Questions on Selecting a Surgeon

[Motion4663]

Hey there. I need to begin the process of consulting with a surgeon (or surgeons) for a Mitral Valve repair/replacement due to prolapse with severe regurgitation. Is there a widely accepted 'best approach' to finding/vetting potential Surgeons? I am located in the Bay Area, Ca but am weighing the possibility of traveling.

If you wouldn't mind sharing any pertinant advice or experience, it would be appreciated.

Thank you!

 

[pellicle]

Hi Motion

first I'm going to say there are about 100,000 of these surgeries done in the USA per year

Reports suggest that 250,000 heart valve surgeries are performed worldwide each year, with approximately 99,000 of those occurring in the United States. In addition to heart valve replacement surgery, patients may also undergo heart valve repair surgery.​

https://www.heart-valve-surgery.com/heart-valve-replacement.php

That's over 270 per day

There is just no way that you can think of this in terms of "who's the best surgeon", what you need to do is instead consider that instead the success of outcomes are linked directly to:

• the rest of the theatre team
• ICU care
• follow up intervention
• cardiac rehab

While the ego's of surgeon's would love you to think "its all about them" its not. No more than its about the driver of the F1 team that wins the races without the rest of the team.

I'm not American but I've been here long enough to know that the issue of hospital selection is key. Some others here can perhaps give you a state by state assessment of hospital outcomes

https://www.ahajournals.org/doi/full/10.1161/circulationaha.105.600973

Conclusions— A number of the US News & World Report top hospitals fell short in regularly applying evidenced-based care for their heart patients. At the same time, many lesser known hospitals routinely provided cardiovascular care that was consistent with nationally established guidelines.​

I recommend reading this and ask yourself "what difference does the surgeon make here"?

My view is that while good surgeons are attracted to good hospitals, good hospital administrators don't want poor performing surgeons at all. So be guided by the hospitals outcomes

Best Wishes

 

[Chuck C]

Hi and welcome to the forum.

In that you live in the Bay Area, you have several world class hospitals to choose from, as well as several top notch surgeons. I'm in Southern California, and was in a similar situation, with LA only 90 minutes away and San Diego 60 minutes drive, I had several choices. We are fortunate to have so many choices, as some don't have any top hospitals nearby.

I'll share with you how I narrowed things down. US News and World Report ranks the top hospitals every year, based on specific medical areas. I started there looking at their rankings of Best Hospitals for Cardiology, Heart & Vascular Surgery. See link below.

https://health.usnews.com/best-hospitals/rankings/cardiology-and-heart-surgery
There were several top hospitals on the list nearby me. I then looked up specific surgeons at these hospitals, to see who was the most experienced and had the best outcomes, meaning the lowest mortality rates. This data is reported and there are resources which can provide it. I can't remember offhand the name of the website I used, but if I think of it I will circle back and link it. It was free, but at some point they required you to join to see the stats.

The top hospitals will have generally excellent surgeons, but there were some differences in terms of experience and outcomes. I narrowed it down to the head of heart surgery at Cedar Sinai and the head of heart surgery at UCLA. Both had over 3 decades of experience in heart valve surgery and both had survival statistics much better than the national average, as well as hospital re-admittance rates lower than the national average. Keep in mind that the survival stats are a 30-day survival rate, and so having a top score here speaks to the surgeon's ability, but also to his team, including the ICU care team. Like many people who go through valve surgery, I had a complication and was very glad that I was in competent hands in ICU, to see me through those rough waters.

I set up a consultation with the surgeon at Cedar Sinai first. He didn't give me much time, and mostly just gave me a small lecture about what aortic stenosis was and my valve condition. Later, I would meet with the UCLA surgeon, who gave me over an hour of his time and answered every question that I had. He was also happy to discuss published medical literature about my condition and demonstrated a depth of knowledge, giving insight into studies which I had questions about. I felt very comfortable with him and decided he was the one. I had these consults months before I was told that it was time for surgery. When an echo months later indicated that it was time for surgery, after meeting with my cardiologist, I scheduled another consultation with the UCLA surgeon to prepare for surgery, discussing the final choices. You will want to specifically ask about how experienced they are with your situation- mitral valve repair and replacement. You also may find that the top hospitals have a particular surgeon who is the "go to" person for repair, when that is a possibility.

I don't think that either of the surgeons saw the first consult this way, but I looked at them as me interviewing them for the job of opening up my chest. I think either one, along with their teams, would have been excellent, but I went with the one who seemed to care the most and was willing to take as much time needed to answer every question that I had.

One other point. Don't take too long deciding on which surgeon. You have indicated in a previous post that you have symptoms. If you have your eyes on a particular surgeon and he is booked for the next 6 months, move on. There are probably over a dozen high caliber surgeons in the Bay Area and probably the biggest mistake that you can make is to wait too long.


Best of luck in choosing your hospital and surgeon. Please keep us posted.

 

[Motion4663]

My view is that while good surgeons are attracted to good hospitals, good hospital administrators don't want poor performing surgeons at all. So be guided by the hospitals outcomes

Thanks Pellicle. Thats helpful for me to hear. I skimmed through your link and will sit down to digest it.

 

[Motion4663]

https://health.usnews.com/best-hospitals/rankings/cardiology-and-heart-surgery

Thanks Chuck for sharing some of your experience. I would be interested in finding the website that reported on patient mortality if you come across it again but will look on my own as well.

edit: I found the Society of Thoracic Surgeons website which ranks different procedures searchable by state Here

 

[V__]

Is there a widely accepted 'best approach' to finding/vetting potential Surgeons?

Don't know about the "best" approach. But here are a few questions you can ask the surgeon, that are specific to the MVr(R):

• Number of mitral valve surgeries they are performing per year. (The results tend to be better, if it's at least 25).
• The odds of repair instead of replacement. (Typically should be at least 90%.)
• The surgeon's "residual regurgitation rate" - basically, how successful the repairs have been in the past. (Should be in high 90s.)
• If you have a Barlow valve. (It's a complication that seems to make the repair more challenging, but still doable. The conclusion is made after examining TEE images.)
• If your tricuspid valve is ok. (Also a result of TEE examination. This valve can be affected by the MV disfunction.)

I also asked about how long the people on the team have been working together. It's about 10 people who have to work together for several hours while you are under.

 

[Gail in Ca]

I lived in the Bay Area most of my life.
When my aortic aneurysm was discovered, my cardiologist recommended Dr Miller at Stanford. They tried to set it up but told me he was on sabbatical. I went with my cardiologist’s
2nd choice. So, for my subsequent 2nd and 3rd surgeries, I was still recommended to go to Dr Miller by my new cardiologist and my sister’s friend, a cardiologist in LA who also said Dr Miller was the surgeon he would use.
I met with him, he exuded confidence, was intelligent and kind.
I asked how many of these surgeries he had done and he said ‘Alot’!
So, he did my surgeries. He’s retired now.
I had great outcomes at Stanford.

 

[carolinemc]

Hey there. I need to begin the process of consulting with a surgeon (or surgeons) for a Mitral Valve repair/replacement due to prolapse with severe regurgitation. Is there a widely accepted 'best approach' to finding/vetting potential Surgeons? I am located in the Bay Area, Ca but am weighing the possibility of traveling.

If you wouldn't mind sharing any pertinant advice or experience, it would be appreciated.

Thank you!

You have to know who have right to perform the surgery there is you have a choice surgeon. Not all are allowed to work in certain hospitals. And here on the board go local to save travel distance. Best to look at the online directory at the hospital and go from there.

 

[Motion4663]

Don't know about the "best" approach. But here are a few questions you can ask the surgeon, that are specific to the MVr(R):

• Number of mitral valve surgeries they are performing per year. (The results tend to be better, if it's at least 25).
• The odds of repair instead of replacement. (Typically should be at least 90%.)
• The surgeon's "residual regurgitation rate" - basically, how successful the repairs have been in the past. (Should be in high 90s.)
• If you have a Barlow valve. (It's a complication that seems to make the repair more challenging, but still doable. The conclusion is made after examining TEE images.)
• If your tricuspid valve is ok. (Also a result of TEE examination. This valve can be affected by the MV disfunction.)

I also asked about how long the people on the team have been working together. It's about 10 people who have to work together for several hours while you are under.

Thank you that is good to know!

 

[tommyboy14]

Hello,

I would advise against talking too to many surgeons, but it is good to speak to a few.

I went to the cleveland clinic london, spoke to three, chose the one with lowest complication rate.
(It isnt just about mortality, but all the other things that can happen after surgery)

I think it would be good to go to a mitral valve repair specialist. There are some doctors who specialise in this. I had an aortic valve redo the last time, so I went to a surgeon who does 60% redo's.

Ideally you would want to pick someone who has published his long-term results on mitral valve repair in reputable journals.

Best of luck with your surgeon search and surgery

Tommy

 

[Motion4663]

Hello,

I would advise against talking too to many surgeons, but it is good to speak to a few.

I went to the cleveland clinic london, spoke to three, chose the one with lowest complication rate.
(It isnt just about mortality, but all the other things that can happen after surgery)

I think it would be good to go to a mitral valve repair specialist. There are some doctors who specialise in this. I had an aortic valve redo the last time, so I went to a surgeon who does 60% redo's.

Ideally you would want to pick someone who has published his long-term results on mitral valve repair in reputable journals.

Best of luck with your surgeon search and surgery

Tommy

Thanks for the advice! How did you go about determining a surgeon's complication rate? Just by asking them, or is there another resource available?

 

[Croooser]

Lots of good advice here. I went to CC in Cleveland because they had a first rate surgeon AND first class facilities AND first class staff that contribute to their record of achieving excellent outcomes.

At CC no matter who the lead surgeon is, it is likely that a resident will open and close... At least that was my experience. I decided that was OK for me. Worth understanding,

 

[pellicle]

hey @Motion4663

I somehow missed mitral repair in that first post, accordingly I want to say "hear hear" to these points

• Number of mitral valve surgeries they are performing per year. (The results tend to be better, if it's at least 25).
• The odds of repair instead of replacement. (Typically should be at least 90%.)

I would advise against talking too to many surgeons, but it is good to speak to a few.

I went to the cleveland clinic london, spoke to three, chose the one with lowest complication rate.
(It isnt just about mortality, but all the other things that can happen after surgery)
...
Ideally you would want to pick someone who has published his long-term results on mitral valve repair in reputable journals.

 

[Survived03]

Motion4663,
I had both of my open heart surgeries at Stanford. One by Dr Miller in 2003, same as Carolinemc and one by Dr Fischbein. Dr Fischbein studies and practiced under Dr Miller. In fact, Dr. Fischbein sat in on my first surgery having just started his fellowship at Stanford. I have nothing but great things to say about Stanford and the teams that I interacted with as a patient. I did also get a second opinion from a thoracic surgeon in the John Muir system. I felt he was highly competent and could do the surgery but I chose to go with those familiar with my original surgery. UCSF is highly regarded as well, but I don't have any personal experience. Let me know if you have any questions.
Good luck.

 

[dornole]

Def look for a mitral specialist / hospital that does high volume of mitral repairs specifically. It’s great to keep your native valve and lots of mitral valves can be durably repaired. I had mine done at the heart hospital near my home in Minneapolis.

 

[dornole]

A cardiologist did my repair not a surgeon. And yes as others mentioned he has several published and often cited journal publications. Not that I knew that at the time. I was just lucky.

 

[pellicle]

Not that I knew that at the time. I was just lucky.

same for me when I was started on my course in 1974 ... not that I knew at the time and I am grateful for having who happened to be the team. When I did understand that I made sure that I'd be using them for #3 ;-)

 

[Protimenow]

When I had my aortic valved replaced in 1991, there weren't many surgeons doing this type of surgery.

My path to the surgeon took three steps -- my PCP referred me to a cardiologist that he thought was one of the best - 30 miles from my home.

That cardiologist evaluated my situation and referred me to one of the cardiac surgery specialists who had done many of these surgeries. He was still 30 miles from home, but apparently the best.

He had a very well tuned surgical team -- one minor complication (seeping through my rib sutures) was quickly managed. I didn't know about this until my wife told me about it.

I echo the advice of others - make sure the doctor doing the surgery has a skilled team - a team that can help during and after the surgery. Many of the hospitals that specialize in this surgery will have departments focused on cardiac surgery.

I know that I'm not telling you anything that others haven't already said more eloquently, and with links that provide useful information.

With so many surgeons now doing these types of surgery, I echo the advice that you should reduce the 250,000 to those who specialize in mitral repair, but are also expert at valve replacement.

The Bay area has a lot of great hospitals, and I'm sure there are a lot of great surgeons and surgical teams.

Good luck narrowing the list of specialists and finding the perfect match.

(FWIW - it's Cedars-Sinai, not Cedar Sinai - I used to work there years ago - the merger of Cedars of Lebanon and Mount Sinai hospitals on the site of Mount Sinai. And, a bit of trivia -- the old Cedars of Lebanon Hospital has been painted purple (I think) and is the headquarters for the Church of (?) Scientology).

 

[Zoltania]

When I found out that I might need mitral valve repair surgery, I started investigating, thinking that I might want to change insurance plans at the turn of the year and select a specialist in the Bay Area where I live. Circumstances forced me to get the surgery that same year, at Kaiser, with no choice of surgeon.

When my assigned surgeon walked into the exam room and introduced himself, he said that his two areas of specialization were mitral valve repair and minimally invasive surgery. I felt better immediately. As far as I can tell, his work was as good as I could have gotten elsewhere, and it was certainly as good as I needed. I know other people on this forum have had negative experiences with Kaiser. Kaiser has so many doctors that it's impossible to pin one label or rating on them. I was lucky and had a good experience.

So it's good to do the research you are doing, but you will very likely do fine with an "ordinary" surgeon, unless you have unique issues.

 

[V__]

at Kaiser, with no choice of surgeon.

Thanks for sharing the story. I can add that, when my surgery was planned last year, Kaiser also had an idea who the surgeon would be. When I got the call to schedule the appointment with the surgeon, I asked about my choices. The explanation was that they first review the cases internally and figure out the best match to the surgeon. At the same time, they are trying to accommodate the patient's preferences. In case of the mitral valve there were 2 surgeons who usually operate on them, so I could go with either one. After thinking a bit, I decided to go with their preference. But the alternative was looking quite good as well. I think they are both very experienced.