asking Questions
That is why it is so important to ask certain questions of the surgeon. Make a list! How many bicuspid (or trileaflet) aortic valves have you replaced (or repaired) this year? Last year? Last five years?  How many aortic aneurym procedures? How many of this exact procedure did you do this year ( last year, last five years, etc.)? (Bypass results are not of interest unless bypass surgery is needed, so be careful to avoid general totals of all heart surgery.) How many people died in the hospital? How many died within 30 days? How many were injured or had complications? What were they? How many had infection? Bleeding? How many needed permanent pacemakers after surgery? How many needed heart medications long term that they did not need before surgery? The Foundation Support Page has additional information that may be helpful.

Listening Carefully to the Answers
The Foundation has heard from some patients who believe they did not receive clear, straight forward answers. Clear communication can be difficult in many settings, but especially so when talking about your own major surgery. Take someone with you. 

For example, if you ask how long a certain valve has lasted in others, listen carefully for general answers such as "I have never had to take one out." Follow up with more questions. Find out if the surgeon is talking about a clinical trial that has been going on for a few months, or a valve that has been used for many years with an established track record. That background can put a whole new meaning around the word "never".

Do your best to avoid things like these that have happened to others:
  • A woman did not realize she was part of a clinical trial until the hospital contacted her months later for a "free" echo of her prosthetic aortic valve.
  • A man arrived home after surgery thinking he had received a certain kind of tissue valve. He had specifically discussed and requested that kind of tissue valve when talking with the surgeon. He was more than a little surprised to discover later that in his chest was a different kind of tissue valve, from a different manufacturer. No one had told him while he was in the hospital. 
  • A man, still in the hospital, was shocked when the technician told him during his echo that he had a beautiful mechanical valve. He and his family were sure he had requested tissue. No one had told him anything about receiving a mechanical valve until the technician made that comment. If there were technical reasons for the mechanical, no one had explained it to him or his family.
  • A woman thought that her ascending aortic aneurysm was replaced with Dacron. When she began to have problems a few months later, in reading her surgery report she discovered that Dacron was not used at all. Her aorta had simply been "shortened". It put her in life-threatening jeopardy as the stitches holding her stretched aorta pulled away from  a newly implanted valve.
  • A man who had previously had his bicuspid aortic valve replaced required another surgery for a large ascending aortic aneurysm. When opening his chest, his aorta was punctured, causing massive, uncontrolled bleeding. He survived the crisis, but after surgery contracted numerous infections. After fighting for many weeks in the hospital, he lost his battle.
Would it have been different for them in other hands? It is an important question to ponder. 

Surgeon's Statistics
Statistics may be available if you search for them. Some states provide a public database of surgical results, however those results may only be for the most common heart surgery performed, bypass surgery. Search and see what you find.

Grateful for Pioneering Hands
Dr. Randall Griepp and Dr. Sharo Raissi

Dr. Randall Griepp, Dr. Teruhisa Kazui, Dr. Sharo Raissi
The phrase "in our hands" takes on special meaning as we think of the great pioneers in aortic surgery.  Dr. Randall Griepp for many years has advanced treatment of the aorta in the chest. His hands have pioneered many lifesaving procedures, taking on the most difficult challenges in the chest from the early days of heart transplants to circulatory arrest and the aorta.

Under his guidance, Mount Sinai developed a rich data resource of results over the years, forming the basis of many important, highly regarded papers on thoracic aortic disease.

The Foundation is grateful for Dr. Griepp's work, and that of other aortic surgeons we have honored, Dr. Nicholas Kouchoukos, and Dr. Teruhisa Kazui. Their work has saved many lives around the world.

Arlys Velebir and Dr. Nicholas Kouchoukos
When it comes time for surgery, may we all do our best to find expert, skilled hands in which to entrust our lives.

No comments:

Post a Comment