Heart & Cardiovascular News from Georgia Regents Heart and Cardiovascular Services
In This Issue
Balloon Aortic Valvuloplasty
Adult Congenital Heart Disease
Welcome to the first letter of the New Year from the Heart and Cardiovascular Service Line. The Medical College of Georgia has a 50-year tradition of taking care of children with heart problems. Therefore, it should not come as a surprise to anyone that these children, now productive young adults, look to us for continuity of their care. The cardiovascular service line has a highly specialized team consisting of a dedicated cadre of physicians, nurses, perfusionists and a parents’ group to take care of these complex patients. Sheldon Litwin, M.D., Professor and Chief of Cardiology at Georgia Regents University, has special expertise and interest in the subject and has written an overview in this edition of the newsletter. I know you will find it interesting and informative. Mary Arthur, M.D., Associate Professor of Anesthesiology, shares with us the benefits of using bloodless medicine as an alternative to donor blood. Almost every week, we discover new complications and side effects of blood transfusions. As such, it behooves us to use all possible means to minimize use of blood and blood products without compromising patient outcomes. I am pleased to report that, owing to our evidencedbased guidelines and a team of driven individuals, blood utilization rates in our cardiac surgery patients are one of the lowest in the country. As we encounter an increasing number of aged patients with concomitant advanced diseases, we find ourselves performing staged procedures to allow these patients time to recover from their multiple problems. Paul Poommipanit, M.D. writes about one such temporizing measure, balloon aortic valvuloplasty, in patients with severe aortic stenosis too ill to undergo definitive surgery. A close coordination between various specialists is essential for optimal outcomes. As always, we are proud of our fellows in training and some of their activities are outlined inside. I am sure you will agree that they are all multifaceted and talented individuals with considerable promise. We have a busy year of CME activities ahead of us (schedule attached). If you have suggestions for new topics or a different format, please let us know. Wishing you and yours the best for the New Year, M. Vinayak Kamath, M.D. Director, Heart and Cardiovascular Services and Chief, Cardiothoracic Surgery
M. Vinayak Kamath, M.D.
Director, Heart and Cardiovascular Services and Chief, Cardiothoracic Surgery Georgia Regents University 1120 15th Street, BA-4300 Augusta, GA 30912 706-721-3226 firstname.lastname@example.org
Balloon Aortic Valvuloplasty Procedure Brought Back to Table Paul B. Poommipanit, M.D. Assistant Professor of Medicine
BAV Balloon Aortic Valvuloplasty Cine image of balloon inflated within the aortic valve, depicted in the center of the image.
For patients with severe aortic stenosis, the option of a less-invasive procedure is becoming more common at Georgia Regents Medical Center’s Heart and Cardiovascular Center. Subsequently, we learned that restenosis within six months is common. Today, balloon aortic valvuloplasty is increasingly used as a “bridge” to more definitive therapy. Balloon aortic valvuloplasty (BAV) increases the aortic valve area by inflating a balloon within a severely stenotic aortic valve. Historically, this procedure was done in hopes of providing a durable, less-invasive solution for aortic stenosis.
With the advent of TAVR, BAV is being performed more frequently.
Since surgical aortic valve replacement (AVR) provides a durable, long-lasting solution for aortic stenosis, BAV has infrequently been performed. But, with the advent of transcatheter aortic valve replacement (TAVR), in which an aortic valve can be implanted percutaneously, BAV is being performed more frequently, providing an alternative treatment for severe aortic stenosis. At the Georgia Regents Medical Heart and Cardiovascular Center, an 84-year-old man with end-stage renal disease recently underwent BAV. This patient has cardiomyopathy with an ejection fraction of 30 percent and moderate aortic stenosis. He presented with a non-ST elevation myocardial infarction, class IV heart failure and hypotension. A cardiac catheterization revealed significant coronary artery disease of the right coronary artery and left anterior descending artery. Surgery was deemed too risky since his EF was now 20-25 percent with severe aortic stenosis and severe mitral and tricuspid regurgitation. The patient underwent high-risk stenting of his RCA and LAD and the previously placed intra-aortic balloon pump was removed the following day. Weeks later, the patient improved, but was still having class III-IV heart failure and receiving daily hemodialysis while having episodes of hypotension. This patient was too deconditioned to –2–
tolerate open-heart surgery and the decision was made to perform BAV as a bridge to future AVR or TAVR. The patient was brought to the cardiac catheterization lab, graciously provided by the pediatric cardiovascular service. Cardiac anesthesia and hemodynamic support were provided. Transesophageal echocardiography demonstrated a valve area of 0.8-0.9cm2 (severe aortic stenosis). One balloon inflation was done and repeat echocardiography demonstrated a valve area of 1.2cm2 (moderate aortic stenosis). The patient then had a 50 percent decrease in the pressure gradient across the valve. Given his other critical illnesses, the team decided to terminate the procedure. The patient has slowly recovered and is working with physical therapy to improve his conditioning. BAV for severe aortic stenosis is used to temporize prior to surgical AVR, assess for response and as an alternative in severely symptomatic patients who are not candidates for other procedures such as AVR or TAVR. A multidisciplinary approach at Georgia Regents University involving cardiac anesthesiologists, cardiac surgeons, interventional cardiologists and cardiovascular imaging specialists improved the patient’s quality of life.
Bloodless Medicine: A Viable Alternative in Cardiac Surgery Mary E. Arthur, M.D. Associate Professor, Anesthesiology and Perioperative Medicine
Blood Enhances Oxygen Blood enhances oxygen-carrying capacity, improves wound-clotting and provides volume support for cardiac output. Nevertheless, more and more patients are seeking safe and effective alternatives to blood transfusions during surgery – even cardiac surgery – because of religious convictions, medical concerns or personal preference. Religious objections tend to be limited to primary components (packed red blood cells, platelets and fresh frozen plasma) while secondary components such as albumin and factor concentrates are generally acceptable. Physicians are increasingly accommodating patients’ preferences for bloodless surgery because of mounting evidence that blood transfusions portend worse outcomes. Minimizing bleeding and limiting blood transfusions have become important elements of quality improvement programs. Bloodless cardiac surgical procedures require special expertise, precise monitoring, state-of-the-art equipment and innovative techniques. The GRU Bloodless Medicine and Surgery Program was designed expressly for these reasons.
How big is the problem? Almost 15 million units of packed red blood cells are transfused annually in the United States during surgery, with cardiac operations consuming as much as 15 percent of the nation’s blood supply. This percentage is growing, largely because of the increasing complexity of cardiac surgical procedures. 1) Patient’s 2) Blood volume restored blood collected using plasma expanders before surgery (Albumin, Hetastarch or Crystallods). begins.
Why do we care? Concerns regarding the safety and efficacy of allogeneic blood transfusions, the impact on patient outcomes and the astounding costs and challenges associated with maintaining an adequate supply of blood products has renewed an interest in alternatives to transfusion. In addition to transfusion-related risks such as infections, respiratory failure and thromboembolic complications, red blood cell transfusions may alter immune function, impacting long-term survival.
What do we know? Most cardiopulmonary bypass patients have sufficient wound-clotting after reversal of heparin and do not require transfusion. Evidence suggests that transfusions might not improve the outcomes of stable non-bleeding patients in nearly 90 percent of the common transfusion scenarios reviewed. Transfusions are only deemed appropriate for patients 65 and older with comorbidities and a hemoglobin of <8 g/dL. Several tools are available to accommodate the need or preference for bloodless surgery, covering all phases of the procedure: preoperative, intraoperative and postoperative.
ANH Acute Normovolemic Hemodilution
3) Off CPB, the patient’s blood is returned, connection maintains closed circut.
One important strategy is acute normovolemic hemodilution, a process increasing the volume of the patient’s own stored blood using expanders such as albumin, hetastarch and crystalloids. The tubing remains connected to the patient at all times, maintaining a closed circuit. The patient’s stored blood, which has all the major clotting factors as well as platelets, is returned to the patient after weaning from cardiopulmonary bypass.
For more information: gru.edu/anh For more information: georgiahealth.edu/medicine/anes/anes-ct-icu.html
How do we involve the patient? Before surgery, a member of the blood conservation team gives the patient a form listing all the factor concentrates. The patient then decides which concentrates can be used during the procedure. Our multidisciplinary blood management team works together to limit blood transfusions and decrease perioperative bleeding while still maintaining safe outcomes. At GRU, about 25 inpatient and outpatient cases per month utilize bloodless medicine techniques across all specialty areas. Four successful bloodless cardiac surgery procedures have been done in the last few months. More than 180 community members attended a Bloodless Medicine and Surgery Program seminar last fall highlighting techniques that enable medical and surgical treatment without blood transfusions, attesting to the acute interest and growing awareness of this burgeoning field of medicine. GRU is happy to fill this vital niche in the community.
In intensive care, the continuous auto transfusion system (which includes a blood-compatible infusion pump with a microemboli filter and non-vented intravenous tubing) allows continuous autotransfusion of chest tube drainage.
Adult Congenital Heart Disease: Focus on Bicuspid Aortic Valve Cardiovascular disease is the leading cause of death worldwide. In addition to acquired diseases associated with aging, heart disease can be present from birth. Because of steady advances in medicine, most patients with congenital heart disease today survive into adulthood and many have normal lifespans. Patients with congenital heart problems are likely to benefit from consultation or ongoing care from a cardiovascular clinician or team with special interest or training in this area.
The most common congenital heart condition is the bicuspid aortic valve.
Sheldon E. Litwin, M.D., Professor and Chief of Cardiology
Figure 1. A Normal, trileaflet aortic valve in open position (transesophageal echocardiogram). B. Normal trileaflet aortic valve in closed position. C. Bicuspid aortic valve open (MRI; arrow points to fused leaflets). D. Quadricuspid aortic valve closed with gap between the leaflets (arrowhead). A
The most common congenital heart condition is the bicuspid aortic valve. About 1 in 100 people have a bicuspid aortic valve. The aortic valve normally has three distinct leaflets (Figure 1A). Each leaflet, or cusp, is associated with a sinus of Valsalva (Figure 1C) in the aortic root. The right and left coronary arteries arise from the respective right and left sinuses of Valsalva. The noncoronary sinus does not give rise to a coronary artery. The three leaflets of the aortic valve open to produce a triangle-shaped orifice (Figure 1A) and when closed, appear like a “Mercedes” sign (Figure 1B). Patients with bicuspid aortic valves have
only two leaflets (Figure 2A valve open, Figure 2B valve closed). In some cases, this results from fusion of the commissure between two leaflets producing a raphe (Figure 2B). In normal individuals, the cellophane-thin valve leaflets perform admirably over the course of 80-plus years. However, bicuspid valves produce turbulent flow patterns that likely contribute to early damage of the leaflets. Degenerative changes of the leaflets, including prolapse or calcification (Figure 2D), may cause regurgitation or leakage (Figure 2E) or stenosis (Figure 2A). These conditions typically do not become evident until adulthood. Echocardiography is generally performed on adult patients with bicuspid valves every one to two years to look for regurgitation or stenosis. Once these abnormalities become clinically significant, surgical valve replacement is usually recommended (Figure 3C).
Bicuspid aortic valve is also linked to abnormalities of the aorta. Bicuspid aortic valve also is also linked to abnormalities of the aorta. Coarctation of the aorta, a narrowing of the descending thoracic aorta just after the take-off of the left subclavian artery (Figure 3D) occurs in up to 40 percent of patients with bicuspid valves. Such narrowings have a number of adverse effects, particularly hypertension of the upper body. In addition to aortic coarctation, the wall of the entire aorta may be abnormal. This may lead to enlargement and/or dissection of the ascending aorta. For this reason, aortic imaging with MRI or CT is often done periodically in patients with bicuspid valves (Figure 3A and B). The natural history of patients with bicuspid valves and aortic enlargement is similar to that of patients with Marfan’s syndrome. Aortic root replacement may be recommended at the time of valve replacement surgery in those with bicuspid valves, or sometimes even before the valve itself requires surgical intervention. Angiotensin receptor blocking agents are increasingly being used to protect the aorta from expansion in patients with various aortopathies, including those with bicuspid aortic valves. Being born with 2 rather than 3 leaflets of the aortic valve requires lifelong monitoring. To effectively diagnose and treat the significant valvular and vascular complications that can arise in patients with bicuspid aortic valve, referral to centers with specialized interest in medical care, imaging and surgical therapy for patients with adult congenital heart disease is appropriate.
Figure 2. A. Calcified and stenotic aortic valve with reduced opening (echocardiograph). B. Bicuspid valve with oval-shaped opening seen on transesophageal echocardiography. C. Bicuspid valve with reduced opening seen on MRI. D. Calcified bicuspid valve, long axis view, transthoracic echocardiography. E. Eccentric jet of aortic insufficiency due to bicuspid valve. A
Figure 3. A and B. Two views of aortic root aneurysm (arrow with dissection of descending aorta (arrowheads). C. CT image of mechanical aortic valve in open position. D. Image of repaired aortic coarctation with native aorta (arrow) and graft going around coarct (arrowhead).
Fellowship Highlights Amin Yehya, M.D. 3rd Year Adult Cardiology Fellow
Fethi Benraouane, M.D. 3rd Year Adult Cardiology Fellow
Justin Mackenzie Vining, M.D. 2nd Year Pediatric Cardiology Fellow
Alberto Morales-Pabon, M.D. 3rd Year Chief Adult Cardiology Fellow
Lauren Holliday, M.D. 1st Year Adult Cardiology Fellow
Michele Murphy, M.D. 1st Year Adult Cardiology Fellow
Jose Cuellar, M.D. 3rd Year Adult Cardiology Fellow
Rod Evan Pellenberg, M.D. 2nd Year Pediatric Cardiology Fellow
Syed S. Zaidi, M.D. 2nd Year Adult Cardiology Fellow
Adult Cardiology Fellowship Highlights
Pediatric Cardiology Fellowship Highlights November 2012
• Rod Evan Pellenberg, M.D., submitted the manuscript, “Papillary Fibroelastoma of Tricuspid Valve in a Pediatric Patient” and was accepted to Annals of Thoracic Surgery.
• Amin Yehya, M.D., was elected President of the Housestaff Organization for 2012-13 .
• Rod Evan Pellenberg, M.D., lectured for first-year medical students’ embryology course. • Justin Mackenzie Vining, M.D., was selected a GRU Fellow Representative Nonvoting member of the Georgia Chapter of the ACC.
• Justin Mackenzie Vining, M.D., was board certified in general pediatrics by the American Academy of Pediatrics.
2013 Pediatric Fellowship Program Match The Pediatric Fellowship Program is happy to announce the match for a new fellow who will start July 1, 2013. Stefani M. Samples, M.D. - Medical College of Georgia at GRU.
2013 Adult Fellowship Program Match The CV Disease Fellowship Program had a highly successful match for new fellows who will start July 1, 2013.
• Amin Yehya, M.D., Alberto Morales-Pabon, M.D. and Fethi Benraouane, M.D. passed the Echocardiography Boards on their first attempt in July. This 100 percent pass rate for our fellows was also associated with some fellows scoring in the 90th percentile. • The 12 adult cardiology fellows completed their first nationwide American College of Cardiology In-Service Exam. Overall program score was significantly above the national average. The final year trainees scored 100 points above the national average for all other third year cardiology fellowship trainees nationally.
• Four of our cardiology fellows presented their research posters at the Annual Georgia Chapter of the American College of Cardiology. • Lauren Holliday, M.D. was selected to be the Fellow Representative Nonvoting member of the Georgia Chapter of the ACC.
Rebecca Napier, M.D. - GRU Residency Program Pratik Choksy, M.D., M.B.B.S. - GRU Residency Program Amudhan Jyothidasan, M.D. - University of Massachusetts Loren Morgan, M.D. - University of South Carolina
• Amin Yehya, M.D., organized the collection of toys for the James Brown Toy Drive for local needy children at the James Brown Arena on December 20.
Please contact us for more information 706-721-2736
February 22 Speaker: Michael Luc, M.D., 2nd Year GRU Cardiology Fellow Topic: “Stress Testing” March 8 Speaker: Simi Kumar, M.D., 1st Year GRU Cardiology Fellow Topic: “Cardiac CT/Cardiac MRI” March 15 Speaker: Ashkan Attaran, M.D., 2nd Year GRU Cardiology Fellow Topic: “Chronic Heart Failure” March 22
Your Heart. Our Hands.
Speaker: Lauren Holliday, M.D., 1st Year GRU Cardiology Fellow Topic: ”Intra-aortic Balloon Pumps”
Speaker: Alberto Morales, M.D., 3rd Year GRU Cardiology Fellow
Speaker: Vincent Robinson, M.D., Program Director, CV Disease
Topic: ”Diastolic Heart Failure”
Topic: “The New ACGME”
Speaker: Michele Murphy, M.D., 1st Year GRU Cardiology Fellow
Speaker: Fethi Benraouane, M.D., 3rd Year GRU Cardiology Fellow
Topic: “Women and Heart Disease”
Topic: “Recanalization of Chronically Occluded Graft: Is it a Paradigm Shift?
April 19 Speaker: Reza Amini, M.D., 2nd Year, GRU Cardiology Fellow
Jan. 11 Speaker: Fethi Benraouane, M.D. 3rd year GHSU Cardiology Fellow
Topic: “Novel Anticoagulation Therapy” April 26
Topic: PFO and cryptogenic stroke, should we close them?
Speaker: Jose Cuellar, M.D., 3rd Year GRU Cardiology Fellow
Topic: ”Comprehensive Approach to Syncope”
Speaker: Amin Yehya, M.D. 3rd year GHSU Cardiology Fellow
Please contact us for more information 706-721-2736
Cardiovascular Conferences GRU Coronary Revascularization Symposium
Cardiovascular Update for Primary Care Providers
June 6-9, 2013 Kiawah Island, SC
October 26-27, 2013 Marriott Riverfront Augusta, GA
GRU Cardiac Conference October 9-13, 2013 Chateau Elan Braselton, GA –7–
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Physician List Director of Heart and Cardiovascular Services M. Vinayak Kamath, M.D. Chief, Cardiovascular Medicine Sheldon Litwin, M.D. Chief, Pediatric Cardiology Kenneth Murdison, M.D. Cardiovascular Electrophysiology Adam Berman, M.D. William Maddox, M.D. Robert Sorrentino, M.D. Cardiovascular Imaging (Echo, MRI, CT and Nuclear Imaging) Preston Conger, M.D. Sheldon Litwin, M.D. Vincent Robinson, M.B.B.S. Pascha Schafer, M.D. Gyanendra Sharma, M.D. Cardiothoracic Surgery M. Vinayak Kamath, M.D. Vijay Patel, M.D.
No-hassle referrals General Cardiology (Inpatient and Outpatient) Preston Conger, M.D. Chris Pallas, M.D. Vincent Robinson, M.B.B.S. Pascha Schafer, M.D. Gyanendra Sharma, M.D. Neal L. Weintraub, M.D. John Thornton, M.D. Interventional Cardiology (Coronary and Vascular) Vishal Arora, M.D. Deepak Kapoor, M.D., M.B.B.S. Paul Poommipanit, M.D. Pediatric Cardiology William Lutin, M.D. Kenneth Murdison, M.D. Henry Wiles, M.D.
Your time is valuable. To make an appointment for your patient, please call: Cardiology
Pediatric Cardiology 706-721-8522 Pediatric Cardiac Surgery
Convenient Locations Augusta Georgia Regents Medical Center 706-721-BEAT (2328) Trinity Hospital (Summerville Bldg.)
Rehabilitation and Prevention Preston Conger, M.D.
Washington Wills Memorial
Vascular Surgery Gautam Agarwal, M.D., R.P.V.I.
Greensboro Lake Oconee