SYSTEMnews -- September 2013

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Volume 13

Issue 1

September 2013

SYSTEMnews

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`` Joey Bellettiere underwent regular stress tests to measure his heart’s increasing strength as the LVAD speed was reduced. Outpatient coordinator Judy Marble turned down his VAD to the minimal possible support and monitored him for any symptoms of heart failure.

CEO’s corner Ralph W. Muller

CEO, University of Pennsylvania Health System

The last few decades have seen many exciting innovations in health care — and Penn Medicine has regularly been at the forefront of these advances. The latest area we’ve made an innovation priority is personalized medicine. Here we use technology to pinpoint the actual molecular makeup of patients. That’s right; we can develop fine-grained portraits of the very genes and proteins that make up our bodies — one person at a time. Then, armed with these remarkable data, we can customize health care decisions to fit the needs of each individual. This includes identifying patients at risk for certain diseases (so prevention plans can be introduced) and matching identified gene variations with particular medications to ensure that patients get the right drug at the right dose. Custom-made medicine is fast becoming a reality. As you might imagine, such a high level of finetuning calls for sophisticated tools and procedures. Individualized data, decision-support software to help guide physicians, and fully integrated electronic health records are all necessary to make the most of personalized medicine. At Penn Medicine we’re moving forward with three major projects that, taken together, will constitute a major step forward in our goal of achieving genuinely personalized medicine. First, we’re working on two new data analysis programs. “Pennomics” takes all of the raw data we have on patients (for example, a patient’s bloodwork, radiology results, and electronic medical record) and converts them into useful knowledge — allowing physicians to tailor their care decisions to meet the precise needs of each patient. We might use the system to determine that a given patient could respond poorly to a specific blood pressure medication or blood thinner. We can also use the Pennomics platform to analyze populations of patients, such as those with mutations of the BRCA genes that raise the risk of breast cancer. A second tool, the Endeca platform from Oracle, was recently purchased to help us search all of the text in our electronic medical records, even the

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Rest  Recovery  Reconditioning The Three R’s of Returning to a Healthy Heart Soon after Joey Bellettiere was born with an enlarged heart, he was brought to CHOP for treatment. Although the newborn was stabilized, his parents were told he might eventually need a heart transplant. This prediction almost came to fruition when, at 19, he started having significant breathing problems that he had never before experienced. Within six months, Bellettiere was at HUP, learning that the left ventricular assist device (LVAD) he needed to survive was being studied as a possible bridge to recovery. Was he interested in participating in this trial? “It was a no brainer.” An LVAD acts as a crutch for a failing heart, helping to pump blood through the body. The LVAD pump and its connections are implanted during open-heart surgery. A computer controller, a power pack, and a reserve power pack remain outside the body. Originally used as a bridge to transplant — ie, keeping patients alive until they were matched with a donor heart — it has also been a ‘destination therapy.’ In these patients, the device is left in place permanently in lieu of a heart transplant. Most recently, the LVAD has been tested as a bridge to recovery, allowing the heart to rest and, hopefully, regain enough strength to beat on its own again. Bellettiere received the LVAD in October 2009. Little by little, the device did less of the work as his heart took over more of the pumping process. By March 2011, his heart

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Inside Clinical Excellence:Inside More than Do You Havetoan Rubenstein Award-Winning Project?...........2 Step Down.................................2 Penn Medicine@Work..............3 From Pastels to PDA’s...............2 Newsmakers..............................4 RoundtableFree Skin Penn’s Medical School Cancer Screening......................3 Camp a Hit with High School Students.....................................5 Shortakes...................................4 26 Penn Medicine Practices Earn Another Title..............................5 Highest National Recognition for Patient-Centered Care............... 5 SOM Ranked #2.........................6 Medical Student Initiative is Catalyst for Asylum Seekers....5 Awards and Accolades.............6

`` Reprinted with the permission of Thoratec Corporation

Skills & Knowledge...................2

was deemed strong enough to remove the device. Today “I feel better than ever,” he said. “I can walk, I can run, without getting out of breath.”

From Implant to Explant: What’s Involved In patients with heart failure, the heart enlarges as an adaptive response to injury. This allows it to keep pumping enough blood through the body, at least temporarily. As Eduardo Rame, MD, medical director of Mechanical Circulatory Support, explained, a normal heart regularly ejects — or pumps — about half of its 40-milliliter volume. Because a damaged heart might pump only 10 percent of its volume, it could enlarge to 200 ml to continue this ejection pace. However, it’s not sustainable. “The heart requires a tremendous amount of energy per day — more than any other organ — to circulate that much blood,” Rame said. “It simply can’t continue doing that much work at that size.” With an LVAD augmenting the blood flow, a patient’s heart can rest and begin the slow process of reverse remodeling, ie, shrinking back to its normal size. Prior to implant, the patient’s heart failure medications are maximized to further help the reversal process. “The LVAD may be a platform that allows them to better tolerate these meds,” Rame said. Routine echocardiograms chart the heart’s changes while the speed of the LVAD is slowly decreased. Echos are the primary imaging modality because they can be done repeatedly with no damage to internal organs. MRIs cannot be used on patients with these implanted devices. The echocardiogram provides detailed information during the turndown, including the heart’s size and function level, how the right ventricle handles the increased blood flow, and a measure of the flow through the aortic valve. According to James Kirkpatrick, MD, of Cardiovascular Medicine, “The LVAD bypasses the aortic valve, but if the heart starts to function as it should, more of the blood starts going out the aortic valve, rather than through the LVAD.” The echo also shows any leakage of the mitral valve, which would occur if the blood went backwards into the left atrium. Most important, if a patient does start to experience symptoms during the turndown, “the echo will tell us why,” Kirkpatrick said. (continued on page 2)

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SYSTEMnews -- September 2013 by Penn Medicine - Issuu