New Advances in Cardiac Surgery Improve Recovery, Survival

As Yale’s new chief of cardiac surgery, Marc Pelletier, MD, MSc, assumes his new role leading one of the country’s top destinations for state-of-the-art and traditional heart surgeries, he remains deeply focused on the patient’s experience.

“For my patients, it’s probably the only time in their lives they are going to have this type of operation,” Dr. Pelletier says. “Many people will measure their life around it. They talk about ‘the time before’ and ‘the time after’ heart surgery. It’s a huge event in their lives and a big responsibility. That’s never been lost on me.”

Dr. Pelletier joined Yale Medicine and Yale School of Medicine in April as chief of cardiac surgery, and physician-in-chief of cardiac surgery for the Heart and Vascular Center of Yale New Haven Health System—where survival statistics for coronary artery bypass, mitral valve replacement, and aortic valve replacement consistently exceed national and regional norms.

A native of a small town in New Brunswick, Canada, he has decades of experience and leadership roles in cardiac surgery at leading institutions in North America. Most recently, he served as division professor and chief of cardiac surgery at University Hospitals/Case Western Reserve University in Cleveland. Before that, he was surgical director of the Transcatheter Aortic Valve Replacement (TAVR) program at Brigham and Women’s Hospital and clinical associate professor at Harvard Medical School.

As a practicing surgeon, Dr. Pelletier has multiple areas of specialty, most of which involve approaches to surgery that are less invasive than traditional heart operations. They include minimally invasive and robotic-assisted mitral valve surgery and TAVR, a minimally invasive procedure that replaces a diseased aortic valve with a new one. He also provides surgical care for heart failure and minimally invasive coronary artery bypass surgery, among other procedures.

During his first two weeks at Yale New Haven Hospital, Dr. Pelletier participated in four heart transplants. He calls that an unusual pace for heart transplants, although he has typically performed 200 to 300 various types of heart surgeries a year. At Yale, 30 to 40 heart transplants are performed each year—a volume that ranks among the leaders in the country for heart transplant surgeries.

Cardiac surgery, as a field, has seen not only dramatic advances but also a steady evolution that is impacting patients positively. In addition to greater use of minimally invasive procedures, he finds advancements in robotic surgery and the use of artificial intelligence (AI) in the operating room to be particularly exciting. Dr. Pelletier plans to build upon an already solid team and continue expanding cardiac surgery’s capabilities with even more innovations.

We spoke with Dr. Pelletier about Yale Medicine cardiac surgery and his plans for expansion and change.

Cardiac surgery is becoming both more complex but also less invasive for the patient. The specialty is advancing forward in multiple areas, especially patient comfort and safety. I've been fortunate to do many different types of heart surgeries, but in the last few years I've migrated toward minimally invasive surgery, especially as it relates to mitral valve surgery.

Traditional open-heart surgery, such as coronary artery bypass grafting (CABG) to treat narrowed or blocked arteries, typically requires making an incision down the middle of the chest, through the breastbone, and temporarily stopping the heart. Full recovery takes a few months for most people, and thankfully most patients fully recover and go on to lead long lives.

While this approach is still necessary and the standard of care in the majority of cases, many patients are increasingly benefiting from minimally invasive, robotic or robotic-assisted surgeries. These procedures often achieve similar goals, but by accessing the heart through small cuts in the side of the chest, between the ribs, where we insert small instruments or tools and cameras that may be partially or fully controlled with exceptional precision by robots. This causes far less trauma to the body, as we don’t have to go through the bone, and the incisions are smaller and less painful.

For example, we can treat a patient’s defective mitral valve—the valve between the upper and lower left heart chambers—by making a small incision between the ribs and a small one in the groin. This allows us to enter the heart and fix or replace the mitral valve. Patients are usually sitting in a chair at the end of the afternoon, and we can send them home three days after surgery. They drive again in a week or two and resume other normal activities in about a month. In some cases, we can do the same thing with the aortic valve, the tricuspid valve, and atrial septal defects, and also with minimally invasive coronary bypass surgery.

Monumental changes have also occurred with structural heart disease. This includes TAVR, which has been a big part of my career for the last 10 or 15 years, and has undergone the most dramatic shift I've seen in cardiac surgery probably in the last 30 or 40 years. If a patient’s aortic valve is narrowing, which becomes more common with age, we replace the entire valve with a manufactured one, working through a small incision in the groin while they are under conscious sedation, awake, and talking to us. It can take an hour. They go home either later that day or the next day.

This has been revolutionary. Along with our colleagues in cardiology, we can work together to fix a leaky mitral valve or even replace it using new evolving technologies, most of which are still in the research stage. There are so many new valves being developed. It’s really an exciting time.

Yale is already a leading institution in many areas of cardiac surgery, such as aortic surgery and valve surgery. We have many talented individuals and a program that is strong and stable.

But many more cardiac surgeries could be done both here and nationally with minimally invasive techniques. For example, only about 20% of mitral valve surgeries in the U.S. are minimally invasive and/or robotic, so there is opportunity for growth there. There are limitations; for instance, sometimes patients are treated at small centers where surgeons don't have the expertise to do minimally invasive or robotic surgeries. There can be many reasons, but sometimes surgeons simply were not exposed to these surgeries during their training and might have limited opportunities to obtain this particular skill. Our job is to both perform these procedures and train the next generation of cardiac surgeons to build upon this.

We plan to continue expanding our capabilities at Yale, building on strong existing programs. We also have a mission to educate the surgeons of tomorrow, to teach them leading-edge surgeries. As a surgical leader, it’s most important that I ensure that we're doing the best and safest operations and that we're using research to advance the field in innovative ways. Yale is already doing a lot of that, and I expect we will do even more over the coming years.

For us to be successful, teamwork is a key component. We do this work well and achieve good results because we have good teams working together with the right supporting structures. Our teams include a multitude of people with special skills, including anesthesiologists, cardiologists, nurses, perfusionists who manage the heart-lung machine, surgical technicians, intensivists, and others. As we undertake more complex procedures, the excellence of a team becomes crucial to success. The cardiac surgeon may lead the team, but that is only one part of the equation.

In some cases, robotic assistance has transformed certain types of surgeries, with smaller incisions and faster recoveries. In heart surgery, there is still a very small percentage of cases that are done robotically in the U.S., but we are slowly seeing an increase in the use of robots to assist with surgery. Even in standard surgeries, assistance from a robot may provide an overall better result. Sometimes the robot provides better visualization for the surgeon. Sometimes it enables the surgeon to perform a less invasive procedure, so the incisions are smaller and recoveries are more comfortable for the patient. The robot may be able to reach areas that would otherwise be harder to access.

A few years ago, the only heart surgeries being done robotically were mitral valve surgery and coronary bypass surgery. That’s changing. You're now seeing robots used in surgery for aortic valves and atrial fibrillation. Recently, in Saudi Arabia, surgeons performed the first fully robotic heart transplant on a 16-year-old who had end-stage heart failure. The use of a robot in heart surgery will continue to increase.

On the AI front, we're still in our infancy. Our use of AI has been mainly limited to surgical planning, where AI and sometimes 3D printing are used to create a model of the patient’s heart in advance of the procedure. This helps us visualize how a new valve might fit in the heart and how we can achieve the best results—by planning ahead.

In the future, AI may help us perform safer surgeries. It may guide the surgeon as they operate, something like when you are driving a car, where you are still in control, but the car will tell you if you’re too close to another car and need to slow down. Similarly, we may use AI to analyze an operation in real time. As an example, it may make a sound to let the surgeon know they are nearing an artery that will bleed if they get closer. These are small things that can improve a surgery and make it even safer.

There was a time when I was doing a lot of basic science research, looking at stem cell differentiation, trying to regrow heart muscle tissue. I was also doing a lot of research on the transplant side, trying to reduce the effects of immunotherapy, rejection of the transplanted organ, and things of that nature.

In the last few years, as my leadership roles have required more administrative time, my research interests have migrated more toward clinical outcomes and innovation. For example, such a study might involve using existing databases to provide insights into such questions as, "What's the best way to do a particular operation? Should I do this type of operation or a different one for this patient? What’s the best medication to prescribe after a particular surgery?" Research questions like those can often impact how care is provided.

There are many facets to being a cardiac surgery leader. There's the administrative component, the regulatory component, and the compliance component. There is taking care of patients, doing research, and educating future surgeons. It can be tricky to balance those things, and it’s not something that we normally learn in medical school.

About 15 years ago, I read an article in The New Yorker magazine by the writer Atul Gawande, a surgeon at Brigham and Women's Hospital and professor at Harvard Medical School. This was a seminal piece for me. He was playing tennis on a vacation in the Caribbean and ended up playing with a coach. Even though he had played all his life, thanks to the coach, he left that vacation feeling that he was a better player. This made him realize that if he could be a better tennis player with a bit of coaching, could he also be a better surgeon by hiring a coach? He eventually hired a retired surgeon (someone he knew and respected) to observe him in the operating room. At the end of a surgery, the surgeon would say things like, “Why did you do it this way? Would it be quicker if you did it another way?” Dr. Gawande said it made his surgeries a little quicker and he had better results.

For me, a light bulb went off, and I chose to hire a coach to help me figure out how I could become a better leader. While I was doing a decent job, I was able to improve some things and become a better chief because I had a coach. I believe coaching and self-improvement can help anyone. For me, the self-assessment component, and developing an action plan to execute on top priorities, have been most helpful.

That’s an important question, because I think that striving for a balanced life has been a key to my success. If our life is out of balance, it becomes hard to function at our best. I've always had a strong philosophy that a mentor taught me, which is to not make your life only about work. Work is important, but so is your health—psychological and physical—and your family and relationships. It’s important to prioritize your health and family whenever possible. If our health and relationships are not good, then how can we excel at our work?

As a surgeon, we must often stand in the operating room for hours at a time, without a break. Hence, being in reasonable physical condition, and taking the time to do so, is essential. You don’t want the surgeon thinking about their back pain when they're working on your heart, or for them to be mentally exhausted.

When surgeries go well and patients recover properly, the work of cardiac surgery is incredibly rewarding. That’s especially true when a patient has recovered from their operation, when they come back smiling and feeling like they've gone through an incredibly difficult moment in their lives, but now they have their life back. I love that about heart surgery. More than anything, that’s what keeps me coming back.