Saturday, 15 January 2011
Last March, I was awarded the Ionescu scholarship by the Society of Cardiothoracic Surgeons of Great Britain and Ireland. The funds for this scholarship were bequeathed to the society by Marian Ionescu (Wikipedia entry). The scholarship is awarded to help surgeons visit other units to learn new
techniques. In my application, I expressed the desire to visit units performing minimally invasive heart valve surgery. Although a significant number of heart valve cases in the USA and Europe are now being done with a minimally invasive approach, in the UK minimally invasive heart valve surgery is still only very rarely performed. There are several possible reasons for this but public scrutiny of surgeons' results must be one.
My first visit to an overseas unit was back in October (2010). I visited Hugo Vanermen and Fran Van Praet in Aalst, Belgium for a week to watch them perform Heartport Mitral Valve surgery. I have blogged about that elsewhere. On my second visit, I have come to Mattia Glauber's unit in Massa, Italy which is in the Massa Carrara region in Northern Tuscany. The area is famous for its Carrara marble and the Tuscan Riviera with the resorts of Forte Marmi, Pietrosanta and Viareggio. I have come for 2 weeks and as I write this I have come to the end of my first week. I flew into Pisa airport from Gatwick, (only UK airport with flights to Pisa in the winter) and drove my hired Fiat Panda 40 km up the Autostrada to my hotel in Cinquale in the Forte Dei Marmi resort. The resort itself is completely dead and most of the restaurants in the surrounding area are closed. If I had to come again, it certainly would not be in the winter!! I imagine the place rocks in the summer and I would not have had to drive all the way to Gatwick!
Anyway, the hospital itself is a 15 minute drive away from my hotel. Both adult and paediatric cardiac surgery are carried out in this unit which is a specialised heart hospital named after a paediatrician. Between 800 and 900 adult cardiac procedures are carried out annually in 2 operating theatres. They get referrals from all over Tuscany and because of Dott. Glauber's expertise in minimally invasive surgery, from all over Italy. All surgeons meet at 8 in the morning to discuss the progress of the patients operated on the previous day and the operative strategy for the patients undergoing surgery on that day. The group then goes around the ICU and then the surgeons who are not operating meet up with cardiologists to discuss referrals. Mattia Glauber decides who is operating on whom on the previous day. He scrubs in for part of most of the operations of the day i.e. 2-4 per day. Since Tuesday, I have watched 4 mitral valve repairs and a redo mitral valve replacement, all done through a right mini thoracotomy. The ascending aorta is cannulated and cross clamped through the right thoracotomy and cardioplegia is also delivered antegradely through the same incision. I have also watched 3 aortic valve replacements (1 with the new sutureless ATS/Medtronic device called Enable) - 2 through a right thoracotomy and one through a ministernotomy. The decision as to which approach is used depends on the result of a CT that all patients undergoing AV surgery undergo. The contrast between the atmosphere in the Flemish operating room in Belgium and that in the Italian is very noticeable - maybe it's just a perception on my part because of my ability (albeit rudimentary) to follow conversations in Italian! What is also very obvious and commendable is the zero tolerance to cross infection. Everyone in the theatre suite (not just in the rooms themselves) must wear full orthopaedic type theatre hat and a mask at all times. Every time the smallest drop of blood is shed, it is immediately cleaned. Everything is sprayed with what I assume to be alcohol spray. I wonder what their nosocomial infection rates (including SSIs) are? Low I imagine. They have 5 ITU beds available to them and this week we finished early on 2 occasions when the third case had to be cancelled because of bed problems. They always leave 1 ITU bed empty for emergencies.