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Space to Operate The newly expanded operating rooms feature advanced monitoring equipment in spaces large enough for a complete cardiac surgery team to comfortably maneuver. "I've been at other facilities where operating rooms were built prior to the introduction of open-heart surgery pro- grams," Dr. La Mendola explains. "We'd have to squeeze equipment in and have to work really hard to maintain sterility. The renovated operating rooms at Good Samaritan Hospital are big and have been specifically designed for heart surgery and nothing else." The size of the rooms is such that, often, two anesthesiologists vigilantly monitor patients while two technicians perform laboratory work within. During bypass operations, two perfusionists monitor the heart/lung machine. Perhaps the most unique aspect of the cardiac surgery team is the experienced first assistant. "We have a specially trained fellow who has specifically performed first assistant duties for many years," Dr. La Mendola explains. "This is a tradition that har- kens back to the way we do things at St. Francis Hospital. In many hospitals, first assistants are physician assistants or nurses, but we prefer to operate in a manner that reflects the days when two physicians performed operations." Additionally, a physician assistant in the operating room acts as the second assistant. During bypass procedures, the second assistant's training is particu- larly important. While the team busily performs its tasks, the second assistant endovascularly harvests pieces of vein — either from the greater or lesser saphenous vein or radial artery — for bypass grafts. After Bypass I n t h e o p e r a t i n g r o o m s , Drs. La Mendola and Rovensky use i n nov at ive t e c h n ique s t o re duce postoperative complications. Nearly two decades ago, physicians identified several side effects caused by the heart- lung machine. Dr. La Mendola helped pioneer a new method of performing the procedure. "The heart-lung machine causes an inflammatory response in the body," he explains. "As the blood circulates out of the body, through the machine and back to the body, it's heated, cooled and beaten up. This causes the release of inflammatory mediators — the response that causes a fever if you catch a cold. These mediators also play a role in some of the potential complications associ- ated with bypass surgery, which include everything from cognitive dysfunction to kidney or respiratory failure." In 1999, Dr. La Mendola bega n p e r f o r m i n g o f f- p u m p c o r o n a r y a r ter y by pa ss su rger y to a ssu a ge such morbidities. "We thought that if we could take the heart-lung machine out of the game and perform the operation without it, we could improve the procedure," he says. "Since then, about 2,000 of approx imately 5,000 procedures I have performed have been off-pump procedures, which involves stabilizing the part of the heart we're sewing the bypass graft onto while the rest of the heart beats around it." U s i n g a n o c t o p u s r e t r a c t o r , Dr. La Mendola manipulates the heart into position, places the retractor's fin- gers on either side of the blocked artery, and then locks the flexible arm in place. In this fixed, typically 2-cm-long area, Dr. La Mendola sews the graft in place. "It's a n excel lent op erat ion for younger patients who only need one or two bypasses," Dr. La Mendola says. "It's also valuable when significant comorbidities, such as vascular or lung disease, are present. The key is finding a surgeon who is comfortable with both techniques and can recommend the best option for each patient. Right now, most open-heart surgeons aren't comfortable performing the procedure off-pump." Looking Ahead Aortic stenosis most commonly begins after age 60, and symptoms typically pres- ent in subsequent decades. When chest pain or tightness, heart palpitations, and shortness of breath do appear, patients are often at such advanced age that open- heart surgery may not be recommended. But new alternatives to open-heart surgery enable physicians to treat aortic stenosis, even in patients at advanced ages. "Elderly patients, whose mobility and physical function are often already limited, may not be candidates for any procedure," Dr. Rovensky says. "At the Dr. La Mendola and Dr. Rovensky discuss a patient's progress in Good Samaritan's newly constructed cardiothoracic intensive care unit. COV ER FE AT UR E 8 | Long Island MD NEWS ■ M D N E W S . CO M