Surgeries and Procedures
The Department of Cardiovascular Surgery at Mount Sinai Morningside is an exceptional place for patients to receive world-class cardiac and cardiovascular surgery. We are a group of highly trained and dedicated cardiovascular surgeons—many of whom have pioneered the latest techniques and procedures. Our surgeons not only collaborate with each other, but also with other specialists, including cardiologists, endocrinologists, neurologists, as well as the patient’s referring physician. This Heart Team approach is key at Mount Sinai Heart, emphasizing communication between all care providers in the interest of providing patients with the safest, most effective care.
Advanced Care for Speedier Recovery
Our surgeons are leaders in minimally invasive surgery, robotic surgery, and hybrid techniques that cause less stress and trauma to our patients. Many are specialists in complex cardiovascular procedures, but the goal is simple: Better quality of life and faster recovery time.
“Less invasive surgery gives patients more confidence—a justified confidence—because when it can be done safely and effectively through a smaller incision, it allows for speedier recovery.” - Omar M. Lattouf, MD, PhD
While the full range of cardiovascular surgeries and procedures are performed at Mount Sinai Morningside, here are some of the procedures that set us apart:
Coronary Artery Bypass Graft Surgery
Coronary artery disease is the leading cause of death in the United States. Thankfully, there are many excellent therapies, including medication, angioplasty (stenting), and coronary artery bypass graft (CABG) surgery. The surgical techniques for coronary artery bypass grafting developed and employed at Mount Sinai Morningside are exceptional. Whenever possible, we use minimally invasive techniques rather than conventional “open-heart” surgery. John D. Puskas, MD, Professor of Cardiovascular Surgery and Chairman of the Department of Cardiovascular Surgery at Mount Sinai Morningside, has been at the forefront of developing the techniques for advanced off-pump coronary bypass surgery, which avoids using the heart-lung machine and minimizes risk of stroke. He has dedicated a large part of his career to advancing the field of coronary bypass and has led numerous national and international clinical trials establishing best practices in coronary surgery and evaluating the benefits of combining minimally invasive robotic coronary bypass surgery and catheter-based stent therapies.
Coronary Bypass Surgery With Arterial Grafts
A key difference of our approach to coronary bypass surgery is our emphasis on using arteries for grafts, rather than veins. Approximately 95 percent of coronary bypass surgery in the United States is performed with just one artery graft and 2-4 vein grafts. Studies have shown that arterial grafts last longer. And while using artery grafts requires more skill on the part of the surgeon, it can add many years of life to the patient. The gold standard is using bilateral internal mammary arteries, arteries that are naturally located inside the breastbone. These very special arteries can remain open more than 20 years. So if a 40- or 50-year-old diabetic patient receives multiple arterial grafts, the chances of ever needing another procedure for a blockage or dying of a heart attack is much smaller than if that same patient had coronary surgery at a typical medical center using mostly vein grafts. We routinely harvest the bilateral internal mammary artery grafts from inside the breast bone with a specialized surgical technique, called skeletonized harvest, that greatly reduces the risk of problems with healing after surgery. This demanding technique is offered routinely at few medical centers in the country.
Very frequently a radial artery from the patient’s arm is also harvested, using a minimally invasive endoscopic technique with a very small wrist incision that can be hidden by a watchband. Our Cardiac Surgery Operating Room physician assistant team focuses on precise and gentle harvesting of those arteries for bypass surgery; together they have more than 60 years of experience in their craft. At Mount Sinai Morningside, we go the extra distance to use as many arterial grafts as possible; most of our patients receive all-artery bypass grafting.
Coronary Artery Bypass with Minimal Manipulation of the Aorta to Reduce Stroke Risk
In addition to using all or mostly artery grafts, we also minimize or avoid altogether manipulation of the aorta during CABG surgery. And while this is a rare procedure elsewhere, this all-arterial, no-aortic-touch bypass surgery is performed on a daily basis in the Department of Cardiovascular Surgery at Mount Sinai Morningside. It has been known for a long time that manipulation of the ascending aorta during coronary bypass surgery is the cause of strokes that occur in approximately 1-2 percent of patients who have coronary bypass worldwide. At Mount Sinai Morningside, we concentrate on using surgical techniques that avoid multiple clamps on the aorta if the coronary bypass operation must be done with the heart-lung machine and avoid clamps altogether if the coronary bypass operation can be done without the heart-lung machine. This contributes to our extremely low incidence of stroke after coronary artery bypass at Mount Sinai Morningside.
Off-Pump Coronary Artery Bypass Surgery
Dr. John Puskas is the national leader in off-pump coronary bypass surgery (OPCAB), having personally performed more than 4,500 OPCAB procedures in his career. In expert hands, OPCAB offers patients complete revascularization of the heart without exposure to the effects of the heart-lung machine. This leads to less blood loss and fewer transfusions, a shorter time on the ventilator and in the ICU after surgery, and earlier discharge to home. Because OPCAB creates the possibility of completely avoiding aortic manipulation during coronary bypass grafting, it leads to lower risk of stroke or cognitive deficit after surgery. Dr. Puskas performed the first randomized trial of OPCAB compared to conventional coronary bypass, demonstrating with coronary angiograms that he could accomplish the same excellent revascularization without the heart-lung machine while documenting numerous benefits of OPCAB to patients.
Robotic Minimally Invasive Coronary Bypass
Dr. Puskas is a national leader in the field of minimally invasive robotic coronary bypass, a procedure in which the left internal mammary artery is harvested with a robotic surgical device via three tiny 1 cm incisions between the ribs under the left armpit and connected to the most important artery on the front wall of the heart (the left anterior descending artery or LAD) via a small skin incision (3-4 cm) between the ribs, without dividing ribs or opening the breastbone. This minimally invasive approach is suitable for selected patients with a limited amount of coronary artery disease and provides them the life-saving benefit of a left internal mammary graft to the LAD without opening the chest. Dr. Puskas has published numerous scientific papers and lectured internationally on this exciting and innovative technique.
Hybrid Coronary Revascularization
Under Dr. Puskas’ leadership, the Heart Team at Mount Sinai Morningside has also served as the National Principal Investigator in the nationwide Hybrid Coronary Revascularization trial sponsored by the U.S. National Institutes of Health. Hybrid Coronary Revascularization (HCR) involves a cardiovascular surgeon performing robotic bypass surgery to the main artery on the front wall of the heart and an interventional cardiologist stenting another artery(ies) on the back side of the heart. The advantage to the patient is that they have two or three vessels treated through minimally invasive techniques without the necessity of the breastbone being opened. This is just one of the many ways we are constantly exploring innovative techniques to provide faster recovery times, fewer complications, and better outcomes. Mount Sinai Morningside is ideally suited to deliver this kind of innovative, collaborative care, because we embrace the Heart Team concept of multidisciplinary collaboration for the benefit of the patient.
Coronary Endarterectomy to Treat Diffuse or Widespread Coronary Artery Disease
Some patients, especially those with diabetes, may develop very widespread atherosclerosis of their coronary arteries. This can be very difficult to manage with medications or stents and yet most surgical programs shy away from such cases because of the technical difficulty of performing coronary artery bypass grafting in this scenario. At Mount Sinai Morningside, we customize our approach to each patient, combining advanced coronary surgical techniques to provide the best outcomes. These techniques include coronary endarterectomy, in which we remove the long plaques causing extensive blockage of coronary arteries and then graft those coronary arteries with a specialized “onlay” crafted from an arterial graft.
Coronary Stentectomy to Treat “Full Metal Jacket” Blocked Coronary Artery Stents
Sometimes multiple stents are placed in a single coronary artery, especially when the first stent(s) become repeatedly narrowed. This can lead to the situation in which an entire coronary artery is full of stents from beginning to end (the “Full Metal Jacket”). When blockage develops repeatedly within a full metal jacket, it is generally considered outside the bounds of surgical treatment and patients with relentless angina are told that “nothing can be done.” However, Dr. John Puskas has developed an innovative program for selected patients that offers hope. He has advanced the principles and techniques of coronary endarterectomy to successfully remove the full metal jacket of stents in the LAD of selected patients with suitable coronary artery anatomy. While this procedure is innovative and performed in only a handful of centers in the world, it offers hope to patients who previously had none.
Surgical Unroofing of Anomalous Right Coronary Artery
When patients with a congenitally abnormal coronary artery (called coronary artery anomaly) develop angina, shortness of breath, loss of consciousness, or even sudden cardiac death, we have a comprehensive non-invasive cardiac imaging program to discover the exact type of anomaly and a skilled and experienced coronary surgical team to repair the anomaly. The most common type of anomalous coronary artery is the anomalous origin of the right coronary artery from the left side of the aortic root. This anomaly creates a “slit-like” origin of the right coronary artery within the wall of the aorta, which can become compressed during exertion, leading to symptoms and even sudden death. There have been several surgical corrections proposed over the years, but the precise surgical “unroofing” of the right coronary orifice is considered the gold standard. Despite its technical difficulty and unfamiliarity to most cardiac surgeons, in experienced hands, it offers patients the most natural and durable anatomic correction. Dr. John Puskas and his team are expert in the evaluation of such patients and the performance of this specialized procedure.
“Redo” Coronary Artery Bypass Grafting Surgery
While Mount Sinai Morningside specializes in the use of arterial grafts during coronary bypass surgery, the vast majority of medical centers in the United States and in the world do not. Thus, literally millions of patients receive multiple vein grafts during their coronary bypass surgery. Since these vein grafts are vulnerable to atherosclerosis themselves, early failure of these bypass grafts is common and sometimes cannot be adequately managed with medications or stents. In this setting, the coronary surgery specialists at Mount Sinai Morningside offer expert redo-CABG, employing arterial grafts and utilizing various alternative approaches to minimize risk and optimize patient outcomes. Sometimes this redo-CABG can be performed without re-opening the breastbone.
Surgical Management of Coronary Artery Fistulas and Aneurysms
Less frequently, patients may develop abnormal connections between coronary arteries and the pulmonary artery or even one of the chambers of the heart itself. These “coronary artery fistulas” are usually small and insignificant. However, they can be very numerous and grow in size to become large enough to drain blood flow away from the working muscle of the heart, leading to chest pain (angina) and shortness of breath. This is especially dangerous when blockages of the coronary arteries are also present. The Mount Sinai Morningside cardiovascular surgery team performs comprehensive non-invasive evaluation and meticulous surgical division of all coronary fistulas to eliminate the “steal” phenomenon and improve blood supply to the heart at the time of coronary artery bypass surgery.
Similarly, coronary artery aneurysms occur infrequently, but can cause multiple heart problems, including chest pain, coronary embolism, and heart attack. Management is usually non-surgical, but in some circumstances, surgical excision and interposition bypass grafting is necessary. This rare procedure is best done in a Center of Excellence for advanced coronary surgery, such as Mount Sinai Morningside.
Heart Valve Surgery
Aortic Valve Repair and Replacement
The aortic valve can be repaired rather than replaced in patients whose aortic valve is otherwise normal but is stretched open by dilation of the aortic root. At Mount Sinai Heart at Mount Sinai Morningside, we have developed a particular focus and expertise in aortic valve-sparing procedures. The valve-sparing procedure restores the normal shape of the aorta, the aortic valve, and fibrous ring at the beginning of the aorta, called the aortic annulus. Leaking of the aortic valve is cured without the need to replace the aortic valve. Specific repair techniques for the leaking aortic valve may include shortening the length of the valve leaflet and reducing the circumference of the aortic valve opening.
Aortic valve-sparing root replacement, or the “David procedure”, is a very good option for patients with connective tissue disorder, patients who cannot take anti-coagulants, and younger patients. The aortic tissue surrounding the aortic valve is removed along with the ascending aorta. The aortic valve and supporting tissue are replaced with an artificial graft. Mount Sinai Heart at Morningside has extensive experience and expertise with this procedure, providing reliable, long-lasting results for patients.
Stenosis or narrowing of the aortic valve generally requires replacement of the valve to reduce or eliminate the obstruction of blood flow exiting the heart to go the entire body. Our faculty in the Department of Cardiovascular Surgery at Mount Sinai Morningside is expert at the surgical replacement of the aortic valve. We offer a variety of options for treatment of the failing aortic valve, including minimally invasive surgical replacement with a mechanical valve in the very young patient and minimally invasive surgical replacement with a biological (tissue) valve in the older patient. We most commonly use the INSPIRIS RESILIA valve, manufactured in the United States, which does not require blood thinner after surgery. Dr. John Puskas was the International Principle Investigator for the FDA trial that earned approval for this valve, which has become the most popular biological aortic valve in the world. He was also International Principle Investigator for the FDA trial that earned the On-X® mechanical valve (also manufactured in the USA) approval for use in patients with lower doses of blood thinner, which makes that valve a safe and attractive option for younger patients.
Transcatheter Aortic Valve Replacement
Aortic stenosis is the narrowing of the aortic valve, which is the valve through which the heart pumps blood into the aorta, the primary blood vessel of the body. Once a patient is showing symptoms of fatigue and shortness of breath from aortic stenosis, medical solutions are no longer advisable and surgery is recommended. The two options are open-heart valve replacement, or a minimally-invasive procedure called transcatheter aortic valve replacement (TAVR).
Mount Sinai Heart physicians were involved in the national trials to gain FDA acceptance for TAVR, and our surgeons are experts in the procedure. Today, TAVR is a common operation and a preferred option for elderly patients, patients with serious medical conditions, or patients who would have difficulty recovering after open-heart surgery.
TAVR is a catheter-based intervention in which the Heart Team surgeon and cardiologist work together to insert the valve, mounted on a narrow catheter, through an artery in the legs. The surgeon guides the valve through the aorta and opens it up within the old valve, without the need to remove it. Today, our surgeons and cardiologists perform TAVR together almost daily with outstanding results.
Mitral Valve Repair and Replacement
The mitral valve can usually be repaired when it leaks and this repair can be accomplished with high reliability by a minimally invasive approach at Mount Sinai Morningside. We use the safest and most reliable techniques to achieve a durable repair for virtually all patients with degenerative disease of the mitral valve. Those patients who develop mitral valve narrowing (stenosis) caused by rheumatic heart disease may require mitral valve replacement.
Tricuspid Valve Repair or Replacement
Tricuspid valve repair is most commonly performed at the time of mitral valve repair or replacement. The surgical team at Mount Sinai Morningside utilizes the most modern techniques to preserve the tricuspid valve and avoid replacing it. This includes using a tricuspid valve ring that was designed at the Mount Sinai Health System and is manufactured in the United States.
Surgery for Infected Heart Valves
Infection of heart valves is called endocarditis. It is most commonly caused by bacteria entering the blood stream from an infection elsewhere in the body. Endocarditis can affect any heart valve, but is most common on the aortic, mitral, and tricuspid valves. It can often be treated with powerful intravenous antibiotics alone, and surgery can be avoided. However, if the valve is destroyed by infection and heart failure results, surgical repair or replacement may be required. Sometimes infected material may break loose from an infected heart valve and cause stroke; this also leads to surgical intervention. The cardiovascular surgery team at Mount Sinai Morningside has extensive experience in the treatment of patients with infection of the heart valves and uses state-of-the-art techniques to achieve the best possible results, even when multiple valves are infected in an individual patient. This scenario may occasionally require an extensive debridement and replacement of both the aortic and mitral valves (a “Commando Procedure”), a technically challenging operation in which our faculty has special expertise.
Gabriele Di Luozzo, MD, specializes in aortic diseases and has been a leader in research into safer, more effective surgical procedures. Many conditions such as aortic aneurysms, Marfan and Loey-Dietz syndromes, and bicuspid aortic valves are first managed by careful monitoring. When surgery is indicated, our Heart Team will present and explain your options to you.
Aortic Aneurysm Surgery
Once an aortic aneurysm reaches a certain size, surgery is recommended to repair it. When the risk of rupture outweighs the benefits of conservative management, the aneurysm needs to be replaced. Each section of the aorta requires a different approach, and every patient brings a unique set of factors to consider. In general, the aortic aneurysm is removed and replaced by a synthetic tube. Mount Sinai Heart at Mount Sinai Morningside has expertise in open, endovascular (catheter-based), and hybrid (combined) surgeries.
The gold standard for aortic root aneurysms is the Bentall procedure in which the ascending aorta, aortic valve, and aortic root are replaced. The valve can be replaced with either a bioprosthetic (animal) or mechanical valve. The choice of valve is dependent on many factors, including the age of the patient. We will thoroughly explain your options and the benefits of each.
Aortic Arch Aneurysm Repair
When the aortic arch develops an aneurysm or dissection, it must be repaired. This requires a variety of complex surgical techniques that include cooling the patient and reducing blood flow for a period of time during the surgery. Protecting the brain, heart, and other organs during this surgery is extremely important. The team at Mount Sinai Morningside has decades of experience in this demanding surgery and provides each patient with an individualized surgical strategy to optimize outcomes.
Repair of Thoracoabdominal and Descending Thoracic Aortic Aneurysms
As the aorta descends into the chest and abdominal cavity, aneurysms may be caused by atherosclerosis or dissection. The gold standard for surgical repair is open surgery, however endovascular surgery may be more suitable for patients who are elderly or have other medical complications. Because of the descending aorta’s proximity to the spine, extreme care and expertise is required for these procedures to avoid paraplegia and few centers perform them frequently. Mount Sinai Heart at Mount Sinai Morningside is a leader in spinal cord protection techniques for lower aortic aneurysms, and has extensive expertise in both open and endovascular surgery. Few centers nationally have the level of experience and expertise that Dr. Di Luozzo brings to the surgical management of extensive aneurysms affecting the aorta throughout both the chest and abdomen.
Pulmonary embolisms are blood clots in the arteries that branch out from the heart to the lungs. Mount Sinai Heart at Mount Sinai Morningside is one of the few heart centers in the United States to treat chronic thromboembolic pulmonary hypertension (CTEPH), which is high blood pressure caused by these clots. The clots cause the heart to work harder and pressure builds up in the arteries. If left untreated, many patients die within five years.
A pulmonary thromboendarterectomy (PTE) is a highly-specialized surgical procedure to remove old and organized clots from the lung arteries. Typically, it is a major operation involving opening the breastbone and placing the patient on a heart-lung machine, followed by opening the involved arteries and directly clearing the areas that are blocked by removing hard plaques that had built up on the walls of such arteries. Omar Lattouf, MD, PhD, Professor of Cardiovascular Surgery at Mount Sinai, is one of the few cardiovascular surgeons nationwide who has a large experience and genuine expertise in this complex procedure.
Surgical Ablation for Atrial Fibrillation
At Mount Sinai Morningside, our faculty in the Department of Cardiovascular Surgery are expert in the surgical ablation of atrial fibrillation. In most medical centers in the United States, patients who have atrial fibrillation in addition to coronary artery disease or heart valve disease are often only treated with surgery for the coronary arteries or heart valves and the atrial fibrillation is left untreated. At Mount Sinai Morningside, we offer comprehensive treatment for all the important heart problems that a patient may have and routinely perform thorough ablation of atrial fibrillation at the time of coronary bypass grafting or heart valve surgery. We use a variety of sophisticated techniques to achieve the best relief of atrial fibrillation and occlude the left atrial appendage to reduce the risk of stroke for each patient who has atrial fibrillation. Among these techniques is cryo-ablation (using a deep-freezing technology) and bipolar radiofrequency clamp ablation (a heat-producing technology).
For patients with long-standing or recurrent atrial fibrillation (AFib), the Convergent Procedure is a minimally invasive and highly effective treatment. AFib causes irregular heart rhythms that can leave patients exhausted and fatigued. Furthermore, atrial fibrillation increases the risk of brain strokes. Patients who have had multiple procedures that have not produced lasting relief have found the Convergent Procedure highly effective.
The procedure requires a team approach between a heart surgeon and a cardiac electrophysiologist. While the patient is under anesthesia, the heart surgeon makes a small incision below the breast-bone and uses a scope to visualize the posterior wall of the left atrium. Using a high-frequency energy source, the surgeon treats—or ablates—the aberrant cells that trigger irregular electrical impulses causing AFib. Once the minimally invasive surgical ablation is completed, the cardiac electrophysiologist then inserts a catheter through the femoral vein to access the pulmonary veins in the left atrium, and frequently also works on the right side of the heart to ablate cells that the surgeon cannot reach. Dr. Omar Lattouf has been an early practitioner of the Convergent Procedure and has trained many other physicians in the technique.
The Full Spectrum of Cardiovascular Procedures
These are just a few examples of the advanced and minimally invasive cardiac surgical techniques found at Mount Sinai Heart at Mount Sinai Morningside. Your care plan will take advantage of the expertise of a range of specialists in order to come up with the right therapy for you. Our commitment is to provide you with the safest, most effective care and very best possible patient experience.