Advances in Cardiac: December 2011

A

S U P P L E M E n t

to

W E s t c h E s t E R

h E a lt h

&

l I F E

M AG A Z i n E

advaNces iN

cardiovascular CARE westchester medical ceNter

‘i dodGEd A BULLEt!’ UGLY VEinS, BEGonE! ‘VAPoRiZinG’ BLoCKAGES GUARdinG tHE AoRtA’S WALLS fiX foR A toddLER’S RACinG HEARt

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coNteNts

HEART & VASCULAR

4 9 6 caRdIology

New wiNdsor divisioN 845.561.2773

hawthorNe divisioN 914.909.6900 imaging 914.909.6925

12

noninvasive cardiology

advaNces iN

cardiovascular care 3

6 9

i N N ovat i o N s

in the cath lab

Electrophysiology/devices

a pass i o N

largest artery

Martin Cohen, M.d.

Paul Eugenio, M.d.

Andrea Cronin, R.n., fnP-C Carmela Musial, PA-C

‘i d o d g e d

heart Failure/vad/transplant

p r ot e c t i N g t h e

a bullet!’

10

Alan L. Gass, M.d.

Gregg Lanier, M.d.

Elizabeth Stevens, R.n., CCRn, MSn, fnP-BC Kathy Brown, R.n., B.S., M.S., A-nP, CCRn

BaNishiNg

ugly veins

12

North state divisioN

l e t yo u r

914.762.5810

blood flow

14

Invasive–Interventional cardiology Hasan Ahmad, M.d.

Martin Cohen, M.d.

Linda Cuomo, M.d.

William Gotsis, M.d.

Gary Silverman, M.d.

Robert timmermans, M.d.

for pictures

4

William frishman, M.d.

John McClung, M.d.

Joshua Melcer, M.d. tanya dutta, M.d.

Joseph Harburger, M.d. nyree Sencion-Akhtar, R.n., fnP-C Vicki Klein, P.A.-C

a l i t t l e B oy s u rv i v e s

a big heart problem Advances in Cardiovascular Care is published by Wainscot Media, Montvale, n.J. © 2011. All rights reserved. the information in this publication is written by professional journalists and/or physicians. However, no publication can replace the direct care or advice of medical professionals.

clinical & nonInvasive cardiology John tighe, M.d.

Stephen Lazar, M.d.

Joseph George, M.d.

Invasive–Interventional cardiology Ahmad A. Hadid, M.d.

Ahmad B. Hadid, M.d.

Gladys Pacenza, R.n., fnP Patricia Rainaldi, R.n., fnP

sURgERy valhalla divisioN 914.493.8793 cardiothoracic surgery Steven Lansman, M.d., Ph.d. david Spielvogel, M.d.

Rocco Lafaro, M.d.

Ramin Malekan, M.d.

Masashi Kai, M.d.

Cindy Yu, R.n., n.P.

hawthorNe divisioN 914.593.1200 vascular surgery Sateesh Babu, M.d.

Pravin Shah, M.d.

Arun Goyal, M.d.

Romeo Mateo, M.d. igor Laskowski, M.d. francis Carroll, M.d.

clinical & nonInvasive cardiology

lasER vEIn cEntERs

Arthur fass, M.d. franklin Zimmerman, M.d. dina Katz, M.d. deborah okoniewski, R.n., fnP Holly Mcnamara, R.n., AnP

Hawthorne 914.593.1200 Mount Kisco 914.241.3204 new Windsor 845.561.2773 White Plains 914.593.1234 Carmel 845.278.9670

go to WEstchEstERhEaRtandvascUlaR.com foR CoMPLEtE AddRESS LiStinGS And to SCHEdULE 2

advances in cardiovascular

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westchesterheartaNdvascular.com An APPointMEnt onLinE.

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a passion foR PiCtURES

This specialist knows how imaging technologies can help treat heart disease—and prevent it t h e y s ay a p i c t u r e i s w o r t h a thousand words, and Westchester

valves and other structures; • a 256-slice ct scanner, which

there are areas of scarring in the heart,” says Dr. Dutta, who trains Westchester

Heart & Vascular cardiologist Tanya

produces detailed images of the heart

Heart & Vascular’s cardiac fellows in

Dutta, M.D., agrees. She interprets

and its blood vessels in less than two

imaging technologies. “These tests also

nuclear stress tests, echocardiograms,

beats of a patient’s heart—so speedy that

help us evaluate treatment that has

cardiac CT (computed tomography)

it uses 80 percent less radiation than a

already begun.”

scans, and cardiac MrI (magnetic

standard scanner; and

resonance imaging) scans. These tools

• a 3 tesla mRI imaging system that

Dr. Dutta believes heart disease, America’s number-one killer, can someday

help her accurately assess patients’

is twice as strong as conventional MrI

be tamed. “With better early

hearts to assure definitive diagnoses—

machines and produces high-resolution

detection, medications and

and also provide assessments to help

images that do not require radiation.

lifestyle modification,” she

“Three-D echocardiography is par-

others stay healthy.

“Today we have many options to treat heart disease that can be used before we

says, “we can make great

ticularly helpful for evaluating the heart’s

progress in preventing heart

muscles and valves and determining if

disease in those at risk.”

have to refer a patient for an angioplasty or surgery,” says Dr. Dutta. “Cardiac imaging studies can help us detect heart disease at an earlier, more treatable stage than other tests. With them, we can often step back from recommending an invasive procedure and better guide treatment with medications and lifestyle changes.”

For patients who require surgery, she adds, cardiac imaging studies can fine-tune the treatment needed and help surgeons plan their procedures. A nuclear stress test or cardiac CT can replace an invasive angiogram for patients who cannot tolerate those tests. ways to view the heart Westchester Medical Center’s cardiac imaging technology, unequaled in the lower Hudson Valley, includes: • 3-d echocardiography, which can be used alone or

a WoUld-BE JoURnalIst gEts to thE

hEaRt oF thE mattER

tanya dutta, m.d.

tanya dutta, m.d., might have been an ace reporter. at first inclined toward a career in journalism, she edited harvard college’s daily newspaper, The Harvard Crimson, before switching to biology and earning her B.a./m.a. degree magna cum laude. “i realized halfway through college that i wanted to do more than interview patients—i wanted to treat them,” says the native chicagoan. while at cornell medical college in New york city, she fell in love with fellow student Neville Bamji—and with cardiology. “there are many fewer women cardiologists than men, yet almost as many american women as men with heart disease,” she says. “i thought i could offer my women patients a fresh perspective.” cardiology, she says, also promised her the ability to practice medicine based on an abundance of clinical research and evidencebased outcomes data. after completing an internal medicine residency at New york presbyterian hospital-cornell and a cardiology fellowship at montefiore medical center in the Bronx, she studied under the “guru of cardiac imaging,” Nathaniel reichek, m.d., at st. Francis hospital in roslyn, N.y. she completed a fellowship there in cardiac mr and cardiac ct and did research in cardiac imaging. she and Neville have two children, daughter tara, 2, and baby son Jayden, born June 14.

with cardiac MrI to assess heart

to find A

physician WMC_Cardio_1011Final_REV1.indd 3

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Innovations in the cath lab

a New

collaBoRatIvE spacE Now in late-stage planning, westchester medical center’s “hybrid” operating room will enable cardiovascular surgeons and cardiologists to work collaboratively with vascular surgeons and neurosurgeons on advanced interventions for patients. “heart and vascular problems often go hand in hand, so we must work together in performing both percutaneous and surgical procedures,” says interventional cardiologist hasan ahmad, m.d. Besides performing cardiac interventions, dr. ahmad also treats peripheral vascular disease, carotid artery disease and other circulatory problems.

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At the region’s largest cardiovascular center, cardiologists and surgeons make heart-disease treatment more effective patieNts are the wiNNers

of clinical medicine at New York Medical

when different kinds of doctors work

College. “The heart does not beat exclusive

together—and that’s what’s happening

of the circulatory system; neither can we

now in the cardiac catheterization (or

afford to work without close collaboration

“cath”) laboratory, once the exclusive

with our vascular-surgeon colleagues.”

bastion of interventional cardiologists.

Since the 1970s, the Medical

Today it has opened its doors to cardiac

Center’s five cardiac catheterization

and vascular surgeons, signaling a more

labs have bustled with interventional

collaborative approach to treating people

cardiologists performing diagnostic

with cardiovascular disease.

angiograms, which let doctors watch

“research today proves that integrating the skills and knowledge of all members of the cardiovascular team

how blood flows through the heart and coronary arteries.

While the patient is sedated with a

results in better outcomes for our patients,

local anesthetic, the cardiologist threads

and that is validated at Westchester

a thin tube, called a catheter, into the

Medical Center daily,” says interventional

femoral or radial artery and up to the

cardiologist and electrophysiologist Martin

heart. Contrast material is injected into

Cohen, M.D., Acting Director of Cardiac

the blood vessels to produce a real-time

Catheterization and an associate professor

X-ray image of the heart and its coronary

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arteries, which the cardiologist views on a monitor. Angiograms can show whether a coronary artery is blocked, help assess blood pressure in the heart’s

martin cohen, m.d.

chambers and reveal the volume of

linda cuomo, m.d.

gary silverman, m.d.

william gotsis, m.d.

blood pumped out of the left ventricle during each heartbeat.

M.D., Director of Westchester Medical

M.D., Co-Director of Interventional

have also used cardiac catheterization to

Center’s Coronary Care Unit. “But

Cardiology, were colleagues at Montefiore

perform minimally invasive procedures

with exciting advances in nonsurgical

Medical Center in New York City. “We

called percutaneous (through-the-

percutaneous procedures coming down the

are thrilled to be working again with

skin) coronary interventions (PCIs) to

pipeline and the hybrid room that is being

one of our mentors, Chair of Medicine

treat blocked coronary arteries. One of

built here, we’ll all be working together.”

Dr. William Frishman, with whom we

Since the late 1980s, cardiologists

these, angioplasty—which uses a small

Among these advances is

inflated balloon atop a catheter to open

transcatheter aortic-valve

a blocked artery—revolutionized the

implantation (tavI), a new

nonsurgical treatment of coronary artery

treatment for patients with

disease. By the mid-1990s, tiny metal

aortic stenosis—a life-

scaffolds called stents were added to

threatening narrowing

angioplasty to help prevent restenosis

of the aortic valve—who

(re-blockage), a common complication.

cannot undergo valve

In 2003, stents began to be coated with

replacement because

medications to make restenosis even

of age or other medical

less likely.

conditions.

Also in the cath lab, interventional

In TAVI, an interventional

cardiologists and electrophysiologists

cardiologist and a cardiac surgeon

(cardiologists who treat heart-rhythm

replace a patient’s damaged aortic

abnormalities) perform:

valve with a bioprosthetic one. They

• laser procedures to vaporize

enter through a small skin puncture in the femoral artery instead of making

blockages; • coronary thrombectomies using

the large traditional neck-to-navel

vacuum aspiration with a catheter to

incision standard in open surgery. Once

remove a blood clot from a coronary artery;

the bioprosthetic valve is implanted, it

• heart biopsies;

handles the function of allowing oxygen-

• implantations of pacemakers and

rich blood to flow from the ventricle to

implantable cardioverter-defibrillators

the aorta and then out to the rest

(ICDs) to correct irregular heartbeats;

of the body.

• transesophageal echocardiograms

“We want to bring TAVI to our

(in which an ultrasound tool is guided down

patients in the lower Hudson Valley,”

the patient’s throat on a scope) to diagnose

says Gary Silverman, M.D., Co-Director of

structural problems of the heart, and

Interventional Cardiology at Westchester

• radiofrequency and cryo-energy

Medical Center and an associate clinical

ablations, which use heat and freezing

professor of medicine at New York

techniques, respectively, to vaporize tissue

Medical College. “Here at Westchester

that causes heart-rhythm disturbances.

Medical Center, we are putting the pieces in place, both diagnostic and therapeutic,

what teamworK caN do

to perform the TAVI procedure and other

“Historically, interventionalists and cardiac

percutaneous treatments that will save

surgeons competed for patients,” says

countless lives.”

interventional cardiologist linda Cuomo,

to find A

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conducted research at Montefiore,” says Dr. Gotsis, who now directs Westchester Medical Center’s interventional cardiology fellowship program.

USING A BETTEr

EntRy poInt

the newest twist on cardiac catheterization is to thread the catheters and other instruments “transradially”—up to the heart through the radial artery in the patient’s wrist instead of the femoral artery in the groin. interventional cardiologist robert J. timmermans, m.d., made the switch to the transradial approach several years ago and strives to use the technique almost exclusively. “the transradial approach results in a 50-percent lower risk of major bleeding complications at the wrist than in the groin—and less pain too,” says dr. timmermans. “patients can sit up immediately following the catheterization and can usually go home sooner than patients who must remain lying down flat for several hours after the femoral approach. “we’re working to minimize delays and return patients home as safely and expeditiously as possible,” adds the doctor.

Dr. Silverman and William Gotsis,

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protectiNg THE

largest artery

A vigilant program at Westchester Medical Center helps save the lives of patients with thoracic aortic aneurysms

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the aorta, shaped liKe a caNdy cane, is the body’s largest blood vessel. It carries oxygenated blood and nutrients from the heart to the rest of the system. Originating in the heart’s left ventricle, the aorta rises and then arches backward over the left lung, descends throughout the chest into the abdomen, and then ends by dividing into the iliac arteries in the pelvis.

In the average adult, the aorta’s strong and fibrous walls

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must withstand the pressure of 10 pints

Heart & Vascular

of blood gushing through at all times.

colleagues,

An aortic aneurysm occurs when

cardiothoracic

the walls of the aorta weaken or balloon

surgeons Steven l.

out. Aortic aneurysms are called

lansman, M.D., Ph.D.,

thoracic if they occur in the chest above

and ramin Malekan,

the diaphragm and abdominal if they

M.D., consider

appear below.

each patient’s stature, family history

david spielvogel, m.d.

and other medical conditions as well preveNtiNg disaster

as the aneurysm’s rate of growth and

Thoracic aortic aneurysms can develop

its diameter.

slowly or quickly. Two famous TV

Thoracic aortic aneurysms usually

comedians lost their lives to problems

do not make their presence known until

in the thoracic aorta: lucille Ball

disaster is imminent. But sometimes the

from a ruptured aorta following heart

condition is uncovered during a CT scan

surgery, and John ritter from an aortic

or other radiologic study for another

dissection.

medical issue.

At Westchester Medical

If an aortic aneurysm is found and

Center, Westchester Heart &

is within a safe size, the patient is placed

Vascular’s internationally recognized

on an individualized care schedule of

cardiothoracic surgeons have

ongoing exams and imaging studies.

implemented a comprehensive Aortic

If a patient has experienced an aortic

Aneurysm Program to prevent such

dissection and has had surgery to repair

tragedies by carefully screening all

it, he or she is immediately enrolled in

patients diagnosed with thoracic

the database because the patient is at

aortic aneurysms and managing their

risk to develop an aortic aneurysm.

care. The surgeons work closely with

ContinUEd on PAGE 8

ramin malekan, m.d.

steven l. lansman, m.d., ph.d.

“

Obviously we prefer to treat a thoracic aortic aneurysm safely and effectively before it reaches a dangerous stage.

”

patients’ primary care physicians, cardiologists and vascular surgeons to track any changes in these aneurysms

WHEn An

anEURysm BURsts

through regular checkups, computed tomography (CT) scans and/or magnetic resonance imaging (MrI) studies.

“Obviously we prefer to treat a thoracic aortic aneurysm safely and electively before it reaches a dangerous stage,” says cardiothoracic surgeon David Spielvogel, M.D., Director of the Medical Center’s Aortic Aneurysm Program. moNitoriNg aortic aNeurysms For many years, a thoracic aortic aneurysm was considered safe until it reached 5 centimeters in size. Today, however, doctors at Westchester Medical Center look beyond this simple cutoff. To determine when to intervene,

an aortic aneurysm that bursts is a medical emergency, requiring immediate attention. call 9-1-1 if you experience: • sudden, intense, persistent abdominal, chest or back pain • pain that radiates to your back or legs • sweatiness • clammy skin • dizziness • loss of consciousness • shortness of breath • signs of stroke: weakness on one side of the body, difficulty speaking, blurry vision

Dr. Spielvogel and his Westchester

to find A

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ContinUEd fRoM PAGE 7

protectiNg THE

largest artery

“Since 2006, when we began this program at Westchester Medical Center,

Cardiovascular Surgery at Westchester

—developed by Dr. Spielvogel—is fast

Medical Center.

becoming the standard at heart centers

we have perfected our surveillance and

around the world.

our surgical techniques so that we have

wheN surgery is Necessary

achieved very successful outcomes

“We look for subtle changes to time

replaces the aortic arch with a Dacron

and very low mortality rates,” says Dr.

elective surgery, rather than risk having

graft. A separate graft containing three

Spielvogel, who is also a professor of

to repair the aorta in an emergency,” says

“limbs” is substituted for the area where

cardiothoracic surgery at New York

Dr. lansman, Chief of Cardiothoracic

three arteries branch off the arch.

Medical College, Director of Heart

Surgery at Westchester Medical Center

Transplantation, and Associate Chief of

and a professor of cardiothoracic surgery

in the descending aorta and the patient’s

at New York Medical College.

medical condition permits, the surgeon

The type of surgery used to

Sometimes when aneurysms are

may use an endovascular stent-graft

treat a thoracic aortic aneurysm

procedure, avoiding “open” surgery to

depends on the site of the weakness.

treat the aneurysm. Because there is no

The “gold standard” of surgery to

large chest incision, both pain and the

treat an aneurysm in the aortic root

risk of complications are reduced, and

and ascending aorta is the Bentall

there is a quicker recovery.

procedure, named for the English surgeon who created it in the 1960s.

During a Bentall, the surgeon

KnoW YoUR

In this procedure, the surgeon

The Westchester Heart & Vascular cardiovascular surgery team also performs complex surgical procedures

removes the area of the aorta containing

through incisions in the chest and

the aneurysm, replaces the aortic valve

abdomen to treat thoraco-abdominal

with a mechanical or bioprosthetic

aneurysms, which lie in both the chest

one, and then re-implants the coronary

and abdomen. Few heart centers have

arteries into a Dacron polyester tube

experience with such extensive aortic

graft that replaces the section of

reconstructions.

anEURysm RIsK

ascending aorta that has been removed.

you’re at higher-than-average risk of aortic aneurysm if you: • are age 60 or older • use tobacco • have high blood pressure • have atherosclerosis (buildup of plaque in your arteries) • are male (but women are at higher risk for rupture) • have a family history of the condition • suffer chest trauma • have a bicuspid aortic valve • have marfan’s syndrome or ehlers-danlos syndrome

Malekan use a technique called valve-

Preventing a stroke during aortic surgery

sparing aortic-root reconstruction for

is a challenge, as a stroke can occur

patients whose aortic valves are healthy.

as the result of tiny particles of debris,

Drs. Spielvogel, lansman and

“This saves a patient from a lifetime of taking anticoagulant medications, which are necessary to prevent blood

guardiNg BraiN aNd spiNal cord

called emboli, traveling to the brain and blocking blood flow there.

At Westchester Medical Center,

clots from forming around a mechanical

special protocols protect the brain during

valve and putting the patient at risk for a

surgery. Methods include connecting the

stroke,” says Dr. Malekan.

heart-lung bypass machine to the axillary artery, keeping blood flowing to the brain

advaNced procedures

while the heart is stopped, and cooling

If a patient requires repair of the aortic

the patient’s body temperature to slow

arch, a procedure called a trifurcated

the metabolism while stopping blood

graft technique will be used. This surgery

flow to vital areas. .

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Center’s Emergency Department

removed when his heart is

on September 6, he was chronically

fully recovered.

short of breath and his heart was

“I’m looking forward

racing at an alarmingly fast rate. An

to driving again and

electrocardiogram was abnormal, and

returning to work,” says

he was promptly admitted.

Aruilio, who is grateful for

Aruilio was hooked up to an

alan l. gass, m.d.

the treatment he received.

extracorporeal membrane

“I placed my trust in Dr. Gass,” he

oxygenation (ECMO)

adds, “and had complete confidence in

machine to help

his ability to save my heart.”

his lungs while a percutaneous

HELPinG PAtiEntS WitH

(through-theskin) CentriMag

®

ventricular assist device (VAD) was implanted through the groin into his heart to take over its function temporarily and pump oxygenated blood through the body. Together the two technologies gave Aruilio’s endangered heart the chance it needed to recuperate.

This combination, pioneered by Alan l.

Gass, M.D., Director, Heart Transplantation

Today’s heart-failure treatments save lives that would have been lost a few years ago

and Mechanical Circulatory Support, and his team at Westchester Medical Center, can be initiated within 15 minutes in an operating room or a cardiac catheterization lab. And it’s helping to change heart-failure treatment today.

At an international conference in Pennsylvania in June 2011, Dr. Gass

Joseph aruilio shudders wheN

presented data from almost 100

he recalls how close he came to dying.

ECMO procedures he and the team

“My doctor says I dodged a big bullet,”

at Westchester Heart & Vascular

says Aruilio, 52, a Carmel resident

have performed over four years. “We

who works as a service manager for a

rescued many of these patients from

medical equipment firm.

certain death, so that we could initiate

What almost killed Aruilio was heart failure, caused by a virus that enlarged his heart and compromised

further treatment and save their lives,” says Dr. Gass.

Aruilio was slowly weaned off

its ability to pump blood. When he

the ECMO machine and discharged

was brought to Westchester Medical

September 26. The device will be

to find A

physician WMC_Cardio_1011Final_REV1.indd 9

hEaRt FaIlURE despite its name, heart failure doesn’t mean the heart stops completely. it’s a chronic condition in which the heart can’t do its usual stellar job of pumping 2,000 gallons of blood daily. and the american heart association says it affects 5 million people in the u.s. many heart-failure patients are helped by lifestyle modifications, including smoking cessation, weight loss, exercise, proper sleep and a low-salt diet, and by medications that remove remove fluid from the body, dilate blood vessels and calm the heart muscle. others require more aggressive treatments such as these, which are provided in westchester medical center’s comprehensive heart Failure program: • Electrophysiology treatments, which utilize a pacemaker to synchronize the beating of the heart’s two ventricles; • percutaneous coronary interventions (including angioplasty and stenting), which open up blocked or narrowed coronary arteries; • latest-generation mechanical assist devices, which perform the pumping action of the heart and serve as bridges to transplant or as a longterm destination therapy; and • cardiac surgery, including heart transplantation, coronary artery bypass, valve repair or replacement and aortic surgery.

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BAniSHinG

ugly

i F va r i co s e v e i N s h av e K e p t you from revealing your legs, stand up and take notice. A minimally invasive

An outpatient procedure has made the treatment of varicose veins simpler and more effective

treatment can get you back into your shorts and dresses without sidelining you for days. “I was surprised by how easy and painless it was,” reports luAnne Izzo of Katonah, 48, who is proud of her legs once again after years of hiding them.

Vascular surgeons at Westchester Heart & Vascular are using the outpatient VNUS Closure™ procedure to treat varicose veins with little discomfort.

Patients often experience immediate relief from burning or throbbing in the legs and can usually go back to work and resume their normal activities the following day.

Healthy leg veins contain one-way valves that open and close to assist the return of blood to the upper part of our body. When these valves become damaged or diseased, blood can pool in the veins, causing a condition called venous reflux or venous insufficiency in which leg veins may become swollen, discolored and knotted. Symptoms— including pain, throbbing, burning, muscle cramps and leg fatigue—often follow. This condition, commonly known as varicose veins, can progress to leg ulcers and dangerous blood clots.

It’s been estimated that nearly 60 percent of all American women and

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G

Who’s at RIsK? you may be at risk for varicose or spider veins if you: • are a woman • have been pregnant more than once • have a family history of the condition • work at a job that requires long periods of standing • do a lot of heavy lifting • are overweight

the most severe cases.

Endovascular procedures are

Closure™ procedure takes about an hour, and patients

performed without an incision instead of

go home one to two hours

with “open” surgical cuts. radiofrequency

later. If an ultrasound test

ablation involves using heat energy to

performed prior to the

remove diseased tissue, in this case the

procedure has shown

varicose veins.

venous reflux disease in

arun goyal, m.d.

veins other than the saphenous, they can the power oF heat Dr. Goyal performs VNUS Closure™ in

be treated at the same time. “research studies have shown that

the Atrium laser Vein Center, using

the Closure™ procedure is about 97

42 percent of men have varicose veins.

local anesthesia. A Closure™ catheter

percent effective,” says Dr. Goyal. “And

And though the problem sometimes

is inserted into the patient’s saphenous

most patients require just one treatment.”

affects younger adults, its incidence

vein percutaneously at the knee through

increases with age.

a small needle prick. Using ultrasound

the next day. Postoperative care involves

imaging to guide him, Dr. Goyal delivers

wearing compression stockings for one to

few conditions that affect clinical health,

quick bursts of radiofrequency energy

two weeks and walking at least one mile a

aesthetics and quality of life,” says

within the catheter to sections of the

day. Any bruising or scarring is minimal.

surgeon Arun Goyal, M.D., Director of

vein’s wall. The heat shrinks the wall,

Vascular Imaging and the Atrium laser

causing it to collapse and seal up. Healthy

satisfied patient Izzo. “If I had known how

Vein Center and an assistant professor

veins take over the job of taking blood

uncomplicated it was going to be, I would

of surgery at New York Medical College.

from the legs back to the heart. The

have done it a lot sooner.”

“Varicose veins are one of only a

“By the time patients come to me, many have suffered for years and greatly curtailed their activities.” closiNg oFF diseased veiNs Until about 10 years ago, doctors treated varicose veins with an invasive procedure called vein stripping, which Izzo recalls her mother undergoing. The patient was placed under general anesthesia while a vascular surgeon made several incisions near the knee and groin and then inserted a medical tool into the great saphenous vein, the major vein in the leg from which smaller veins branch off. The saphenous vein was tied off and then pulled from the leg. Because smaller veins broke during this process, blood frequently leaked into surrounding tissues; patients had postoperative pain, soreness and bruising, and recovery took up to four weeks.

In the early 2000s, the surgeons at Westchester Medical Center began performing a procedure called radiofrequency endovascular ablation to treat varicose veins. As embodied in a system known as VNUS Closure™, it has

“

Patients usually go back to work

“There was no down time,” says

If I had known how uncomplicated it was, I would have done it a lot sooner. along camE ‘spIdERs’

”

spider veins are varicose veins’ annoying but harmless cousins: tangled groups of tiny blood vessels that turn blue or red from mild venous reflux, located near the surface of the skin. people at risk for varicose veins are also at risk for spider veins. spider veins can be caused by ultraviolet rays of the sun, certain medications or an injury to the skin surface. generally, spider veins are treated with one of two noninvasive or minimally invasive methods: • sclerotherapy, the injection of an irritant solution into the spider veins, which causes them to seal shut. the veins are absorbed by the patient’s body.

• laser treatment, during which a device is used to deliver heat to the surface of the skin to destroy the veins.

Because these treatments are considered cosmetic procedures, they are not covered by health insurance. patients usually require four treatments over a period of six months. although general practitioners, dermatologists and other healthcare professionals offer spider-vein treatments, dr. goyal recommends consulting a boardcertified vascular surgeon. “we have extensive knowledge about the complex functioning and malfunctioning of the entire circulatory system, so that if there are other medical issues affecting this system we can address them too,” he says.

since replaced vein stripping in all but

to find A

physician WMC_Cardio_1011Final_REV1.indd 11

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d i d yo u K N ow yo u r B lo o d travels through roughly 60,000 miles of arteries, veins, capillaries, organs and cells of your body every day? When it circulates normally, this blood (about 10 pints in the average adult) distributes oxygen and nutrients, then picks up waste matter and carbon dioxide from organ and tissue cells. When something impedes blood flow—either by blocking or weakening blood vessels or by damaging valves inside veins—a person is said to have vascular disease.

Fortunately, today’s endovascular (inside blood vessels) treatments can in many cases restore good health to people with vascular disease without long hospitalizations.

At Westchester Heart & Vascular,

let your

six board-certified vascular surgeons specialize in diagnosing and treating conditions of the circulatory system.

They work closely with a team of cardiologists and cardiothoracic

blood flow Endovascular procedures often can restore healthy circulation without a long hospital stay

surgeons to provide comprehensive care of the entire cardiovascular system. Our vascular surgeons are also an integral part of Westchester Medical Center’s level I Trauma Center team, which treats patients who often require immediate emergency care.

Vascular disease can be caused by: • atherosclerosis, a slow, progressive disease marked by a buildup of plaque (fat, cholesterol, calcium) in an artery; • inflammation in a blood vessel that leads to narrowing or blockage; • blockage by an embolus (tiny mass of debris) or thrombus (blood clot); or • injury or trauma to blood vessels. miNimally iNvasive procedures “By far the most exciting advances in the treatment of vascular disease involve minimally invasive endovascular procedures,” says Sateesh Babu, M.D., Chief of Vascular and Endovascular Surgery at Westchester Medical Center and professor of clinical surgery at

12

advances in cardiovascular

WMC_Cardio_1011Final_REV1.indd 12

care

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New York Medical College. “These can

anatomy is different,” says Dr. Babu,

often spare a patient major surgery

“a vascular surgeon’s decision to use

to prevent or stop a life-threatening

an endovascular procedure (in about

vascular condition.” With Pravin Shah,

75 percent of cases) or an “open”

M.D., Dr. Babu cofounded the Medical

repair (25 percent) must take into

Çenter’s oldest vascular surgery

consideration the location of the

practice in 1980; it has since joined

aneurysm, any twists and turns of the

Westchester Heart & Vascular.

aorta and any blockages in arteries on

sateesh Babu, m.d.

pravin shah, m.d.

the way from the femoral artery up to preveNtiNg “triple a” disasters

the AAA.”

In the past decade, the endovascular treatment of a common yet potentially

carotid artery disease

deadly condition called abdominal aortic

A major risk factor for stroke, carotid

aneurysm (AAA or “triple A”) has spared

artery disease occurs when plaque

many patients complex abdominal

builds up in one or both carotid arteries

surgery that would have required a

located in the neck, which carry blood

hospital stay.

to the brain and supply blood to your

An AAA is a ballooning of the aorta

face, scalp and neck. A stroke can

in the abdominal area, most often below

occur if plaque narrows the artery

the kidneys. If it ruptures, this can cause

or if a blood clot sitting atop plaque

death in up to 50 percent of patients

breaks off and then blocks blood flow

before they reach the hospital. By far

to the brain.

the greatest risk factor is cigarette

Dr. Babu and his colleagues took

smoking. (See “When an Aneurysm

part in a major National Institutes

Bursts,” on page 7.)

of Health clinical trial investigating

Insidious by nature, AAAs do not

two treatments for carotid artery

usually cause any symptoms. Often

disease. The Carotid revascularization

they are discovered during a physical

Endarterectomy versus Stenting Trial

exam or an imaging test for another

(CrEST) demonstrated that carotid

medical condition.

endarterectomy, a traditional surgical

“Once we know a patient has an

procedure to clear a blockage, and

AAA, we develop a surveillance plan of

the minimally invasive endovascular

checkups and ultrasounds to keep an

angioplasty/stenting used to open

eye on it,” says Dr. Babu. “In men, we

up a carotid artery had similar out-

may recommend treatment if it grows

comes (though there is a slightly higher

above 5.5 centimeters, in women above

stroke risk with stenting in patients

5 centimeters, and in both if the AAA is

over age 80).

growing rapidly. There is also a familial

Open surgery entails removing

risk, so we recommend ultrasound

plaque and diseased portions of the

screening for family members.”

artery through a small neck incision.

During endovascular AAA repair, a

“

By far the most exciting advances in the treatment of vascular disease involve minimally invasive endovascular procedures.

”

The stenting procedure involves

stent graft is threaded up to the site

threading a balloon-tipped catheter,

of the aneurysm from the femoral

metal stent and a tiny umbrella-like

Dr. Babu. “Once the blockage goes

artery. The stent graft acts as a bridge

“embolic protection device” (to guard

over 75 percent, the stroke risk leaps

between the healthy parts of the aorta,

against the formation of embolisms)

to 7 to 10 percent per year. Surgical

reinforcing the weakened section and

up from an artery in the groin to the

endarterectomy and stenting have

allowing blood to flow through the

carotid artery in the neck.

similar success rates, so the choice of

graft and avoid the aneurysm, which eventually shrinks.

“Because every patient’s

to find A

physician WMC_Cardio_1011Final_REV1.indd 13

“A carotid artery that is less than

treatment is based on each patient’s

75 percent blocked carries only a 1

individual anatomy, medical condition,

to 1.5 percent risk of stroke,” explains

age and overall health.”

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A little boy survives a

big heart problem How an electrophysiology procedure cured a rapid heart rate i n s e p t e m e r 2 0 1 0 , s h a nn o n

pediatric cardiology team. By this

Holmes of Millbrook, N.Y., thought her

time, Hunter’s heart rate was up to 225

three-year-old son, Hunter, was coming

beats. An electrocardiogram revealed

down with a bug. Even the excitement of

supraventricular tachycardia (SVT),

his cousin’s birthday party didn’t get him

a disturbance of the heart’s electrical

up and running.

system that starts in the upper chambers.

On September 28, a call from Hunter Holmes, 4, above and with friends Noah Mead, 4 (left), and Isabella Marie Tibodeau, 2, at a summer carnival

“Children,” says pediatric electrophysiologist Irfan Warsy, M.D., “may not know how to convey that they are experiencing heart palpitations. They may describe their heart as ‘beeping’ or say they are ‘having chest pains.’” If your child does so, go first to your regular pediatrician, who may recommend a pediatric cardiologist; 16 of them are on the faculty of the Maria Fareri Children’s Hospital at Westchester Medical Center.

14

advances in cardiovascular

WMC_Cardio_1011Final_REV1.indd 14

rest in between beats and its chambers

sent Shannon into a whirlwind of activity,

cannot fill with blood properly to create

ending in Hunter’s being diagnosed in

the force for normal blood flow.

the Pediatric Emergency Department

Is my child having palpitations?

“Our first step was to use maximum

(ED) of Maria Fareri Children’s Hospital

dosages of an intravenous medication

at Westchester Medical Center with a

to try to break the SVT, but his heart

dangerous abnormal heartbeat, known as

continued to beat too fast,” says Irfan

an arrhythmia.

Warsy, M.D., who was called in to

Upon the recommendation of

supervise Hunter’s treatment. Director

Hunter’s pediatrician—who measured

of Pediatric Electrophysiology at Maria

the boy’s heart rate at 194 beats per

Fareri Children’s Hospital and an assistant

minute instead of the normal 90 to

professor of pediatrics at New York

110—Shannon and her husband, Mark,

Medical College, Dr. Warsy specializes in

made the one-hour drive to Maria Fareri

heart arrhythmias in children.

“When a second medication also

Children’s Hospital.

As they reached the Emergency

care

When a heart beats that fast, it cannot

Hunter’s child care provider, also a nurse,

failed, we had to consider: Was Hunter’s

Department (ED), the family was

enlarged heart a result of the SVT or was

immediately met by the hospital’s

it, perhaps, a reaction to something viral?”

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11/23/11 11:39 AM

recalls Dr. Warsy. “We formulated a plan

the 60 or so children each year that

to treat him in the hospital’s Arlene and

Dr. Warsy treats and cures with this

Arnold Goldstein Pediatric Intensive Care

procedure. After an overnight stay, he

Unit with another potent medication and, if

returned home with no evidence of

necessary, to use a ventilator to breathe for

the SVT. He underwent imaging tests

him so his heart could rest.”

every couple of months until Dr. Warsy

Fortunately, a third medication broke

discharged him from his care eight

the SVT overnight, and a ventilator was

months later, noting that his heart

not needed. Hunter’s heart returned to a

function had normalized. There are no

normal rhythm after about four days of an incessant rapid heartbeat.

restrictions on Hunter’s future activities.

Irfan Warsy, M.D.

“We were allowed to stay all seven

“I finally exhaled when Dr. Warsy said he was cured,” says Shannon with a laugh.

days that Hunter was in the hospital,” says

disturbances in children to discover

Shannon. “By the fourth day, he started to

if a true arrhythmia exists. “Inducing an

of SVT can be a burden for children,

look like himself and wanted to play again.”

arrhythmia is not dangerous in children,”

notes Dr. Warsy: “They often become

the doctor says. “Within the carefully

withdrawn and anxious and live in fear of

that Hunter had a rare form of SVT called

controlled environment of the EP lab, we

recurrences that can bring an ambulance

permanent junctional reciprocating

can provoke the heart into an arrhythmia,

to their school. This procedure, which

tachycardia. The culprit was not a virus,

study the characteristics of the substrate

carries just a minimal one to three per-

but a group of cells called a substrate.

and then pace the heart back to normal.

Further tests revealed to Dr. Warsy

“A substrate is present from birth and

In the majority of children on whom we

acts as a kind of short circuit,” explains Dr.

perform this test, if we can’t induce a

Warsy. “It is patient and waits in a child

disturbance, there is no arrhythmia.”

until there’s a perfect environment of

A “roving” catheter moved

heart maturity, neurological growth and

by the electrophysiologist can

hormones, then it acts up.”

pinpoint a substrate, such as Hunter’s, within millimeters. “The

diagnosing arrythmias

key is to avoid the atrioventricular

Dr. Warsy oversees the only pediatric

(AV) node, electrically the ‘holiest’

electrophysiology (EP) service in the

spot in the heart,” says Dr. Warsy.

region. This subspecialty of cardiology

Because the medication Hunter

involves the diagnosis and treatment of

was taking to control his SVT can

arrhythmias, disturbances in the heart’s

cause significant side effects, Dr. Warsy

intricate electrical conduction system.

recommended a minimally invasive

Electrophysiologists divide arrhythmias

radiofrequency ablation procedure to put

into tachycardias, in which the heart rate

an end to the arrhythmia permanently.

is faster than normal; and bradycardias, in

While Hunter was placed under

which it is slower. Noninvasive cardiac tests

general anesthesia, Dr. Warsy employed

used to diagnose arrhythmias include:

catheters placed in stable predetermined

• electrocardiograms (EKGs);

positions to provoke Hunter’s SVT with

• short- and long-term home EKG

electrical currents. Using 3-D imaging, he determined the pathway of the SVT

Holter monitoring; • event monitors and loop recordings (which detect palpitations); and • exercise stress tests (which

and guided a roving catheter to locate the offending substrate tissue. Within millimeters of the substrate he used

evaluate the heart’s ability to respond

radiofrequency energy heated to 60º

appropriately to exercise and assess

Celsius (140º Fahrenheit) to destroy the

medications’ effectiveness).

substrate, monitoring the temperature with

Dr. Warsy and his EP team also use invasive tests to provoke rhythm

to find A

physician WMC_Cardio_1011Final_REV1.indd 15

special technology within the catheter.

Living with recurrent episodes

cent risk, can turn a child’s life around.”

Ventricular arrhythmia, in which the heart’s lower pumping chambers beat faster than normal, can result from a structural abnormality of the heart muscles, a problem with the coronary arteries or a channelopathy, a genetic aberration of the heart’s electrical conduction system. If not treated promptly, it may cause sudden cardiac arrest.

If such an arrest in a child is successfully relieved, a small device called an implantable cardioverter-defibrillator (ICD) can be used to maintain a regular heartbeat.

“The advanced ICDs we now use can differentiate between pathologic tachycardia and a normal fast heart rate during a child’s everyday activities,” says Dr. Warsy.

“Once the ICD determines via complex algorithms that the rapid heart rate is truly an abnormal arrhythmia, it can simply pace the heart out of the arrhythmia or send a small electrical current to shock it into a normal rhythm, saving the child’s life.”

Happily, Hunter became one of

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11/23/11 11:39 AM

Westchester Medical Center.

One of America’s 100 Best Hospitals for Cardiac Surgery.

Since 1977, our team of world-class physicians has dedicated as much effort to advancing cardiac treatment methods as it has to perfecting them.

That’s why, with nearly 6,000 hospitals in the United States, HealthGrades®, the most trusted, independent source of physician information and hospital quality ratings, has placed us in the top 100 for Cardiac Surgery.

877•WMC•DOCS westchestermedicalcenter.com Maria Fareri Children’s Hospital • Westchester Heart & Vascular • Cancer Center • Transplant Center Neuroscience Center • Joel A. Halpern Regional Trauma Center • Burn Center Behavioral Health Center • Advanced Imaging Center • Advanced OB/GYN Associates

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