Innovations in Treating Heart Valve DiseaseHybrid procedures combine the best of bypass surgeryand catheter-based interventions.As minimally invasive surgical techniques continue to advance, surgeons are

becoming more adept and more creative in applying them. For patients with heartvalve disease and coronary artery disease, this means new and better options –and for many, the chance to avoid more traumatic surgeries.

The heart has four valves that control the flow ofblood into and out of the heart. Most commonly,valvular disease affects the aortic valve. If the aorticvalve becomes narrowed (stenotic), the heart mustwork harder to push blood into the aorta and to therest of the body.

According to Mathew R. Williams, MD, SurgicalDirector of Cardiovascular Transcatheter Therapiesand Co-Director of the Heart Valve Program, severeaortic stenosis usually requires replacement of theaortic valve. In some cases, patients who have hadvalve replacements will also need to have additionalprocedures to correct blocked arteries. Until recently,these procedures were traditionally both done throughopen surgery.

But open surgery may be too risky for certain patients, and may be particularlyproblematic for patients who have coronary artery disease, or who had prior heartsurgery and need re-operation. If they were not able to withstand open bypasssurgery, such patients previously had no choice but to endure their symptoms astheir hearts grew weaker. Now, the advent of hybrid surgeries–which combinecatheter-based procedures with minimally invasive surgical techniques–are provid-ing a broader and better range of treatment options.

As Dr. Williams explains, “Hybrid procedures are done in order to minimize riskand simplify surgery in instances where combining two procedures into one wouldbe simpler, safer, and more durable.” Dr. Williams is one of the only surgeons inthe nation dually trained in both catheter-based (interventional) procedures as wellas traditional cardiac surgery.

He says that hybrid valve procedures are most appropriate for older patientswho need a valve replacement and who also have coronary artery disease (harden-ing of the arteries). Rather than performing a bypass operation to address thearteries and then a separate valve operation later, the hybrid procedure allowsboth problems to be corrected using minimally invasive incisions and catheter-

Fall 2011

healthpoints is published by theColumbia University Department of Surgeryas a service to our patients.You may contactthe Office of External Affairs for additional information and to request additional copies.Please call: 201.346.7001

For physician referrals, please call:

1.800.227.2762Please visit us and sign up for the

healthpoints e-newsletter at:

www.columbiasurgery.org

Deborah Schwarz, RPA, CIBEExecutive Director, Office of External Affairs

Jada FabrizioDesign and Photography

Sherry KnechtManaging Editor

Department of SurgeryIn affiliation withNewYork-Presbyterian Hospital

A L L T H E P O S S I B I L I T I E S O F M O D E R N M E D I C I N E

continued on page 4

Mathew R. Williams, MD

Surgical Director of Cardiovascular Transcatheter Therapies andCo-Director of the Heart Valve Program

IN THIS I SSUE

1 Heart Valve Repair & ReplacementSafer, simpler treatments for heart valve disease

2 Peripheral Arterial DiseaseSaving limbs through collaborative care and endovascular interventions

3 HeartSource Partners withMiddle East Hospital New cardiac surgery program to open inAbu Dhabi, UAE

4 In The News

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2 healthpoints • fall 2011

Most people are familiarwith atherosclerosis, also calledhardening of the arteries.Atherosclerosis is responsiblefor a significant number ofheart attacks and strokes in theUnited States every year. Whatpeople may not know is that thevery same disease process –buildup of plaque within theheart blood vessels – can affectthe arteries in the rest of thebody as well.

When it occurs beyond theheart, blockage of the arteries is called peripheral arterialdisease, or PAD. Patients with coronary artery disease areat risk for PAD and vice versa; the risk factors for bothdiseases include obesity, diabetes, hypertension, highcholesterol, cigarette smoking, and family history.

PAD most commonly affects the legs, but may occurelsewhere as well, says Danielle Bajakian, MD, AssistantProfessor of Clinical Surgery, Columbia University College ofPhysicians and Surgeons, and Director, Critical LimbIschemia Program, NewYork-Presbyterian Hospital/Colum-bia University Medical Center. Even if a person has nosymptoms, the presence of PAD still indicates systemicdisease that must be addressed. When symptoms doappear, they usually begin with claudication, or cramping inthe back of the leg while walking. Such pain usually stopsduring rest, and then resumes while walking. Symptoms mayoccur in just one leg. “Mild disease can usually be treatedwith changes in lifestyle such as losing weight, smokingcessation, exercise, and managing blood glucose andcholesterol levels,” says Dr. Bajakian.

If PAD progresses, blockages in the arteries can lead tomore serious symptoms such as pain in the feet while lyingdown, wounds or ulcers in the legs and feet that don't heal,and in the most advanced stages, gangrene. This occursmore commonly in patients with diabetes or who smokecigarettes but can occur in anyone. These symptoms indicatecritical limb ischemia resulting from impaired circulation,and if untreated, could result in amputation of the leg.Moderate or severe disease may require treatment to openthe blood vessels to restore circulation. “People withdiabetes face a particular risk for critical limb ischemia,”

cautions James F. McKinsey, MD, Chief, Vascular Surgeryand Endovascular Interventions. “Up to 20% of diabeticsmay eventually lose a limb if preventive measures and carefulmedical and surgical management are not part of their care.”

To address the unique needs of diabetics and otherpatients who have PAD (or are at risk for it), the Division of Vascular Surgery and Endovascular Interventions atNewYork-Presbyterian/Columbia has established a dedi -cated program for the prevention and treatment of criticallimb ischemia. This multi-disciplinary, comprehensiveprogram not only treats PAD, but works with patients to treatall underlying risk factors. Formalized in 2010 under theleadership of Dr. McKinsey, the critical limb ischemiaprogram includes a collaborative team of experts: vascularsurgeons, endocrinologists, cardiologists, podiatrists, woundcare specialists, and imaging specialists. The program offersmany treatment options that are unavailable elsewhere,including the latest endovascular techniques for restoringcirculation to both large and small arteries in the legs.

Peripheral Arterial DiseaseNew Critical Limb Ischemia program addresses all factors involved in peripheral arterial disease, providing options for diabetics and others with advanced arterial disease.

Danielle Bajakian, MDAssistant Professor of Clinical Surgeryand Director, Critical Limb Ischemia Program

� Endovascular Procedures for PAD

The Critical Limb Ischemia Program offersevery available therapy to restore blood flow to the lower extremities, including newtherapies to treat smaller vessels. Over 90% of patients who require surgery can betreated with minimally invasive endovasculartechniques rather than open surgery. Theseminimally invasive techniques are performedunder sedation and local anesthesia ratherthan general anesthesia, and most patientsreturn home the following day.• Angioplasty: After accessing the blockagethrough a catheter, angioplasty involvesplacing a balloon in the affected area andinflating it to keep the artery open.

• Atherectomy: Using mechanical devices(inserted through a catheter) to removeplaque in the artery.

• Stenting: Placement of a wire mesh strutwithin a narrowed area of the artery inorder to keep it open.

Peripheral Arterial Disease ~ Continued on Page 3

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NewYork-Presbyterian Hospital/Columbia UniversityMedical Center is poised to expand its network ofhospitals by partnering with Lifeline hospital in AbuDhabi, United Arab Emirates.

The new affiliation is part of the Columbia Heart-Source program, which helps other hospitals toestablish or improve the quality of their cardiovascularprograms. At this time, HeartSource currently workswith 17 other hospitals to provide programmaticsupport including quality improvement, recruitmentand transfer of innovation to community based hospi-tals. The affiliation in Abu Dhabi will be the secondinternational program in the department and the first inthe Middle East, according to Larry Beilis, Chief Finan-cial and Administrative Officer of the Department ofSurgery and HeartSource. Mr. Beilis visited Abu Dhabiin early February 2011, where he met with hospitaladministrators regarding the partnership.

“I think it is important to share Columbia’s expertiseand help programs abroad to provide great qualitycardiac surgery,” says Mr. Beilis. “The new heart surgeryprogram in Abu Dhabi will provide a unique relation-ship that will benefit the United Arab Emirate region.”

The Columbia HeartSource program has helpedfour hospitals to develop brand-new cardiac surgeryprograms, including Mary Imogene Bassett Hospital(Cooperstown, NY); Bon Secours Maryview Hospital(Portsmouth, VA); Robert Wood Johnson UniversityHospital (Edison, NJ); and Stamford Medical Center(Stamford, CT). Other hospitals in numerous stateshave enlisted HeartSource’s expertise to restructureand improve the quality of their cardiovascularprograms.

Centers in the Columbia HeartSource Communityare able to claim affiliation with the Department ofSurgery Division of Cardiothoracic Surgery aftermeeting rigorous requirements in training and educa-tion, implementation of surgical protocols, and qualityoversight.

In Abu Dhabi, HeartSource will establish the adultheart surgery program first, possibly to be followed byother clinical services. n

Columbia HeartSource toAdd Affiliate in Abu Dhabi, UAE

3 healthpoints • fall 2011

“In most places today, patients see multiple doctorswho each address a single problem, but do notcommunicate with one another. Results for patientsare not optimal,” explains Dr. Bajakian. “Manypatients need care for multiple problems, andreceiving coordinated care is far more effective.”She stresses that anyone who experiences pain inthe legs with walking, or wounds that don't heal in six weeks — and particularly anyone who isoverweight, has diabetes, or smokes — should seekan evaluation by a critical limb ischemia specialist“expeditiously.” As Dr. Bajakian explains, “If youwait, it may be too late. The sooner you go in forevaluation, the higher the chance your leg, foot, ortoes can be saved.” She also notes that while manypatients have been told elsewhere that they couldnot be helped, the program at NewYork-Presbyter-ian/Columbia can often provide treatment options.“Because of our comprehensive expertise, manytimes we can offer further treatments and save alimb when others cannot.” n

The critical limb ischemia program is activelyresearching new technologies including stents,bypass grafts, gene therapy, and autologous stemcell therapy to promote growth of new bloodvessels. Learn more at www.columbiavascular.org

Gangrene

Non Healing Ulcer

Blockages in the arteries can lead to more serious

symptoms such aswounds or ulcers

in the legs and feet that don't heal,

and in the most advanced stages,

gangrene.

Peripheral Arterial Disease ~ Continued from Page 2

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• Fall 2011

Heart Valve Surgery ~ Continued from page 1

4 healthpoints • fall 2011

based instruments. A valve can be surgically replacedthrough minimally invasive incisions in the chest, while theblocked arteries are fixed via the groin using catheter-basedtechniques and stents. Patients can recover more quicklyafter such hybrid procedures than after open surgery, andthey do not need to return for multiple procedures. Accord-ing to Susheel Kodali, MD, Assistant Professor of ClinicalMedicine and Co-Director of the Heart Valve Program,“Valve replacement and bypass surgery require a fullsternotomy (large chest incision). If the patient has had anyprior cardiac surgery, this can be very complicated. Minimallyinvasive hybrid surgery can lower the risk in these patients bysimplifying the procedure.”

Hybrid surgery is gaining traction throughout the nation,but at this time remains available only in select institutionsbecause of the need for specialized operating rooms andmultidisciplinary expertise. Hybrid procedures require close

collaboration between interventionalists and surgeons, atype of cooperation not usually found in institutions withtraditional departmental divisions. At NewYork-Presbyter-ian/Columbia, such cooperation underpins the newlyestablished Heart Valve Program, where a multidisciplinaryteam from the Department of Surgery and the Center forInterventional Vascular Therapy collaborates to determinethe best course for each patient. “Instead of having to go toseparate appointments to see a cardiologist, surgeon, orother physicians,” says Dr. Kodali, “patients can come to ourclinic for a full evaluation including catheterization, echocar-diography, and physical evaluation in one visit.” n

The Heart Valve Program at NewYork-Presbyteria/Columbia consists of a team of specialists who evaluate, treat and provide long-term care for patientswith heart valve conditions. Learn more atwww.columbiaheart.org or by calling 212.342.0444.

IN THE NEWS

www.twitter.com/columbiasurgery www.facebook.com/columbiasurgery

After Daughter's

Kidney Transplant,

Mother Raises Funds

for Transplant PatientsIn July 2001, Jane Calem's daughter wassuffering from end stage renal failure andreceived a successful kidney transplant atNewYork-Presbyterian/Columbia.Tenyears later, Jane was inspired to mark herdaughter's milestone by helping otherpatients in need. Despite having neverdone something like this, Jane raisedmore than $12,000 to assist indigent pa-tients with the cost of medications andtravel to the renal transplant program atNewYork-Presbyterian/Columbia.

To read the full story, see the Department of Surgery's blog,www.columbiasurgery.net

Faculty Announcement:

Yanghee Woo, MDThe Division of GI/Endocrine Surgery in the Department of Surgery at Columbia University Medical Center ispleased to welcome its newest facultymember, Yanghee Woo, MD. Dr. Woooffers open, laparoscopic and roboticsurgery for diseases of the stomach,pancreas, and thyroid. Selected to leadthe division’s effort to deliver state-of-the-art care to patients with gastric cancer, Dr. Woo will collaborate withthe division's medical oncologists, GIoncologists and other medical profes-sionals to develop a Center of Excel-lence in Gastric Cancer as part of theComprehensive Cancer Center at Co-lumbia University Medical Center.

Annual

Pancreatic Cancer

Awareness Day

11/12/11, NYCExperts from NewYork-Presbyterian Hospital, Columbia University MedicalCenter, The Pancreas Center and TheMuzzi Mirza Pancreatic Cancer Preven-tion & Genetics Program will provide afree patient education program aboutscreening and early detection of pancreaticcancer.

For more information and reservations, contact Christine Rein: Telephone: 201.346.7014 or email: cmr2146@columbia.edu Online registration: www.columbiasurgery.org

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