Cardiac surgeon Dr. John Elefteriades, the William W.L. Glenn professor of surgery at Yale School of Medicine, has treated more than 10,000 patients in his over three-decade career. Given his reputation and experience doing complex cardiac procedures, Elefteriades was a natural choice when the NFL needed a surgeon to treat one of its famed referees, Bill Vinovich, who has been tapped as an official for the upcoming Super Bowl XLIX on February 1. In 2006, Vinovich suffered a life-threatening tear to his aorta, the main artery of the human body. The condition prevented him from doing his job as an NFL official. In search of help and a way back onto the field, Vinovich came to see Elefteriades, one of a handful of cardiac surgeons nationwide with the skill and expertise to correct the condition. YaleNews talked to Elefteriades, who directs the Aortic Institute at Yale with Dr. Sandip Mukherjee and wrote the book “Extraordinary Hearts,” about his experience treating the referee, who returned to the game in 2012.
What condition did Bill Vinovich have prior to surgery?
Bill had what’s called an aortic dissection. It’s the splitting apart of the aorta into two layers. The aorta is a tube, and when a patient suffers a dissection of the aorta, it splits into two sections. Bill’s dissection happened in what we call the descending aorta. He also had an aneurysm along the ascending aorta. So he came to me having suffered the descending aortic dissection. It happened when he was lifting weights. Our Yale team had uncovered years earlier the relationship between weight lifting and having this terrible catastrophe happen.
What were the symptoms? How did he know something went wrong?
When the aorta tears, the symptom is pain, the most intense pain that the human body can feel. It makes childbirth seem like child’s play. A kidney stone is nothing compared to the pain of aortic dissection. It’s a knife-like, tearing pain.
What caused this problem? Was it his lifestyle?
It’s not related to diet. It’s not related to cigarette smoking. We’re finding here at Yale, and at other centers that study this disease, that it’s inborn. If we look carefully, we find other family members have the same type of problem. But then the instigation for the tearing to occur at one moment in time in a vulnerable patient tends to be one of two things: It’s either a very intense physical exertion, like when you are lifting a heavy barbell, or an extremely intense emotion — something really bad, like losing a family member or having a financial reversal.
Why did the condition prevent him from working for so many years?
It’s a dangerous condition, and you don’t want the patient to be exposed to a stressful environment or severe physical exertion. And that’s what made our decisions difficult when he came here.
He had suffered this dissection, and when he came to see me four years later, I knew from experience that the dissected portion was probably healed in a way and unlikely to rupture. But the ascending aorta was very thin and very dilated, and I was more worried about that part.
When the descending aorta dissects, 90% of the time you survive. When the ascending aorta dissects, it’s lethal.
What would have happened if he had not undergone surgery — what were the risks?
He would have been vulnerable to a dissection happening there, in the ascending aorta. And his ascending aorta was at a size where the likelihood of tearing would have been about 2%-3%. The NFL and Dr. Jeffrey Borer, the great cardiologist who had looked at him, had very appropriately decided that it would not be safe for Bill to be on the field, and I agreed with that. But Bill told me repeatedly that he would do anything to get back on the field. He would not hold me responsible for any outcome. He had explained that, other than his family, being an NFL referee was his life. So I told him I had to think about it. I said:, “Give me a week.” After exactly one week, he called me, and I came up with a plan: If he allowed us to replace the vulnerable part of the aorta, the ascending part about which I was concerned, I would let him go back on the field.
You proposed doing surgery to replace the ascending part of the aorta?
That’s right. However, Bill’s aneurysm extended into the aortic arch. In the heart, you have the ascending aorta, the aortic arch, and the descending aorta. The aortic arch is what we call the “high-rent district.” In other words, it contains the branches to your brain and your arms. We had to replace all of those arteries as well in addition to the ascending aorta, so it was a high-intensity, large-magnitude operation.
How many other procedures of this kind have you performed?
So it wasn’t new territory but it was still a serious procedure?
There aren’t that many places in the world that do those operations on a routine basis. Yale is one.
What were the risks or challenges of this procedure?
The dangers are three: death, stroke of the brain, and bleeding. Those are the three biggest dangers. You can imagine how many times I’ve had that discussion with patients, probably 10,000 times, about the risks of operation. And I just go over the major risks, one by one. I make sure the family understands. Concomitantly, we explain the dangers of the condition so the family can weigh the options. Usually surgery is a lot safer than the condition.
What is the aorta replaced with?
We cut out the bad part, and we sew in a graft. It’s made of Dacron, like my shirt. And it lasts forever. The Dacron grafts have been in use for 65 years, and they never break down.
Now to replace the arteries, we put the patient in a deep freeze. The deep freeze allows us to turn off the heart-lung machine. So there is no blood flow; there’s no blood pressure; the EKG is flat. It’s indistinguishable from not being alive. When you make the patient very, very cold, you have 45 to 60 minutes to do the work.
Was the surgery routine, or did anything unexpected happen?
It went very well. We did have one tense moment. I walked back with him from the operating room to the ICU, and I stayed at the bedside. He was oozing a bit — remember, I mentioned that bleeding can be a problem — he was oozing a bit, and I wasn’t happy about that. I watched him for an hour, and we walked him right back to the operating room to take another look inside, which we do about 1 time out of 20. It’s usually not catastrophic in any way; it’s usually well tolerated. But we watched him. We did not need to open and look inside again. And then we traveled back to the ICU and from there he did fine.
Bill was able to return to the NFL in 2012. What is his condition today?
He’s doing great. We’ve been watching him every weekend on TV. He’s highly respected. The announcers only have the kindest words to say about him. Referees can get a bum rap. I’ve never heard an announcer say anything but the most kind words about Bill.
Is he likely to need any more care?
I have discussed with him that the part of his aorta that suffered the original dissection, the descending aorta, is pretty large. Something will need to be done eventually for that part.