Stephen Spindel MD @StephenSpindel Twitter profile

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Stephen Spindel MD

@StephenSpindel

1 year

With the flood of tricuspid endocarditis over the last few years, pacemaker implantation in these patients is undesirable post TV replacement. Here’s a nice trick @APolancoMD showed me which avoids conduction complications

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Stephen Spindel MD

@StephenSpindel

2 months

Grateful to have performed my final Ross procedure at Ochsner a few days ago. I’ve worked with an amazing team these past 6 years and am thrilled to join Montefiore next week, continuing my love of aortic surgery, heart and lung transplant, but now in New York!

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Stephen Spindel MD

@StephenSpindel

2 years

What is your favored method for aortic arch debranching? Side biting clamp on the aorta with sequential grafting (Y graft), off pump, is my preference. As seen here in this 61 y.o. male with rapidly enlarging chronic type B dissection involving distal arch

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Stephen Spindel MD

@StephenSpindel

1 year

This 38 y.o. with bicuspid AV was found to have aortic and mitral endocarditis, plus 4.6cm aortic root. Intraop, a large vegetation on MV with perf meant MV replacement. What would be your strategy? I chose Ross plus mechanical MVR, an odd combo

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Stephen Spindel MD

@StephenSpindel

1 year

Interesting how many 3.8cm ascending aorta referrals we see but somehow the really big ones slip through the cracks. Did a 3rd time sternotomy, hemi arch, root replacement on this 7.2cm ascending aorta patient (prior BAV). What other large ones have you guys seen?

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Stephen Spindel MD

@StephenSpindel

7 months

Although Commando is usually for endocarditis, the approach is helpful for combined aortic/mitral stenosis with MAC, such as radiation heart disease. It can make a significant difference in decreasing the technical difficulty when dealing w severely calcified aortomitral curtains

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Stephen Spindel MD

@StephenSpindel

7 months

Destruction of the aortomitral curtain may seem like a big undertaking to rebuild it, yet it is not as complicated as some may think. This video we put together provides the basic steps for reconstruction which may help out some folks in tricky situations

Aortomitral curtain reconstruction: demystifying a complicated situation

mmcts.org

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Stephen Spindel MD

@StephenSpindel

2 years

What is your post cardiopulmary bypass method for tackling low EF mitral regurgitation patients? @APolancoMD joined me for direct insertion impella for this mitral and tricuspid repair patient which assured a postop course on minimal vasoactive drips, no end organ dysfunction

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Stephen Spindel MD

@StephenSpindel

2 years

Our first wet lab of 2023: mitral repair. Plenty of fun and great teaching moments with the residents, fellows, and @APolancoMD

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Stephen Spindel MD

@StephenSpindel

2 years

TAVR is used often lately in small aortic annuli in sexagenarians. I prefer extended Nick’s in this population to allow for future valve in valve TAVRs. 19mm valve up to 25mm valve, 5mmHg MG on TEE in this 63 year old

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Stephen Spindel MD

@StephenSpindel

2 years

What’s your favored less invasive technique for mitral surgery? 8cm incision with full sternotomy is my preference. I accredit restricting the degree of chest retraction to limiting the pain, and decreasing LOS. Complex MV repair on this 80 year old male, home on POD 4.

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Stephen Spindel MD

@StephenSpindel

1 year

Surprisingly, there aren’t many technical videos out there focused on aortic arch debranching. Here is a step-by-step video for off pump arch debranching which is simplistic and easy to duplicate, via @ctsnetorg

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Stephen Spindel MD

@StephenSpindel

2 years

What strategy would you choose to help this 57 y.o. male with prior LIMA-LAD, multiple PCI to occluded pLAD, and 95% stenosis at LIMA-LAD anastomosis? I used a free RIMA to the proximal/mid LIMA then to the LAD

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Stephen Spindel MD

@StephenSpindel

3 months

It’s uncommon to operate solely for myocardial bridge over the LAD, but this 47 y.o. with recurrent angina had a rather impressive degree of dynamic LAD stenosis. Pretty straightforward operation to expose the intramyocardial LAD and great postop relief of symptoms

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Stephen Spindel MD

@StephenSpindel

4 months

This has been my go-to technique for hemi arch replacement in patients with non-calcified aortic arches. Nice to avoid hypothermia and circulatory arrest

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Stephen Spindel MD

@StephenSpindel

6 months

As surgeons, it’s key to pursue fresh perspectives. At times, reevaluating dogma can spur innovation. This AVR technique by @LuisCastroMD is precisely that: a pioneering approach to a conventional procedure. It’s my go-to technique and I recommend giving it a shot

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Stephen Spindel MD

@StephenSpindel

8 months

@bedi_ryan Definitely. If you’re doing a left axillary cutdown, you can replace the rest of the arch without circulatory arrest too. I have a full video on it but here’s the final result with the limb for left subclavian tunneled through the pleural space

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Stephen Spindel MD

@StephenSpindel

8 months

Being the associate program director for cardiothoracic fellowship at Ochsner, I try to emphasize case preparation. This video we created details key steps and pitfalls for cardiopulmonary bypass. It’s helped the fellows/residents here and hopefully others will benefit too

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Stephen Spindel MD

@StephenSpindel

2 years

As we see more and more SAVR following failed TAVR, the discussion grows on the increased difficulty of these cases. This 72 year old 5’6” male’s Evolut bored into the mitral valve and extended to innominate artery. Redo chest, circ arrest, hemi arch, AVR, and MVr took some work

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Stephen Spindel MD

@StephenSpindel

2 years

Always a pleasure doing these wet labs with our cardiothoracic fellows, general surgery residents, and @APolancoMD . Aortic root surgery was today’s focus

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Stephen Spindel MD

@StephenSpindel

2 years

Better quality video for Y graft with SVG off LIMA:

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Stephen Spindel MD

@StephenSpindel

3 months

@Westsaeed10 Personally, I arrest the heart. With the numerous bleeding epicardial veins and risk of RV entry, unenjoyable to do off pump. These can be deep too (2.5cm in this one due to heavy epicardial adipose burden). It’s only a 15-20 min XC time. Get in, arrest the heart, get out

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Stephen Spindel MD

@StephenSpindel

1 year

@jearlugo Agreed. Still, the concern for uterine bleeding was high. To help with lessening the coagulopathy, only cooled to 26 degrees (with ACP), and 16 min circ arrest time plus 73 min cross clamp. No blood products needed luckily

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Stephen Spindel MD

@StephenSpindel

1 year

@LuisCastroMD @APolancoMD @drraycleemd @AkiItohMD @AortaSurg @DevenPatelMD @OPreventzaMD @AspiringCTS I wear the Designs For Vision version, which is very lightweight and decent brightness. Not quite as bright as the plug-in older school headlights, but significantly less hassle, minimal slippage, easy to maneuver around the OR, never heavy enough to cause headaches

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Stephen Spindel MD

@StephenSpindel

2 years

Small LVOT with a solution

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Stephen Spindel MD

@StephenSpindel

11 months

@DHeartsurgeon @TungVu38 @ctsnetorg Yep. By taking deep bites into the aorta (1cm) and then through 4-8 rungs of graft material, it forces the graft to lie within the aorta when it is everted. I found it helps significantly with hemostasis.

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Stephen Spindel MD

@StephenSpindel

1 year

@JoChikweMD Totally agree. It’s a great trick that helps you get out of the OR when doing aortic root cases with persistent mild bleeding. Always thankful to Dr. Paul Stelzer and the years we spent doing these cases, and my time with @JoChikweMD doing mitral and aortic work. Amazing mentors

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Stephen Spindel MD

@StephenSpindel

10 months

@schneida42 A rectangular patch works too, yes. I like a crescent or arc shape since I find it aligns more anatomical.

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Stephen Spindel MD

@StephenSpindel

2 years

@drraycleemd @APolancoMD @jaye_weston @PeterDowneyMD @AortaSurg @DrZeigler1 @tomcnguyen @koriannj @DrDePasquale @EcmoNinja @LuisCastroMD @USCHeartFailure Great case, Ray! That’s quite a doozie and certainly one of those that keep you motivated to do more. I also agree that it seems these ARSCA patients have higher incidence of dissection. Fantastic work!

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Stephen Spindel MD

@StephenSpindel

1 year

@JJahanyarMDPhD There are a number of articles published per cardiac tumor cryoablation, but no long term follow up. It sounds feasible and that was the standard at Mt. Sinai for myxomas after resection (cryo the margins). Here, deep and wide myectomy in the LV apex wasn’t very appealing to me

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Stephen Spindel MD

@StephenSpindel

11 months

@rgmarenchino @TungVu38 @ctsnetorg Absolutely. Here it is

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Stephen Spindel MD

@StephenSpindel

4 months

@jloumiotis @CristianRosuMD I agree with you both. Nondominant RCA can be an issue if the button is misplaced. Unfortunately, these usually need to be addressed. It amazes me how much the RV relies on a tiny RCA though

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Stephen Spindel MD

@StephenSpindel

2 years

@samsaid75 @BobbyYanagawa @UofTCVsurgery Wow, now THAT is a true invention! I enjoy taking the Cabrol patch concept and applying it to other scenarios, but using it for an AV groove disruption really tops the list for creativity

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Stephen Spindel MD

@StephenSpindel

1 year

@JJahanyarMDPhD Agreed, unconventional. Thromboembolic & hemorrhagic events higher with 2 mechanical valves vs 1 and a lot of recent data showing benefits of Ross, so I think it’s an interesting concept to consider & discuss for young patients with multivalve disease. @Abedeanda @juan_lehoux

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Stephen Spindel MD

@StephenSpindel

2 years

@JJahanyarMDPhD Thank you. For root abscesses, I prefer aortic homograft root replacement. What is your preference?

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Stephen Spindel MD

@StephenSpindel

7 months

@JJahanyarMDPhD Excellent point to highlight. Radical, not conservative, debridement is key

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Stephen Spindel MD

@StephenSpindel

1 year

@RajaFlores Thanks Dr. Flores. Seeing all the raw surface area of the open uterus (and my concerns for heparinization/bleeding) reminded me of the many mesothelioma surgeries during my time with you guys. Yet, you never had any takebacks for bleeding. Amazing

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Stephen Spindel MD

@StephenSpindel

10 months

@JJahanyarMDPhD @schneida42 You’re absolutely right. In general, it isn’t necessary for AM curtain reconstruction since you can use the anterior mitral leaflet of the homograft. In a prior Yang, the native LVOT is still very small (18mm here) so an oversized patch helps for placing a bigger (24mm) homograft

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Stephen Spindel MD

@StephenSpindel

1 year

@BobbyYanagawa Thanks Bobby. It was quite unique to perform the surgical time out for aortic dissection planning while there’s a baby crying in the background. Unforgettable

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Stephen Spindel MD

@StephenSpindel

2 years

@drraycleemd @MammothMountain @PeterDowneyMD @APolancoMD @jaye_weston @tomcnguyen Amazing man! Growing up in New Orleans, my snow sport involvement unfortunately was low (some snowboarding experience). But was here in Japanese Alps last week and learning to appreciate the difference in snow quality

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Stephen Spindel MD

@StephenSpindel

2 years

Contrast with CKD patients is a significant concern for TAVR. At Ochsner, the two wire technique is something we favor in these individuals given the zero contrast usage with excellent visualization of the aortic annulus

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Stephen Spindel MD

@StephenSpindel

1 year

@JJahanyarMDPhD @schneida42 @pomyers @samsaid75 @RakanINazer I do the same: running 7-0 prolene (not locking), which is how I learned it from Mount Sinai. My partner does it similar to @drraycleemd and just opens it up, no suturing afterwards. Fun case overall

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Stephen Spindel MD

@StephenSpindel

8 months

@LuisCastroMD Great tricks! Especially the hypogastric clamp. If the patient has no carotid stenosis, I proceed w neuro monitoring alone, just like carotid endarterectomy or arch debranching. But I agree, separate innominate cannulation is good too. I’ve used the pigsticker here in the past

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Stephen Spindel MD

@StephenSpindel

10 months

@JJahanyarMDPhD @schneida42 Absolutely! Happy holidays!

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Stephen Spindel MD

@StephenSpindel

2 years

@LuisCastroMD Definitely will give it a shot. Amazing just how efficient it is with the aortic valve. Next up, mitral

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Stephen Spindel MD

@StephenSpindel

1 year

@ajpedroza_md @MarkELindsay Surprisingly, it was a very beat up trileaflet valve with fenestrations. Agreed, genetic testing is necessary. But no family history of connective tissue disorders

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Stephen Spindel MD

@StephenSpindel

6 months

@jloumiotis @AortaSurg @JordanBloomMD @schaefers_hans @JJahanyarMDPhD @DrZeigler1 @ovidiogarciav I agree. If the patient is short stature or very thin aortic root tissue: replace it. Otherwise, bio AVR alone in this patient is a great choice. For Ross, if <60: yes; >65: no. 60-65: depends on comorbidities, expected long term survival. But a 25mm valve is great option here

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Stephen Spindel MD

@StephenSpindel

8 months

@CristianRosuMD Absolutely. Once switching from pledgetted to nonpledgetted sutures, it amazed me how there was no difference in bleeding, including repair sutures. Very different than the conventional teaching

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Stephen Spindel MD

@StephenSpindel

2 years

@samsaid75 @DrZeigler1 @CristianRosuMD For a prior manuscript I was involved with, I’ve read @RakanINazer article (which is great) on use of innominate vein but never seen it done. I think it’s an excellent usage. I typically prefer the RA since it’s just a stab wound for the fistula instead of sewing a graft

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Stephen Spindel MD

@StephenSpindel

3 months

@APolancoMD @Abiomed Amazing technique and really great strategy when dealing with difficult impella cases. For tiny females with limited access, I use upper hemisternotomy, but I like your method better

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Stephen Spindel MD

@StephenSpindel

1 year

@cardioaustral Here’s the graft, which is great for the 2nd stage frozen elephant trunk due to its radio opaque markers. In this case with the bovine arch, I tailored it a bit. Zone 2 arch

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Stephen Spindel MD

@StephenSpindel

2 years

@igeorge1975 @LuisCastroMD Totally agree, I’ve done nonpledgetted AVRs when I was at Mount Sinai. Nice to do. But the amazing aspect of @LuisCastroMD technique is the spacing. Makes it extremely efficient, cuts time, and no PVL

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Stephen Spindel MD

@StephenSpindel

1 year

@marianocoppa Wow, an octogenarian with a 9cm aorta is a rare find. Strong work!

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Stephen Spindel MD

@StephenSpindel

2 years

@mj_pucci I find a standard 10mm 60 degree scope from a laparoscopy tray works well. You lose an assistant/scrub tech in the process but easy to work around that. The head mounted cameras are often too shaky, in my opinion

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Stephen Spindel MD

@StephenSpindel

2 years

@DrZeigler1 Thanks. I use a standard 10mm laparoscopic camera held by the assistant. You might lose your only assistant so I try setting it up as solo operation

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Stephen Spindel MD

@StephenSpindel

1 year

@juan_lehoux @JJahanyarMDPhD @Abedeanda That is certainly something to consider. I’m not saying this should be the norm, just a discussion. Many centers have shown low operative mortality with the Ross, but I think that strongly depends on the familiarity of doing it and the ICU team

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Stephen Spindel MD

@StephenSpindel

1 year

@RakanINazer Thanks. Transmitral was pretty straightforward. Easier if it was robotic though. Nice to avoid the risks associated with a ventriculotomy, but it was considered, yes, if transmitral wasn’t feasible

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Stephen Spindel MD

@StephenSpindel

2 years

@JamesHBlackMD I’m unfamiliar with the Lemole, but the design looks very effective. Always looking to improve my instruments. Great advice

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Stephen Spindel MD

@StephenSpindel

1 month

@BobbyYanagawa Thanks, Bobby!

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Stephen Spindel MD

@StephenSpindel

8 months

@CristianRosuMD Yea, that’s a great trick. We truly are standing on the shoulders of giants when it comes to cardiac surgery

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Stephen Spindel MD

@StephenSpindel

8 months

@clubby73 Exactly. Cannulate the arch just below the left subclavian artery. As long as you have space to clamp between the innominate and left carotid, you’re good

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Stephen Spindel MD

@StephenSpindel

1 month

@bedi_ryan Heck yea

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Stephen Spindel MD

@StephenSpindel

2 years

@rafatinm Cannulate distal arch just inferior to L carotid/subclavian, cool, circ arrest, keep cannula in place, resect aorta, anastomosis with 4-0 SH prolene from 4:00 position to 10:00, switch to other side, 4:00 counterclockwise to 10:00. No felt, big bites & moderate travel on aorta

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Stephen Spindel MD

@StephenSpindel

8 months

@CristianRosuMD Overall, I rarely use pledgets (for cannulation, hemostasis, etc.). For AVR, MVR, or CABG, I use zero. For root surgery, maybe 2-4 for bleeding in fragile aorta. The redos are so unappealing with pledgets. For these hemi arches, non-pledgetted, no wire, and distal cannulation

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Stephen Spindel MD

@StephenSpindel

2 years

@gustaorellanas Totally agree. The debridement is always my favorite part though since you’re resecting chunks at the same time as thinking about how to put it all back together, just like Legos as a kid

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Stephen Spindel MD

@StephenSpindel

8 months

@bedi_ryan Mobilizing the arch will allow plenty of space. Main concern is the recurrent laryngeal nerve since injury carries such significant morbidity. Minimal cautery here, mostly using metz scissors

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Stephen Spindel MD

@StephenSpindel

7 months

@FarivarRobert Absolutely. Some create their own grafts for this technique but I use a prefabricated Gelweave branched arch graft. It has radio opaque markers which help with TEVAR

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Stephen Spindel MD

@StephenSpindel

2 years

@pomyers @Mitrovalvology @LuisCastroMD That’s a great question for @LuisCastroMD . I generally perform aggressive decalcification, but not sure how it’d be with less. Otherwise, I placed sutures in usual depth but different spacing, no pledgets. Found the stiff AS and flexible AI annulus didn’t differ

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Stephen Spindel MD

@StephenSpindel

2 years

@downing3003 @APolancoMD Clips or CorKnots are both adequate radio opaque markers, so can use either one. Clips are significantly cheaper though

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Stephen Spindel MD

@StephenSpindel

7 months

@ctayg Amplatzer deployed into the LSA helps prevent endoleak. It’s already bypassed so no worries there

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Stephen Spindel MD

@StephenSpindel

1 month

@APolancoMD Thanks, Antonio!

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Stephen Spindel MD

@StephenSpindel

1 year

@drraycleemd @BobbyYanagawa @EcmoNinja @LuisCastroMD @APolancoMD Never used the Bavaria graft but I really like the concept. When at Mount Sinai, I did a lot of Thoraflex with Allan Stewart as part of the initial trial. It’s a pretty good system. That skirt can be a bit tricky due to size discrepancy w distal arch, but still good overall

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Stephen Spindel MD

@StephenSpindel

2 years

@BobbyYanagawa @UofTCVsurgery That’s awesome, Bobby! The times we had at Mount Sinai were great. Certainly spending 6 years with Paul Stelzer was amazing. He’s a wizard in the OR

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Stephen Spindel MD

@StephenSpindel

1 year

@RajaFlores Thanks, Dr. Flores. Always great to pull out the thoracoscopic instruments, reminding me of fun times with you guys

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Stephen Spindel MD

@StephenSpindel

7 months

@gustaorellanas After debranching, go on full flow bypass as usual and 34C temp. It can be done for acute dissection but go on bypass after LSA bypass is completed, debranch arch with flows down (tissue quality), clamping arch vs lower body circ arrest depends on tissue quality too

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Stephen Spindel MD

@StephenSpindel

2 years

@Chentemr Exactly. Supraclavicular bypass, zone 0, and Gore TAG graft

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Stephen Spindel MD

@StephenSpindel

2 years

@MGibreel1 I agree. Patients with these unusual left main anatomies can be challenging. I performed a quadruple bypass on this individual with similar difficult anatomy.