John D. Puskas, MD, left, with Samuel “Skip” Vichness, who in May received the totally endoscopic coronary arterial bypass (TECAB).

Mount Sinai Heart has become one of the few centers in the world offering an innovative heart bypass procedure without major incisions or cutting through the breastbone. The procedure, known as totally endoscopic coronary arterial bypass surgery (TECAB), is performed using only micro-incisions and offers eligible patients a much quicker recovery with less pain, scarring, and risk of infection.

Two TECAB procedures were performed in May at Mount Sinai St. Luke’s by John D. Puskas, MD, Chair of Cardiovascular Surgery at Mount Sinai St. Luke’s, Mount Sinai West, and Mount Sinai Beth Israel, and Director of Surgical Coronary Revascularization, Mount Sinai Health System, with Gianluca Torregrossa, MD, Associate Director of Robotic Heart Surgery, Mount Sinai St. Luke’s.

“This is a very technically demanding procedure, with few cardiac surgeons having the expertise or experience to perform it. Our cardiac team is equipped to handle such intricate, advanced procedures, and our modernized facility is outfitted with a state-of-the-art surgical robot to assist them,” says Arthur Gianelli, President of Mount Sinai St. Luke’s. “By offering this innovative bypass procedure, our team leaps ahead in coronary artery bypass grafting surgery in New York and the Northeast.”

Each of the TECAB surgeries—a single bypass and a double bypass—was performed through four fingertip-size “keyhole” incisions. The surgeons placed robotic instruments through the micro-incisions to harvest the mammary artery. Then, they used the Flex-A®, a highly specialized device made by Aesculap Inc., to connect the mammary artery to the coronary artery of the heart with a high degree of precision. In a traditional bypass procedure, the surgeon makes a large incision, up to 12 inches long, spreads open the patient’s chest, and sews the arteries together by hand.

“In a traditional coronary bypass, there is a lot of manipulation inside the chest, and a prolonged recovery time,” Dr. Puskas says. “Typically, patients are in the hospital for a week or so after surgery, and it may be two to three months before they can return to truly normal activities.” In contrast, after the closed-chest TECAB procedure, patients can go home in one to three days, and return to normal activities in a few more days. “This is a much less invasive way to achieve an arterial bypass, which is the longest lasting, most life-giving bypass that we can provide,” says Dr. Puskas, a leader in robotic coronary revascularization.

The best candidates for TECAB are bypass patients with only one or two blockages on the left side of the heart who want to avoid a traditional operation. Surgeons cannot perform TECAB on patients who have had previous heart surgery or radiation therapy to the chest.

The number of surgeons worldwide who now perform TECAB is “in the single digits,” Dr. Puskas says. “And that is unfortunate, because this procedure has the potential to take coronary surgery to an entirely new level.” As an example, he cited Samuel “Skip” Vichness, one of the two patients who underwent the TECAB procedure in May. Before the surgery, Mr. Vichness, 71, had severe angina and could barely walk across the room. One month later, “He is deliriously happy with how he is doing. He is back on the golf course and has resumed all full activities. He is back to work,” Dr. Puskas says.

Dr. Puskas sees a future in which TECAB might become a common therapy for blocked arteries, comparing its development with that of early coronary artery bypass grafting (CABG). “Thirty years ago, the use of the internal mammary artery graft as a bypass conduit was thought to be too difficult,” he says, “and there were many senior, famous surgeons who said, ‘This will never become commonplace.’” However, because of advances in technology and training, CABG with arterial conduits has become the standard of care for many patients. Dr. Puskas says, “I would like to think that we will make similar progress, perhaps faster progress, with the TECAB minimally invasive robotic procedure.”

Novel ways to prevent and treat Alzheimer’s disease, deploy immunotherapies to fight cancer, and train pediatricians to teach brain-building skills to new parents were among the topics discussed by experts from the Mount Sinai Health System at the 2019 Aspen Ideas Festival in June. For seven consecutive years, Mount Sinai’s leading doctors have participated in the Festival, which is a unique forum for the exchange of ideas held each summer in Aspen, Colorado.

“The Aspen Ideas Festival is a special place where innovation is showcased,” says Kenneth L. Davis, MD, President and Chief Executive Officer of the Mount Sinai Health System. “Mount Sinai is an academic medical system on the leading edge of discovery. We have a lot to share.” As a panelist and moderator, Dr. Davis participated in discussions on several topics, including ways to stem increasing drug prices that cost Americans an estimated $460 billion a year. “We want to ensure that patent laws favor innovative drugs and not just brand-name drugs with patents that extend their market exclusivity, even when there’s no additional benefit to patients,” Dr. Davis told an audience.

Kenneth L. Davis, MD, second from right, led a roundtable discussion in Aspen about the future of health care.

Dr. Davis also moderated a panel discussion titled “What Will it Take to Prevent Dementia?” which offered attendees a positive glimpse of future developments. The panel of experts said that within the next five years they expect to see new blood tests to predict Alzheimer’s disease and new drugs to slow its development in the brain, which can take 20 to 30 years.   

Dennis S. Charney, MD, Anne and Joel Ehrenkranz Dean, Icahn School of Medicine at Mount Sinai, and President for Academic Affairs, Mount Sinai Health System, discussed his role in co-inventing a patented method for treating patients with treatment-resistant depression, SPRAVATO™ (esketamine) nasal spray, which was approved by the U.S. Food and Drug Administration in early 2019. SPRAVATO uses the first new mechanism of action in decades to treat major depressive disorder (MDD). It is estimated that approximately one-third of U.S. adults with MDD have treatment-resistant depression. The discovery, Dr. Charney said, came from “a small group of researchers who met every week to share ideas. We also created a collaborative relationship with a pharmaceutical company to bring forth a treatment for a devastating disorder that has a profound impact on people’s lives.”

Three Mount Sinai cancer specialists participated in a panel discussion about the latest methods to harness the immune system to fight cancer: Steven Burakoff, MD, Dean for Cancer Innovation and Chief of Pediatric Oncology; Fred Hirsch, MD, PhD, Executive Director of the Center for Thoracic Oncology in The Tisch Cancer Institute; and Miriam Merad, MD, PhD, Director of the Precision Immunotherapy Institute, and Director of Mount Sinai’s Human Immune Monitoring Center. They said some of these immunotherapies are being used successfully in conjunction with traditional chemotherapy.

Lung cancer expert Dr. Hirsch told the audience that over the past decade there has been “tremendous progress in the treatment of patients with lung cancer, particularly those with metastatic disease.” This, he added, was due to the development of “molecular targeted therapies and most lately, immunotherapy,” which have extended survival rates to five years from seven to nine months, for certain patients. The targeted therapies require physicians to sequence the tumor mutations to find out which drug will work best for that tumor.

Dr. Burakoff urged cancer patients to get a full genomic panel review of their cancer. “Twenty-five years ago you would go to an oncologist who treats many cancers, but now everything is very specific,” Dr. Burakoff said. “It is important to go to a tertiary care center where the subspecialty expert will look at the tumor and the type of mutations you have to help identify or define the treatments.”

Dr. Merad, Mount Sinai Professor in Cancer Immunology, said that the development of immunotherapies to treat cancer represented a revolution in care and that these therapies would improve over time as researchers gained more knowledge. Her laboratory is currently investigating novel biological pathways and new clinical trials.

“We have never been as excited as we are now,” Dr. Merad said. “There has been success, but not 100 percent success, and my group focuses on those cases that resist this treatment.” 

In a panel discussion on reinventing the pediatric visit, Carrie Quinn, MD, Executive Director of the Mount Sinai Parenting Center, discussed the Mount Sinai Health System’s collaboration with the nonprofit Bezos Family Foundation to enhance learning opportunities for children in their first years of life, when their brains are primed to learn. In addition to leading an eff ort to create upbeat messages that encourage enhanced communication between parents and their babies that will be placed throughout Mount Sinai’s labor and delivery and pediatric hospital units, Dr. Quinn has helped build and pilot a free and self-directed online curriculum to train pediatric residents about the science of early childhood development.

“How the parent responds to a child’s cues and emotions really builds those brain connections,” said Dr. Quinn. “It might be a baby turning their head away or crying, or arching their back. That’s a signal, that’s a sign of communication for an infant. So we want to help parents recognize those cues, the language of babies, and respond back and forth with them.”