Inside This Issue The Young Low LDL & Normal Remote Moni ......Page 2 | Cardiac Consult | Summer 09...
Transcript of Inside This Issue The Young Low LDL & Normal Remote Moni ......Page 2 | Cardiac Consult | Summer 09...
Low LDL & Normal Blood Pressure Slows Arterial Plaque Growth p4
CardiacConsult
The Young Helpingthe Old? p3
Indicationsfor Ventricular Assist Devices Expanded p6
Remote Moni-toring in Heart Failure p16
Genetic Cause of Deadly Irregular Heart Beat Discovered p17
Inside This Issue
Heart and Vascular News from Cleveland Clinic | Summer 2009 | Vol. XVIV No. 2
Featured Article
Minimally Invasive Cardiac Surgery Comes of Age- p8
Flashback:
Dear Colleagues,
Minimally invasive surgery is no longer exotic. Thirteen years ago, Delos M.
Cosgrove, MD, performed the fi rst minimally invasive aortic valve surgery.
In 2008, we performed 462 minimally invasive aortic and mitral valve
procedures, with 0 percent hospital mortality. Cleveland Clinic surgeons
now consider a minimally invasive option fi rst for nearly every patient.
This issue of Cardiac Consult offers a brisk review of Cleveland Clinic’s minimally
invasive thoracic and cardiovascular surgery program. You’ll fi nd mention of the
highly successful valve procedures, along with our robotic surgery program,
video-assisted lobectomies, and new percutaneous techniques.
Medical technology is racing to keep ahead of demand for minimally invasive
alternatives. The appeal is obvious: less pain, fewer complications, shorter hospital
stays. Minimally invasive cardiac surgery is bound to be a hot topic at the big
The Treatment of Cardiovascular Disease: Legacy & Innovation symposium, being
held here in June. We invite you to join us for this one-time “state of the heart”
global overview of the very latest in cardiac surgery, vascular surgery, cardio-
vascular medicine, and their related disciplines.
The other articles in this issue of Cardiac Consult refl ect the breadth and variety
of our fi eld: new views on ventricular assist devices, lung transplant donation,
remote monitoring in heart failure and more.
We continue to be inspired by the way new technologies advance medicine
and transform lives. As minimally invasive techniques become commonplace,
you’ll fi nd us at the frontier of the next big advance, whatever it may be.
Sincerely,
Christopher Bajzer, MD Sean Lyden, MDAssociate Director, Peripheral Intervention Staff Surgeon, Interventional Cardiology Vascular Surgery
A. Marc Gillinov, MDThe Judith Dion Pyle Chair in Heart Valve ResearchThoracic and Cardiovascular Surgery
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Cardiac Consult offers updates on state-of-the-art diagnostic and management techniques from Cleveland Clinic heart and vascular specialists. Please direct correspondence to:
Medical Editors
Christopher Bajzer, MDA. Marc Gillinov, MDSean Lyden, [email protected]@[email protected]
Managing Editor
Ann Bungo
Marketing Manager
Megan Frankel
Art Director
Michael Viars
Photographers
Tom MerceSteve TravarcaDon GerdaRussell Lee
clevelandclinic.org/heart offers informa-tion on new procedures and services, clini-cal trials, and upcoming CME symposia, as well as recent issues of Cardiac Consult.
The Sydell and Arnold Miller Family Heart & Vascular Institute, ranked No. 1 in the nation for cardiac care by U.S.News & World Report every year since 1995, accommodates nearly 300,000 patient visits each year in world-class facilities. Staff are committed to researching and applying state-of-the-art diagnostic and management techniques. Cleveland Clinic is a not-for-profi t, multispecialty academic medical center.
Cardiac Consult is written for physicians and should be relied upon for medical education purposes only. It does not provide a complete overview of the topics covered, and should not replace the inde-pendent judgment of a physician about the appropriateness or risks of a procedure for a given patient.
© The Cleveland Clinic Foundation 2009
Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 3
The Young Helping the Old?
Can younger or newer stem cells give a regenerative boost to
donors could help older patients who are recovering from heart attacks or aortic stenosis.
Marc Penn, MD, PhD, Cleveland Clinic Stem Cell Biology and Regenera-
tive Medicine and Department of Cardiovascular Medicine, investigates
how hearts damaged by heart attacks attract adult stem cells by sending
out “homing” signals. Stem cells found in the bone marrow respond to this
signal and migrate to the damaged area to become new heart tissue cells.
Dr. Penn’s research has expanded to also focus on how aging might affect
the homing process and the stem cells’ ability to specialize, or differenti-
Dr. Penn induced aortic stenosis in mice. Stem cells from the bone marrow of
an older generation of the mice were transplanted into younger mice with the
condition. The younger mice didn’t respond well and the condition worsened.
However, stem cells from the younger mice’s bone marrow were trans-
planted into the older generation — with noticeable improvement to the
older mice’s cardiac health.
“It would appear that stem cells may tire out over time. There’s evidence
that aging does play a role on stem cell function. Now we’re trying to
determine if it’s the heart not sending out the message to stem cells, or the
stem cells not responding to the signal,” Dr. Penn says. “The heart needs
to grow new vessels to nourish the new cells. But if the stem cells aren’t
getting to the heart, the heart dilates and the patient develops heart failure
in response to aortic stenosis.
“We hope that by deciphering the signaling process we will be able to
develop new therapies for patients with aortic stenosis and weak hearts.”
To coordinate the range of stem cell and regenerative medicine research
projects focused on cardiovascular diseases, Dr. Penn organized the
Center for Cardiovascular Cell Therapy. The center currently has six
clinical trials involving laboratories at Lerner Research Institute and
Cleveland Clinic, as well as being a founding partner in the National
Institutes of Health’s Cardiovascular Cell Therapy Research Network.
Additionally, Dr. Penn directs the Skirball Laboratory for Cardiovascular
Cellular Therapeutics and is Director of Cleveland Clinic’s Earl and Doris
Bakken Heart-Brain Institute.
“The new center and our role in the NIH’s consortium are working to
actually bring what we’re learning about cardiovascular cell therapies
to patients,” he says.
Marc Penn, MD, PhD
Page 4 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
Cleveland Clinic Researchers: Low LDL and Normal Blood Pressure Slows Arterial Plaque Growth
Low levels of LDL cholesterol coupled with normal blood pressure can significantly slow the progression of coronary artery disease, according to a study by Cleveland Clinic researchers.
The study, which was published in the March 31 issue of the Journal of the
American College of Cardiology, is the first to show that aggressive treatment to
lower both cholesterol and blood pressure can slow plaque build-up in patients
with a history of coronary artery disease.
“The take-home message here is that heart disease is caused by many factors
and it’s likely that aggressive management of just one risk factor alone is
not the answer,” said Cleveland Clinic cardiologist Stephen J. Nicholls,
MD, PhD, a co-author of the paper. “In this study, we looked at aggres-
sively controlling multiple risk factors to see if it would have an impact.
And it did.”
The study examined 3,437 patients with coronary artery disease,
using intravascular ultrasound (IVUS) to track the formation of
plaque in their arteries. The researchers found that very low
levels of LDL (70 mg/dl or less), in combination with normal
systolic blood pressure (120 or less), significantly slowed
arterial plaque formation.
“What this study shows is that when it comes to blood
pressure and cholesterol ‘good’ control isn’t enough,” said
lead author Adnan K. Chhatriwalla, MD, an intervention-
al cardiology fellow at Cleveland Clinic. “Optimal con-
trol should be the goal of treatment because it is shown
to have a greater effect on slowing the progression of
atherosclerotic plaque.”
The authors suggest that a randomized controlled
trial to directly test the clinical benefit of aggres-
sively treating multiple risk factors would
provide further support for this concept.
Researchers from Cleveland Clinic’s depart-
ments of Cardiovascular Medicine, Cell
Biology, and Radiology participated in the
study, along with the Cleveland Clinic
Center for Cardiovascular Diagnostics
and Prevention.
| Cardiac Consult | Summer 09 | Page 5 Visit clevelandclinic.org/heart
Case Study: Cervical Carotid Aneurysm
REFERENCES
(1) Painter T, Hertzer N, Beven E, O’Hara P. Ex-tracranial carotid aneurysms: report of six cases and review of the literature. J Vasc Surg 1985;2:312-8.
(2) Moreau P, Albot B, Thevenet A. Surgical treatment of extracranial internal carotid artery aneurysms. Ann Vasc Surg 1994;8:404-16.
(3) Knight GC, Hallman GL, Reul GJ, Ott DA, Cooley DA. Surgical Management of ExtracranialCarotid Artery Aneurysms:Report of 17 Cases. Texas Heart Inst J 1988;15:91-7.
(4) McCollum CH, Wheeler WG, Noon GP, DeBakey ME. Aneurysms of the Extracranial carotid artery. Twenty one years’ experience. Am Jour Surg 2005; 196-200.
(5) Davidovic L, Dusan K, Maksimovic Z, Markovic D, Dragan VM, Duvnjak S. Carotid artery aneurysms. Vascular 2004;12:166-70.
(6) Kaupp H HSJMBJTO. Aneurysms of the ex-tracranial carotid artery. Surgery 1972;72:946-52.
(7) Zwolak R, Whitehouse WJ, Knake J, Bernfeld B, Zelenock G, Cronenwett J. Atherosclerotic extracranial carotid artery aneurysms. Jour Vasc Surg 1984;1:415-22.
(8) May J, White GH, Waugh R, Brennan J. Endoluminal repair of internal carotid artery aneurysm: a feasible but hazardous procedure. Jour Vasc Surg. 1997;26:1055-60.
(9) Szopinski P, Ciostek P, Kielar P, Myrcha P, Pleban E, Noszczyk W. A series of 15 patients with extracranial carotid artery aneurysms:Surgical and Endovascular treatment. Eur Jour Endovasc Surg2005;29:256-61.
(10) Miksic K, Flis V, Kosir G, Pavlovic M, Tetickovic E. Fusiform and saccular extracra-nial carotid artery aneurysms. Cardiovasc Surg 1997;5(2):190-5.
(11) Radak D, Davidovic L, Vukobratov V, Il-lijevski N, Kostic D, Maksimovic S. Carotid Artery Aneurysms: Serbian Multicentric Study. Ann Vasc Surg 2007;21(1):23-9.
(12) Attigah N, Kulkens S, Hansmann J, Ringleb P, Hakimi M, Eckstein H, et al. Sugical Therapy of Extracranial Carotid Artery Aneurysms:Long term results over a 24 year period. Eur Jour Endovasc Surg 2008;37:127-33.
Presentation
artery aneurysm found on an incidental CT scan of her sinuses for deviated septum and upper respiratory tract infections. She denies any recent or past trauma and has no history of peripheral aneurysms.
Examination and Diagnosis
CT scans of the aortic arch to the Circle of Willis and cerebral angiography were performed, resulting in the following images (See Fig 1 and 2.)
Due to the proximal extent of the internal carotid artery aneurysm in the neck, an ENT consult also was obtained for potential mandibular manipulation to allow access to the vessels.
Treatment
The patient underwent resection of the aneurysm with end-to-end anastomosis due to redundancy of the vessels and their large caliber. Surgical pathology was consistent with atherosclerotic aneurysm.
Discussion
Cervical carotid aneurysms are rare and represent less than 1 percent of all carotid pathologies treated surgically. In the past, mycotic aneurysms were more prevalent and now atherosclerotic aneurysms are more commonly diagnosed. Patients can present with symptoms such as dysphagia, neck swelling, hoarseness and less commonly with bleeding or rupture. The prognosis with nonoperative management is poor with the seqeulae of neurologic symptoms such as stroke or TIA with either embolization of aneurysm contents or thrombosis of the aneurysm.
aneurysms with carotid ligation in London in 1808 and the patient did well. Today, standard surgical therapy consists of aneurysmorraphy with patch or interposition bypass with an autologous conduit. This patient had a very redundant internal carotid, so primary resection with end-to-end repair was possible. Results with open surgery are superior to nonoperative
similarly low. Endovascular options also are available, but have not been evaluated for long-term durability and success.
Contact Dr. Sunita Srivastava at 216.445.6939 or [email protected].
Figure (1)
Figure (2)
Sunita Srivastava, MDVascular Surgery
Indications for VADs Expanded
“Most individuals with medically refractory heart failure may potentially qualify for VAD therapy,” says Cleveland Clinic heart transplant surgeon Gonzalo Gonzalez-Stawinski, MD.
Building a better VAD
Early VADs were large and cumbersome. Ongoing innovations in technology eventually produced smaller, more powerful devices. By 2000, VADs were more successful than medical therapy for patients with end-stage heart failure, but morbidity remained high. Subsequent advances in design and biocompatibility have resulted in improved safety.
Two years ago, changes in Northern Ohio’s organ allocation system reduced the number of donor organs available in the region. Simultaneously, the number of baby boomers with advanced heart failure exploded. Circumstances were ideal for testing a new generation of VADs, and with 30 years’ experience, Cleveland Clinic was poised to meet the need.
“The newer pumps are sturdier, longer-lasting and less prone to infection. We had become good at predicting complications associated with VADs and were having fewer failures. There have been few complications,” says Dr. Gonzalez.
With a low overall mortality rate of 9.7 percent for VAD patients, Cleveland Clinic was approved by the Centers for Medicare and Medicaid Services and Food and Drug Administration (FDA) to offer this life-saving therapy as a treatment for heart failure.
VADs remain a valuable resource for patients awaiting transplantation. Yet a newer, larger group of benefi ciaries are patients with heart failure who are deterred by the potential complications of lifetime immunosuppression, but desire a better quality of life.
Cleveland Clinic also utilizes VADs as a bridge to medical decision in selected patents, primarily those with acute processes that stun the heart, such as myocarditis. In these patients, a VAD may support the heart during recovery and enable appropriate treatment to be initiated later.
Cleveland Clinic has one of the oldest and largest ventricular assist device (VAD) programs in the United States. In the 1970s, Cleveland Clinic surgeons pioneered
and technology have given newer models a wider application. Of the record 49 VADs implanted at Cleveland Clinic in 2008, nine were used as destination therapy, nine as a bridge to decision and 31 as a bridge to transplantation.
Page 6 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
Gonzalo Gonzalez-Stawinski, MD
“The newer pumps are sturdier, longer-lasting and less prone to infection.
We had become good at predicting complications associated with VADs
and were having fewer failures. There have been few complications.”
| Cardiac Consult | Summer 09 | Page 7Visit clevelandclinic.org/heart
A design for every need
Cleveland Clinic is one of few institutions worldwide with access to multiple FDA- approved VADs from a variety of leading manufacturers.
“This allows us to choose the device that will best suit each patient’s clinical needs,” says Dr. Gonzalez.
VADs with pulsatile turbines readily adjust to the body’s metabolic demands, enabling the patient to participate in physical activity. Such VADs are designed to provide circulatory support for one to three years, depending on the model.
Second-generation VADs are non-pulsatile, continuous fl ow pumps. These small, powerful machines are totally implantable. Biocompatible design and materials reduce thromboembolism and require minimum anticoagula-tion. Cleveland Clinic now uses Thoratec’s HeartMate II as bridge to transplantation, and is using the device in a clinical trial of destination therapy in patients who are not considered candidates for transplantation.
Although a series of HeartMate II devices built prior to June 2006 was recalled in December 2008 due to cracks in the driveline, Cleveland Clinic never en-countered one of the faulty devices, says Dr. Gonzalez. Thoratec has since changed the design and eliminated the problem that led to the recall.
Miniaturized third-generation VADs have a single mov-ing part, are highly biocompatible and are resistant to wear and corrosion, making them ideal for per-manent use. Cleveland Clinic is studying several HeartWare (Thoratec) models with extended-life batteries. These models may be recharged using a household current.
The surgeons also are studying the total artifi cial heart (TAH) as a bridge to transplantation. The safety arm of this study has been completed, and they are now evaluating a portable power source that would enable patients with the device to leave the hospital.
For more information
To discuss the potential for VAD therapy in a patient with advanced heart failure, please call 877.8-HEART-1 (877.843.2781).
More patients with medically refractory heart failure now qualify for VAD therapy
Page 8 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
Cardiac Surgery Comes of Age
A new chapter has been
opened in the history of
cardiac surgery. Minimally
invasive surgery is now
the standard treatment for
an increasing number of
cardiovascular procedures.
As techniques improve,
more and more minimally
invasive procedures are able
to duplicate the outcomes of
conventional surgery, with
fewer complications, and
more rapid recovery time.
| Cardiac Consult | Summer 09 | Page 9Visit clevelandclinic.org/heart
The goal of minimally invasive surgery (MIS) is
to complete the surgical task with the minimum
of insult to the patient’s body. MIS techniques are
usually accomplished without sternotomy, and
may not involve stoppage of the heart, or extracorporeal
circulation. Smaller incisions offer less opportunity for
post-surgical wound infection, and speed recovery times.
They are the clear preference of most patients.
Surgeons in the Department of Thoracic and Cardiovas-
cular Surgery at Cleveland Clinic have been pioneers
in evaluating and adopting minimally invasive surgical
techniques. Delos M. Cosgrove, MD, performed the
international broadcast from Cleveland Clinic in 1996.
Cleveland Clinic cardiovascular surgeons, cardiologists
and cardiovascular imaging specialists work as a team
to prepare for and execute an increasing variety of
minimally invasive techniques.
This special section of Cardiac Consult offers an overview
of Cleveland Clinic’s minimally invasive interventions.
We invite you to refer patients for evaluation for minimally
invasive cardiac surgery at Cleveland Clinic by calling
216.444.3500 or 877.8HEART1.
Page 10 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
Mitral Valve Replacement and Repair
Mitral valve repair is the most frequently
performed minimally invasive cardiac
surgery. A. Marc Gillinov, MD, and
Tomislav Mihaljevic, MD, who share a
great deal of experience in all minimally
invasive cardiac procedures (including
robotically assisted), indicate that it
is possible to both repair and replace
valves minimally invasively. However,
they believe that long-term outcomes
are superior with repair, and recommend
repairs in most cases. More minimally
invasive mitral valve repairs have been
performed at Cleveland Clinic than at
any other medical center.
Robotically assisted mitral valve repair
is the least invasive approach to mitral
valve repair. Robotically assisted pro-
cedures are performed endoscopically,
through small ports (rather than formal
incisions) in the right side of the chest.
A Minimally Invasive Approach
Minimally invasive mitral valve repair
can be performed through a 2 to 4-inch
incision, either a right mini-thoracotomy
or partial upper sternotomy. The surgical
approach or technique for each patient
is based on age, condition, co-morbidi-
ties and anatomical considerations.
The right mini-thoracotomy is performed
with a 2- to 3-inch skin incision created in
a skin fold on the right chest, providing an
excellent cosmetic result. The heart is ap-
proached between the ribs, providing the
surgeon access to the mitral valve. There
is no sternal incision or spreading of the
ribs required for this surgical technique.
Using special instruments, the surgeon
and place an annuloplasty ring, just as
in conventional surgery. A partial upper
sternotomy includes a 2- to 3-inch skin
incision and division of the upper portion
of the sternum, as opposed to the 8- to
10-inch incision of a full sternotomy. The
partial upper sternotomy offers the sur-
geon an excellent view of the mitral valve
and may be an appropriate approach for
patients who require combined mitral
valve and aortic valve procedures.
These minimally invasive approaches
also can be used when mitral valve
repair is combined with ablation for
has been instrumental in developing
Robotically Assisted Mitral Valve Surgery
Robotically assisted mitral valve surgery
is a type of minimally invasive surgery
in which the surgeon uses a specially-
designed computer console to control
surgical instruments on thin robotic arms.
The robotic arms are introduced through
1- to 2-cm incisions in the right side of the
chest. The surgeon’s hands control the
movement and placement of the endo-
scopic instruments to open the pericar-
dium and to perform the procedure.
Robotically assisted mitral valve surgery
provides the surgeon with an undistort-
ed, three-dimensional view of the mitral
with the use of a special camera. This
approach enables surgeons to perform
complex repairs without the need for
| Cardiac Consult | Summer 09 | Page 11Visit clevelandclinic.org/heart
division of the sternum or spreading of
the ribs, in most cases.
At the current stage, all patients who have
leaky mitral valves and or tricuspid valves
can be evaluated as a potential patient
for minimally invasive robotic surgery. It
is even an option for selected patients
who have already had conventional heart
surgery – even after previously failed at-
tempts at repairing the mitral valve.
Robotic surgery requires specially trained
surgeons and a specially trained operat-
ing room team. In the rare event that the
robotic approach needs to be switched
to conventional surgery (fewer than 2
percent of all cases) the team needs to
be able to make that switch quickly and
built robotic surgical suite, this can be
accomplished in less than two minutes.
Cleveland Clinic has excellent results
with minimally invasive mitral valve
surgery. In 2008, 53 percent of all
isolated mitral valve procedures done
at Cleveland Clinic were performed
robotically, with 0 percent mortality.
Coronary Artery Bypass Graft Surgery
The traditional coronary artery bypass
graft (CABG) surgery, which was pio-
neered at Cleveland Clinic in 1967, is
performed every day at academic medical
centers and community hospitals alike.
But recently, surgeons have been success-
fully performing this operation through
a smaller incision and – in some cases –
without the use of a heart-lung machine.
Joseph F. Sabik, MD, Chairman of
Thoracic and Cardiovascular Surgery is
now performing a “mini” coronary artery
bypass through 3- to 4-inch incisions.
The traditional method, by comparison,
requires a patient’s sternum to be split.
“The mini-procedure offers less pain and
a hospital stay that’s shorter by about
two days,” says Dr. Sabik. In addition,
the surgery is most often done without
a blood transfusion.
As with the traditional CABG, the mini-
procedure uses a healthy artery or vein
from the patient’s chest, leg or arm to
bypass the clogged artery.
Decisions are made on a case-by-case
basis, weighing a patient’s size, coronary
artery quality and the number of grafts
needed. “Many people can take advantage
of this new procedure,” Dr. Sabik says.
“For an average person who needs two or
three grafts, we can perform the mini-
CABG procedure instead.”
Percutaneous Procedures
Some cardiac procedures that are usually
done through full exposure or minimally
invasively, can now also be performed
percutaneously. Some of these techniques
are experimental. Others are part of every-
day clinical practice. For instance, many
patients currently receive percutaneous
valvotomy for stenosis of the mitral, aortic
or pulmonic valve. In this procedure, ex-
plains interventional cardiologist Samir K.
Kapadia, MD, a balloon-tipped catheter is
inserted into the femoral artery and guided
to the site of the valve. The balloon is
Page 12 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
leaving nothing but a valve that is more
“There are a lot of patients, especially old-
open heart surgery for various reasons,”
says surgeon Lars Svensson, MD, PhD,
of Thoracic and Cardiovascular Surgery.
“We’ve been able to develop techniques
that we can approach these valves with-
out having to open the patient’s chest.”
Other percutaneous valve procedures
are still in the experimental stage.
to study percutaneous aortic valve
replacement using a new compressed-
tissue heart valve. The valve is placed
on a balloon-mounted catheter and
positioned directly over the diseased
aortic valve. “When we know we are
in the right position, we get the heart
to race faster so it’s not pumping as
much,” says Dr. Svensson. “Then we in-
balloon is withdrawn. Cleveland Clinic
is participating in a U.S. Food and Drug
Administration study to determine the
feasibility of this treatment.
“What surprised many of us in the surgical
profession is that this has worked out very
well,” says Dr. Svensson. “Obviously there
are higher risks than a routine open heart
operation, but it is an option for older or
high-risk patients.”
Another experimental technique is being
tested at Cleveland Clinic for the treatment
of mitral valve regurgitation. A very small,
specially made metal clip device is deliv-
ered via catheter to the mitral valve. The
center of the valve, allowing the blood to
clip is adjusted until optimal improvement
valve are observed. When the catheter is
in position, which limits the leakage.
The mitral valve itself is untouched in
another experimental percutaneous treat-
ment for mitral valve regurgitation. In
this novel approach, a small metal bar is
guided by catheter into the coronary sinus
to a position just alongside the annulus
of the mitral valve, and left there. The
slight rigidity of the bar exerts pressure on
the dilated annulus, pushing it and its at-
Cleveland Clinic surgeons and cardiologists
percutaneous valve placement to remedy
the impact of tricuspid regurgitation on
the body using a special device developed
at Cleveland Clinic. This may eventually
provide a means of treating valve disease
caused by radiation treatments to the
chest, which sometimes render the patient
unsuitable for open surgery.
In considering all these techniques, it
should be kept in mind that mortality
for conventional valve replacement and
| Cardiac Consult | Summer 09 | Page 13Visit clevelandclinic.org/heart
lower than the national averages (0.3
percent for primary isolated mitral valve
repair in 2008). This means that experi-
mental minimally invasive alternatives
are most frequently recommended for
patients who are too frail or elderly for
conventional surgery.
Video-assisted Thorascopic Lobectomy
Patients with small, early stage, primary
lobectomy, which removes the tumor along
with the lobe of the lung were it resides. A
conventional lobectomy is performed dur-
ing a thoracotomy. Cleveland Clinic is now
one of the few centers in the nation that
-
mally invasive alternative to this approach.
Video-assisted thoracoscopic surgery
lobectomy (VATS lobectomy) is performed
through three 1-inch incisions and one
3- to 4-inch incision in the chest. A
thorascope and specially adapted surgical
instruments are inserted into the incisions.
Guided by the images from the thorascope,
the thoracic surgeon cuts and removes the
tumor and other affected tissue. If an early-
stage cancer tumor is being removed, the
lymph nodes in the mid-chest area also
may be removed or biopsied to ensure that
the cancer has not spread.
“Small lung cancers and lung cancers
that tend to be more toward the surface
of the lung are the best candidates for
VATS however most lung cancers can be
removed by VATS, says David Mason, MD
of the Department of Thoracic and Cardio-
vascular Surgery. “The CT scan should be
able to identify the location of the tumor
and the likelihood of removal with VATS.”
The outcomes for VATS lobectomy are
comparable to those for conventional
surgery. Traditional thoracotomy may
be more appropriate for some patients
with large tumors, involved lymph
nodes, or prior chest surgery. VATS
techniques are also applied to other
procedures, including wedge resection,
lung biopsy, drainage of pleural effu-
sions, and mediastinal, pericardial and
thymus thoracoscopic procedures.
“Minimally invasive lung surgery is clearly
-
racic diseases that require surgery,” says
Dr. Mason. “However, few surgeons are
trained in these techniques and only a
minority of thoracic surgery procedures are
performed minimally invasively around the
country. At Cleveland Clinic, all thoracic
surgery patients are considered for mini-
in these techniques exists. In our experi-
ence, outcomes for cancer cure is identical
to more traumatic techniques and clearly
this is not a compromise procedure.”
Minimally Invasive Vein Harvesting
Cleveland Clinic cardiac surgeons
established the superiority of the internal
thoracic artery as a conduit for coronary
artery bypass. Prior to that, the saphen-
ous vein was the preferred conduit for
this procedure. Today, the saphenous
vein continues to be used where the
internal thoracic artery is inappropriate
or unusable, and for bypass procedures
in the legs for peripheral artery disease.
The radial artery in the arm may also be
harvested and used as a conduit.
The saphenous vein and radial artery are
traditionally harvested through a long in-
cision that is often uncomfortable for the
patient. More and more, however, these
conduits are being harvested minimally
invasively, using an endoscope. Cleve-
land Clinic surgeons have considerable
experience in performing endoscopic
saphenous vein harvesting and have
expanded its use for lower extremity
bypass. To harvest the saphenous vein,
the surgeon makes a small incision in
the groin and one or two 1-inch inci-
sions in the leg, near the knee. Special
instruments are slid down the inside leg,
alongside the vein. A miniature camera
allows the surgeon to view the vein,
and measure off the length that will be
needed. That length is cut and the vein
is removed through the incision.
In 2005, Cleveland Clinic surgeons
expanded the minimally invasive
approach to include harvesting of radial
arteries. In this procedure, the surgeon
makes a small incision near the wrist
and one near the forearm.
“Applying endoscopic vein harvesting
for lower extremity bypass is a bit more
challenging than for coronary bypass
for a variety of reasons,” says Cleveland
Clinic vascular surgeon Vikram Kashyap,
reduced pain, morbidity and hospital
length of stay can be accomplished for
these patients.”
“Minimally invasive lung surgery is clearly beneficial to patients for almost
all thoracic diseases that require surgery. However, few surgeons are trained
in these techniques and only a minority of thoracic surgery procedures are
performed minimally invasively around the country.” - Dr. David Mason
Page 14 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
Important Genetic Findings
There were two major genetic discoveries from Qing Wang,
PhD, Department of Molecular Cardiology and Director of
the Center for Cardiovascular Genetics:
A year ago, researchers found that a cluster of genetic variants
artery disease (CAD) in white people in northern Europe and
North America. People who have that genetic quirk are more
susceptible to developing CAD or having a heart attack. Dr.
Wang and his team have shown the same genetic material also
is associated with coronary artery diseases in the South Korean
identify people at risk of arterial diseases or heart attacks.
lead to new diagnostic tests and treatment options for cardiac
patients. Qing K. Wang, PhD found the new gene – NUP155
– by analyzing the genetics of a family with severe, early-onset
tailored treatment strategies to prevent and/or treat the common
Using Drugs to Facilitate PCI for Myocardial Infarction
The results of an international clinical trial led by Cleveland
Clinic Cardiologist Stephen A. Ellis, MD, should have high im-
pact on the treatment of patients presenting with heart attacks
caused by blocked coronary arteries. Before the study, it was
given certain blood-thinning agents, either singularly or in
combination, before being taken to a catheterization lab to get
an angioplasty, or other percutaneous intervention (PCI). But
Dr. Ellis’s study showed that administering the drugs before
may actually cause harm by promoting bleeding.
New Findings in Vascular Surgery
Cleveland Clinic Vascular Surgeon Vikram S. Kashyap, MD,
-
fectiveness of using the anticoagulant bivalirudin in patients
undergoing lower extremity bypass. This small study suggests
anticoagulant in lower extremity bypass.
Blockage of the large blood vessels in the pelvis (aorta and
iliac arteries) can starve the lower extremities of blood and
lead to the need for amputation. Traditionally, this condition
is treated with major surgery: the grafting of a y-shaped syn-
thetic tube to bypass the blockage. Less invasive alternatives
are available, but it has not been known for certain how well
they compare to the bypass graft. Now, in a retrospective
review of cases performed at Cleveland Clinic, Dr. Kashyap
has shown that outcomes from percutaneous angioplasty and
stenting for this condition compare favorably to bypass graft-
ing – a step forward for patients who hope to avoid major
surgery for pelvic blockages.
Research RoundupHighlights of Recent Heart and Vascular Research from Cleveland Clinic
| Cardiac Consult | Summer 09 | Page 15Visit clevelandclinic.org/heart
Critical Care Transport
Staff
Our team is made up of Cleveland Clinic physicians and pediatric intensivists, nurse practitioners, critical care nurses, paramedics and allied health professionals. Each medical team is customized to meet the needs of the patient and is ready at a moment’s notice for regular patient transfers, as well as transfers of highly acute patients with ST-elevation acute MI (STEMI) and acute aortic syndrome.
Services Offered
24/7 Adult critical care transport by ground or air by a team experienced in critical care and/or emergency services and trained in transport environment care, 24/7 pediatric critical care transport by ground or air by a team specially trained in neonatal and pediatric intensive care, emergency and transport medicine and flight physiology.
More Beds
To make sure your patients get the specialized care he or she needs, we now have 24 dedicated Cardiovascular ICU beds with adjacent imaging and cath labs, and a cardiology fellow in attendance, 24/7. In addition, we have a dedicated heart failure ICU and two surgical ICUs (totaling more than 100 Cardiovascular ICU beds).
Our Fleet
Patients can be transferred to Cleveland Clinic by fully staffed Mobile Intensive Care Units. Our air transport capabilities include a Sikorsky S-76 A++ for our immediate 250-mile radius, and a Beechjet 400A and Hawker 800 for longer distances – both staffed and equipped as “flying ICUs.”
For more information, visit clevelandclinic.org/cct.
In the Spotlight
Instructions for TransportNEW! Acute transfers (acute stroke, STEMI, ICH and acute
aortic syndrome conditons), call 877.379.CODE (2633).
with no delay-causing dispatch protocols.
Routine transfers, call 216.444.8302 or 800.533.5056
Have the following information ready
Patient name
Date of birth
Cleveland Clinic medical record number
Insurance information
Diagnosis and location of patient
Need for telemetry
If the patient has invasive lines, assistive devices or drip;
if the patient is hemodynamically stable
Cleveland Clinic’s Critical Care Transport team is ready to respond 24/7 to just about any 9-1-1 call, anywhere in the world. Our transport team can start tertiary care during transfer to one of our many facilities, thus improving the outcomes for many serious and complex conditions.
Page 16 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
Remote Monitoring in Heart Failure
a new era of remote monitoring. These devices provide a steady stream of data that can be remotely monitored to assess and manage patients with heart failure. For cardiologists, the immediate challenge is to access these data in a timely fashion
“With the broad application of im-
planted device therapies, we now
have the unprecedented access
to physiologic data,” says W. H.
Wilson Tang, MD, a cardiologist
and Research Director of the Sec-
tion of Heart Failure and Cardiac
Transplantation at the Sydell and
Arnold Miller Family Heart & Vas-
cular Institute at Cleveland Clinic.
“This data includes measurements that were originally devised
to monitor device integrity. Now we can take advantage of them
to provide insight into the clinical stability of patients with heart
failure, particularly in between their clinic visits.”
Of particular interest is the ability of devices to measure
changes in impedance in the thoracic cavity. Impedance is
the body’s resistance against an electrical current. “Impedance
was originally a self-check measurement to assess the status of
recognized that impedance technology also can indirectly assess
cardiac hemodynamics. Physiological changes may correlate
the thorax. This detectable change in impedance may occur
weeks before the actual event of hospitalization. The hypothesis
that is currently being tested is whether this early warning can
provide opportunities for early intervention, whether it is by
changing drugs or by intensifying counseling.”
Such measurements have been widely available as part of
complementary data on some CRT-Ds and ICDs, but not for
indications for treatment or alerts. “In fact, when we review
such data in front of our patients, we can even go back and
uncover unreported events,” says Dr. Tang. “It’s a powerful tool
if used appropriately. We have incorporated such information at
the time of clinic visit, as well as systematically reviewed them
when downloaded at the time of remote device interrogation
as part of our heart failure disease management program.”
There are some limitations as data from these remote devices
can be variable. “Some patients have big changes and some
patients have small changes,” says Dr. Tang. “Like any diagnos-
tic test, individual measurements need to be interpreted in
the context of the patient’s clinical status. We also don’t know
how frequent we should monitor these data, nor do we have a
universally agreed upon strategy to approach these patients. If
in doubt, we contact the patient to clarify or ask them to come
and see us for follow-up.” The value of this approach has been
supported by the availability of CPT codes for this purpose.
“For now, observing changes in device data can raise suspicion
regarding a patient’s clinical instability,” says Dr. Tang.
The next step is to perform large studies to establish the safety
Bruce Wilkoff, MD, Randall Starling, MD, MPH, and several
members of the Center for Electrical Therapies of Heart Failure
at the Miller Family Heart & Vascular Institute are actively
participating in the design and conduct of prospective clinical
trials to determine the value of these measurements in differ-
of heart failure.
“We have the challenge of establishing what is the most ap-
propriate response to these diagnostics,” says Dr. Tang, who is
leading several of these studies. “Up until now, the treatment
of heart failure has been reactive, based on a patient feeling
worse. In this generation, we would like to be proactive, using
drugs, counseling, following up closely, and calling the patient.
The advent of broad implantation of these devices in this popu-
lation allows us to test usefulness of this data in a management
strategy. It’s a tremendous opportunity to advance the treat-
ment of heart failure, perhaps way before patients demanded
the need for hospital admissions.”
W.H. Wilson Tang, MD
| Cardiac Consult | Summer 09 | Page 17Visit clevelandclinic.org/heart
Genetic Cause of Deadly Irregular Heart Beat Discovered
Qing K. Wang, PhD, Cleveland Clinic Lerner Research Insti-tute’s Department of Molecular Cardiology and Director of the Center for Cardiovascular Genetics, and his colleagues found the mutation of the gene NUP155 by analyzing the genetics of a family with severe, early-onset AF and sudden cardiac death.
AF is the most common rhythm disturbance of the heart found in the clinical setting. It affects 3 million people in the United States alone. AF accounts for nearly 15 percent of all strokes and is also associated with worsening heart failure and increased mortality. Despite signifi cant advances in AF management, available treatment options remain far from optimal.
“The new finding may provide a new molecular target to develop patient-tailored treatment strategies to prevent and/or treat the common form of atrial fi brillation,” says Dr. Wang.
Each cell in your body contains instructions encoded in your DNA that are parceled into 23 pairs of chromosomes. Approxi-mately 39,000 genes, which are the instruction booklets con-taining the DNA, are found dotted along all the chromosomes. Differences in people come from slight variations in these genes, which determine everything from hair and eye color to whether or not a person is more or less susceptible to certain diseases.
The DNA in genes is translated or decoded into another ge-netic material called RNA in the nucleus of a cell. Then, the RNA is transported from the nucleus to the liquid inside the cell called cytosol by a special apparatus called the nuclear pore complex (NPC). In turn, RNA in the cytosol produces proteins that are the basic building blocks and workers of each cell in the body. This conversion – DNA to RNA to protein – is a tightly regulated process.
NUP155 makes a protein that is a critical component of the NPC. The NPC acts as a gateway to control the exchange of ma-terials like RNA and proteins between the cell’s nucleus and the cytosol that surrounds the nucleus. This exchange of RNAs and proteins through a nucleus membrane is essential to numerous functions of the cell.
could lead to new diagnostic tests and treatment options for cardiac patients.
Dr. Wang’s studies revealed that mutant NUP155 causes atrial fi brillation by altering how RNAs are exported out of the nucle-us and how proteins are imported into the nucleus. Specifi cally, NUP155 affects the gene/protein called Hsp70, a protein that can be induced by stress, exercise, surgery, heat shock, and decreased blood supply to heart tissues.
Hsp70 plays a role in maintaining the proper balance of cardiac calcium and protecting the structure of heart tissue cells, both of which are cellular processes important to the maintenance of heart rhythm. If the level of Hsp70 is low, the heart is not protected from development of abnormal heart rhythms.
“Identifying a gene linked to AF could lead to new ways to genetically screen people. For example, individuals in families with a history of AF could be screened to see if they carry the mutated NUP155 gene and, therefore, have a greater likeli-hood of developing AF,” Dr. Wang says. “It also explains a molecular process or pathway that we might be able to control with new therapies. These therapies could stop AF from devel-oping in the fi rst place, or treat it after it has been diagnosed.”
Dr. Wang’s research team included Xianqin Zhang, PhD, Shenghan Chen, PhD, Shin Yoo, Susmita Chakrabarti, Teng Zhang, PhD, Tie Ke, Carlos Oberti, Sandro L. Yong, Fang Fang, Lin Li, Lejin Wang, and Qiuyun Chen, all of Molecular Cardiology, and R. de la Fuente, PhD, Department of Cardiol-ogy, Ospedale Italiano Umberto I, in Uruguay.
The research was published recently in Cell ( www.cell.com/ 2008; 135(6) pp. 1017-1027). This study was supported by the American Heart Association, the State of Ohio Wright Center of Innovation grant and Biomedical Research and Technology Transfer Partnership Award (BRTT, Ohio’s Third Frontier Proj-ect), and the National Basic Research Program of China.
Page 18 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
First Implant of Heartware Ventricular Assist System at Cleveland Clinic
In March 2009, Nicholas Smedira, MD, a cardiac surgeon with the
of the Heartware® Ventricular Assist System, developed by Heartware International, at Cleveland Clinic.
Only a handful of the miniaturized circulatory assist devices have been implanted in the United States to date. The HeartWare® Ventricular Assist System features the HVAD™ pump, the only full-output pump designed to be implanted next to the heart, avoiding the abdominal surgery generally required to implant competing devices.
HeartWare has completed an international clinical trial for the device involving five investigational centres in Europe and Australia. The device is currently the subject of a 150-patient clinical trial in the United States for a Bridge-to-Transplant indication.
A Comprehensive International SymposiumThe Treatment of Cardiovascular Disease: Legacy & InnovationJune 3-5 InterContinental Hotel & Bank of America Conference Center Cleveland, Ohio
Diabetes and the Heart August 6-7 Intercontinental Hotel & Bank of America Conference Center Cleveland, Ohio
A Primer in Vascular DiseaseSeptember 25-26InterContinental Hotel & Bank of America Conference CenterCleveland, Ohio
Congenital Heart Disease in the Adult: The Second Annual Ronald and Helen Ross SymposiumOctober 9 InterContinental Hotel & Bank of America Conference CenterCleveland, Ohio
2009 Heart-Brain SummitOctober 15-16Sheraton Chicago Hotel & Towers Chicago
For more information about the above events, call the Cleveland Clinic De-partment of Continuing Education at 216.444.5696 or 800.762.8173,or visit clevelandclinicmeded.com.
CME Calendar
Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 19
DrConnect Make Your Next Report Electronic
DrConnect is an Internet-based service developed to provide our community physician colleagues real-time electronic medical record information about the treatment their patients receive at Cleveland Clinic.
After establishing a DrConnect account with a secure log-in
personnel to receive security rights, allowing DrConnect patient updates to be immediately integrated into a busy medical
Web address (URL) gives you one-click access to all newly released patient-related information, which is presented in easy-to-navigate “What’s New” screens for quick access and effective case and time management.
Establishing your own DrConnect account is easy. 1) Log onto drconnect.clevelandclinic.org. 2) Click on the OnLine Signup button. 3)including choosing a secure password, and submit.
Special Assistance for Out-of-State PatientsThe Cleveland Clinic’s Medical Concierge program is
a complimentary service for patients who travel to
Cleveland Clinic from outside Ohio. Our patient care
representatives facilitate and coordinate the schedul-
ing of multiple medical appointments; provide access
to discounts on airline tickets and hotels, when avail-
able; make reservations for hotel or housing accom-
modations; and arrange leisure activities.
For more information: call 800.223.2273, ext.
55580, visit clevelandclinic.org/services, or email
HVI ReferralsTo refer cardiology patients, please call 216.444.6697 or 800.553.5056.
To refer surgical patients, call 877.843.2781.
New patients, in most cases, can be seen by a cardiologist within one week of calling for an appointment. Most patients requiring surgery also can be accommodated within one week.
Same-day Visits Now AvailableThe Miller Family Heart & Vascular Institute has begun offering same-day appointments
for new patients and follow-up visits. Patients who want or need to be seen immediately
will be scheduled with a HVI Cardiovascular Medicine staff member.
same-day visit, call 216.444.6697 or 800.659.7822.
C L E V E L A N D C L I N I C A C C E S S G U I D E
The Cleveland Clinic Foundation9500 Euclid Avenue/AC311Cleveland, OH 44195
A Primer in
Vascular Disease
Save the DateSeptember 25-26, 2009InterContinental Hotel & Bank of America Conference CenterCleveland, Ohio
www.ccfcme.org/Vascular09This activity has been approved for AMA PRA Category 1 Credit™.
CardiacConsult