HeartBeats Episode 5: Minimally Invasive Heart/Lung Surgery with Dr. Michael DeFrain

Good morning hello and welcome to HeartBeats I'm Cathy Murtaugh-Schaffer and I'm your host for this episode of HeartBeats. This podcast is brought to you by Shipley Cardiothoracic Center, an educational series dedicated to providing our patients and the community with information and education about our cardiothoracic surgery program, Lee health, and matters affecting your health. Today we have Dr. Michael DeFrain, one of shipley's minimally invasive surgeons to talk about the minimally invasive surgery program at Shipley Cardiothoracic Center. Welcome Dr. DeFrain, thank you so much for being here. I know one of your passions is to provide your patients with the safest, least invasive and most effective surgical procedure for their heart or lung disease. You have over 20 years of experience in cardiothoracic surgery, how has the evolution of minimally invasive techniques helped you to deliver this kind of care?

Thank you for that question and I'm glad to be here and I'm happy to have this opportunity to talk to my patients both past, present and future probably. When you look at a patient in their condition I think the first thing to consider is what is the best approach for them regardless of what techniques we have to offer. Focus always begins on the patient and their unique situation. There is no cookbook answer for everyone but the promise of the minimally invasive techniques is to minimize the trauma on the patient. That's the goal, and whatever technique is utilized, the focus is to impact the patient the least way in order to get the most effective outcome for their condition. So, as relates to lung surgery, you know the robot provides a unique opportunity to avoid rib spreading and have access to the lung tissues which would normally only be accessed in the past by placing a retractor between the ribs space and opening that up. That's a big trauma to the patient and so the minimally invasive technique, which utilizes robotic technology, allows us to avoid that completely and go between the ribs and no tension or force applied to the ribs provides unique patient benefit, which is worn out in the literature as relates to survival benefits, reduced pain medication, short length of stay, less blood utilization, and a host of other benefits. So, in that world the application of technology to unique patient circumstance provides tremendous benefit to their total experience for the treatment of their condition. As it relates to cardiac surgery, the ability again to avoid midline incisions offer different approaches to the same disease process, which would normally be accessed by a surgeon through the mediastinum or sternotomy. We can avoid that and there are benefits to that, in again, a unique set of patients with a unique set of condition. So, again the focus begins with the patient, choose the best technique for their unique situation and then let the whole process benefit from the technology that we can provide.

I think you bring up a really good point in that reducing the trauma to the body really has a tremendous amount of benefits to the patient. I think what has surprised me the most in my years of doing this type of work, is patients don't really understand the amount of trauma that really does ensue with this major surgery. I think they don’t understand the amount of difficulty there is in accessing these sites and having surgeons in there messing around with their body parts so to speak so I think your point is well taken. I know that you received your training from a very renowned training program at the University of Texas at the Texas Heart Institute and MD Anderson center in Houston TX and interestingly that's where I became a PA at their rival institution with Baylor College of Medicine. I'm curious was there someone or something in your training at these prestigious institutions that helped frame how you were going to practice surgery?

I was very fortunate to train in Texas Heart. I love that place, Houston was an exciting town and full of talented people, Rice University being there, yeah, it was full of energy, intellectual power and various very interesting characters. I learned a lot there and mainly the lesson to never stop learning.

I think that was one of the main things that was key there, the experts that existed there they weren't ever satisfied with where they were, they wanted to be better. I love that thought and that practice in life, whether it's in medicine or any other aspect of life I always want to be better than I am today. And so, that leads to innovation and I think minimally invasive surgery, like we talked about earlier, is a product of that and as relates to mentors along the way, yeah there's so many. It's not just limited to training I think, you know, I didn't leave Texas Heart the surgeon then as I am today, I've grown tremendously from my relationships with other surgeons that are both senior to me and some even junior, that I have learned from and taking their techniques and I think whatever I do in the operating room today is a product of a weave of different techniques of many different surgeons that taught me a variety of things and I've taken the best of each of them and as I think about the various institutions that they've trained at, all of that, and I'm sure their skills are a product of their own progression in their career. That's why I love this field, because you learn so much. You're constantly improving and everyone else around you is full of that same energy and so it provides an opportunity to help people in a way that I think few people get such experience in life. I really enjoy what I do and I'm happy to provide that to patients and I think when I talk to patients, like I'm talking to you now, they feel that same energy. I think they feel confident that they're going to receive care that is the best that can be possibly delivered because we're all dedicated to that here and I think they when they come and meet us in our team they sense that and they like it. (host) I think that's what's so special about Shipley for sure. I think it's our community here beyond Shipley you know all of the people in the hospital that are part of this team, I think that's a key part of engendering patient’s confidence in treatment.

I think one of the more exciting refinements in the minimally invasive field is the advent of the daVinci Robot but I know there are people out there that worry that they think that a robot is actually performing their surgery and taking away the human factor perhaps you could clarify the role of the robot and how you use this extraordinary tool.

That is an interesting point thanks for asking that, I don't know that patients feel that way or not I don't sense it when I explain it. I usually show a picture of the robot; I say you know this is the tool I use similar to a scalpel or forceps, that we use a traditional surgery. The robot simply a tool, the main benefit comes from the topic we discussed earlier, it's 8 millimeter arm. Generally, 8 millimeters fits between your ribs so really the only thing the robot does is allow us to access the interior of the body without spreading the ribs. So it just goes between the ribs and then once that's accomplished the rest of the technology of the robot provides is basically the ability for the surgeon to, I sometimes I stand inside there but that's kind of silly, but basically you have full function of your hand inside the body without being there to create the space for your physical hand go. So the robot is a tool for a surgeon to use that enables that as it relates to thoracic surgery, but otherwise it's under full control the surgeon. There’s nothing automated about it and the visualizations better, the functionality of your hand within the chest is better. I always describe the patients as a win win. I think it is the best approach for thoracic oncology, the reason for that is all the functionality that I described but also what is key to patients with a lung malignancy of particular, is to accurately stage them so that they get the best treatment available for whatever condition they have. In other words, this stage of their cancer, how much has it spread or how much has it not. The robot excels in both of those situations in that if a patient does not have nodal metastases within the lung, the robots going to be the best at finding that and establishing that reality and in that case the patient avoids chemotherapy and radiation. In the converse, where nodal metastases exist, where cancer is spread from the site in the lung, the tumor site in the lung to the lymph nodes in the lung or in the mediastinum, then robotics excels the most at finding that. In that case that patient will benefit from having received chemotherapy post op if they choose to pursue it and radiation. We will give him that recommendation and then their lifespan will increase as a consequence of discovering the problem and the treating it properly. So, for all these reasons the benefits of recovery and decrease trauma to the body by delivering that surgical treatment with the robot all of those are the reasons why I promote it and I think it's the best thing for lung cancer patients in particular and other thoracic and oncology well.

I think you bring up a good point I recently did a promo with our system to talk about making sure patients understand that treating early stage disease is much better option in lung cancer and to encourage people to continue their screenings despite all this COVID-19 stuff that's going on and keeping people at home. I think that it's a great point and talking about early stage disease versus late stage disease and how much better patients do when we get them early versus late in lung cancer. One of the advances in heart surgery has been the minimally invasive approach to valve surgery, we now have transcatheter procedures which allow deployment of a new valve in the same manner that a patient would have a heart Cath. We also have minimally invasive surgical procedures which allows the surgeon to do valve replacements as well, can you tell us a little bit more about those type of techniques?

That has been one of the best developments in my field, being a cardiac surgeon, in the last decade and that really is the heart valve team. That involves cardiologist, cardiac surgeons, pulmonologists, noninvasive cardiologist, a whole team of people that are expert in cardiac care all from different aspects. Each brings their own talents to that setting and the evaluation of a patient with that array of talent around them, I think will give them the best possible outcome. So for any given patient the objective is to provide them the best possible outcome for whatever condition they have that requires treatment. The valve team, with the patient can decide what is best. The product of the valve team is to execute that decision for treatment with the patient, so that may involve a catheter based technique or it may involve surgical technique and the goal is to give the patient the most durable outcome, longest lasting, best quality of life possible. The valve team, through their analysis, is the best way to achieve that and the tools that we have are either catheter based, surgical based, and within the surgical world minimally invasive or our traditional approach. So you know every part of that array of treatment options is enabled and directed by the valve team for the best possible outcome. Within the catheter based treatments we have both mitral and the aortic valve treatments as well as PCI done by the interventional cardiologist. So again, almost all of the therapies we can do surgically, we can do with the catheter. They're not the same though, there's differences and depending on the patient characteristics, one of those two worlds either surgical or catheter based becomes most appropriate. In general, when patients have a longer life expectancy, we want the longest lasting, most durable procedure for their condition and that typically, not all cases but typically, involves an open surgical procedure- either a minimally invasive technique or a more traditional technique. If patients have limited life expectancy or are high risk for surgery or have other health conditions which make surgery less desirable to treat their cardiac condition, then the catheter best based techniques are an option and we explore them. Within the surgical world and for patients with long life expectancy who are either young or old but in very good shape other than their heart condition, you know, the minimally invasive surgical techniques have a lot of appeal and fortunately our team here has, long before I arrived, developed these programs for the treatment of these patients that keep them safe and provide them very good outcomes. Unique to Shipley, there aren't many programs across the country that can offer the type of minimally invasive technique that we do and we’ve become adept and expert at it as a result of our team. I'm happy to be part of that team and I benefit from all of the expertise that was created even before I arrived. As a consequence of that being here, it's easier to push it now forward from where it was five years ago and in particular the right chest approach that we do I think is superior in many ways to a lot of the other minimally invasive techniques that are offered in various parts of the world for cardiac surgery. In particular, patients are curious about robotic mitral valve repair, of course I’m a fan of the robot as we've talked about previously but as it relates to this technique I don't think it provides an advantage over a minimally invasive right chest direct approach to the heart. In many ways I think our technique is both less of an incision, less of an invasion into their body and provides them a faster more reliable recovery with less perioperative risk. So I think where we are, which is not created by us, we are students of other masters elsewhere that have taught us this, there's no question about that. But, because of their excellence we've been able to take that and push it forward and I think our patients here it benefit from that. It’s unique, it's not well known we don't advertise it, we just take care of our community and and they're benefiting from it and that's our primary mission. I think though that as we're able to have programs like this and we're able to talk about it in a larger environment hopefully it will have greater penetration throughout cardiac surgery across the region, across the country and in time it will reach other audience (host) become the standard of care throughout the country I think for the diseases that we currently treat it should be.

Do you have any recommendation for our listeners in regards to how to take care of their health? We see a lot of people come through here who I think want to take care of their health but they're not sure exactly how to manage all of that, any recommendations from a renowned heart surgeon?

Thank you for the compliment about being a renowned heart surgeon, but I do my best everyday with our team, which are excellent. The main key to that question I think is to find a doctor that you trust. Any accolade that I or some other person may have matters little to someone who needs healthcare and needs help from the person, in this case a doctor. I think that like all relationships, you have to trust the person you're talking to and relying on for advice and that's simple. I think that's the kind of lesson you learn in kindergarten, you know, how does this person respond to you, they listen to what you're saying and you believe the advice that they're giving you. I think anyone can determine that and I think that's the most important thing in a doctor patient relationship is trust and genuine interest in the other. I think that's very common, I think most physicians possess that, and so that when you are talking with your doctor listen, both ways, doctors need to listen to the patient and patients need to listen to the doctor and then you have to implement what's being delivered in terms of advice. So you know, primary care I think is the way to go. I mean I have a primary care physician, I trust that person, they give me good advice and I try to do my best to follow it. That's step one, you know beyond that when you develop more specific conditions relative to what I treat, the cardiologist is the first line of knowledge and information for those patients. Once you get to a heart surgeon you're pretty far down the line, you've already seen experts, your primary care doc plus your cardiologist, they've already done the hard work and then we execute a lot of what they direct us to do along with the patient talk them through that, that's where our expertise comes in. I love to talk to patients about their conditions but I recognize that the expertise for what they need lies in their primary care doctor or their cardiologist primarily and then very specialized end stage stuff that we execute for them is where are our talents lie.

Dr. DeFrain, thank you so much for being here with us today. Is there anything else you want to add before we close?

Well thanks opportunity talk today, it was fun. I think that I just like the close saying that you know this is a tremendous community. We are the Shipley Cardiothoracic Center here but everything that we've accomplished is the consequence of so much support around us and having established the team that exists here that's what makes us unique. I don't think everyone knows that about us except for the people that come through here and our patients that we treat, probably 1600 a year. I think the vast majority of them are shocked that this existed in their backyard and I'm very grateful to all the people that make that possible. I'm fortunate that mostly patients identify me, at least the ones that come under my care, think that you know I'm going to did all this but clearly not you know when I tell them that every time that you know there's so many talented people around me and my partners and our team here that support us that make this place great. I am proud to say if I had to have heart surgery I would have here. I could go anywhere and many of our patients who come here could go anywhere but for me or my family, my wife, my children, and my extended family I would encourage him to come to this facility for heart surgery. I'm grateful to be here I think we're all fortunate, I think many of us appreciate the value of this team and I'm here today partly in an effort to promote them.

Thank you thank you so much Dr.DeFrain for being with us today to talk about Shipley Cardiothoracic's minimally invasive surgical program until next time I'm Cathy Murtaugh-Schaffer and this has been HeartBeats Shipley Cardiothoracic Centers podcast dedicated to bringing research innovation and education to our patients and the community.