Prof. Dr. Şahin Şenay, Head of the Department of Cardiovascular Surgery at Acıbadem University and cardiovascular surgery specialist at Acıbadem Maslak Hospital, explains the symptoms of blockages in the heart vessels, who needs coronary bypass surgery, the latest developments in coronary bypass surgery and robotic surgery.
What kind of symptoms occur if a person has a blockage or narrowing of the heart vessels? Can you count the warning signs?
SYMPTOMS OF HEART DISEASE IN DIABETICS MAY REMAIN HIDDEN
"The most common picture we encounter here is usually chest pain, a feeling of tightness in the chest. Our patients usually describe this feeling of tightness as a weight on the chest. If there is such a complaint, coronary artery disease should definitely be investigated and ruled out, but there is such a situation. Sometimes, especially in diabetic patients, this chest pain that we typically describe may not be present. In other words, complaints may remain hidden. In such cases, the first complaint of our patient is shortness of breath or rapid fatigue. In fact, the complaint we typically expect in a patient with stenosis in the coronary arteries is chest pain. Usually this is in the form of squeezing. However, especially in diabetic patients, if there is no such complaint, but there is a picture of shortness of breath or fatigue, I think it is definitely useful to be investigated in terms of heart."
BEWARE OF CHEST PAIN!
Well, do these complaints usually come with exertion? Or can they also occur when the person is not exerting, for example when sitting? Is there anything special about chest pain and shortness of breath?
"It often comes with exertion. This is the case in most of our patients. But sometimes it can also start at rest. This is a more dangerous scenario. In such cases, a more serious and urgent picture may develop. However, in most patients, as I have just mentioned, it usually presents as chest pain that comes with exertion and goes away at rest. Patients with such complaints can plan and undergo diagnostic procedures and apply to the hospital. However, pain that occurs during rest and without exertion is very important. Therefore, it is useful to investigate these urgently."
ARE THE SYMPTOMS OF HEART DISEASES DIFFERENT IN MEN AND WOMEN?
Thank you very much for this warning message. I will ask one more thing. It is always said that the female heart and the male heart are different. Are the symptoms of cardiovascular diseases different in men and women? Can heart diseases be a bit more silent in women?
"It is definitely different. In fact, there is such a difference not only in cardiovascular blockages, but in heart diseases in general. This difference is related to both the formation of the disease and the course of treatment. There are many structural reasons for this. There are hormonal-based factors. There is a dimension related to some habits. However, we can basically say that coronary artery diseases, i.e. cardiovascular blockages, are not expected in pre-menopausal women due to the protective effects of the hormone osterogen. It is more common in the post-menopausal period. However, if there is a genetic predisposition independent of this situation, it can be seen at a very early age. We can use a general statement that the age of onset of heart diseases is definitely earlier in men. We need to underline the genetic predisposition here. Especially in recent years, we can face cardiovascular diseases at younger ages, especially in men where familial predisposition is at the forefront."
CORONARY BYPASS SURGERY OR STENT TREATMENT?
Now let's come to the main topic of our interview. When do you recommend coronary bypass surgery for a patient? Does the degree of stenosis matter? Does its location matter?
"First of all, I would like to emphasize that the treatment of coronary artery disease requires a multidisciplinary approach. We try to look at it as a heart health center. We take our patients into a general evaluation without making a distinction such as only surgical treatment or stent or drug treatment. We try to produce the most appropriate solution. First of all, the prevalence, severity and degree of coronary artery disease, i.e. cardiovascular occlusion, and their determination are important.
We can only treat an important group of patients with medication. The collaboration of cardiology, cardiovascular surgery and radiology is important here. Radiology has advanced a lot, especially in the field of imaging. For example, all heart vessels can now be scanned without the need for classical angiography. Such methods support us a lot in planning the treatment.
If the cardiovascular occlusion is not at a very extreme level, our first-line treatment is actually medication. In addition to this, the patient is also advised to optimize, that is, improve, certain lifestyle habits. If the patient smokes, he/she should quit smoking, if he/she does not do sports, he/she should be recommended some sports activities that he/she can do, and he/she should pay attention to his/her diet. In fact, these are the main risk factors for coronary artery disease. When these are regulated and risk factors are removed, a very serious group of patients benefit.
In the patient group where the stenosis in the coronary artery vessels is more serious, a procedure called “revascularization” may be required to open or blood supply the blocked vessels. We have two options here. One is to open the blockage with a stent and the other is bypass surgery. In other words, blood supply to the heart by anastomosing a new vessel. We decide which treatment to use depending on the extent of the vascular disease and the severity of the stenosis. If the level of stenosis is very serious and the involvement is widespread, the results of stent treatments in such patients may not be as good as surgery. On the other hand, if the severity of the stenosis is lower and the extent is less common, stent treatment alone may be sufficient without undergoing a more complex process such as surgery. The important issue here is to think patient-oriented and to produce a solution specific to that patient. This is why it is extremely important to work together to determine the most appropriate treatment for the patient with a multidisciplinary approach."
RECOVERY IS FASTER IN ROBOTIC CORONARY BYPASS OPERATIONS
Now let's say a patient comes in and is evaluated with a multidisciplinary approach. As a result, it is decided that he needs coronary bypass surgery. Today, there are methods called minimally invasive surgery, which are performed through small incisions and are popularly known as “closed surgeries”. How do you decide whether to operate on the patient with the open or closed method?
"Heart surgery is actually known as an important surgery in our society. In other words, when one of our relatives undergoes heart surgery, we look at it as a very important surgery. However, it is possible to say that this perspective has changed a little with the developments in technology and knowledge. As you said, it is now possible to perform operations with the closed method. What are the advantages of performing heart surgery with the closed method? The most positive aspect is that the post-operative period is more comfortable compared to open-method operations. The patient can return to his/her life before the surgery sooner. This is a very important thing. In other words, shortening the time that a person stays away from social activities, business life, is actually a very valuable thing for that patient.
When it comes to closed surgery, this is actually a wide spectrum. In closed operations, there is no bone incision made in open surgeries. Closed heart surgery can be briefly described in this way. Closed surgeries are performed with different methods. The basic method used especially for bypass surgeries is to perform the surgery through a small incision on the left side above the breast. Robotic support can be used during these procedures. This is the method known as robotic heart surgery. The procedure can be performed completely on a robot or partially on a robot. If a multi-vessel coronary bypass operation is to be performed, we perform robot-assisted surgery in our hospital. A significant portion of our coronary bypass operations have now evolved into this field. The number of open surgeries has decreased very, very much. The main reason for this is that, as I said before, the patient can return to normal life in a shorter time. But more importantly, since there is no bone incision, issues such as postoperative infection and bleeding risk are less common. Especially in diabetic patients and those with obesity problems, its contribution to the health process is very valuable. Another factor is the comfort our patients experience in the postoperative period. Much less pain, ease of breathing and physical movements. When you add all of these up, there is a side where robot-assisted surgeries actually touch and benefit the patient's life. In addition, these methods have evolved into a process that can be performed in the same time as normal operations and can intervene in all vessels of the heart. We had a patient in whom we performed coronary bypass in 7 vessels. I can state that the most positive aspect of closed and robotic coronary bypass surgeries is the early return of the patient to normal life."
MANY PATIENTS COME FROM THE CAUCASUS, MIDDLE EAST AND THE BALKANS FOR HEART SURGERY
Where is Turkey in the world today in terms of open heart surgery and robot-assisted heart surgery? From which countries do most patients come to Turkey to have coronary bypass surgery?
"This is a very important issue. There are actually more than one aspect to this. After all, when you create a certain surgical program in a center, it is not only about the work done, nor should it be. There is an academic dimension, an organizational dimension, know-how accumulation. First of all, I would like to state that our academic structure is very strong in this field. We don't just look at it from the point of view of patient arrival. This is a know-how. We think that the more useful we can be to our patients and colleagues on this subject, the better. I am also on the board of directors of the International Society of Minimally Invasive Cardiothoracic Surgery. We have an organization like this. We have colleagues from neighboring countries who come to observe the operations performed with this method. Most recently, a team from London came and we hosted them here. In May, a team from Canada will come, and teams from Saudi Arabia and India are also planned to come. This scientific know-how is constantly evolving. The goal is always to take patient health to the next level. Reducing the complication rates of these operations and ensuring that our patients benefit in the best way possible. We have presented the accumulated knowledge related to this operation in the form of papers and articles in different scientific environments. They have been very well accepted, supported and shared... As a result, there has been a formation like a center here. We also have patients from neighboring countries. Many patients come from nearby geographies such as the Caucasus, the Middle East and the Balkans. Apart from that, we also have patients coming from Europe. But we can say that our foreign patients mostly come from the Caucasus, the Middle East and the Balkans. We also have patients who consult or come from countries such as Germany and England. But I can say that our awareness in this field is just developing in these countries."
HOW LONG AFTER HEART SURGERY CAN YOU RETURN TO YOUR COUNTRY?
Well, let's think about a patient coming from Greece to have heart surgery, coronary bypass surgery. Now, of course, the answer to this question depends on the patient. Because each patient's treatment is unique. But I will ask you to give me an average day. If everything goes well, how many days in advance should a person with a blockage in a heart vessel come here for a robot-assisted surgery? How long will his/her treatment take before and after the surgery? How many days will he be in intensive care and when can he return home to Greece?
"This is a very important issue. As you said, we plan such issues on a patient-specific basis. First of all, we need to review the cardiac procedure. What is our operation plan? We need to clarify this. Coronary angiography is one of the main criteria for making an operation decision. We also evaluate the body tomography of our patients. Evaluation of both the chest and abdomen is one of the main factors in making the operation plan. Here we look at the anatomical structure of the heart, its positioning in the chest cavity, the structure of the aorta and related vessels. In fact, a simulation of the operation is planned before surgery. And a specific plan is made for each patient. To talk about average values, if a robotic-assisted operation is decided after such an evaluation, the operation takes about 4 or 5 hours on average. Our patients usually stay in intensive care for one night after surgery. On average, they stay in the ward for 4 or 5 days. We discharge our patients for a follow-up visit about a week later. We often try to make a plan to see our foreign patients one week after discharge. When the post-operative check-up is taken into account, this is roughly a two-week period. After that, if everything is fine, our patients can get on a plane and return abroad or to their hometowns."
WHETHER HEART SURGERY WILL BE PERFORMED WITH THE OPEN OR CLOSED METHOD IS PATIENT-SPECIFIC
When can a person drive a car after bypass surgery? How does this situation differ from open or robot-assisted closed surgery?
"It is important to underline here that open operation is not a very bad option. Open operation may be the best option for some of our diseases. According to the result of the tomography taken before the operation, if the patient's condition is appropriate, physical activities such as driving a car can often be done after the second week after our robot-assisted operations. This more or less corresponds to our control time. This period may be longer in open operations. This is also an issue related to bone healing. After closed surgeries where bone healing is not required, the process of returning to normal life, including driving, can begin earlier."
SEXUAL LIFE AFTER HEART SURGERY
So, do you restrict sexual life for a certain period of time after coronary bypass surgery? Again, does this vary according to the technique applied? Because in open heart surgery, as you have just mentioned, the chest cage is opened, while the closed method is performed through a tiny incision.
"Closed surgeries are an advantage in physical terms. However, we try to discuss this issue on a patient-specific basis. Because there are other factors that affect this issue. For example, pulse rate, exertion capacity or the state of lung function. Yes, as you said, closed heart surgeries are an advantage in this sense. But as I said, it would be more appropriate to decide this issue on a patient-specific basis, taking into account the partner."
WHAT IS THE PROCESS OF HEART SURGERY IN FOREIGN PATIENTS?
Well, let me ask you this last question. Let's talk about the example of a patient who has a problem with his/her cardiovascular system and is thinking “Should I go to Turkey for treatment?”. What kind of tests do you ask such a patient to undergo before coming to Turkey?
"First of all, we need to see the coronary angiography and tomography. After examining and evaluating these two, three-dimensional anatomical structures are created and studied. According to these, the operation plan needs to be clarified. These are the two main examination methodologies we look at technically. Also, sharing information about his chronic diseases, if any, and evaluating some blood tests showing his latest condition are also necessary for the planning stage of his surgery."