- Good evening, everyone.  So, I'm a surgeon and surgeon always start on time, and it's 6:30 and medical school is in session.  So now we're going to get things going.  Those of you who have been here before, Craig and I usually have easier duty than this.  We get to sit down and watch, but today we are part of the event.  I never get to introduce Craig Kent, but let me just briefly.  Craig was recruited by our dean, Bob Golden, who sends his regards, a year and a half before I was recruited, from New York.  He could choose to go to just about any medical center, university, in the country, but he was recruited here because he saw something special that he then convinced me was absolutely the case here in Wisconsin at the School of Medicine and Public Health.  His department of surgery, they do great clinical care.  Remarkable results, I think is the brand. 

 But beyond the excellent care clinical care, they're also educators and they are scientists and they are consistently in the top 10 nationwide in terms of NIH funding.  So please join me in welcoming our moderator for today's session, my good and friend and colleague, Dr. Craig Kent.  Let me say that again.  Dr. Craig Kent.  [applause]  - Thank you, Rick.  That's very kind.  Again, I think we have a really great program for you, and the central theme is going to be two patients.  This is Mr. and Mrs. Smith.  [laughter] Now, you can't see there, but they're celebrating their 75th wedding anniversary.  [laughter] And they're having a hell of a time. 

 [laughter] Okay.  So, Martha, Martha Smith, has problems with her carotid arteries and she has some heart disease, and Mr. Smith has had an aneurysm and also has a valve problem in his heart.  So they're struggling a little bit, and what they did is came to us at the University of Wisconsin Cardiovascular Center, where we happen to have what we call the magic potion.  And I think that's the focus of tonight's talk is to tell you a little bit about what that magic potion might be.  Badgers go.  And so they had a little of that magic potion, and this is the result.  [laughter] Now, results are not guaranteed.  [laughter] In any event, we do have a story to tell you.  And we're going to begin with a younger Mr. and Mrs. Smith.  They're in their 50s. 

 Mrs. Smith works as a 6th grade teacher and becomes a bit lightheaded a couple of minutes while she's instructing her class, and then she collapses.  Within a few seconds, she's responsive again.  She wakes up, but she's kind of nauseated, a little clammy, and just doesn't feel well.  Everybody around her says, "Mrs. Smith, "you've got to go to the hospital, you've got to be checked." The school actually calls the paramedics, but she doesn't go in and takes the rest of the day off.  She does go to her primary care doc, and he refers her to a UW specialist, Dr. Hamdan.  So I'll introduce Dr. Hamdan, who is the Mildred and Marv Conney Endowed Chair in Cardiology, and he's also the professor and chief of the Division of Cardiology at UW.  Dr. Hamdan is a national, maybe that's not right, worldwide expert in arrhythmias.  He's published very widely.  He's been the principle investigator of multiple trials on atrial fibrillation and multiple other studies around arrhythmias.  He's published over 75 articles and authored a number of books and chapters related to this process. 

 So please welcome Dr. Hamdan, our chief of cardiology.  [applause] - Thank you, Craig, for the kind introduction.  And good evening, everyone, and thank you all for being with us this evening.  So the subject of my next eight to 10 minutes is fainting spells.  How do we approach patients with fainting spells? So, fainting, first, is a very common problem.  As we get older, the likelihood of you having had a fainting spell in your life increases.  Around 50% of patients, by the age of 70-80, would have had at least one fainting spell.  There are many causes why people faint.  The most common are cardiovascular causes, but also you can lose consciousness because of a neurologic problem, a stroke or seizure, or due to a metabolic problem such as low blood sugar.  When we suspect that fainting is due to a transient drop in blood pressure and the brain not getting enough oxygen, we call that syncope. 

 So there are a lot of elements of the history that tell us whether this was a syncopal event or not.  Usually with syncope, the onset is abrupt, the duration of loss of consciousness is usually quite short, 30 seconds or less, and the recovery is spontaneous and complete.  You don't need to do CPR.  Patients, within a minute or two, they know exactly where they are.  So when you have all these elements that highly suggests that what you had was a syncopal event.  If the answer to any of these questions is no, then you should suspect a neurologic event or a metabolic event.  It's important to know why the patient lost consciousness.  Not only to better treat them, but also to share with them the prognosis.  So this is data from the Framingham study, which is a large cardiovascular study involving thousands of patients, looking at survival in patients who had an episode of loss of consciousness.  And what you see in red here is that the survival is the worst when it's due to a cardiac cause. 

 On the other hand, when it's a benign cause, that I'm going to be discussing later, the prognosis is excellent, and it's not much different than patients who never had a fainting spell.  On the average, patients who have a fainting spell, they see around three doctors before a diagnosis is made.  They often present to the emergency room if they had trauma, otherwise they see their primary care physician, and then they get referred to a cardiologist and maybe neurologists.  And, on the average, they see three doctors, and the rate of diagnosis despite all these visits is around 50%.  So that was really the trigger for creating the Faint and Fall Clinic that we started three years ago here at the University of Wisconsin.  The idea with the Faint and Fall Clinic is instead of you going and seeing all these doctors, we bring all the specialists to you.  So this clinic is staffed by a cardiologist, a geriatrician, and a neurologist as needed, and patients are seen within 24 hours if need be.  And the approach in the clinic is very standardized.  In other words, we don't order every test hoping that we make the diagnosis.  We follow protocols that are driven by the guidelines. 

 So, what is our approach in the Faint and Fall Clinic? Well, the first question we ask is, does the patient need to be admitted to the hospital? Often, when you have a fainting spell, the concern is, is this a precursor of sudden death? Is this a precursor of a heart attack? Do I need to be admitted to the hospital? And there are several elements of the history and we look at your records and try to determine whether the patient needs to be admitted or not.  Majority of cases you do not need to be admitted.  Only very few patients required admission for further evaluation of a fainting spell.  The next question is, do we know what went on? Do we know the diagnosis before ordering any tests? And sometimes we know the diagnosis just listening to the patient and checking their blood pressure and vital signs.  And after that, if we have a diagnosis that's certain, then we initiate treatment.  If the diagnosis is uncertain, then there are several possibilities why the patient had syncope.  The one that concerns us the most is cardiac syncope.  And by cardiac syncope I mean losing consciousness because of electrical or mechanical problem in your heart.  And if that were to happen, then the pump is not going to be working for a few seconds, and that causes the drop in blood pressure.  So what you have here on the top is the EKG, normal EKG, of a patient. 

 And these big spikes that you see represent, basically, electrical activation of the bottom chambers of the heart.  In patients who have heart disease, particularly patients who have had a heart attack, they are sometimes at risk of having a very rapid heart rate that can cause your blood pressure to plummet.  And these are the things that we are concerned about in somebody with a history of heart disease.  And there are several elements in the history that's going to help us determine whether this was likely to be a cardiac syncope or not.  So, if somebody has a history of heart disease, if they have an abnormal EKG, if they fainted with exercise, if they fainted while laying flat, if they had palpitations before losing consciousness, all these are red flags that the event was most likely cardiac.  The second most common type of fainting, by far, actually it is the most common type, is what we call reflex syncope.  And reflex syncope is the medical term we use when your cardiovascular system shuts down for a few seconds.  And the problem there is that the brain sends the wrong message.  And in response to certain triggers, such as seeing blood, getting an IV, standing up for a long period of time, heat, anxiety, all these things could cause the brain to make everything slow down.  So what happens is your heart rate slows down and sometimes may stop for a few seconds, and the vessels dilate. 

 And that combination of the pump not pumping enough and the vessels dilating causes your blood pressure to plummet.  This is a very benign condition.  And once we make the diagnosis, there are treatments to make sure that patients don't have recurrence of injuries.  In some cases, particularly above the ages of 60 and 70, we have concerns about simply a drop in blood pressure because of too much medications, dehydration, and sometimes neurologic problems that do not allow you to deal well with standing up for a long period of time.  So we call that orthostatic stress because the heart is not seeing enough blood, and your cardiovascular system has to work harder to keep your blood pressure where it is.  And if it doesn't do its job, then the blood pressure is going to plummet and that might cause you to faint.  And lastly, sometimes too much stress can cause people to faint, and we call that psychogenic syncope.  And, in some patients, that's how they present when they have a lot of these problems.  So, with this standardized approach that I summarized in three minutes for you, our rate of diagnosis in the Faint and Fall Clinic at 45 days is 70%.  When you compare that to the conventional approach, which is the standard of care in most places, it's around 39%. 

 So it's a significant increase in the rate of diagnosis.  And this is data that actually we just crunched just the past few days, and with more than 500 patients evaluated in the clinic.  The rate of diagnosis at two years was close to 90%.  So we're very proud of that, and now we're looking at the recurrence rate and survival in these patients.  In addition to evaluating patients with fainting spells, we also evaluate patients with falls.  And particularly we have interest in patients who have unexplained falls.  So I'm not talking about accidental falls, tripping and so on.  We're talking about patients where, out of nowhere, they fall.  This is a tracing from a patient, 82-year-old retired professor, who has been having these falls two to three times a year for the past several years, and he tells you that I never had loss of consciousness.  Sometimes he has seizure activity after hitting the ground, and has been treated for seizures without much improvement. 

 So, long story short, we monitored the patient to see if the falls were due to a sudden drop in blood pressure, and when the brain doesn't get enough oxygen, often you lose postural tone and you can collapse.  And what we found that indeed this patient, his heart rate was pausing, and that was causing him to fall.  And what you see here is actually the noise artifact because of the seizure activity that he has.  So this patient ended up getting a pacemaker and haven't had any recurrences.  So back to Mrs. Smith.  Good for her, the diagnosis is very benign.  She has the most common type of fainting that falls under reflex syncope, the one I described earlier.  We call it vasovagal syncope.  That's when, again, the brain makes everything slow down.  In her case, it's probably because she's been standing up for a long period of time. 

 And the hint that that's what she had is because she felt nauseous and sweaty and had some warning signs, and that always indicates that this is more likely to be a benign condition.  So treatment is straightforward.  We give her fluid and salt intake.  We elevate the head of the bed to minimize what we call nocturnal diuresis so that when she wakes up in the morning, she's not as dehydrated.  Compression stockings are extremely helpful, particularly in patients above the age of 60 and 70.  And what you see here are some maneuvers that you can do when you start feeling dizzy that can help elevate your blood pressure and buy you time until you can go and sit somewhere and recover from the event.  So, with that, this is the number for our Faint and Fall Clinic.  These are the providers in the clinic, Dr. Walsh, and we have wonderful nurse practitioners.  And we have two locations.  One here at UW and recently opened another Faint and Fall Clinic at the American Center. 

 So, with that, I want to thank you for your attention, and I think we're taking questions at the end.  [applause]  - That was excellent.  And thank you.  Thank you so much.  So, Mrs. Smith recovers and she does well.  In fact, I think it was a...  Dr. Hamdan, a syncopal episode? Is that what it was? I guess vasovagal, right? Nothing serious.  So, the Smiths, after this episode, decide that they want to relax a little bit.  So they book a trip to Hawaii.  And there they are in their seats in the plane, and the plane takes off, they're up in the air, and Mr. Smith now says, "I'm having some chest pain," and he's a little out of breath. 

 And she ignores him as usual, right? And then a few minutes later, he slumps over in his seat, and she's not able to arouse him.  She cries out for help.  So, to talk about this episode, I'm going to introduce my partner in crime, Dr. Rick Page, who you all know well.  But the part that you don't know about him is that, of course, he's the Chair of Medicine at UW, and medicine is really the behemoth of any medical school.  He has 350 faculty members in his department, and that includes all of the endocrinologists, the gastroenterologists, the cardiologists, the rheumatologists, and so many of the primary care physicians.  I think sometimes leading physicians is similar to herding cats, and he has a very large number of cats to heard.  [laughter] Dr. Page, outside of his administrative responsibilities at UW, is a national figure.  If you go the airport and you see these defibrillation machines, you know? Which have saved literally thousands of lives around the country.  Dr. Page and a few of his cohorts around the country are the people that are responsible for that happening.  And it's very unusual that one physician has the ability to have an impact nationally where literally thousands of lives have been saved, and Rick is that individual. 

 He's the past president of the Heart Rhythm Society.  He currently chairs one of the FDA panels.  The FDA is the one that approves all new devices and drugs, and he's really a leader in new device development.  And lastly, he's published over 200 papers, and one of his most recent editorials was in the "New England Journal," which is really our primary journal that's most prestigious in medicine.  So, please give us a warm welcome to Dr. Page.  Thank you.  [applause] - Thank you, Craig.  So, back to Mr. Smith.  You saw an EKG that Dr. Hamdan showed you.  Remember those two panels, and there was one that was kind of slow and narrow and there was one that was a little bit faster? The top rhythm being normal; the second one being bad. 

 Unfortunately, Mr.  Smith's was even worse.  This is Mr. Smith's EKG.  What's the likelihood that he'd survive this rhythm? This is the heart's electrical activity.  Instead of pumping regularly, it's quivering.  And if it's quivering, it's not pumping blood to the brain, the rest of the body, to itself.  And the AHA analyzed the likelihood of survival, and they pretty much got it right back in 1997 when they identified if you didn't do CPR and you didn't convert that rhythm with what's called a defibrillator, less than one in 50 could survive.  On the other hand, if you do CPR early and shock earlier and earlier, they estimated that if hypothetically you could have a defibrillator right where someone dies, you could have as many as one in three surviving.  Well, back to Mr. Smith.  He was on an airplane that American Airlines had just begun putting AEDs on aircraft. 

 And I got to work with them in this program back in the late 90s when I was at the University of Texas in Dallas.  An AED is an automated external defibrillator.  You've seen them on the wall at the airport.  They analyze the rhythm, then they talk to you and they tell you what to do.  And within 21 seconds, this device can actually convert the heart.  This is what it looks like, and this could be Mr. Smith and that could be the flight attendant on his flight.  You get out this device, you make the chest bare, you put these adhesive patches on, and then you turn on the machine and it tells you what to do.  It analyzes the rhythm, and if the rhythm is a dangerous rhythm, if it's that ventricular fibrillation that must be shocked in order to survive, it tells you to push the button, and that's what happens.  So, back to Mr. Smith.  He has the device put in place. 

 It says, "Analyzing heart rhythm; do not touch the patient." And there's that chaotic heart rhythm.  You push the button when it tells you to.  Shock delivered.  And then this was the rhythm afterward.  The cardiologist will see it's not perfectly normal, but it's slow and it's adequate and the individual patient from this paper that we published-- I must confess Dr. Hamdan was part of the et al.  He was a co-author back when we worked together in Texas.  This patient survived and was awake when he left the aircraft.  And indeed, Mr. Smith has survived.  Now, we got to study this when Mohamed and I were in Dallas, and we looked at the data behind the American Airlines experience, and we wrote it up in "New England Journal." In all cases, we found that ventricular fibrillation was recognized in all cases when the shock was applied.  In one case, someone had terminal cancer and their family said don't give the shock and the flight attendants respected that. 

 But in all 15 where a shock was applied, it converted the rhythm, and 40%, six out of those 15, survived their hospitalization and went home with their usual functioning.  The same time the experience from the casinos was published and the odds were even better at the casinos... [laughter] Where they reported if you got a shock within three minutes by the security guard, of all things, up to one in four died.  Three out of four survived.  Pretty good odds indeed.  Now, the American Heart Association recognizes that it's a chain of survival to remind you gotta know CPR and recognize that someone's in cardiac arrest.  You defibrillate soon with the defibrillator.  You get advanced cardiac support with an ambulance, and you go to a hospital that specializes in caring for such patients.  Now, Mr. Smith survived.  However, he was taken to the hospital and they found the reason he had his cardiac arrest was he was having a heart attack.  A heart attack is not the cardiac arrest. 

 A heart attack is when the blood vessel is suddenly blocked and part of the heart isn't getting blood flow.  And what happened is the cardiologist did an angioplasty and placed a stent, and I'll explain both of those terms to you in just a moment.  But if you do it soon enough, you can save the heart so the person has no permanent damage.  This is a normal EKG.  It didn't look like what he had to begin with.  Unfortunately, this is the EKG that someone like Mr. Smith might have.  I'm not going to go into detail, but these waves here that go up there instead of being flat, cardiologists call those tombstones.  That means your heart is really hurting, and if you don't open up that blood vessel, there will be a lot of damage.  This is the heart arteries.  This is a normal heart artery. 

 But if you imagine one of these is blocked, what would that look like? Well, let's take a look at a cross-section of the blood vessel.  So, again, the artery is going along the heart, but looking across it, if you cut it across, it would be a circle, right? But this individual has, due to a few extra hamburgers perhaps or whatever, plaque in their heart, and then if there's bleeding in that, suddenly a blood clot can block the artery.  And if you don't get to that right away, that's what is a heart attack.  Now, getting to this right away involved blowing up a balloon, but it's not just blowing up a balloon.  A number of years back, we identified that the balloon itself doesn't hold the blood vessel open, so you put a stent in.  A stent is a wire cage.  So at the top, it's before it's been deployed.  At the bottom, you blow up the balloon, you deploy the cage to hold the blood vessel open, and then you collapse the balloon and take the catheter out.  And this is what it looks like inside the artery.  Here you've got this stent holding the blood vessel open, and that blockage is pushed out of the way. 

 Now, even stents aren't perfect.  And Dr. Kent mentioned that I'm working with the FDA with their advisory panel.  And just imagine, it was a great advance to get a stent that would hold the blood vessel open.  The problem is what happens with stents,  if you look at the left, this is, again, looking down the blood vessel.  This circle, those little black dots blown up here, those are the stent.  But you can see the blood vessels blocking off again.  It held the blood vessel open, but you're getting more scar there.  So people came up with the idea of a drug coated stent.  A drug coated stent is shown here on the right.  Isn't that amazing? Instead of having all that scar tissue, here you have these black dots. 

 Again, those are the metal struts that are holding open the blood vessel.  But there's a problem with that.  Our body doesn't like having foreign objects in it.  They-- Our body wants to close them off, and having this exposed metal gives rise to blood clots.  And you don't want blood clots in your heart arteries.  Wouldn't it be amazing if you had a blood, a stent that was deployed and then disappeared? And that's what I actually got to review at the FDA recently.  And the-- This quote came from that meeting.   We voted to approve a stent that does exactly that.  And the quote is: "The holy grail is the idea of putting in a stent that stays open, elutes a drug to keep it open, and then disappears.  People have been talking about this sort of thing for the past two decades, as far as I'm aware, and I consider the technology potentially transformative." Now, this isn't approved yet. 

 We voted for approval, but I wanted to give you all a glimpse of the future.  And you'll be hearing more about stents as we're going through tonight's presentation.  So, back to Mr. Smith.  He survived the cardiac arrest.  The sudden death event.  He survived the myocardial infarction.  The heart attack.  The blockage of the vessel.  He's now got that one vessel opened.  And he didn't have a lot of other disease. 

 There's no significant heart damage.  He got immediate care.  And he goes back to work and goes on with his life.  And now Dr. Kent will tell you more about the saga of Mr. Smith.  Thank you.  [applause]  - So, wasn't Mr. Smith lucky  that Dr. Page was sitting in the seat next to him, right? [laughter] Well, so there's good news, right? Mr. Smith did okay.  He had his angioplasty and all was well.  But he didn't learn very well from his experience.  So, what did he do? They got their kids off to college, and he and his wife were having a heck of a life.  You know, they gained a little too much weight. 

 They don't exercise much.  Dr. Hamdan's told him to take a statin, but they won't take their statin.  And things aren't going so well.  So, at some point, they're walking down the mall together and Mr. Smith can't get down the mall, right? Because he gets out of breath.  And this goes on for a couple of months or so.  Finally, Mr. Smith sees his internist, refers him to Dr. Hamdan.  Dr. Hamdan says, I think you have two problems.  One is you have coronary artery disease again.  You're blockages have come back.  The stents clogged up. 

 And also you have a problem with you aortic value.  And the heart has four valves, but the aortic valve is the one that's really important.  It's the one where the blood is pumped out to the rest of the body, and that valve is stenotic, meaning it's narrowed and not enough blood is coming out.  So, Mr. Smith is referred to one of our illustrious cardiac surgeons, Dr. Lucian Lozonschi.  Dr. Lozonschi is part of my department.  An associate professor of surgery.  A very talented and brilliant, I will say, cardiac surgeon.  His clinical expertise is minimally invasive surgery.  You're going to hear some about that today.  He's really an expert in a program called TAVR, which is a minimally invasive way of fixing heart values, and also robotic cardiac surgery. 

 Can you believe that you can fix a heart with a robot? You'll learn more about that also.  Dr. Lozonschi is also a true surgeon scientist.  Somebody who is excellent in the operating room but also is doing great research.  In fact, he does work with stem cells and has somehow convinced these stem cells to become an artificial heart.  You know, one that actually beats in a Petri dish.  So, give us a warm welcome for Dr. Lozonschi.  [applause]  - Thank you very much, Craig.  So, Mr. Smith is now 68 years old.  And he had the following symptoms.  He has chest pressure and tightness. 

 Shortness of breath, gets winded easily with exertion, and increase tiredness.  So he got the following studies: a positive exercise stress test and echocardiography that showed severe aortic stenosis.  For many of you may not know, echocardiography uses the same principle as sound waves to create the motion picture of the heart.  And same way we look at the babies as fetus and during the pregnancy, monitor that.  Here's some pictures, examples of what we see on echocardiography.  And so here's actually the stenotic aortic valve of Mr. Smith.  You see the valve is thickened and barely opens.  Compared to a normal valve that has the leaflets, those moving things, opened widely, they're thinner, and also we look with the color Doppler on this valve to see the speed of the blood.  And it's in the normal valve, you can see how there's just blue blood that's non-turbulent flowing through this normal aortic valve.  But here you see a lot more yellow and red and orange against the [inaudible] that flows through the stenotic valve here. 

 So, he went to the cath lab, and you've seen from Dr. Page's presentation that how do we get this angiograms is just getting this catheter that's run from the groin, about two millimeters in diameter, and we inject dye that's absorbed by the kidneys and cleared by the kidneys afterward in the urine, and we can define the anatomy by injecting that opaque dye for X-ray.  In this case of Mr. Smith, we found a narrowing and blockage, almost here you can say, in the right coronary artery.  But also, we found on a later inspection on the same angiogram that a ghost vessel appears here, which is the main vessel in the heart.  It has a bad name.  It's a widow maker vessel.  That tells you how important this vessel is.  And so in preparation for the next procedures, Mr. Smith got a CAT scan.  And so this doughnut takes about several hundred X-rays while the patient gets in and out.  And we found that Mr. Smith has a porcelain aorta.  Here's an example, if you don't know. 

 The aorta, what it means is that the valves, a ring of calcium in the position that hardens and that has implications in the treatment options for him.  We'll get back to that later.  So, what are the choices for Mr. Smith now? Facing conventional heart surgery, which we do very successfully for the past 50-60 years in the world.  And by that which means opening the breast bone and putting the body on a heart/lung machine and stopping the heart and doing what we need to do here with the chest open.  Or, in this case, he has, because of the anatomy, he has an option of having a minimally invasive heart surgery assisted by the robot.  And I'll get to that, more details.  Here's what the hybrid approach.  Mr. Smith needs stenting of the right coronary artery.  Dr. Page introduced that concept before.  And the robotic assisted bypass, so-called CABG. 

 It's abbreviated as Coronary Artery Bypass Grafting.  This is the comparison of the incisions in traditional and robotic-assisted bypass.  I had to put an arrow to make sure nobody misses the incision right there.  And so that's what we did.  We took Mr. Smith to the cath lab, we fixed that artery that had the blockage with a stent.  It was not an absorbable stent yet, but it was a good stent.  Very good results.  And next Mr. Smith went home.  Stayed overnight just for observation.  And he could have had a robotic procedure on the same admission, but he had some business to take care of, and so he decided he can come back in a few weeks, which is acceptable from our perspective. 

 Here's an example of how we do the robotic procedure.  And there's some robotic arms attached to the ports.  There's some plastic tubes that go in the chest of the patient.  Here they're getting attached right there.  I have Dr. Kohmoto here assisting at the table.  This is the camera in the middle that's positioned.  There are three ports.  One camera and one for the instruments.  The instruments go through those ports.  It could be scissors, electrocautery and clip applier. 

 Here's me controlling the movement of the robotic arms.  And the robotic arms translate to my movements of the hand or the joysticks there on a one to one scale.  And here's the artery, the mammary artery that runs behind the breast bone.  It's very important for bypassing the vessels.  And we make that artery, a new artery for the heart.  We prepared that very carefully.  We separate it off the chest wall and tie the-- And clip the branches, the bigger ones, and electrocauterize the smaller ones.  So once that's prepared, we make an incision about two inches.  An incision just above or below the nipple, but right on top of the blocked artery that we need to fix and bypass.  And here we bypass directly under direct vision through that small incision. 

 And off pump without stopping the heart.  And that's-- We do that with a thread that's as thin as a hair.  You actually can see I'm tying that suture, and water is used to make sure that the suture doesn't break while I'm tying.  This is done already.  The bypass is open.  And then we check, actually, the flow.  This is a Doppler probe to check the flow and make sure the bypass works properly there.  Then we enclose the incision, which is about two inches.  We just showed, measured the incision.  The usual handshake at the end. [laughter] And the patient gets off to the ICU. 

 And he was extubated in the operating room, had the breathing tube out, and here's him walking later that day.  Which is-- He was very happy about the progress and how things went.  So he went home on day three because he has a tube that has to stay there for a day or so to make sure there's no bleeding from this.  So now, comparing the return to normal activities between traditional and CABG and robotic, this is the CABG, I'm sure a few of you in the audience would know what the difference is.  I was thinking to poll, but it would take too much time.  It's one month for driving.  And it just-- Once patient is off pain medicines, they can drive the car with the robotic assisted CABG.  This man actually went to work in two weeks.  Swimming, golfing, and lifting more than 20 pounds takes about three months because you need the breast bone to let it heal.  Compared to the no breast bone incision, in the robotic procedure, the return to activities can be as short as two weeks. 

 We have one more thing with Mr. Smith to fix.  Because of that porcelain aorta, we couldn't do a traditional bypass.  So, for that reason, we had performed a transcatheter aortic valve replacement.  How that is done is by putting a bigger sheet, this time in the groin, in the artery, and we bring over a wire that's placed in the heart.  We bring a balloon and we crack first open the valve, which is right here.  And so we remove the balloon that's deflated, and then we come back up with the compressed collapsed valve that's sort of similar to the ones we use in surgery, but we're going to place this on top of the old one.  And so this valve comes very nicely across the aortic arch.  What you can see there.  It's 180-degree turn to get to the heart.  And we positioned the valve very precisely across that. 

 At some point, we're going to actually fibrillate and make the heart quiver, as Dr. Page was saying, intentionally so when we deploy this valve there's no movement.  So the valve doesn't go anywhere but the place it's intended to be.  So here we do the last final adjustments.  And then we inflate the balloon while the heart is quivering and leave the valve behind on top of the old one.  And there's a little squirt there, right here.  The polyester the latest generation of valves that's used to better seal the valve in place.  And that device comes out and he's done well.  Here's actually an example of what we do in the cath lab, in hybrid operating room, where here the valve is collapsed and we check the position.  And here, with how we inflate and deploy that valve on top of the old one, we have all sorts of markers here that I'm not going to go into details, but you can see how this valve is deployed.  That was real life; not an animation, obviously. 

 So, he, Mr. Smith got a 26-millimeter aortic valve.  Procedures done awake and he was walking the halls as well, again, evening of the procedure and went home in two days after this.  So, in summary, he got a hybrid coronary vascularization.  The best of both worlds.  Using the artery, that mammary artery behind the breast bone, so that widow maker vessel, and then stenting with a stent that can be better than the usual vein grafts that we take down from the leg.  And the transcatheter aortic valve, which offers excellent alternative to high risk patients or those who cannot go on to go regular heart surgery.  So what sets us apart is that we are the only hospital in Wisconsin that offers the robotic cardiac procedures.  Hence, the only hybrid robotic program in Wisconsin.  And we have the largest experience with this expandable valve.  We're the only center that participates in the national trials with the testing of the newest valves under FDA. 

 And, to look in the future here, I just want to share with you that I was involved with developing and designing a new valve for the mitral, diseased mitral valve in the heart.  It's the second most important valve.  Or the first.  It depends on who you ask.  To develop this, I helped implant this valve earlier in 2014, the first in human, and also more recently, the first few valves in the world in a clinical trial as well as in the United States.  So, Mr. or Mrs. Smith, they're in good shape.  Should their mitral valve get diseased, we're going to be able to help them.  Thank you.  [applause]  - Okay, so, lo and behold, after a lot of work from UW, Mr. and Mrs. Smith are actually doing fairly well.  And there's a good ending here. 

 But they're worried, right? They have a son and a daughter.  One's 38 and the other's 40, and they're in good health, but they really don't want the same thing that's happened to them to happen to their children.  So what they do is meet with their internist and say "Is there any way to prevent this disease from happening?" And, as such, the internist refers both the son and daughter to Heather Johnson.  Now, Heather is a newly tenured associate professor of surgery at UW.  Bravo.  To get tenure at UW, it means that you have to be nationally-known and well-published and an expert in your field.  And Heather's field is preventive cardiology.  She's done some really seminal research trying to understand how to better control high blood pressure in young people.  And, of course, as we all know, if you can prevent the blood pressure from happening, you can prevent cardiovascular disease.  She's really one of the national experts in preventative cardiology, and she's going to tell us about how to take care of the Smith's son and daughter. 

 Heather.  [applause] - All right, well, good evening.  I don't have any exciting videos or anything to share.  No surgery on my end.  You wouldn't want me doing it.  But we're going to talk about how to be able to prevent a first issue regarding heart attack, stroke, blocked arteries, etc, or how to prevent another episode.  So it's the ABCs to prevent cardiovascular disease.  Can everyone hear me? Okay. All right.  So, Dr. Page actually showed a picture of a blood vessel that had a clot in it, and it was a cross-sectional picture.  And what should really be highlighted is the fact that the atherosclerosis, the blocked arteries, those fatty cells that clog the arteries, actually begin very, very early in life. 

 So this particular picture is the vessel.  The same vessel, again, in a cross-sectional view.  And on top are the different layers as far as the progression of how we get to that ruptured or that clogged artery.  The other thing that's highlighted here, though, is that it actually starts in our first decade in life.  So by the age of 10, we already begin to have some changes in our blood vessels.  Here we're talking about the third decade and ultimately the fourth decade.  Now, what's also interesting is that Tom and Mary, Mr. and Mrs. Smith's children, are here.  Tom is 38.  Mary is 40.  They had not yet had an event. 

 And that's called primary prevention where we work with patients in our UW Cardiology Clinic to help them not have their first event.  To not have their first heart attack, their first stroke, or to have major blockages in their limbs or in their arms or legs.  But then, Mr. Smith we're talking about a secondary event as far as not having another heart attack, not having another heart arrest.  Now, for Mrs. Smith, we talked about some blockages in her vessels, but we didn't really talk about a heart attack.  And one point we wanted to highlight is that for men and women, heart disease and death from heart disease is number one.  One heart attack occurs every 43 seconds.  One in three people die from heart disease or stroke.  So both Mr. and Mrs. Smith are at risk of dying from heart disease.  When we talk about the ABCs of prevention, the next few slides I'm talking about is really preventing that first event.  And A is for aspirin. 

 Again, primary prevention.  So there's been a lot of research and a lot of discussion about what dose may be better and is higher better.  What's been demonstrated recently is that aspirin, at a dose of 81 milligrams, that's that baby aspirin dose that we hear about, is the safest dose.  But the age range as far as where we seem to have the best benefit to prevent that first event is between 50 to 69 years old.  And these are for people who are at increased risk for heart disease, do not have an increased risk of bleeding.  We're talking about do not have an increased risk of bleeding in the stomach, stomach ulcers.  But it's important to have this discussion with your doctor before starting the aspirin.  Now, again, to prevent a first event, there's not a lot of data in other age groups.  But again, Mr. and Mrs. Smith already having some disease, aspirin will definitely be discussed.  Blood pressure is the B. 

 So, recently the US-- There was a huge document released in the US about how to even diagnose high blood pressure.  And for someone who's at least 40 years of age, who had what's called a high normal blood pressure, it's borderline.  It's not quite at that high blood pressure range.  Who may be overweight or even certain race and ethnicities, particularly African Americans, blood pressure should be checked yearly.  So if any of these things apply, at least a blood pressure check on an annual basis.  But what we're learning-- So, high blood pressure is also called hypertension.  And more and more we're learning that high blood pressure is contributing to so much heart disease.  Almost 69% of heart attacks are contributed because of high blood pressure.  77% of strokes.  Majority of heart failure, kidney disease. 

 But most concerning is the fact that someone with high blood pressure, if it's not treated, if it's not well controlled, this can result in a shorter life expectancy.  It takes years off of your life, and that's extremely important.  There's also a lot of discussion about 'What should my goal blood pressure be?' 'How low?' 'What should I be treated to?' Overall, in general, the consensus is that that top number should still be less than 140, and that bottom number still less than 90.  But we're learning more and more the purpose of individualized discussions.  Maybe your doctor may recommend a lower target.  Maybe a higher target.  We heard about people who may have fainting spells or falls.  Nevertheless, if medications are started, on average in the United States, two to three medications are needed to get to your particular target.  We also know that lowering your blood pressure will lower your risk for a heart attack, stroke, kidney disease or dialysis, and also lower your risk for heart failure.  So the A was aspirin, the B blood pressure, and C we're talking about cholesterol. 

 For this brief time, we'll just talk about the bad cholesterol.  What's known as the LDL or the low density lipoprotein.  Again, there's been a lot of discussion about statin medications.  We know that statins are recommended if you already have heart disease or vascular disease, like Mr. and Mrs. Smith.  But in talking with their children, if their bad cholesterol is at least 190, if they may have diabetes, or if it's determined that they're at higher risk for heart disease just based upon other issues they may have, like tobacco use, overweight, etc, then a statin may be recommended.  We also know that statin medications can lower your bad cholesterol over 50% as far as that value.  But the biggest benefit for patients is that it lowers your risk for a heart attack by up to 40%.  So, again, going back to really trying to protect those vessels and prevent or help to stabilize those blockages.  It also lowers your risk for stroke by approximately 25%.  So a huge health benefit regardless of all the other things we're hearing about statins. 

 So the D is dietary.  Of course, this occurs right before we go out to our reception here.  [laughter] But, nevertheless, regardless of all the discussion about diets, one of the things that's been agreed upon is called the DASH diet.  It stands for Dietary Approaches to Stop Hypertension.  However, we're also learning it helps to lower cholesterol.  It's been supported by the American Heart Association, the National Institutes of Health, and it focuses on a low sodium diet.  Less than 2,000 milligrams a day.  Low in saturated fat and high in fruits and vegetables.  Low-fat dairy.  I didn't say no cheese. 

 I understand we're here in Wisconsin, but just lower fat.  And reducing our red meat intake.  So yes, you can do Brat Fest and things like that, just not Brat Fest every day, though.  So that's a big difference.  Exercise.  Physical activity.  It helps to lower blood pressure and cholesterol, but it's moderate in intensity.  You don't have to strain yourself all the way to the point of passing out or anything, but something moderate.  Maybe you can do only 10 to 15 minutes at a time.  Even working up to 10 minutes. 

 That's okay.  But gradually getting in maybe 30 to 40 minutes a day will be very, very helpful.  When we say moderate, what does that mean? Whatever your level of activity is, a brisk walk.  Maybe it's moving the arms, doing chair exercises.  tMaybe we do a lap around the reception table before we all eat.  But the key is that it's exercise as being active to help support our arteries and our heart.  So, what we encourage everybody and what we're learning tonight is knowing about your risk.  Notice the shorter column here.  Things we can't change.  Mr. and Mrs. Smith, yes, they have heart disease and their children, yes, they have a family history now of their parents having heart disease. 

 We all gain birthdays each year, so we can't control age.  And race and ethnicity play a role too.  What we can change: Notice the longer list here.  We can be more active.  So, having a sedentary lifestyle.  Reducing our fat and sodium intake.  Quitting smoking, one of the best things we can do.  Reducing and managing our stress.  And if we have to lose a few pounds, gradually working towards that.  If we have a diagnosis of high blood pressure or hypertension, if we have high cholesterol or diabetes, working with our clinical team in order to be able to manage those conditions. 

 So, here at UW Preventive Cardiology, there's a lot of research going on.  My lab is NIH funded, and, as was discussed earlier, we focus a lot on risk factors here in Wisconsin.  Looking at the effects of high blood pressure across all age groups.  But this was published in one of the top hypertension journals, and each line represents a different age.  The lower lines here, the blue and red, are our younger age groups.  About 18 to 31 years old.  And what we notice is that overall, even if they had high blood pressure for years, only about 44% actually received a diagnosis of high blood pressure.  Meaning they weren't getting diagnosed, they weren't getting treated.  And we're working throughout Wisconsin to help improve that.  For patients who may have been over 60 years old, almost 75% received a diagnosis, but it's not at 100% yet. 

 We have a ways to go.  So our clinic is really focused on helping patients understand what their risks are.  Preventing the first event, like with Mr. and Mrs. Smith's children, and preventing another event, like with Mr. and Mrs. Smith.  We work on a personalized plan.  What is your individual risk for heart disease or for another event as far as what we can do? You get to meet with our exercise physiologist to develop a plan or prescription to help you determine how to be active and make it effective.  Then you can use the app that was just discussed also.  You get to meet with a dietician individually.  We have stress reduction plans and programs.  And also, individualized as far as your medication plan.  Which ones may be best for you to help lower your blood pressure, lower your cholesterol, and reduce your risk for heart disease. 

 Thank you.  [applause]  - Thank you, Heather.  That was great.  I think you're going to have about 700 people signed up for your clinic tomorrow morning.  So you better watch out.  So this has been a great story.  I think we've all learned a lot.  Certainly, you've passed your cardiovascular section of mini medical school.  Every story has to have an epilogue, and so they lived happily ever after.   Here's Mr. and Mrs. Smith. 

 They're in their 90s.  Fabulous villa just off the coast of France.  So that worked out okay for them.  Their daughter, CEO Goldman Sachs.  Not bad.  Son, campaign manager, Hillary Clinton.  [laughter] Both are in fantastic health.  Running five miles a day, looking forward to inheriting the villa.  So, that ends our story.  What I'd like you to do is just give a fantastic round of applause to all of our speakers. 

 [applause]  Thank you. ECHO is on.