Welcome

Dear Colleague,

Welcome to the first letter of the New Year from the Heart and Cardiovascular Service Line.

The Medical College of Georgia has a 50-year tradition of taking care of children with heart problems. Therefore, it should not come as a surprise to anyone that these children, now productive young adults, look to us for continuity of their care. The cardiovascular service line has a highly specialized team consisting of a dedicated cadre of physicians, nurses, perfusionists and a parents' group to take care of these complex patients. Sheldon Litwin, M.D., Professor and Chief of Cardiology at Georgia Regents University, has special expertise and interest in the subject and has written an overview in this edition of the newsletter. I know you will find it interesting and informative.

Mary Arthur, M.D., Associate Professor of Anesthesiology, shares with us the benefits of using bloodless medicine as an alternative to donor blood. Almost every week, wediscover new complications and side effects of blood t ransfusions. As such, it behooves us to use all possible means to minimize use of blood and blood products w ithoutcomprom ising patient outcomes. I a m pleased to report that, owing to our evidenced based guidelines and a team of driven individuals, blood utilization rates in our cardiacsurgery patients are one of the lowest in the country.As we encounter an increasing number of aged patients w ith concomitant advanced diseases, we find ourselves performing staged procedures to allow these patients time to recover from their multiple problems. Paul Poommipanit, M.D. writes about one suchtemporizing measure, balloon aortic valvulop lasty, in patients with severe aortic stenosis too ill t·o undergo definitive surgery. A close coordination between various specialists is essential for optimal outcomes.

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As always, we are proud of our fellows in training and some of their activities are outlined inside. I am sure you will agree that they are all multifaceted and talented individuals wit h considerable promise.

We have a busy year of CME activities ahead of us (schedu le attached). If you have suggestions for new topics or a different format please let us know.

Wishing you and yours the best for the New Year,

In This Issue• Welcome• Balloon

Aortic Valvuloplasty

• Bloodless Medicine

• Adult Congenital HeartDisease

• Fellowship Highlights

• Conferences

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M.Vinayak Kamath, M.D.Director, Heart and

Cardiovascular Services andChief, Cardiothoracic Surgery

Georgia Regents University 1120 15th

Street BA-4300 Augusta, GA 30912

706-721-3226kamath@gru.edu

G HealthGEORGIA REGENTS

HEART & CARDIOVASCULAR SERVICES

M.Vinayak Kamath, M.D.

Director, Heart and Ca rdiovascular Services

and Chief, Cardiothoracic Surgery

Assistant Professor of

For pat ients w ith severe aortic stenosis, the option of a less-invas ive procedure is becoming more common at Georgia Regents Medical Center's Heart and Cardiovascular Center.Subsequently, we learned that restenosis within six months is common. Today, balloon aortic valv uloplasty is increasingly used as a"bridge" to more definitive therapy. Balloon aortic valvu loplasty (BAV) increases the aortic valve area by inflating a balloon w ithin a severely stenot ic aortic valve.Historically, this procedure was done in hopes of providing a durable, less-invas ive solut ion for aortic stenosis.

With the advent of TAVR, BAV is being performed more frequently.

Since surgical aortic valve replacement (AVR) provides a durable, long-last ing solut ion for aortic stenos is, BAV has infrequently been performed. But, with the advent of transcatheter aortic valve replacement (TAVR), in w hich an aortic valve can be implanted percutaneously, BAV is being performed more freque ntly, providing an alternat ive treatment for seve re aortic stenos is. At the Georgia Regents Medical Hea rt and Cardiovascular Center, an 84'-year-old man with end-stage renal disease recent ly underwent BAV. This patient has cardiomyopat hy with an ejection fraction of 30 percent and moderate aort ic stenosis. He presented with a non-ST elevation myocardial infarction, class IV heart failu re and hypotens ion. A ca rdiac catheterization revea led s ignif icant coronary artery d isease of the right coronary a rtery and left anterior descending artery. Surgery was deemed too risky since his EF was now 20-25 percent with severe aortic stenosis and severe mitral and tr icuspid regurgitation.

The pat ient underwent high-risk stenting of his RCA and

LAD and the previously placed intra-aortic balloon pump was removed t he fo llowing day. Weeks later, the patient improved, but was still having class III-IV hea rt fai lureand receiving daily hemodialysis wh ile havirig episodesof hypotension. This patient was too decondition ed to

tolerate open-heart surgery and the decision was made to perform BAV as a bridge to futu re AVR orTAVR.

The patient was brought to the cardiac catheter ization lab, gracio usly provided by the pediatr ic ca rdiovascular service. Cardiac anesthesia and hemodynamic support

were provided. Transesoph ageal echocard iography

demonstrated a valve area of 0.8-0.9cm2 (severe aortic stenos is). One balloon inflation was done and

repeat echocardiography demonstrated a va lve area of 1.2cm2 (moderate aortic stenosis).The patient then had a SO percent decrease in the pressure gradient across the

va lve. Given his other crit ical illnesses, the team decided to terminate the procedure. The patient has

slow ly recovered and is wor king with physical therapy to improve his conditioning.

BAV for severe aortic stenosis is used to temporize prior to surgica l AVR,assess for response and as an alternative in severely symptomatic patients who are not candidates for other procedures such as AVR orTAVR. A multidisciplinary approac h at Georgia Regents University involving cardiac a nesthes iolog ist s, cardiac surgeons, interventiona I cardiolog ist s and cardiovasc u lar imaging specia lists improved the patient 's quality of life.

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Mary E. Arthur, M.D. Associate Professor, Anesthesiology and Perioperative Medicine

Blood Enhances Oxygen

Blood enhances oxygen-carrying capacity, improves wound-clotting and provides volume support for cardiac output. Nevertheless, more and more patients are seeking safe and effective alternatives to blood transfusions during surgery- even cardiac surgery- because of religious convictions, medical concerns or personal preference. Religious objections tend to be limited to primary components (packed red blood cells, platelets and fresh frozen plasma) while secondary compo nents such as albumin and factor concentrates are generally acceptable.

Physicians are increasingly accommodating patients' preferences for bloodless surgery because of mounting evidence that blood transfusions portend worse outcomes.

Minimizing bleeding and limiting blood transfusions havebecome important elements of quality improvement programs. Bloodless cardiac surgical procedures require special expertise, precise monitoring, state-of-the-art equipment and innovative techniques.

The GRU Bloodless Medicine and Surgery Program was

designed expressly for these reasons.How big is the problem?

Almost 15 million units of packed red blood cells are transfused annually in the United States during surgery, with cardiac operations consuming as much as 15 percent of the nation's blood supply. This percentage is growing, largely because of the increasing complexity of cardiac surgical procedures.

1) Patient's blood collected

2) Blood volume restored using plasma expa nders (Albumin , Hetastarch or Crystallods).

Why do we care?

Concerns regarding the safety and efficacy of allogeneic blood transfusion s, the impact on patient outcomes and the astounding costs and challenges associated with maintaining an adequate supply of blood products has renewed an interest in alternatives to transfusion. In

addition to transfusion-related risks such as infections

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respiratory failure and thromboembolic complications, red blood cell transfusions may alter immune function, impacting long-t erm survival.What do we know?

Most cardiopulmonary bypass patients have sufficient wound-clotting after reversal of heparin and do not require transfusion . Evidence suggests that transfusions might not improve the outcomes of stable non-bleeding patients in nearly 90 percent of the common transfusion scenarios reviewed. Transfusions are only deemed appropriate for patients 65 and older with comorbidities

and a hemoglobin of <8 g/dl.Several tools are available to accommodate the need

or preference for bloodless surgery, covering all phases of the procedure: preoperative, intraoperative and postoperative.

ANH Acute Normovolemic Hemodilution

1blood is

returned,

3) Off CPB, the patient'sconnedion maintainsclosed circut.

One important strategy is acutenormovolemic hemodilution, a process increasing the volume of the patient'sown stored blood using expanders such as albumin, hetastarch and crystalloids. Thetubing remains connected to the patient atall times, maintaining a closed circuit. Thepatient's stored blood, which has all themajor clotting factors as well as platelets, isreturned to the patient after weaning from cardiopulmonary bypass.

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How do we involve the patient?

Before surgery, a member of the blood conservatio n team gives t he pat ient a form listing all the facto r concentrates. The patient then decides which concentrates can be used during the procedure.

Our multidisc ip linary blood management team works toget her to limit blood transfus ions and decrease per ioperat ive bleeding while st i ll mainta ining safe

outcomes. At GRU, about 25 inpatient and outpatientcases per month utilize bloodless medicine tec hniques across all specia lty areas. Four successful bloodless cardiac surgery procedures have been done in the last few months.

More t han 180 comm unity members att ended a Bloodless Medicine and Surgery Program seminar last fall highlight ing techniques t hat enable medical and surgical treatment w ithout blood tra nsfusions, attesting to the acute interest and growing awareness ofthis burgeoning field of medicine. GRUis happy to fil l this vital niche in t he community.

Cardiovascu lar disease is the leading cause of death wor ldwide. In addition to acquired diseases associated wit h aging, heart disease can be present from birth. Because of steady advances in medicine, most pat ients with congenital heart disease today survive into adulthood and many have normallifespa ns. Patients with congenital heart problems are likely to benefit from consultat ion or ongoing care from a cardiovascu lar clinician or team with specia l interest or training in th is area.

The most common congenital heartcondition is the bicuspid aortic valve.The most common congenital heart condit ion is the

bicuspid aortic valve.About 1 in 100 people have a bicuspid aortic valve. The aortic va lve normally has three distinct leaflets (Figure 1A). Each leaflet, or cusp, is associated wit h a s inus of Va lsalva (Figure 1C) in t he aort ic root.The right and left coronary arteries arise from the respective right and left sinuses ofValsalva.The noncoronary sinus does not give rise to a coronary artery. The three leaflets of the aort ic valve open to produce a t riangle-shaped orifice (Figure 1A) and whe n closed, appear like a "Mercedes" sign (Figure 1B). Patients w it h bicuspid aort ic valves have

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only two leaflets (Figure 2A valve open, Figure 28 valve closed). In some cases, this results from fusion of the commissure between two leaflets producing a raphe (Figure 28).

In normal individuals, the cellophane-thin valve leaflets perform admirably over the course of 80-plus years. However, bicuspid va lves produce turbulent flow patterns that likely contr ibute to early damage of the leaflets. Degenerative changes of the leaflets, including prolapse or calcification (Figure 20), may cause regurgitation or leakage (Figure 2E) or stenosis (Figure 2A). These conditions typically do not become evident until adulthood. Echoca rdiogra phy is generally performed on adult patients with bicuspid valves every one to two years to look for regurgitation or stenosis. Once these abnormalities become clinically significant, surgical valve replacement is usually recommended (Figure 3C).

Bicuspid aortic valve is also linked to abnormalities of the aorta.

Bicuspid aortic valve also is also linked to abnormalities of the aorta. Coarctation of the aorta, a narrowing of the descending thoracic aorta just after the take-off of the left subclavian artery (Figure 3D) occurs in up to 40 percent of patients with bicuspid valves. Such narrowings have a number of adverse effects, particularly hypertension of the upper body. In addition to aortic coarctation, the wall of the entire aorta may be abnormal. This may lead to enlargement and/or dissection of the ascending aorta. For this reason, aortic imaging with MRI or CT is often done periodically in patients with bicuspid valves (Figure 3A ang B).The natural history of patients w ith bicuspid valves and aortic enlargement is similar to that of patients with Marfan's syndrome. Aortic root replacement may be recommended at the time of valve replacement surgery in those w ith bicuspid valves, or sometimes even before the valve itself requires surgica l intervention. Angiotens in receptor blocking agents are increasingly being used to protect the aorta from expansion in patients with various aortopathies, including those with bicuspid aortic valves.

Being born with 2 rather than 3 leaflets of the aortic va lve requires lifelong monitoring . To effectively diagnose and treat the significant valvular and vascular complications that can arise in patients with bicuspid aortic valve, referral to centers w ith specia lized interest in medical care, imaging and surg ical therapy for patients with adult congenital heart disease is appropriate.

A B c

D

A B

Figure 3. A and B. Two views of aortic root aneurysm (arrow withdissection of descending aorta (arrowheads). C. CT image ofmechanical aortic valve in open position. D. Image of repaired aorticcoarctation with native aorta (arrow) and graft going around coarct(arrowhead).

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Alberto Morales-Pabon, M.D. 3rd Year ChiefAdult Cardiology Fellow

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lauren Holliday, M.D.1st YearAdult Cardiology Fellow

Michele Murphy, M.D.1st Yea rAdult Cardiology Fellow

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Jose Cuellar, M.D. 3rd YearAdult Cardiology Fellow

Rod Evan Pellenberg, M.D.2nd YearPediatric Cardiology Fellow

Syed S. Zaidi, M.D.2nd YearAdult Cardiology Fellow

Amin Yehya, M.D. 3rd YearAdult Cardiology Fellow

Pediatric Cardiology Fellowship Highlights

November 2012·Rod Evan Pellenberg, M.D., submitted the manuscript,"Papillary Fibroelastoma ofTricuspid Valve in a Pediatric Patient"and was accepted to Annals ofThoracic Surgery.

·Rod Evan Pellenberg, M.D., lectured for first-year medical students'embryology course.

·Justin Mackenzie Vining, M.D.,was selected a GRU Fellow Representative Nonvoting member of the Georgia Chapter of the ACC.December 2012·Justin Mackenzie Vining, M.D., was board certified in general pediatrics by the American Academy of Pediatrics.

201.3 Pediatric Fellowship Program Match

The Pediatric Fellowship Program is happy to announce the match for a new fellow who will start July 1,2013.

Stefani M.Samples, M.D.- Medical College of Georgia at GRU.

2013 Adult Fellowship Program Match

The CV Disease Fellowship Program had a highly successful match for newfellows who will start July 1,2013.

Rebecca Napier, M.D. - GRU Residency Program

Pratik Choksy, M.D., M.B.B.S.- GRU Residency Program

Amudhan Jyothidasan , M.D.- University of

Massachusetts Loren Morgan, M.D.- University of South

Carolina

Fethi Benraouane, M.D. 3rd YearAdult Cardiology Fellow

Justin Mackenzie Vining, M.D. 2nd YearPediatric Cardiology Fellow

Adu lt Cardiology Fellowship Highlights

August 2012·Amin Yehya, M.D., was elected President of the Housestaff Organization for 2012-13 .

October 2012• Amin Yehya, M.D., Alberto Morales-Pabon, M.D. and Fethi Benraouane,

M.D. passed the Echocardiography Boards on their first attempt in July. This 100 percent pass rate for our fellows was also associated with some fellows scoring in the 901h percentile.

·The 12 adult cardiology fellows completed their first nationwide American College of Cardiology In-Service Exam. Overall program score was significant ly above the national average. The final year trainees scored 100 points above the national average for all other third year cardiology fellowship trainees nationally.November 2012·Four of our cardiology fellows presented their research posters at the AnnualGeorgia Chapter of the American College of Cardiology.

·Lauren Holliday,M.D. was selected to be the Fellow Representative Nonvoting member of the Georgia Chapter of the ACC.

:"'::oo!!• -· · Amin Yehya, M.D., orga nized the collection of toys fortheJames BrownToy Drive for local needy children at the James Brown Arena on December 20.

report.gru.edu/archives/13424

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' " ,, -CME-- LeCtures' .

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February 22

Speaker: Michael Luc, M.D., 2nd Year GRU Cardiology Fellow

Topic: "Stress Testing"

March8

Spea ker: Simi Kumar, M.D., 1st YearGRU Card iology Fellow

Topic: "Cardiac CT/Ca rdiac MRI"

March 15

Speaker: Ashkan Attara n, M.D., /nd Yea rGRU Card iology Fellow

Please contact us for more information106-72 -2136 ' .

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Topic:

March22

Speaker:

"Chronic Heart Failure"

Lauren Holliday, M.D., 1st YearGRU Cardiology Fellow

"Intra-aortic Balloon Pumps"Topic:

March 29

Speaker: Alber to Morales, M.D., 3rd Year

GRU Cardiology Fellow

Topic: "Diastolic Heart Failure"April12

Speaker:

Michele Murphy, M.D., 1st YearGR U Cardiology Fellow

"Women and Heart Disease"Topic:April19

Spea ker: Reza Amini, M.D., 2nd Year,GRU Cardiology Fellow

Topic: "Novel Anticoagulation Therapy"

April26

Speaker: Jose Cuellar, M.D., 3rd Year GRU Cardiology Fellow

Topic: "Comprehensive Approach to Syncope"

May3

Speaker: Vincent Robinson, M.D.,Program Director, CV Disease

Topic: "The New ACGME"

May24

Speaker: Fet hi Benraoua ne, M.D., 3rd YearGRU Cardiology Fellow

Topic: "Recanalizat ion of Chronically Occluded

Graft: Is it a Paradigm Shift?

Cardiovascular Conferences'

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GRU Coronary Revascularization SymposiumJune 6-9, 2013Kiawah Island, SC

GRU Cardiac Conference

October 9-13, 2013 Chateau Elan Braselton, GA

Cardiovascular Update for Primary Care Providers

October 26-27, 2013 · Marriott Riverfront Augusta, GA

Please contact us for more information

706-721-2736