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Your Doctor

By Chris Motola

Ayman Iskander, M.D. Cardiologist who once played professional soccer introduces innovative procedure, the MitraClip, which is an alternative to open heart surgery for some patients Q: What is the MitraClip procedure, and how did you come to use it? A: So to understand the MitraClip procedure, we have to understand why it's needed. We have a lot of patients with severe mitral valve regurgitation, which means that the mitral valve leaks. When it gets into the moderate to severe range, they're at enormous risk for congestive heart failure, about 50 percent or more if left alone. About 50 percent of those patients will be turned down for surgery because they are considered high-risk surgical candidates. The MitraClip was introduced as a way to treat high-risk surgical candidates with leaking heart valves. It became FDA approved recently, and the rollout from the company has been very slow since the devices are very sophisticated and requires a lot of training. We were lucky to be one of the first centers to be selected and had our first two cases in October. Q: How does the device work? A: It's essentially a tiny implant that we put in the mitral leaflet that captures the leaflets and holds them together. We can insert multiple clips as needed. It's made of a metal alloy called cobalt chromium that has a polyester fabric covering, which promotes tissue growth so that it will eventually become part of the lining of the heart and no longer foreign to it. The mitral valve is one of two independent leaflets. With the device, we can attach the tip of the two leaflets together and essentially take a one-orifice valve and turn it into a two-orifice valve. So it lessens the degree of the leakage. The procedure is usually done in the catheterization lab under general anesthesia. We get access through the femoral vein in the groin. We go up through the vena cava that leads up the right atrium. In the right atrium we perform a puncture through the wall separating the right and left atrium.

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In the News In October St. Joseph’s Hospital physicians Ayman Iskander and Ronald P. Caputo led a team that performed the first MitraClip cases in Central New York. MitraClip is a less invasive treatment option for high risk patients with mitral regurgitation, which is caused by a leaky heart valve. The MitraClip device is a small clip that is attached to the patient’s mitral valve, allowing the valve to close more completely and helping to restore normal blood flow through the patient’s heart.

We're able to introduce a catheter through that hole. From there we start steering up the catheter for the MitraClip device until we get close to the orifice of the mitral valve. From there we cross the mitral valves, we deploy the two wings of the device, then we pull back until the leaflets fall into those two wings. Then we capture the wings with a gripper. If we're happy with this, we can bring the leaflets together. If everything checks out and the leakage is mitigated, we eventually release the MitraClip from the catheter was holding it into place.

without high risks.

Q: So this is a minimally invasive procedure? A: This is catheterization procedure, so it's extremely minimally invasive. Most patients left the hospital the next day. So it's a very simple procedure for the patient. They're left with a small puncture wound near their groin. For us, it's a very sophisticated procedure. Having said that, the MitralClip is not at this stage a replacement for surgery. I strongly believe that surgery is the standard of care and that the patient should get surgery if they're able to. The MitralClip is a good alternative for patients who are unable to undergo surgery

Q: What are the risk factors? A: For the pathological version, one of the most common pathologies here in the U.S. is mitral valve prolapse. Aging. Bacterial infection of the valves. Some autoimmune diseases. For the second type, the functional type, is usually a result of debilitation of the heart due to heart failure.

IN GOOD HEALTH – CNY’s Healthcare Newspaper • January 2016

Q: Do valve leaks tend to be genetic in origin? A: There are two types of leaky mitral valves. The first type has to do with the abnormality or pathology of the valve. The second type has less to do with the valve than the enlargement of the valve's orifice. As of now, the MitralClip is only indicated for the first type. There are studies being done now on using it to treat the second type. Neither of them are congenital. They are acquired during life.

Q: Do you see further possible applications of this technology down the road? A: As I said, we're waiting on the results of the clinical trials for functional valve leaks. That would be a huge improvement, because those patients usually have a very weak heart muscle and tend not to be good candidates for surgery anyway. Another possible use being looked at is for other types of valve regurgitation. Q: What do you think medical students can do to prepare them-

The MitraClip next to a penny. It's made of a metal alloy called cobalt chromium that has a polyester fabric covering, which promotes tissue growth so that it will eventually become part of the lining of the heart.

selves to deal with a surgical landscape that includes a lot of rapidly evolving technologies? A: The MitralClip falls under a category that is exploding these days. It's called structural heart disease, which we are promoting a lot at St. Joe's as part of an effort to become a center for treating it. Anybody who is going to be interested in cardiology has to be familiar with all of these procedures because they're evolving very rapidly. In 2012, we introduced the TAVR valve replacement and three years later we're on the third generation of the device, which is totally unheard of. So a resident or even a physician needs to be familiar with the technology or at least know when to refer a patient for a procedure using the technology. There are meetings and seminars that help. Q: What can smaller cities like Syracuse do to stay on the cutting edge? A: It depends on the mindset of the institution. We're lucky because St. Joe's is very proactive about cardiology. St. Joe's is actually the place where the first angioplasty took place. We also serve a large region that draws patients from Canada down to Binghamton, which helps us function as a center of excellence. We've maintained good outcomes and metrics, which has allowed us to earn the trust of patients. Q: I understand you were a professional soccer player at one time. A: I was. I was a member of the Egyptian national under-17 team. I left when I went to medical school. Maybe I should have made another decision? (laughs)


Name: Ayman Iskander, M.D. Position: Attending physician, St. Joseph’s Medical Center; assistant professor of medicine, SUNY Upstate Medical University; interventional cardiologist, endovascular specialist and structural heart disease specialist with SJH Cardiology Associates. Hometown: Cairo, Egypt Education: Ain-Shams University, School of Medicine (Cairo), Lahey Clinic Medical Center, Burlington, Vt. Affiliations: St. Joseph’s Medical Center Organizations: American College of Cardiology, Family: Married, three children Hobbies: Former professional soccer player (Egypt), scuba diving, wood working

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