Join Dr. Tompkins as he highlights the innovative work at Baptist Health’s Miami Cardiac & Vascular Institute, with a special focus on the cardiac surgery team. He will introduce the team members, discuss the various surgical procedures being performed, and explore key programs. Don’t miss this insightful conversation about the collaborative efforts in cardiac surgery.
Bryon Tompkins, M.D. , is a board-certified surgeon specializing in cardiothoracic surgery at Miami Cardiac & Vascular Institute. Prior to joining Baptist Health, Dr. Tompkins completed a three-year cardiothoracic surgery fellowship at Johns Hopkins Hospital. Dr. Tompkins earned his medical degree from SUNY Upstate Medical University and completed his surgical residency at Jackson Memorial Hospital/University of Miami, where he served as administrative chief resident. In addition to his clinical training, Dr. Tompkins published his research in multiple medical journals including Journal of Cardiac Surgery and the Journal of Thoracic and Cardiovascular Surgery. He is a member of the Society of Thoracic Surgeons and American Association for Thoracic Surgery. Dr. Tompkins dedicates his time to continually looking for ways to improve outcomes for his patients by using minimally invasive techniques, robotic surgical skills or open surgery approaches as needed. In his free time, Dr. Tompkins enjoys playing tennis, running and going to the gym.
For more information visit BaptistHealth.net/Heart or call 786-596-1230 to refer a patient or make an appointment.
Good afternoon and welcome to our cardiac and vascular lecture service. I am Doctor Gar Hakim, assistant Vice President of International Health Care Partnerships and insurance Development at Baptist Health International. It is my pleasure to welcome all of you to this informative presentation. I would like to extend warm greetings to our friends across Latin America, the Caribbean and everyone joining us today. During this interactive presentation, you'll have the ability to ask questions via the Q and A feature located on the bottom of your screen. I will be your moderator for today's lecture this afternoon. I have the distinct pleasure of introducing doctor Brian Tompkins who will be presenting a lecture titled Cutting Edge Cardiac Surgery at Baptist Health Miami Cardiac and Vascular Institute. Doctor Tompkins is a board certified surgeon at Baptist Health Miami Cardiac and Vascular Institute, specializing in cardiothoracic surgery. He has a specialty and and interest in the use of minimally invasive technologies and open surgery approaches. Doctor Hopkins earned his medical degree from S UN Y up upstate Medical University in Syracuse New York and completed his surgical residency at Jackson Memorial Hospital, University of Miami where he served as an administrative chief resident. Prior to joining Baptist Health, Doctor, Doctor Tompkins completed a three year fellowship in cardiothoracic surgery at Johns Hopkins Hospital in Baltimore, Maryland. Dr Tompkins has published numerous research publications and in journals including in the journal of cardiac surgery and journal of thoracic and cardiovascular surgery. He's a member of the Society of Thoracic Surgeons and an American Association for Thoracic Surgery. Please let's give a warm welcome to Doctor Tompkins. Doctor Tompkins. What a pleasure seeing you again. Thank you so much for accepting our invitation. The floor is yours. Thank you very much. I really appreciate this uh Doctor Hakeem. That was a wonderful welcome. Um And thank you to Baptist Health International as a group just for allowing me to, to, you know, speak on behalf of uh our Miami Cardiac and Basket Institute. Um Thank you all for listening. Um What I really wanted to bring home today really was uh not so much me as an individual, but I wanted you all to be aware of what um kind of groundbreaking work we're doing here at the Miami Cardiac Ambassador Institute. Uh We as a whole. Um and I'm gonna present now, the surgeons that, that we work with are really almost secondary to none here in Florida as a state. And, and we wanna make sure that you know that we're your, your liaison um to, to uh a anything that you may need uh from a cardiac standpoint, see if I can get this thing moving here. So as you can see here, here are the uh the surgeons uh the top left here. Uh Doctor Wen, he just joined us uh last year. He is our cardiac, he sorry, he's our CME. Um So he's in charge of uh the MC B I as a whole. And then just next to him is uh doctor mcginn. He's the chief of cardiac surgery, Mead Gore. She specializes in aortic work. Doctor Hoff. Um He specializes in a f uh ablation and off pump below him. It is Doctor Nakamura. He also specializes in uh coronary work. He works very closely with Doctor Winn and minimally invasive work. And Doctor Bologna also specializes in aortic work and I kind of am a, a jack of all trade. I really enjoy uh working um on not only the coronary multivessel coronary art bypassing but minimally invasive valve surgery as well. So what makes us as a group unique really? You know, we tackle the most complex cases in South Florida. Uh We have an Aortic center now. Uh and we're gonna go over what that entails and what we do and we do complex coronary artery bypass grafting. Um I'll tell you what that means in a minute and minimally invasive heart surgery. Um We do uh just pretty much everything that can be done minimally invasively, we will do it and we have an ECMO program. ECMO program basically keeps people on life support uh for a period of time and we'll go over the indications for that and, and uh why, how we can be of help to you in the future? I think what's important is also um what people when they think of heart surgery or open heart surgery or minimally invasive of man, this is gonna hurt, but it doesn't always have to be the case and pain control is very important And I just have a, a quick um uh thought on that at the end of this. And as well, collaboration is huge collaboration amongst us as surgeons and, and, and amongst different um um medical specialties because without everybody that works around us, we could never get this done and put together properly. And the complexity of cases, we do complex aortic dissection repair. We can do total endovascular repair of the entire aorta from the root, which basically is the aortic valve coming off of the heart going all the way down to the Iliac Ross procedures, which we'll discuss valve sparing roots. So you have dilated uh a an aorta dilated aorta and, and uh we can preserve your valve. We will, we do multivalve reconstruction, we do multi arterial bypass grafting and we do re redo valvular redo chest, uh redo coronary work um which can be uh quite vexing at times, but we are equipped to handle that. So I just want to start off with uh you know, uh bread and butter, uh, cabbages, corn and art or bypass grafting. You know, we pride ourselves. We've historically been an ST S3 star program. The Society of Thoracic Surgeons is pretty much what judges every, uh, thoracic surgeon in North America and, uh, the groups as a whole. And they basically give you stars and they tell you, hey, this is, you're a one star, two star or high end three star and it is exceptionally hard to get to that level. Uh, and it goes everything from fro from, um, how long someone's intubated, obviously morbidity as a whole mortality. Um, and, and uh basically out to 30 days, um, people who, uh, have to come back in, uh for any particular, uh thing postoperatively is kind of counted against you. So, and not only that, but it's also medications, you know, are you taking the right medications before you're discharged? They look at everything and we are at the top of the echelon when it comes to that. And I mentioned multi arterial grafting because historically, um, you know, cabbages are done with, uh your, your left internal memory artery which runs on your chest wall and it's the lifeline of cabbages. And then we also typically use a vein that runs in people's legs and that's the standard of care across over 90% of practices in North America. We try to, uh, to change the, the paradigm and, you know, we're not the only people to do it. But multi arterial grafting kind of gives you better outcomes uh over the long term. And uh we also champion hybrid uh cases. So, you know, some people happen to be eligible for, you know, the stent and maybe a left internal memory artery done minimally invasively and they have excellent outcomes um over long periods of time. And um so the point of the matter is is that we collaborate with our interventional cardiologist to come to that logical conclusion. And of course, the patient is the most important one to say, hey, yeah, I agree with this or I don't off pump bypass, grafting. It's something where it's, you know, open chest or minimally invasive and the heart's still beating and they're not on bypass. And so, uh it makes it a little bit more complex, but, you know, our, our group can uh can do that and we do it on a daily basis. And then finally, a minimally invasive cabbage is what I was alluding to. Uh this is something that's done um where you do, uh I'll show you shortly about um small incision in the chest and you're able to bypass the arteries that way. So, multi arterial artery bypass grafting, um you see the, the image there on the left. Um historically, it goes right through the, you know, midline of the sternum and there's this, this large um artery that runs in the chest wall, we uh meticulously dissect that down and we use that, you know, um as you can see on the left hand side, and we use this to bypass the left internal memory artery, which is your lifeline, your widow makers, uh so to speak. And, and then on occasion, we may use a SAIN is vein to the other side. We may use this R A as you can see there as your radial artery. So it's the artery that runs in your arm. And uh some people are candidates and some people aren't. But on occasion, we tend tend to use that and then all the way to the right hand side, if you have a left internal memory artery that runs on your chest wall, well, there's on the opposite side, there's a, a right internal memory artery that runs and we tend to use both of those to bypass the most important vessels. Why is it important? Well, you know, there is a recently, a recent publication of a multi arterial study showed that at 10 years after following a million patients just shows exactly how important this. Um this is this is to, to, to patients because at the end of the day, veins are nice. But you know, they say about 60% of veins kind of tend to go down after 10 years, 10 to 15 years out these arteries, the main ones, the left internal memory and the right internal memory remain open. 9895 to 98% of the time at 10 to 15 years. And then there's a little chart here. Um all the way to the right. That kind of just shows, you know that there is a dichotomy uh when you're reaching towards the 10 year mark outside that shows, hey, that, you know, this is uh something that's important, something that surgeons should be doing for patients that are um uh can meet the criteria, so to speak. Here's hybrid coronary order bypass grafting. I just want to show you this uh once again, just to let you know what that means and what we uh what, what we do with it. So, percutaneous coronary intervention as you're probably well aware of is basically putting stents, um maybe in the right in the, in the circumflex on the L AD depending on the situation. But on occasion, you know, we're able to do um just a, a Lima, you know, left into a memory artery to the, the L AD, which is your lifeline again. Just so, you know, and then if they can bypass that with small stents, you know, they tend to stand open, stay open for a long period of time and they have great outcomes. And it's important for maybe patients uh you know, that are higher risk for a longer bypass time. They have a kidney injury, you know, they have a history of stroke, uh uh carotid disease. There's a lot of these reasons And as you can see here, it kind of tells you a little bit of a idea of like, you know, cabbage may be better first versus uh, coronary, um, stenting later. Um, just the fact that you can initiate antiplatelets. Um, and after surgery, once the patient is obviously dry and everything, then you can go back and do a PC I and when somebody does a PC I and you already have a bypass graph to your lifeline, then it makes it easier for the interventionalist and less risky for them to do higher risk PC I. Ok. Um, let me go on to the next one. the next topic is our Aortic center. Uh, you know, one of the, the big veins of OO of, of cardiac surgery, uh, in the sense that this is your emergency case. These are the things that we do get shipped quite often. Our patients with, uh, emergent aortic dissections and we'll discuss those in a minute. We're doing total endovascular aortic repair like I alluded to earlier from the route all the way down to the iliac. And now we are just starting to do something called an endo beal. And I'll, I'll discuss that with you in a minute. We do root enlargement. So people who need to get an aortic valve replaced, um, that are young and, um, they're candidates for surgery. We wanna make sure we give them the biggest valve possible. So, on occasion, we have to actually do a procedure to enlarge the aortic annualy to accommodate a larger valve. So that in the future, not only the hemodynamics better, but in the future, if they need another valve, we can do a tor, meaning you can put another valve through the groin into your previously placed valve. And so as you can imagine, when you have a bioprosthetic or a tissue valve, they kind of over time tend to wear out. Well, you wanna be able to put another valve in a valve if possible in the future. So it prolongs people's lives, you know, 3040 years and then there's valve sparing roots and a ROSS procedure, which we'll get to. So when people think of aortic surgery, you know, you've got here, um just the o or, you know, here is your, what I was, here's your aortic valve. It comes right off of the heart. Here are your coronary arteries and then here's your ascending aorta, your head vessels and everything that goes down to the rest of your body. We get referred people uh that have these things. These are big aortic aneurysms. And of course, once they reach a certain size, they can rupture, they can cause a dissection. Obviously, we don't want that to happen. We wanna catch it in time and repair it. And as you can see here, we tend to do that with a tube graft, we can do it open. If you look all the way here to your right. This is an open aortic surgical procedure that goes from the aortic root, your ascending aorta, encompassing your head vessels and all the way down to your abdominal viscera and down to your iliac. Now, we can and do, do them open, but we can also do them endovascularly depending on the situation, of course. And then what I was alluding to earlier is here's the aortic dissection, You know, you have your, your, your type A which is basically your ascending aorta, you know, coming up all the way to your left subclavian artery. That's your type aortic dissection and your type B basically from your left um suban all the way down to your iliac. We deal with all these and, and all different flavors. Um And like I said, we can do them endovascular and we can do them open and uh depending on the situation, we'll repair them. So if you ever have people that happen to have an aortic aneurysm and they need, you know, someone to, to watch it, we're more than happy to, to uh get on the case and either contact via zoom or they can come and see us and we can repair them, you know, before they get to this. That's the most important thing, obviously. And typically our size cut off for uh operating is with an ascending is five centimeters. So once you hit that mark, you should be thinking about an operation to, to spare their life in the future. Now, this slide actually is uh interesting because um I was a part of this case right here and I just wanted to give you this is AC T scan an axial cut basically from the patient's feet all the way up to their head. And this right here in the center is their, their aortic arch. So it's, it's this area right here. It's the aortic arch, your head vessels basically come, you don't see it in here. But this one obviously goes to the left arm and then one will go to the right arm and to the carotid and so forth. This patient as it was about 85 years old, calcified AO in the aorta very hard to do an open operation with. But um and, and really not a good surgical candidate at all but came in with this dissection. This was a type B and it was really at the takeoff of this right here, the left sula an artery. So we ended up doing was this graft which you see right here, you know, never mind this. Uh this uh aneurysm you see here, this person had this dissection bleeding outside the sack right around here. So we are the first group in South Florida to do this particular graft. A TB E aortic uh graft to essentially exclude this bleeding aneurysm and save this guy's life. Um These are the rest of these pictures here are, you know, to give you an idea of, of what can and what we do do. And you know, this is basically taking the left subclavian and the carotid artery and bypassing it all the way over here to the anoint. This is the other carotid artery just to exclude this aneurysm and or what could be a dissection. And this is all done through the groin and done through the wrist if necessary or done through the subclavian artery. So, um these um are all done endovascularly as well. And this is protecting the renal, the uh the uh mesenteric vessels as well all the way down to the iliac and down here to your bottom, right? I just want you to be aware of something that's really futuristic and what we're doing now. And as a matter of fact, we're doing one tomorrow, somebody who has a root dilation. And again, the root is the part of the aorta that comes off of the heart. And when that gets dilated, you know, five centimeters, like I was saying, you need an operation. Well, the problem is is you got these coronary arteries that come off of here. So what makes it very difficult is you can't just put a graft on there just like these without occ including these. And when the aortic valve is involved, how do you fix that? Well, what we've done um is uh we've created this, this hybrid graft where we take a tver trans aortic valve that goes through the groin and that self expands and we end up sewing that valve to one of these grafts, cutting the holes in for the coronary arteries. And, and excluding that big aneurysmal portion. Huge case, not very common. Doctor Gas is the one who, who's been championing this, this thing and we're doing it tomorrow and it's very few have been done in the world. Uh But that's, that's cutting edge surgery that we're we've gotten and embarked on. And um it's very exciting. So I just show you this slide, uh a little messy maybe, but this is what we have to do when we do our, our, our uh you know, sometimes you do this big aortic work. You see how we have to do this open procedure for this huge aneurysm. Well, as you saw in the previous slide, we can now do that all endovascularly. But on occasion, you know, you, they, you know, they don't meet the requirements for it. Well, just uh yesterday we did this case and this is just a quick um video that basically shows the fact that this graft that was here. Now you see here, this, this is already sewn to the aortic arch. The graft is down here. This person had an endograft, it unfortunately got infected. So we had to do this huge operation to remove that endograft. So this graft down here clamp this portion to give blood to the head and basically stopped the pump for a short period of time while we sewed this graft down here after removing it, as you see here. And here's what it shows it looks like on the back table. This is one big infected graft. We pulled it out of here and then sewed this graft down to here. You know, that's huge, huge surgery, uh, patients doing great. Uh, and again, there aren't many places uh in the country that are doing these kind of things. Um, valve sparing root. What is that? That's when the uh the aortic valve itself is working just fine. Ok. Here's the aortic valve coming off of the aorta or out of the heart, it's working just fine, but itself, it's just dilated and you wanna preserve this thing if you have a young person so suitable for patients under 65. And why do we say that? Because is it really worth all that work because it's very complex surgery? It's hard to do. It's harder on the patient. Is it worth all that work to preserve this when we could have put a mechanical valve in here and then plug these coronary arteries in there. Well, if you're young and, and, and you want this valve to work another 30 years. Yeah, it's worth it. Uh If you're older, 7585 well, it's, it's probably not worth doing all that work. Now, the Ross procedure is a whole another ball game. This is when you're actually taking, this is when you're actually taking the, the pulmonic valve, you're resecting that and you're putting that in place of the aortic valve and the aortic root and then you, and then you put a, a homograph, so somebody else's root in place of where the pulmonic valve was. That's huge surgery as well as you can imagine that's done for, for, um, for those whose valves that we would like to repair like a valve spring root, but the valves themselves are just not gonna tolerate it. They're no good, but the patients are young. They have a contraindication for anticoagulation. They're, they're young enough, they wanna get pregnant and they obviously can't take anticoagulation. Well, you may want to embark on something like a Ross procedure and then moving on to minimally invasive cardiac surgery as opposed to what you just saw, which is maximally invasive uh valve repair, valve replacement. We do coronary work and atrial fibrillation, ablation. Um This is a, a quick video that I wanted to show you that shows one surgeon here at the head, one at the body. Here we're working in conjunction. This is um working to the fastest growing uh procedure and heart surgery right now is removal of tver implants. So, Tavis again are the valves that we can put up to the patient's groin when they're older and you have to, you know, remove the valve because they've been sclerotic and they're stenotic and you put a new valve in its place, a bioprosthetic, a tissue valve in its place. And we work in conjunction with the cardiologist to do that. Now, um, as you can imagine, those valves, kind of, they, they deteriorate over time and some people just are not candidates for a valve inside of a valve or there's, you know, for whatever reason they need open heart surgery. Well, here's the procedure in which, which is done uh minimally invasively. So this is just for um how we go on peripheral bypass. You know, we just put a wire up there, we put Cannulas up there and we connect somebody to the heart lung machine. Here's the aorta in front of us through that small incision he was making, he's clamping the aorta. He's giving cardioplegia right now to stop the heart. Then after that, we make a cut in the aortic wall itself. Uh and this again is, you know, right where the root is coming off of the aorta. And as you can see there, he's exposing that valve and that valve in there is a tver valve that was placed. Why did we have to do it? Well, unfortunately, this valve had endocarditis and you can't put another valve and valve and endocarditis. As you can imagine, it'll get infected. Well, through a minimally invasive techniques, we put another new bioprosthetic valve in its place, obviously, not as fast. As this procedure is showing you online, but uh it was done successfully and it's something that we pride ourselves in doing um in, in the right uh situation. Here's some cases I've done. Uh This right here is a uh o on the far left is the incision that we tend to make for a mitral valve. So somebody has a mitral valve that needs to be repaired or, and, or replaced, we'll do it through, through the um through the right chest. And as you can see here, this uh incision in the middle slide is an aortic valve that I did minimally invasively different kind of uh incision as opposed to the mitral valve, which is kind of down here and why? Well, it, you gotta look at the valve from different views depending on, on. Um you don't get the same view from each, each incision, unfortunately, but we're able to go in between the intercostal muscles and go and go through the rims. And then down here, this is somebody that I did uh like last week, which was a Tricuspid valve. So somebody who had isolated tricuspid regurgitation, he was in his fifties and ended up just repairing the valve through a small incision here on the right side, bottom, right side of the chest. He ended up going home in post op day three. That's the good thing about these things is, you know, getting them up and moving, uh you know, this one right here was an elderly man, but you get them up and moving, you're not going through the, through the breast bone, um which is not always the worst thing to go through the breast bone and, and, and again, um I, I will re harp on a pain control and why people think, hey, this is scary and it is, it's open heart surgery. Don't get me wrong, but no matter how you slice it, no pun intended, that's open heart surgery, whether it be minimally invasive or through the breast bone. But we can help control that pain one way or the other. Sometimes these people with these minimally invasive incisions, they get up and they go a little bit qui uh well, I should say muscle hurts a little bit more to go through than bone, believe it or not. But we don't have to wait for the bone to heal. You just wait for muscle to heal. So you wait about 34 weeks and they get back to playing golf. Here's minimally invasive bypass grafting. Ok. Um So instead of going to the right side of the, through the right side of the chest, minimally invasively, we go through to the left side of the chest. Um Now this is uh done uh with a heart stabilizer without being on pump without cross clamping the heart. And uh this is a kind of a, it, it, it kind of goes back to the whole thought of that do a hybrid technique where you can do a minimally invasive left internal memory artery which runs right on this chest while we take it down, painstakingly take this down. And then we do uh we suture anastomosis to the left um uh the, the L AD OK, which comes right down here. I'm gonna show you a quick video of that. It is kind of done at uh two X speed. But as you can see here, it's um done to the left side of the chest, like a small incision. He's going through the intercostal muscles. He's gonna put a little uh uh trocar in there so we can get um any kind of suction devices in there, chest tubes in there, postoperatively, um devices to hold the heart down if we need to. And then this is a camera view of what we see when we take down that mammary artery which runs on that chest wall through a minimally invasive technique. It's as hard as what it looks like right here. It's not easy. Now, we cut it off. As you can see the heart down there is still beating, it's moving, he's gonna open all this up. He's taking down extra fat that lies um on top of the heart itself and then he's gonna go into the pericardium and once you get into the pericardium, you retract the pericardium itself and you can get a direct view of the heart and then he's got a heart stabilizer in there uh to kind of stabilize his heart while, while we uh open up the, the, the L AD and then we bring this mammary artery down. And this is just one technique to kind of get it in place so we can sew it without the help of somebody else. Because as you can imagine, it's hard for one person to see, let alone two to sew this artery down onto the other artery while the heart's moving in a very small, small uh incision. This is just showing you what the vitals are like. The heart still beaten. The, the, the blood pressure is 100 and 50. He's having a lot of blood there. He tends to shunt these when uh when you get a lot of blood. Um but it's done, takes a little while. But you know what, again, three weeks they're home, we tend to control their pain with paint pumps and so forth. And now he's tying it down, he's gonna check for some bleeding. And once it's all tied down, it looks good, he opens it up, checks the flows, it looks perfect, puts the chest tube in place and that's the pain pump that goes right there. And um underneath the endo thoracic fashion, the plural space help control any patient's pain post-operative, that's the lung that's coming up and then he closes the little intercostal area that we uh made our incision through then finally, uh minimally invasive cardiac surgery, atrial fibrillation, somebody who has a FB um it generally goes to the electrophysiologist, but when they need help, they may call on us to do uh thoracoscopic uh ablation. Uh meaning going through the ribs, small incisions on either side or sub zipp hoid just underneath the chest, uh and, and ablating it. And then we can also do through a thoracoscopic uh incision. We can ligate the left atrial appendage, left atrial appendage, um which I'll sh which so here, here's thos scopic, you can go from the right side of the chest, the left side of the left side of the chest or vice versa. You can put this device across it. It'll burn the pulmonary arteries on our uh pulmonary veins, I should say on e either side because that's where a lot of the, the FCI of these A FB occurs, you burn them on both sides and you hope to capture it. And thoracoscopic, as you can see here, this is the left atrial appendage. It's the top of the, of the heart, so to speak that before it goes down into the ventricle, all this blood. Well, this appendage is a vestigial appendage. It's something like like your, your appendix. Uh it's not very well needed. But what when someone's an A FB, unfortunately, as you can imagine, and you probably know that clots can form and they tend to 90% of the time clots that go into form strokes come from that appendage and we can clip that appendage from a Thach copic approach. And we'd also do it in open procedures too if it's necessary. Um Here's a convergent procedure which would I was uh uh alluding to subxiphoid small incision. Here, we get into the pericardium. We put this long device down in here with a camera and the device goes behind the heart and right where the pulmonary veins are, we tend to burn, burn, burn and ablate the whole area uh in an effort to try to stop the foi that's causing the atrial fibrillation. And we do this in conjunction with our EP colleagues. And then finally, we're going to uh lastly, I guess is our ECMO program uh extra caporal membranous oxygenation. Well, what does that stand for? Well, basically, it's the heart lung machine that we tend to do when we stop the heart and or go on bypass. And this is this complex circuit over here on the left. This is just basically showing you this is the oxygenator, this is the pump, this is the bright red blood that we go in. We put back into the body and the dark blood as we pull from the body, we give it blood, we give it to oxygen, we remove the CO2 and impurities. Uh And then this here is the box that can tell you how many liters per flow we can flow. Uh And then this little um diagram I just wanted to show you here. It just kind of gives you an idea of how we tend to do. We can do it central, which is through the open chest if we need to. Uh we do it 10, we tend to specifically do it peripherally. Uh meaning through the groin, bilaterally, maybe the femoral artery and the femoral vein or the internal jugular artery in the, in the femoral artery tend to sometimes even go through the subclavian through a cut down technique as well. So we can, we can get somebody on bypass fairly quickly and we can, and we can do it from multiple sources. And this is just a nice big slide that gives you the uh the indications for why somebody would want to be on bypass and and why you should be aware of what, what we can do for you. So basically somebody is in cardiogenic shock where it be from a uh you know, uh acute myocardial infarction, someone who's in an arrhythmia and is in storm and is refractory ventricular tachycardia, someone who's in sepsis that needs to have profound cardiac depression. If you don't have cardiac depression, you can't do ECMO uh because then you kind of fighting the same battle, you're trying to give somebody a good oxygenated blood which the the pump, your pump, your heart is already giving to you. So, sepsis only in cardiac depression, drug overdose and toxicities. That also cause cardiac depression, myocarditis, which we now have seen in COVID people with pulmonary embolisms that are uh cardiovascularly collapsing cardiac trauma on occasion and acute anaphylaxis. Um And then sometimes we use them as a bridge to decision, a bridge to, to a left ventricular cyst device if necessary a bridge to transplant, which makes you a one a indication for transplant if you're in hospital on an ECMO device. And then, and that's, and that's again for the heart lung and then sometimes just for the lungs, there's an indication for VV. So you can go uh uh vein to vein to bypass the lungs which aren't working. And people with a R DS, which we have seen tons of in 2020 with COVID, some with the, with the pulmonary contusions, uh poor smoke inhalation. Um And uh you know, we also use it for, for uh lung transplant, primary graft uh uh failure, uh massive hemoptysis and pulmonary hemorrhage are also indications as well. So any time you think of people that may fit the bill for this and basically what's important for you to know is someone's just not doing well, but they have not maxed out on the vaso pressure support. Uh you know, they're not in, in, in flued renal failure, liver failure, they don't have a stroke, they don't have a contraindication to getting systemic heparin because that's very important for amo you know, call us sooner rather than later. And that's again, for everything I've discussed. When you start, things, see things go downhill, you see an aneurysm getting bigger. Somebody who may prefer an al multi arterial bypass grafting, call us sooner rather than later. And we can have a discussion via zoom. Uh and, and, and, and take it from there and, and this is one of our, you know, getting down to the, to the last slides here. What's important. I, you know, that people understand that pain control is something that we, we do think of and we do know is important. This was the on cue pump on the far left that was put on during the multi uh vessel, coronary bypass, grafting through that small left thor eot that I showed you. This is uh you know, continuous lidocaine that's going there that we leave in place for the next several days while the patient recovers gets out of off the ventilator gets up, starts walking. Then we start giving some narcotics as necessary to wean off, get that pump off. And then in the center is something that I tend to do on almost all of my patients. I I no longer use wires when I close old school cardiac surgeons which is fine. They use, you know, those wires that you twist that can break. Uh I tend to use cables which actually has AAA tightener, that kind of gauges how tight it is and how firm that that chest is together and then I add the sternal titanium sternal plates. And the reason why is, is what I found and what many surgeons have found actually is that when you get that stern, I'm really tight and it's not moving the next day after surgery and they're holding that pillow and they're coughing and that sternum's not moving. They're not feeling it. It's as if they didn't even have surgery in the first place. Most people who complain of pain after this mainly are from the chest tubes that we put underneath. And in the next couple of days, those chest tubes come out, pains resolved. Uh And, and, and people are walking faster. They're taking deeper breaths. They're not, you know, on bipap or high flow and in, in trouble getting reintubated because they're not taking deep breaths from, from pain. Um, and they're home 23 days early and everybody wants to go home. That's, you know, the most important thing, get them home safely. And this little Cryo isa Blader, which is something you should be aware of is when we do minimally invasive surgery. Um, when the lung is down and collapsed over here, we take that probe right there and the end of that probe, we stick it right here while these inner, right where the intercostal nerves are coming in place. And then one above and two below, right where that incision was we cryo ablate those nerves. And then over the next three months they start to grow back. So, at that point, well, that incision is now well healed and you're not feeling it anymore again. That's something that's going through the intercostal muscle and, and like I alluded to before, um, I really, I've seen it, uh, on many occasions, people who go through muscle when you go through muscle, younger patients especially, they tend to complain more about pain than your elderly ladies. You know, we go through the chest bone in the center, if there's less muscle there either, maybe just because they're women and they have less, they have higher pain tolerance than men in general. That could be. But also the fact that I've noticed, you know, they don't complain as much pain and that's without the, the, you know, the sternal uh plating system. But when you go through the muscle man that hurts, uh as you can imagine, uh you pull a muscle, it hurts. So, so when you cry abate these nerves, you know, uh uh uh many times they're not complaining of pain post operatively and we can get them home faster and, and after doing the more important things in life and then finally, collaboration is something that we really um harp on here, not only amongst surgeons, but just amongst, you know, a a multidisciplinary approach here to everything that we do. The aortic work that you see here on the right. You've got an Italian surgeon here. You got an Iranian surgeon here and then an American vascular surgeon over here. So, multicultural, multi uh a multidisciplinary approach to this aortic work that we do here. And then over here, uh we just did the A mi clip. So people who are not candidates for surgery but have this massive a mitral valve regurgitation that they may need to have a clip placed. Uh Well, we, we did the first one just recently here at South Miami. That's me here. Uh And then this is our cardiac interventionalist uh Doctor Vanna who does I do tas with often and do mili with. Um and um and it's important to know that this is a, a big team approach and, you know, Baptist kind of has it all. We have the entire team here, you know, from, from physical therapy to getting discharged properly, making sure people are able to walk when they get home. Uh and they don't have to rebound to the hospital because of pain or they're not walking properly. We did the wrong thing and these kind of things. Well, we collaborate, you know, in the, or, or in the hybrid suite with interventional radiology to do endovascular aortic work. Uh So, you know, just so, you know, that's my family here. Um It was my daughter, my son and my wife, of course, and what's important for you to know about this is that we treat everybody like this like it's our family and I want you guys to know that because we're here for you. And if you have any questions, please let me know. We're really happy uh to uh to be talking to you today and I really appreciate Baptist Health International for letting me speak Doctor Tomkins. You must start and end your presentation with that beautiful picture of your family. Thank you. You are an amazing, amazing family. Look, uh I, I here I am in, in the office with my team and uh this is quite impressive. Uh You have uh managed to just put in chapters and recapitulate exactly what we do at M CD I uh in the trajectory that uh this incredible institute has had in the past 10 years has been nothing but impressive. Uh Your peers have uh astonished the world really uh the caliber of physicians that you have in your team. It is simply amazing, Dr Wen and Qureshi and mcginn. Uh and the others are simply simply amazing physicians. But what most impressive of uh of all of this is that uh uh you have such a way uh a comprehensive approach to every single one of the different diagnoses uh that uh in essence a cardiothoracic surgeon or other invasive cardiothoracic uh fellows uh need to actually take into account to correct some of these ailments. Wow. Um One that uh stuck to my mind was uh the ROSS procedure when you said that uh for young people, especially pregnant women and uh and those that are resistant to anticoagulation, I mean, this was unheard of in the past. It, it was kind of challenging for physicians to actually deal with this kind of uh of um conditions, especially on pregnant women. So um I, I just wanted to highlight uh to our audience. Uh one important thing uh some of the pearls that you shared today, but more importantly, it is uh a congratulations to you and to the entire team at MC B I, the T S3 star program that you guys have achieved is simply remarkable. And that is where uh now Baptist, Miami Cardiac and Vascular Institute and baptism in itself has been placed on a platform uh that uh no other institution around the world or perhaps are at the at par with other great institutions around the world. We receive uh tons of patients internationally uh simply because they know that you are in our team and that you have this incredible talent. So I cannot commend you enough. We are very impressed with your accomplishments and of course, of the entire team. Uh now doctor uh there are some concerns uh always concerns and you did express it well, when you said these are uh scary procedures. I mean, you're, you're working on the heart. Uh And uh what um came as a quick highlight, especially to some of my peers is obviously you're operating on a beating heart that uh uh you, you no longer use this incredibly, I'm sure they do still uh this incredibly complex machines to extra corporeally circulate the blood. Uh How is that in relation to complication has uh brought um been brought to light in, in essence, what I'm trying to ask is has that decreased the complication of uh certain procedures? The fact that uh you're doing this on a beating heart? Yeah. So it's a good question. Um Not all of us do this oo on a beating heart. Uh A few of us do a few of us don't. So the, the, the answer to that and it's a little complex is that if you're able uh very good point is if somebody has a totally calcified aorta, OK? And um you need to cannulate the aorta, frost clamp the aorta to stop the heart in order to do the bypasses. Well, uh it, it, their risk of stroke is very high because anybody with a lot of calcium, once you mess with that aorta, it can go anywhere uh especially to the brain, obviously. So the, the least amount that you can touch the aorta in those, in that patient population, the better. Uh Now the caveat to that is, is even when you do it off pump, you can um a lot of what we do is do a side biting clamp. We don't do fully across it. Side bite just a portion of the, of the, of the aorta because remember you still gotta put the, the uh the grafts distally to the artery and then you gotta bring them proximally to the aorta as well. And, and you gotta find a soft spot, so to speak, to do it. You can do it with a heartstring device which is just like a small punch device and it has, it's an upside down umbrella and then you can sew through that while there's still blood circulating underneath the aorta and a very small, small soft spot, um which Doctor Hoff does exceptionally well does all the time. Um And the thing is you can do, uh which is interesting is, is this hybrid approach that I kind of uh discuss with you is also hey, you do the left internal memory and maybe you do too, you left and right internal memory arteries, you don't have any proximal anastomosis and you do all distally and you don't have to mess with the aorta at all. And then secondarily, it's also if you're gonna have a long case um because it's just a difficult case for whatever reason when you can do it off, uh pump and not cross clamp them if somebody has kidney injury and these kind of things, well, the the the body doesn't like the pump so much as you can imagine. So we tend to kind of go as fast as we can to get him on and off of it when you do it off, pump you have a little bit more time and that's the kind of like uh what the uh what the numbers kind of show as well. Mhm. Tomorrow, you mentioned that you're going to uh participate in this uh very complex surgery, the aortic surgery uh with doctor Keshi. Um uh we're also very, very fortunate to have him in our team since he is such a, an incredible aortic specialist. Uh As a matter of fact, yesterday, I was at MC B I and I got to see the actual valve, uh the sample, which is the technology and it, it's, it's amazing. I have no idea how um biotechnologies can actually think of this incredible things, the thoracic surgeons, um any expected complications uh after that particular procedure, what is uh your, your biggest fight uh for the? So, uh depends on the, the, the, the part of the aorta that we're dealing with. I mean, the biggest thing is, is especially with dissections and so forth is bleeding, bleeding, bleeding, bleeding because it's just these patients, uh we tend to cool them down, we they, they tend to bleed. Uh Doctor Gashi actually does dissections, not cold so that they have a less chance of bleeding and keeping them normothermic. Um The other thing um else is um again, when you're stopping any blood to certain parts of the body and the aorta is a lifeline to the rest of your body, your chance of stroke, re renal injury and visceral injury are through the roof and, and, uh, that's why you gotta work kind of fast. And so, especially in the thing that we did yesterday, um, where, um, we basically stopped the pump and everything in the lower body was not getting blood for 2030 minutes, but we kept them cool. So, you've got, your kidneys are at risk. Your vis are at risk, your lower extremities at risk and also guess what, your spinal cords at risk. Um, so, uh, and especially when you're putting, if you're doing it endovascularly, your spinal cord is really at risk. So those, those are the scary top, scary things that we, we really worried about. And what period of time do you consider that? Uh, the, it, it's safe to now breathe? Yeah. So basically, um, as soon as they come up pump and they start and, and we wean the, the sedation and they move everything, I'm happy. That's it. Now, the next part about it is, of course, you're always looking at your hourly, hourly urine output, you're checking your peripheral pulses to your feet. Um, and, and, um, and once we can extubate them and they can talk to us, I don't have the pain in my legs. I can move everything, you know, that and that's in the next couple of hours depending on how big the surgery is. You know, sometimes you have to keep them intubated because they need a lot of transfusion. They are on pressers and so forth. So that's when it gets a little nerve wracking and you're like, oh my God, they have to keep them intubated and sedated and so forth. I just wanna see what their neuro function is, you know, amazing. It's just simply amazing. I remember before. I mean, it's, uh, it was, uh, a 15 day, probably stay in the hospital, especially on a group of bypass and uh and gasping for air because obviously now we have to deal with the seasons and, and issues of that nature and the skin and, and, and sequela later on, especially because of the leg and, and if you're taking the Sueno vein and all that stuff. So uh how is that in comparison to the past is, I mean, I know it has changed the paradigm. Uh but uh do we still see those kind of complications at, at, at any point? Say that one more time which to the minimally invasive uh bypass? Of course. Yeah. Um You still, yes. Yeah. So the minimum like like cabbages, you do normally invasive cabbages or M MA and BS, you still see complicate tho those complications. Luckily, they're not very often. And luckily, you know, the surgeons here are exceptional. So if you really don't see them that often, but you know, for example, um Joe mcginn is a, a champion and a world expert on minimally basic coronary bypasses. Um on occasion, you come here from, you know, Washington and you have to go on pump, you have to open the sternum is the, the, it's not zero, you know, so that's not necessarily a complication. It's just what you gotta do to get the patient through th this particular surgery. Um, but a lot of these patients, ironically are very young, you know, he tends to get a very nice young patients, not the older people that don't tolerate these kind of procedures or whatever. Um And so his patients do exceptionally well. But yes, those compli and as a matter of fact, anything you do minimally invasively, the risk of complication is probably uh magnitudes higher because just as you saw in that video, the vision is so small. So if something goes wrong, you don't have a, you have to be able to get into the chest quicker, you know. Uh so, but luckily we really don't see that here. Um We just, just the, the, the caliber of surgeon that's here is exceptional. Um And, and, and importantly, it's uh anticipation before things go wrong. That's absolutely right. You know what Doctor Tompkins, we can keep you here for hours on end. This is absolutely fascinating, but we know you have to prepare uh you were actually we were late because doctor uh Tompkins was in the middle of a tower and we have to wait for him to actually change and join us this afternoon. So, um I know, you need to prepare for tomorrow's surgery. I wanna thank you on behalf of our entire team at international. We are so so very proud to have you in our team and uh thank you for everything that you have done for our patients and to all of you for participating and attending this conference. Uh Thank you. If you have additional questions or you have a concern about one of your patients or you would like to refer or speak to Doctor Tompkins. Uh Please let us know, send us an email at BH I webinars Baptist health.net. And we look forward to seeing you all in our next cardiac and vascular lecture service which is scheduled for Wednesday, October 30th 2024. Thank you again and have a wonderful afternoon. Thank you, Doctor Thompsons. You too and have a wonderful surgery tomorrow. Thank you. Bye. Thank you.
