No heart, no life – it’s as simple as that! As the organ responsible for supplying oxygen and nutrients, this central pump acts as the body’s engine, keeping the blood circulating. The human heart, which is about the size of a fist, beats sixty to eighty times a minute, pumping around 7,000 liters of blood through the body every day. This fascinating hollow organ is divided into two halves by a septum, with each half consisting of an atrium and a ventricle. Oxygen-rich blood is pumped into the circulatory system on the left via the aorta, the main artery; on the right, the used, oxygen-poor blood is returned via the right ventricle to the pulmonary circulation, where the blood is re-oxygenated and flows back to the heart via the pulmonary veins. A sophisticated system that tolerates no interruptions. And one on which it is best to consult a proven specialist with extensive experience: Prof. Dr Alexander Albert.
An interview report by Alexandra Pfitzmann
There are a multitude of conditions that can put a strain on our heart. Fortunately, medical progress has been enormous in the fields of cardiology and cardiac surgery too. The editorial team at Leading Medicine Guide had the honor of speaking to one of the world’s leading cardiac surgeons. Professor Dr Alexander Albert is one of the world’s leading specialists and offers a fascinating insight into the impressive possibilities of cardiac surgery. Since autumn 2019, he has been Director of the Heart Clinic in Dortmund, North Rhine-Westphalia, and has over twenty years of professional experience.
For many people, heart surgery is still one of the most feared operations of all, just like brain surgery, for example. One of the most common heart operations is bypass surgery, which becomes necessary when there are life-threatening narrowings of the blood vessels. Only then can the heart’s oxygen supply be guaranteed. The most common reason for bypass surgery is coronary heart disease, which affects around one million people in Germany. Metabolic disorders, high blood pressure or arteriosclerosis are among the causes.
Open-heart surgery vs. minimally invasive surgery
In bypass surgery, a distinction is made between open-heart surgery and minimally invasive surgery, in which the procedure is performed via very small incisions using the so-called keyhole technique. “The decision on the surgical approach depends heavily on the anatomy of the coronary arteries,” explains Professor Dr Alexander Albert, adding: “Diagnostic and therapeutic approaches are always discussed within our interdisciplinary team to ensure we meet the individual needs of each patient. Personally, I perform minimally invasive surgery on ninety per cent of my patients.” Now imagine the following: in open-heart surgery, regardless of the reason, the patient’s entire sternum must be opened. This is a major procedure in itself, and the recovery period for the patient is lengthy, lasting several weeks, and is also associated with some pain. Minimally invasive heart surgery is much gentler, but requires a high level of expertise and dexterity. “Many surgeons achieve poorer results with minimally invasive procedures than with open-heart surgery, simply because they lack the experience. After all, minimally invasive surgery is performed on a beating heart. It is pulsating and moving, and yet every movement and subsequent suture must be executed cleanly and precisely using the correct suturing technique – a particular challenge," explains Prof. Dr Albert, who spent a year in 2004 with the ‘pope’ of ‘off-pump’ surgery, the Belgian heart surgeon Prof. Dr Paul Sergeant, who perfected this surgical method. “Off-pump” refers to heart surgery without the use of a heart-lung machine.
Practice makes perfect!
“Most patients are pleased when I explain to them that we are performing the procedure without the use of a heart-lung machine. After all, in operations involving a heart-lung machine, the heart is stopped – a rather daunting prospect. The fact that only small incisions are needed to reach the surgical site is also a positive aspect. Ultimately, this significantly shortens the healing process, and the entire operation is less traumatic for the patient as there is no need to open the chest,” comments Prof. Dr Albert on the procedure. “The subsequent stroke rate, which occurs following the use of bypasses, also falls to below 0.2% with minimally invasive surgery. However, the right technique is crucial in minimally invasive heart surgery. And here, the saying ‘practice makes perfect’ certainly applies!” explains Prof. Dr Albert, highlighting the challenge of the surgical technique.
Of course, you don’t practice on live patients. He himself has conducted veritable “suturing courses” at his living room table using simulators. He has repeated suturing techniques up to 1,000 times. “Today, I operate on patients two to three times a week using minimally invasive surgical techniques. These are mostly bypass and mitral valve operations,” says Prof. Dr Albert, who is one of the world’s most renowned specialists in off-pump surgery and minimally invasive bypass surgery, continues to develop surgical techniques and heads the European training center for minimally invasive bypass surgery run by Medtronic in Dortmund.
Each half of the heart has a valve with a leaflet (atrioventricular valve) and a valve with a pouch (semilunar valve). The atrioventricular valves are located between the atrium and the ventricle and are called the bicuspid valve or mitral valve (left) and the tricuspid valve (right). The semilunar valves are situated between the ventricle and the outflow tract and are called the pulmonary valve (right) and the aortic valve (left).
In a single day, the four valves open and close around 100,000 times, with the volume of blood pumped amounting to approximately 7,000 liters in 24 hours. Nevertheless, the valves generally withstand this strain, provided they have not been altered or previously damaged by additional conditions.
After the operation is before the operation
Prof. Dr Albert places particular emphasis on providing good aftercare for his patients, who come to his clinic for a ‘quality of life check’ approximately two months after heart surgery. “For many patients, it is very important to speak to their surgeon again after an operation and rehabilitation. Many still have questions and need an empathetic and competent person to talk to. They can pick up further tips and reassure themselves that everything is fine. Some also need emotional support, particularly if their social circle is small or non-existent, or if they are still experiencing pain or shortness of breath,” explains Prof. Dr Albert, who always treats his patients with great empathy. “I’m always thrilled when I hear about my patients’ successes, such as when a patient for whom I performed a double bypass successfully took part in the Ironman Triathlon,” says Prof. Dr Albert enthusiastically.
Sustainability matters when it comes to the heart
Human natural tissue is always the better choice, particularly when it comes to the treatment of heart valve diseases. It is part of Prof. Dr Albert’s philosophy to preserve the biological and natural structures of the heart rather than using prostheses. “Prostheses are always inferior to natural tissue and can cause side effects,” explains Prof. Dr Albert, adding: “At the Dortmund Heart Clinic, for example, heart valves are ideally repaired. This is successful in almost 100% of cases, particularly with mitral and tricuspid valve insufficiency. And this is also achieved in almost 100% of cases using a minimally invasive approach.”
Help even in the terminal stages of heart disease
Prof. Albert and his team also seek solutions for patients whose heart function has become so weak that neither medication nor conventional procedures can help. In Dortmund, for instance, he implants mechanical cardiac support systems such as the LVAD Heartmate III or performs total heart replacement using Syncardia. “However, we always try first to avoid these invasive therapies, which are intended as a bridge to heart transplantation or as a permanent solution. All options are always discussed within the interdisciplinary team, and we have our own outpatient clinic for patients with heart failure. We are open to innovative methods. For example, together with the cardiologists, we recently succeeded in restoring the shape of a deformed heart with advanced heart failure using a novel procedure (Revivent ventriculoplasty) with wires, without the use of a heart-lung machine. “This means we sutured the diseased areas on the beating heart, thereby sparing the patient the need for an artificial heart,” recalls Prof. Dr Albert with justifiable pride.
Dortmund Mobile ECMO Team
When heart failure occurs suddenly, swift action is always required. Sometimes a patient suffers a sudden cardiovascular collapse that can no longer be resolved using the conventional means available to a standard hospital; in which case transport to a larger cardiac center is usually no longer possible due to the shock that has occurred, or the chance of survival is very low. Cardiac arrest is imminent, and organ failure begins.
Together with the Dortmund Ambulance Service, Prof. Dr Albert founded the so-called “Mobile ECMO Team Dortmund”. ECMO stands for Extracorporeal Membrane Oxygenation, which refers to an intensive care technique in which a machine takes over the patient’s respiratory and/or cardiac function. This innovative service saves lives. “Around 40% of affected patients have survived without subsequent deficits thanks to this 24-hour service,” emphasises Prof. Dr Albert, who has published his experiences with “extracorporeal life support” in high-impact journals. So, if a patient suffers acute cardiovascular failure at home, for example, and the ECMO team is alerted, a cardiac surgeon, accompanied by a cardiac technician, immediately drives directly to the patient in a car equipped with a mobile heart-lung machine. Because only if action can be taken quickly is there a chance of survival. “Thanks to the mobile stabilization measures carried out at the patient’s location, we gain ‘bridge-to-decision’ time, allowing us to then initiate the correct therapies in hospital. Upon arrival at the Heart Center, everything is prepared for the patient,” explains Prof. Dr Albert.
The team led by Prof. Dr Albert offers an exceptionally wide range of services by international standards, enabling them to provide each patient with a tailored, personalized treatment plan. The team possesses outstanding expertise in minimally invasive bypass and heart valve therapy, complex aortic and aortic valve surgery (endocarditis operations, Ross procedure) and mechanical cardiac support using artificial hearts. However, the management of faulty pacemaker leads or the removal of infected ones is also a demanding task and is carried out willingly and effectively in Dortmund.
Vision with a heart
Professor Dr Albert stands out not only for his immense expertise in the field of cardiac surgery. He is also endowed with what may well be an innate, artistically gifted dexterity. Whether this has anything to do with growing up in an artistic family with a music professor for a father … The prudence that always characterizes Prof. Dr Albert is also evident in his unconventional and personal decisions. He recounts the story of a patient with a serious heart condition. “The patient weighed 180 kg and has diabetes. That’s a lot. He had been trying to lose weight for a long time, but he never got below 160 kg. With that level of obesity, a bypass operation makes no sense in the long term. So, together with the abdominal surgeons, we performed a minimally invasive bypass operation and, during the same hospital stay, a gastric bypass. Just three weeks after the procedure, he weighed 140 kg – a reduction of 20 kg – and no longer required insulin. “Being overweight and having diabetes always pose an additional risk for heart patients,” explains Prof. Dr Albert, who literally has a heart for his patients and always focuses on further progress. The meticulousness he brings to cardiac surgery is what sets him apart. “As the boss, you have a lot of leeway,” he says, laughing, and is already on his way to his next appointment.
Professor Dr Albert, thank you very much for this interesting conversation and the detailed insight into the fascinating world of cardiac surgery!
Albert A et al. (eds.) Operative techniques in coronary artery bypass surgery – An illustrated guide to personalized therapy, Springer International, London
ISBN: 978-3-030-48496-5
To be published in autumn 2020
