Areas of expertise
Mitral Valve Repair
The mitral valve is one of the four valves of the heart and separates the left atrium from the left ventricle. This valve disease is one of the most frequent valve pathologies in our environment. Depending on the type of affectation that the valve presents, it must be replaced by a valve prosthesis (mechanical or biological) or repaired (Mitral Plasty or Repair). Mitral repair, when possible, has been shown to be superior to valve replacement or replacement in terms of survival and improvement of the patient's quality of life and should always be the first option. However, it is a technique that requires a lot of experience and is more technically demanding than replacement.
Dr. Montero was a pioneer in the Valencian Community in this mitral repair technique and is possibly the most experienced cardiac surgeon in this type of surgery. In recent years, Dr. Bel, who is part of the Mitral Repair Working Group of the Spanish Society of Cardiovascular Surgery, has also acquired a very important experience in this technique during her years of professional practice at H. La Fe, hand in hand with Dr. Montero, and completing his training with the most prestigious European surgeons in the field.
Coronary artery bypass surgery
When the coronary arteries (those responsible for supplying the heart) are severely obstructed, symptoms such as angina or even myocardial infarction and sudden death may appear. The number of lesions, their location, and the degree of obstruction should be assessed by catheterization or coronary angiography and, depending on this test, it will be decided whether a coronary artery bypass surgery (Coronary Bypass) is necessary.
Coronary Bypass surgery consists of implanting an artery or vein of the patient himself beyond the coronary obstruction so that the heart has irrigation by these grafts. The number of bypasses will depend on the number of damaged coronary arteries and the degree of obstruction thereof.
Coronary Surgery can be performed with or without Extracorporeal Circulation and each case must be evaluated individually since both techniques have their advantages and disadvantages. Numerous studies have shown that the use of arterial grafts (the two mammary arteries and / or the radial artery) has advantages over veins, especially in young patients.
In the Cardiac Surgery unit of Dr. Montero we frequently use the double mammary and the radial artery to try to optimize the durability of these bypasses as much as possible.
1. Comparison between the radial artery and the right internal thoracic artery: which is the second arterial graft choice? Mª J. Dalmau, S. Cánovas, F. Hornero, O. Gil, R. García Fuster, J.A. Montero.Th. Cardiovascular Surgery 2003, 51 (si) CSD-5115
2. Trends in Coronary Artery Bypass Surgery: Changing Type of Surgical Patient. Garcia Fuster R, Montero JA, Gil O, Hornero F, Canovas S, Bueno M, Buendia J, Rodriguez I. Rev Esp Cardiol. 2005 May;58(5):512-522.
Hypertrophic cardiomyopathy
In Hypertrophic Myocardial Disease (HOM) there is an alteration of the geometry and morphology of the heart muscle that causes a pathological thickening of the heart muscles. This thickening results in an obstruction of the flow of blood from the heart to the rest of the body, which can cause dyspnea (shortness of breath), arrhythmias, loss of consciousness and sometimes sudden death.
Depending on the intensity of this thickening, medical treatment is not enough and surgical treatment consisting of resection of part of this muscle hypertrophy is recommended. This surgical technique, known as Septal Miectomy, is performed with a sternotomy and extracorporeal circulation. Dr. Montero is one of the most experienced surgeons nationwide in the treatment of this type of pathology, having even developed his own technique with which hundreds of patients have already been treated (SEE VIDEO).
Publication: Experience, outcomes and impact of delayed indication for video-assisted wide septal myectomy in 69 consecutive patients with hypertrophic cardiomyopathy. Heredia Cambra T, Doñate Bertolín L, Bel Mínguez AM, Hernández Acuña CE, Schuler M, Pérez Guillén M, Margarit Calabuig JA, Montero Argudo JA.
Eur J Cardiothorac Surg. 2013 Jul; 44 (2): e149-55.
Aortic aneurysms
The thoracic aortic aneurysm is a pathology with a high mortality and risk of complications if it is not acted on soon, especially when this aorta reaches a certain size (about 55 mm). In some patients it may be necessary, in addition to the median sternotomy, to make an additional incision below the clavicle (to access the subclavian artery) or in the groin (to access the femoral artery).
Generally, it is only necessary to replace the dilated aorta segment, to prevent its rupture or dissection, but other times the intervention to be performed may be more complex. When dilation also encompasses the so-called sinus portion (the part most proximal to the heart, from where the coronary arteries originate and where the arctic valve is located), it is necessary to perform more complex techniques where we must reinsert these coronary arteries to the graft or tube that we use for the substitution. This is what is called Bono-Bentall surgery, when we also change the arctic valve for a prosthesis or David or Yacoub Surgery or Intervention when we can maintain the patient's native valve. This last type of surgery is a highly demanding intervention from a technical point of view, only performed by specialized and experienced surgeons, and when possible, it is the best option for the patient, thus avoiding the implantation of valve prostheses.
In our Clinic we have extensive experience in the treatment of different pathologies of the aorta (Dissection, Aneurysm ...). We will study your case and, depending on the type of pathology and the segment to be treated, the most appropriate strategy will be carried out, individualizing each case in particular.
Minimally Invasive Aortic Surgery
The aortic valve separates the left ventricle and the aorta, the main artery of the body that is going to divide to give arterial branches to the rest of the organs. The disease of this valve can produce AORTIC STENOSIS (when there is an obstruction of the outflow of the aorta due to calcification of the valve), AORTIC INSUFFICIENCY (when the valve is not competent when closing and there is a "leak" towards the ventricle) or a combination of both.
What type of surgery is performed? It will depend on the type of injury (stenosis, insufficiency), the age of the patient and the severity of the pathology, among other factors. Surgical replacement is generally preferred, but sometimes another option is transcatheter aortic valve implantation (TAVI, see below). Also, as in the case of the mitral valve, a valve repair and not replacement can be performed, but it is less frequent than in the mitral valve.
In recent years it has been shown that the use of minimally invasive surgery (avoiding a complete sternotomy) for the implantation or repair of the aortic valve, in addition to being more aesthetic, can reduce postoperative bleeding, ICU stay and hospital stay , less postoperative pain, and a faster return of the patient to his usual life. Our surgeons will study your case and, after analyzing all the options, we will offer you the most appropriate one for you (repair vs. replacement, biological vs. mechanical prosthesis, standard or minimally invasive surgery, ...).
TAVI
Transcatheter aortic valves (TAVI) are an option for patients who for some reason are considered high or intermediate risk for conventional surgery. This approach must be carried out jointly with the Hemodynamics team given the characteristics of this type of implant.
The procedure consists of introducing a prosthesis through catheters to the position of the aortic valve, guiding ourselves mainly through a fluoroscopy system. Once it is positioned in the aortic ring, it expands and thus fixes it, it is verified that the valve works well and the catheters are removed. Among the advantages of this type of valve is that they do not need extracorporeal circulation, they can be implanted with local anesthesia and sedation, and the rapid recovery of the patient (who can be discharged in less than 72 hours).
There are several ways of approaching the introduction of these valves:
• Transfemoral route: the prosthesis is inserted by puncture of the femoral artery, located in the groin area.
• Transaxillary route: the axillary artery is accessed, after making an incision below the clavicle, and the valve is inserted through it.
• Transapical route: for this approach we perform a small thoracotomy (an incision between the ribs) and to access the tip of the heart, which is where the prosthesis is inserted directly into the heart.