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Surgery Williams underwent advisable only 'for cosmetic reasons,' expert says

Newfoundland Premier Danny Williams speaks with reporters after a meeting with Prime Minister Sephen Harper in St. John's on Jan. 29, 2010.

Paul Daly/paul daly The Globe and Mail

An international expert on heart repair says he would rarely recommend the type of surgery Newfoundland and Labrador Premier Danny Williams received this month at a Miami hospital because its only long-term benefit is cosmetic.

Thierry Mesana, chief of cardiac surgery at the University of Ottawa Heart Institute, said Tuesday he would only consider offering the "minimally invasive" procedure to young women hoping to avoid a chest scar.

The mitral valve repair Mr. Williams received Feb. 4 at Mount Sinai Medical Center involves surgeons making a five-centimetre incision on the side of the chest, near the armpit. Slender surgical tools are then inserted between the ribs to reconstruct the valve.

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The traditional method requires a 10-centimetre incision in the middle of the chest and cutting through the breast bone, or sternum.

A damaged mitral valve can cause blood to leak backward in the heart, causing heart infections, an enlarged heart and heart failure.

Dr. Mesana issued a statement saying a survey published last month by the Society of Thoracic Surgeons expressed "caution" about the less invasive procedure because the rate of complications - strokes in particular - is higher.

"Many world-renowned experts do not advocate it," the statement said.

"It is done in Canada, but again, with caution. I propose it only for cosmetic reasons in a young woman who dislikes the idea of having a scar visible in summer."

However, the doctor confirmed there are short-term advantages, including a more rapid recovery, less need for blood transfusions and less likelihood of an irregular heartbeat after surgery.

Marlene Orton, a spokeswoman for the Heart Institute, stressed that Dr. Mesana was not commenting specifically on the Newfoundland Premier's case or his choice of treatment.

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Dr. Mesana is considered one of the world's top authorities on mitral valve repair, having recently co-authored an expert guide for the New England Journal of Medicine.

Hugues Jeanmart, a cardiac surgeon at the Montreal Heart Institute and nearby Sacre Coeur Hospital, disagreed with Dr. Mesana, saying the less invasive surgery is as safe and effective as traditional methods, with fewer complications.

As well, he said the advantages of the procedure, which has been around since the 1990s, are more pronounced than Dr. Mesana suggests, particularly when it comes to recovery.

"[Patients]have less pain, they have less chance of bleeding [and]the risk of having a chest infection is very, very low," Dr. Jeanmart said in an interview from Montreal.

"The patient can leave the hospital and, as soon as they're home, they can do what they want."

Recovery from the larger chest incisions, known as sternotomies, typically takes about six to eight weeks because more time is needed for bones to heal.

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Mr. Williams has said his doctors told him he would only be offered full or partial sternotomies.

"The big priority for me, to be quite honest with you, was get something done that would get me back to work as soon as possible, given the importance of the spring in any fiscal calendar for any government," the Premier said Monday.

"It was indicated to me that I would've had to get the partial sternotomy in Canada ... I then chose to go to the Miami route on the basis that I could get minimally invasive, get in and out quick, get it repaired quick."

Dr. Jeanmart said he was surprised to hear that advice.

"I guess that it's somebody who didn't have any contact with the [Canadian] surgeons who are doing these procedures," he said. "We are among the leaders in many fields of surgery, especially in cardiac surgery."

Dr. Jeanmart said he wasn't aware of the details of Mr. Williams's case, but he said he couldn't see an obvious reason why the premier couldn't have the surgery at his hospital, where the procedure has been offered since 2006.

"Most patients who present with mitral valve leakage ... are candidates for minimally invasive approach," he said, adding that the two centres in Montreal are typically completing two or three surgeries every week.

"We can repair all kinds of valves through the minimally invasive approach."

Blair O'Neill, incoming president of the Canadian Cardiovascular Society, described the type of surgery Mr. Williams received as "a work in progress," having yet to undergo a full, scientific comparison with more traditional types of open-heart surgery.

"When it's first coming into common practice, there's only going to be a few places that offer it," said Dr. O'Neill, a practising cardiologist at the Mazankowski Alberta Heart Institute in Edmonton.

Of the 30 heart centres in Canada, no more than four offer the procedure.

"I believe [Dr. Mesana]takes the right approach in saying we should be cautious whenever we're introducing new procedures," Dr. O'Neill said.

But he said it would be a mistake to assume Mr. Williams received better care in the United States where, on average, cardiac surgeons do fewer operations per year than their Canadian counterparts.

As well, he stressed that wait time problems in Canada have been solved when it comes to cardiac surgery, with most serious cases requiring only two or three weeks in the queue.

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