Division of Cardiothoracic Surgery
As with most clinical programs, incremental changes in medical management and surgical techniques occur almost without recognition. Although perhaps not worthy of singling out, the cumulative effect of each small change results in steady improvement in the overall parameters of patient care including the traditionally monitored variables of cost and length of stay. Our adult cardiac surgical service has served as an exemplary model for the institution in this respect. Singular highlights have emerged in the past year, however, and these also have occurred on the adult cardiac surgical service.
At a time when it seemed like there would be little new on the horizon in options for prosthetic valve replacement, an exciting new type of bioprosthesis was released by the FDA about three years ago. These pig valves have been treated by very low-pressure or even zero-pressure fixation with glutaraldehyde and can be implanted in virtually the same position and space as was taken up by the native aortic valve. This configuration enables the surgeon to maximize the functional opening of the new prosthesis to minimize the pressure gradient across the valve. Early results suggest that left ventricular mass that has increased as a response to native aortic valve disease may regress more rapidly and completely to normal. The inference from these observations is that overall left ventricular function and longevity may be improved. Led by Dr. Nicolosi, these prostheses have been introduced and are now used regularly in appropriate patients with aortic valve disease presenting at both the Froedtert Hospital (FH) and at the Zablocki VA Medical Center. Early results suggest excellent clinical recovery and highly reproducible and reliable prosthetic valve function.
Traditional coronary artery bypass surgery has necessarily employed the use of the heart-lung machine. An increasing trend throughout the country has been the attempt to perform coronary artery bypass operations without the use of the heart-lung machine, so-called off pump coronary artery bypass or opCAB. Institution of these techniques has been led by Dr. Almassi at FH and at the VAMC. Prudent, careful application of these new technologies has resulted to date in satisfactory results that suggest that expanded application may be justified in certain groups of patients. At the same time, we continue to apply highly advanced techniques for coronary vascularization in particularly complicated and difficult cases.
The clinical programs of our division are logically broken up into three traditional categories of cardiothoracic surgery, adult cardiac surgery, pediatric cardiac surgery, and general thoracic surgery. Some overlap of faculty exists among the three subspecialties, but they tend to function autonomously.
Adult cardiac surgery is offered at FH and VAMC. These programs are directed by Dr. Nicolosi and Dr. Almassi, respectively. At both hospitals a full spectrum of services is provided to patients with valvular heart disease and coronary obstructive disease. Surgery for valvular disease includes both replacement and repair, with repair applied particularly to patients with mitral valvular insufficiency of degenerative etiology and to patients with aortic valve insufficiency from acute aortic dissection or with annuloaortic ectasia. The full spectrum of valve replacement options is available to our patients. These include the traditional mechanical prostheses along with porcine and bovine stented xenograft bioprostheses. Additionally, we offer patients aortic valve homografts, the newly introduced stentless porcine aortic xenografts, and, for selected patients, the pulmonic valve autograft implanted with the operation known as the Ross procedure. Obstructive coronary disease is treated in all of its manifestations from acute coronary syndromes to chronic coronary ischemia with diffuse three-vessel involvement and often with poor left ventricular function. Advanced application of arterial conduits for coronary revascularization is a characteristic feature of our surgical techniques. End-stage heart disease, usually manifested as severe heart failure, may result from either valvular or ischemic etiologies, but often is the result of intrinsic myocardial disease. Dr. Nicolosi leads the surgical side of our program in end-stage heart disease with heart transplantation and ventricular assist device therapy available to patients who present with failure of medical therapy. This latter program is carefully integrated with the program in end-stage heart disease directed within the Division of Cardiology. Surgical ablative therapy for chronic atrial fibrillation has been proven to be efficacious in selected patients and is provided by Dr. Almassi. Dr. Almassi has had a long-standing interest in atrial fibrillation and surgical treatment of arrhythmias and is nationally recognized for expertise in this area.
Thoracic aortic disease, including aortic dissection, aortic aneurysm, and aortic disruption from trauma, is included within the discipline of adult cardiac surgery, but may be exclusive of the heart. Our service at Froedtert is an important resource for thoracic aortic surgical care in southeastern Wisconsin. Aneurysms and dissections of the thoracoabdominal aorta are managed in concert with members of the Division of Vascular Surgery.
General thoracic surgery under the direction of Dr. Haasler must be regarded as particularly exemplary. Also practicing with Dr. Haasler are Drs. Gasparri and Tisol. While services are provided at both FH and VAMC, particularly difficult and complicated general thoracic problems are referred to the Froedtert service. Coordination of care now through the Cancer Center with integrated evaluation and treatment using both traditional and advanced modalities of radiation therapy, chemotherapy, and operative staging and resection provide patients with thoracic malignancies highly coordinated, state-of-the-art care. Surgical treatment is available, in addition, for patients with such far ranging nonmalignant conditions as thoracic outlet syndrome, chronic pulmonary embolism, end-stage lung disease that cannot be managed in other ways. Lung transplantation is offered through a highly developed program that coordinates the services of pulmonary medicine, thoracic surgery, social services, and rehabilitation.
The pediatric cardiac surgical service is based at Children's Hospital of Wisconsin. Dr. Tweddell serves as principle surgeon and Director. He is supported by Dr. Litwin, the founder and former director. This service enjoys a highly sophisticated support system of pediatric specialists. The full spectrum of pediatric cardiac surgical diseases is seen on a regular basis. Particularly notable results have been achieved in children with hypoplastic left heart syndrome. Dr. Tweddell directs the pediatric heart and pediatric lung transplantation programs and is assisted by Dr. Nicolosi and Dr. Haasler, respectively, in the care of these patients. We have a satellite program at the Marshfield Clinic and provide services at Loyola University Medical Center in Chicago.
Each of these services is supported by a combination of Division-based support staff, including specialized nurses, residents in various levels of graduate medical education, and hospital-based nursing and allied health professionals. Center-based coordination of care is emerging at all three hospitals to enhance delivery of patient service.