2012 Heart and Vascular Outcomes Report
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2012 Heart and Vascular Outcomes Report

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Heart and Vascular Center at Rogue Valley Medical Center hopes you find this information both interesting and helpful in choosing the best treatment options for your patients. Together we can provide ...

Heart and Vascular Center at Rogue Valley Medical Center hopes you find this information both interesting and helpful in choosing the best treatment options for your patients. Together we can provide our patients the best cardiovascular care.

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2012 Heart and Vascular Outcomes Report 2012 Heart and Vascular Outcomes Report Presentation Transcript

  • 2012 Heart and VascularOutcomes Report
  • Heart and Vascular Outcomes 2012W elcome to the 2012 Heart and Vascular Outcomes Report for the Heart and VascularCenter at Rogue Valley Medical Center. Among the Rogue Regional to Asante Three Rivers and to Sky Lakes Medical Center in Klamath Falls. The satellite TV link allows active participation from the remote the variety of databases and quality assessment organizations in which we participate. A commitment to ongoing quality improvement is essential; and asmany new aspects of our program is the hospital’s new sites. We believe that top-quality patient care requires discussed in the Quality: Our Approach section of thisname: Asante Rogue Regional Medical Center. It’s the collaboration and teamwork. The teamwork begins report, we describe the new Performance Improvementsame buildings and the same capable staff, but there when the primary care physician refers a patient to one in Cardiac Care Team (PICCT), which took the leadis an increased emphasis on creating an integrated, of our physicians; continues as that patient is served in optimizing patient outcomes.collaborative system of patient care. by our skilled nurses, technicians, and therapists; and ends only after that patient has been treated and As in previous editions, this report will also reviewThe cardiologists, cardiac surgeons, and vascular educated and returns to his or her community. new technologies and procedures as well as providesurgeons now all have offices in the same building—the an overview of our programs.Cardiovascular Institute on the Medford campus. This We work hard to provide excellent cardiovascularworking arrangement facilitates communication and care to the patients we serve. This report outlines our We hope you find this information both interesting andconsultation among the various cardiovascular specialists. approach to giving the patient a positive experience, helpful in choosing the best treatment options for yourThere is an active satellite cardiology program at Asante and it details the statistics we use to objectively evaluate patients. Together we can provide our patients the bestThree Rivers Medical Center in Grants Pass, staffed our outcomes. How does one evaluate a cardiovascular cardiovascular care.by cardiologists who also manage patients in Medford. program? It isn’t simple because many factors mustThe weekly cardiology conference, which began in be considered. In this report we present our statistics — The physicians and surgeons of the Heart and Vascular1974, continues and is video-linked from Asante supporting program volumes and outcomes. We describe program at Asante Rogue Regional Medical Center
  • The Heart of Asante Rogue Regional Medical Center Cardiac disease is the leading cause of death in Oregon and California. Fortunately, effective therapy is available. Asante Rogue Regional Medical Center is a tax-exempt 378-licensed-bed facility created more than 50 years ago by and for the people of Southern Oregon and Northern California. Our heart and vascular program is nationally recognized and provides highly specialized heart and vascular care. Our Mission 1958 1968 1973 1977 1981 2003 2005 Asante exists to provide quality healthcare services in Asante Rogue Cardiac First Cardiac First open First coronary ASSET Patient Tower a compassionate manner, valued Regional opens Intensive Care Catheterization heart surgery balloon program constructed by the communities we serve. Unit opens Laboratory opens angioplasty established Cardiac Facilities at Asante Other Team Members Our Vision Rogue Regional Medical Center The first numeral represents the total number of people working in that department. Numerals in parentheses represent people • Cardiac Intensive Care Unit (16 beds) with 10 or more years of experience in that particular field. Asante will be recognized for • Heart Center (40 telemetry beds)medical excellence, for outstanding • Operating room: 10 (7) • Cardiac catheterization laboratories • Cardiac perfusionists: 4 (4) customer service, and as a · 2 outpatient labs • Cardiac surgery physician assistants: 4 (4) great place to work. · 5 inpatient labs • Cardiac Intensive Care Unit: 54 (21) • Cardiovascular Recovery Unit • ICU-based nurse practitioner: 1 (0) • 3 operating rooms for cardiovascular procedures • ICU-based physician assistant: 1 (0) · 2 dedicated to open heart procedures The Values in · The region’s only endovascular angiographic suite • Cardiac catheterization laboratory · Asante Rogue Regional: 20 (10) Which We Believe • Imaging Services · Asante Rogue Regional Cardiovascular Lab · Echocardiography at the Cardiovascular Institute: 12 (5) Excellence in everything we do · Stress nuclear • Cardiovascular recovery: 18 (6) · Cardiac CT Respect for all • Heart Center: 112 (36) • Cardiac Clinical Case Managers: 7 (6) Physicians (all board certified) Honesty in all our relationships • 13 cardiologists • Cardiac Rehabilitation: 7 (5) • Echocardiographers: 12 (7) • 4 cardiothoracic surgeons Service to the community, • Vascular ultrasound: 3 (2) • 6 vascular surgeons physicians, and each other • 8 cardiac anesthesiologists • Stress testing: 13 (9) • Cardiopulmonary: 7 (3) • 6 intensivists Teamwork always • Clinical quality analysts: 6 (2) • 15 hospitalists • STEMI nurse coordinator: 1 (0) • Critical Care clinical practice adviser: 1 (0)4
  • Heart and Vascular Outcomes 2012Table of ContentsWelcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Natural History of Carotid DiseaseThe Heart of Asante Rogue Regional Medical Center . . . . . . . . . 4 Electrophysiology Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Risk of Ipsilateral Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Cardiac Facilities at Asante Diagnostic Electrophysiology Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Who Should Be Considered for Carotid Stenting? . . . . . . . . . . . 45Rogue Regional Medical Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Tilt Table Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Criteria for Increased Surgical Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Other Team Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Intracardiac Ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Current CMS Coverage for Carotid Stents . . . . . . . . . . . . . . . . . . . . . . 45 Pulmonary Vein Antral Isolation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Patients at Normal Surgical Risk:Quality: Our Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Device Implantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 NIH–Sponsored CREST Trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Quality: How We Measure It and Lead Extractions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Continuously Strive to Improve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Indications for ICD Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Noninvasive Diagnostic Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Leapfrog Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Indications for Biventricular Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49CMS Quality Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 New Anticoagulants: Dabigatran, Medicare Coverage for CT Coronary Angiography . . . . . . . . . . . 49Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Rivaroxaban, and Apixaban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Cardiac Catheterization and Coronary Intervention . . . . . . . . . . . 8 Heart Transplant Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Preventive Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Myocardial Infarction: The ASSET Program . . . . . . . . . . . . . . . . . . . . . . . . 9 Cardiac Rehabilitation, PreventiveASSET Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Congenital Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Medicine, and Cardiac Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50The Chain of Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Adult Congenital Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Cardiac Educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Coronary Artery Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Some Comments from Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Historical Myocardial Infarction Mortality Rates . . . . . . . . . . . . . . . . 13 Cardiothoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Therapies on the Horizon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52National Recognition for the ASSET Program . . . . . . . . . . . . . . . . . . . . 14 Coronary Artery Bypass Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Cryptogenic Stroke and Patent Foramen Ovale . . . . . . . . . . . . . . . . 52Asante Rogue Regional Medical Center Asante Valve Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Resistant Hypertension: RenalCardiovascular Lab at the Cardiovascular Institute . . . . . . . . . . . . 16 Valve Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Artery Radiofrequency Ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Radial Artery Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Minimally Invasive Valve Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Atrial Fibrillation: Preventing StrokeAppropriate-Use Criteria for Using a Left Atrial Appendage Occluder . . . . . . . . . . . . . . . . . . . . . . . . . . 53Percutaneous Coronary Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Prosthetic Heart Valves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Fractional Flow Reserve Measurement 3D Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Close Working Relationship withwith a Pressure Wire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 STS Risk Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Oregon Health & Science University . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Chronic Total Occlusion: Increasing Success Endovascular Treatment of Thoracic Aortic Aneurysm . . . . . 40with Percutaneous Coronary Intervention . . . . . . . . . . . . . . . . . . . . . . . . 19 Physician Biographies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Transmyocardial Revascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Asante Cardiovascular and Thoracic Surgery . . . . . . . . . . . . . . . . . . . 54Percutaneous Cardiac Assist Devices: Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Impella and Tandem Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Southern Oregon Cardiology, LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Maze Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Impella Use in High-Risk Coronary Stenting . . . . . . . . . . . . . . . . . . . . . . 21 Oregon Surgical Specialists, PC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Enhanced External Counterpulsation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Hypothermia for Cardiac Arrest Patients . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Comprehensive Vascular Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Carotid Endarterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Hospital Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 5
  • Quality: Our Approach Quality: Our Approach Quality: How We Measure It Leapfrog Guidelines and Continuously Strive to Improve Coronary Artery Bypass Grafting Percutaneous Coronary Intervention Asante Rogue Regional Medical Center has a rigorous quality improvement program. Patient • Favorable hospital volume • Favorable hospital volume volumes and outcomes are carefully tracked and (450 or more procedures per year) (400 or more procedures per year) compared with external benchmarks. Quarterly • Participation in STS data collection • Participation in the American College of Morbidity and Mortality (M&M) conferences are • STS score exceeds the national average Cardiology National Cardiovascular Data held to review program statistics and individual patient for risk-adjusted mortality Registry or > 80 percent adherence to the experiences. These conferences provide our physicians • Minimum surgeon volume per year Leapfrog Expert Panel and staff with the opportunity to see what is going for coronary artery bypass grafting (CABG) • Endorsed Process Measures for Quality well and to identify areas in need of improvement. (100 cases per year) Score better than the national average The recently organized Performance Improvement in for risk-adjusted mortality Cardiac Care Team has been charged with identifying • Minimum surgeon volume per year for areas in which the care process can be improved and percutaneous coronary intervention (PCI) facilitating those improvements. The team consists Leapfrog Evidence-Based (75 cases per year) Hospital Referral Safety Standard of a senior cardiologist, an experienced nurse data coordinator, and a clinical nurse specialist. The PICCT Recommended Annual Volume organizes the quarterly M&M conferences, reviewing Asante Rogue Regional Medical Center Volume American Heart Association’s and presenting statistical data as it becomes available. ACTION Registry-Get with the Guidelines® The team meets with various members of the care team to help solve problems and improve patient flow. Award for Coronary Artery Disease: Gold Status in 2008 to 2010 and Asante participates in a variety of national quality Platinum Status in 2011 improvement initiatives and databases, including the American College of Cardiology and the Society of Volume Thoracic Surgeons (STS). We strive for a high level of compliance with subspecialty guidelines and with the Centers for Medicare & Medicaid Services (CMS) core measures for best practice guidelines. We support the transparent public reporting of healthcare quality data by participating in the following quality initiatives: Percutaneous Aortic Valve Coronary Replacement • CMS Hospital Compare Intervention www.hospitalcompare.hhs.gov Coronary Artery Abdominal Aortic • STS Consumer Reports Bypass Gra ing Aneurysm Repair www.sts.org • Healthgrades Asante Rogue Regional Medical Center www.healthgrades.com performance improvement staff 6
  • Heart and Vascular Outcomes 2012 CMS Quality Measures Acute Myocardial Infarction CMS Quality Measure Congestive Heart Failure CMS Quality Measure Top Percent of Hospitals in the Nation Asante Rogue Regional Medical Center Top Percent of Hospitals in the Nation Asante Rogue Regional Medical CenterCompliance Compliance Aspirin Smoking Primary Percutaneous at Discharge Cessation Coronary Intervention Le Ventricular within Minutes Assessment Aspirin ACE Inhibitor/Angiotensin Receptor Beta-Blocker at Arrival Blocker for Le Ventricular LV at Discharge Clear Discharge ACE Inhibitor/Angiotensin Systolic Dysfunction at Discharge Instructions Receptor Blocker for LV Systolic Dysfunction at Discharge Coronary Artery Bypass Gra Surgery CMS Quality Measure Top Percent of Hospitals in the Nation Asante Rogue Regional Medical Center American Heart Association Mission Lifeline Recognition forCompliance Heart Attack Care Performance Achievement Award in 2012 Prophylactic Prophylactic Beta-Blocker within Antibiotics within Antibiotics Discontinued Peri-Operative Hour within Hours Period Acumentra Health Hospital Prophylactic Controlled A M Urinary Catheter Quality Awards for Excellent Care: Antibiotics Selection Post-Operative Removed by High Performance (95 percent) on Serum Glucose Post-Operative Day SCIP and Heart Failure Measures in 2010 and 2011. Thomson Reuters® Top Quintile Health Systems Award in 2011 7
  • CORONARY ARTERY DISEASE Coronary Artery Disease Cardiac Catheterization and Coronary Intervention Cardiac catheterization facilities at Asante Rogue Regional Medical Center were established in 1973. Five catheterization and angiographic laboratories are dedicated to state-of-the-art diagnostic coronary angiography, coronary interventions, peripheral angiography and interventions, electrophysiologic procedures, and device implants. Board certification in cardiology is required of all cardiologists. Cardiologists who perform coronary interventions are board certified in interventional cardiology. Expertise is maintained by focusing procedural Asante Rogue Regional Medical Center continues to experience within a small group of high-volume, adhere to the PCI guidelines written and recommended experienced interventionalists whose low complication by the American Heart Association, the American rates and excellent outcomes exceed national College of Cardiology, and the Society for Cardiac benchmarks. Coronary interventional volume for Angiography and Interventions. These guidelines the institution and for each interventionalist exceeds are as follows:* volume recommendations established by the Leapfrog Group, Thomson Healthcare, and the American College • Operators perform at least 75 procedures at of Cardiology. A proven record of satisfactory outcomes high-volume hospitals (more than 400 procedures Asante Rogue Regional Medical Center and active participation in quality improvement per year) with on-site cardiac surgery. cath lab team programs is mandatory for all physicians. • Operators and institutions should have outcomes comparable to those reported in contemporary national data registries. The five interventional cardiologists are board certified • For ST-segment elevation myocardial infarction in both cardiovascular disease and (STEMI), emergent PCI should be performed interventional cardiology and provide by experienced operators who do more than 75 elective PCI procedures per year and, ideally, at around-the-clock coverage. least 11 PCI procedures for STEMI each year. Ideally, these procedures should be conducted in 1981: Coronary institutions that perform more than 400 elective interventional program started 14,751 coronary PCIs per year and more than 36 primary PCI procedures for STEMI per year. at Asante Rogue Regional interventions have been Medical Center performed since 1981. *Levin GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, 13 cardiologists and four Ting HH. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology cardiothoracic surgeons work together Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and to provide care around-the-clock. Interventions. Circulation. 2011;124:e574-e651.8
  • Heart and Vascular Outcomes 2012Myocardial Infarction: The ASSET Program ASSET Regional STEMI receiving hospital for primary PCIASSET (Acute ST-Segment Elevation Task Force) is a regional heart attack response team that coordinates thesimultaneous activation of paramedics, emergency departments, and the cardiac catheterization laboratory at Asante • Asante Rogue Regional Medical CenterRogue Regional Medical Center for rapid identification, triage, and treatment of ST-segment elevation myocardial Meets all American Heart Associationinfarction patients (severe heart attacks) throughout Southern Oregon and Northern California. The ASSET program Class I criteria for STEMIhas received national recognition for its dramatic reduction in death rates from heart attacks and is serving as a modelfor other programs in development across the country. The program represents the integration of care supported by the ASSET STEMI receiving hospital for primary PCI if patient requestedefforts of hospitals within the direct ASSET service area, hospitals within the regional support services area whose initialmanagement may include thrombolytic therapy followed by emergent transfer for possible rescue PCI, and those hospitals • Providence Medford Medical Centerhaving PCI capability supported by the cardiothoracic surgical program at Asante Rogue Regional Medical Center. ASSET Service Area STEMI referring hospitals for primary PCI ASSET Program Mission Statement • Ashland Community Hospital • Fairchild Medical Center To facilitate the accurate and rapid diagnosis, treatment, and transport • Asante Three Rivers Medical Center of patients with acute ST-segment Elevation Myocardial Infarction (STEMI) from throughout the region to the Asante Rogue Regional Medical Center ASSET Regional Support Services Area hospitals providing thrombolytic therapy cath lab for emergent percutaneous coronary intervention (PCI). with emergent transfer to Asante Rogue Regional Medical CenterASSET Service Area • Curry General Hospital • Lake District Hospital Coos Bay O R E G O N • Sutter Coast Hospital ASSET Service Area Coquille Bandon Roseburg ASSET Regional Cardiothoracic Surgery Support Myrtle Point Support Services Area Myrtle Creek • Mercy Medical Center • Sky Lakes Medical Center Port Orford Paisley Core Partnership—Emergency Services Chiloquin Grants Pass • American Medical Response (AMR) Redwood • Ashland Fire & Rescue Gold Beach Rogue River Asante Rogue Regional Medical Center • Jackson County Fire District 3 Medford Altamont Klamath Falls • Medford Fire Department • Mercy Flights Brookings Cave Junction Ashland Lakeview • Northern Siskiyou Ambulance Harbor Malin Dorris • Rogue River Fire District 5 Tulelake Happy Camp Crescent City Yreka Montague Participating Heart Specialists C A L I F O R N I A • Asante Cardiovascular and Thoracic Surgery • Southern Oregon Cardiology, LLC 9
  • CORONARY ARTERY DISEASE Coronary Artery DiseaseThe Chain of SurvivalGloria Ferguson, 52Vancouver, WashingtonGloria, a math and science coordinator, was accompanying her 13-year-old son on a five-dayBoy Scout bicycling trip that began at Crater Lake National Park. On the first day, she was bicyclingand developed severe angina. A Boy Scout leader recognized the symptoms and drove her to the park’snorth entrance, where she lost consciousness soon after arrival. “Fast and deep” chest compressionswere promptly begun by two Boy Scout leaders. Seven park rangers quickly descended on the scene,and a physician from a waiting car arrived as well. Approximately six to seven minutes after Gloria lostconsciousness, an automated external defibrillator (AED) was brought to the scene. Three shocks weregiven over three to four minutes, with chest compressions in between, before a pulse was noted. Thrombotic occlusion in proximal Large thrombusThe Mercy Flights helicopter crew promptly This resuscitation exemplifies what can left anterior descending in filter basketarrived, diagnosed an acute anterolateral happen when each link in the chain of survivalSTEMI, and brought the critically ill patient works: the prompt recognition of cardiacdirectly to the Asante Rogue Regional Medical symptoms by the Boy Scout leader; the quickCenter cardiac catheterization laboratory. decision to head to the ranger station; the “fast andEmergent coronary angiography revealed a deep” chest compressions; the AED availabilitythrombotic occlusion in the proximal LAD and prompt and proper use; the rapid arrival and(i.e., widowmaker lesion) (figure 1). Emergent transport of a critically ill patient by helicopter;mechanical thrombectomy was successful the direct transport from the helipad to the(figure 2) and reestablished flow, followed by awaiting cath lab for emergent angiography,stent deployment (figures 3 and 4). Gloria was mechanical thrombectomy, and stent deployment figure 1— Baseline angiogram figure 2— Mechanicalin cardiogenic shock and required epinephrine (door-to-balloon time of 29 minutes, including showing a “widowmaker lesion” thrombectomyboluses, norepinephrine, dopamine, and an intubation); the cardiac support with intra-aortic (i.e., proximal thrombotic occlusionintra-aortic balloon pump. She also had 12 balloon pumping; the subsequent hypothermia in left anterior descending) Stent with large patent leftepisodes of ventricular tachycardia/fibrillation protocol to prevent brain injury; and the anterior descendingrequiring electrical cardioversion. round-the-clock vigilant care in the Cardiac Intensive Care Unit. Her situation was precariousShe was then transferred to the Cardiac Intensive throughout, and any failures along the wayCare Unit and improved over the next hour to would probably have resulted in her death.the point that hypothermia could be initiated.She improved on a daily basis, was taken offthe ventilator five days after admission, and 12days later was discharged home functional andneurologically intact. Gloria is now back to workfull-time and has resumed playing golf. figure 3— Balloon inflation and figure 4— After stent deployment stent deployment10
  • Heart and Vascular Outcomes 2012 – ASSET Patients Average Median Time to Treatment for STEMI Time at Referring Hospital Paramedic Transport Time Time from Emergency Department Door to Cardiac Cath Lab Door Cardiac Cath Lab Arrival to Open Artery at Asante Rogue Regional Medical Center minutes door–to–balloon time All ASSET Patients Jun –Dec n minutes door–to–balloon time All ASSET Patients Jun–Aug n minutes door–to–balloon time All ASSET Patients Jan–Dec n minutes door–to–balloon time All ASSET Patients Jan–Dec n minutes door–to–balloon time All ASSET Patients Jan–Dec n minutes door–to–balloon time All ASSET Patients Jan–Dec n minutes door–to–balloon time All ASSET Patients Jan–Dec n minutes door–to–balloon time All ASSET Patients Jan–Dec nTime in Minutes Arrival at Asante Rogue Regional Medical CenterMyocardial Infarction: Time Is MuscleCross-sectional image of the left ventricle during an inferior myocardial infarction Healthy heart muscle Dead heart muscle i e myocardial infarction heart a ack Blood within the heart hours hours hours 11
  • CORONARY ARTERY DISEASE Coronary Artery DiseaseCoronary Artery Stenting ASSET STEMI Patients Coronary artery atherosclerotic plaque Transfer from Referring Hospital Paramedic Asante Rogue Regional Medical Center TotalLow-profile stent and balloon advanced across blockage Balloon inflation results in stent deployment Balloon removed; stent maintains an open arterySTEMI In-Hospital Mortality Patients with Door-to-Balloon Time within Minutes – – Total number of STEMI patients from 2003 through 2011 = 1,19312
  • Heart and Vascular Outcomes 2012Historical Myocardial Infarction Mortality RatesHistorical National Hospital Mortality Rates for ST-Elevation Myocardial Infarction Heart A ack 3.9 percent is the mortality rate for 2011 and is also the cumulative mortality rate for the ASSET program since its inception in 2003 (1,193 patients)—among s s s ASSET Program at the lowest reported in the nation. Asante Rogue Regional Medical CenterSource: Clinical Practice Guidelines AHCPR Publication No. 94-0602. – nST-Elevation Myocardial Infarction In-Hospital Mortality ComparisonAsante Rogue Regional Medical Center versus Other Hospitals 89 percent of patients had hospital door–to–balloon times within 90 minutes in 2011, making ASSET one of the elite myocardial infarction National Registry of Asante Rogue Regional ASSET Program at Myocardial Infarction Medical Center Asante Rogue Regional programs in the country. “Similar Hospitals” Medical Center n 1,193 patients were treated at Asante Rogue Regional Medical Center for STEMI from June 2003 through December 2011. 13
  • CORONARY ARTERY DISEASE Coronary Artery Disease National Recognition for the ASSET Program “An Approach to Shorten Time to Infarct Artery Patency in Patients with ST-Segment Elevation Myocardial Infarction” American Journal of Cardiology 2007;99:1360-63. “Integration of Pre-Hospital Electrocardiograms and ST-Elevation Myocardial Infarction Receiving Asante Rogue Regional Medical Center Center (SRC) Networks: Impact on Door-to-Balloon Emergency Department staff Times Across 10 Independent Regions” Journal of the American College of Cardiology: Cardiovascular Interventions 2009;2(4):339-46. Primary percutaneous coronary intervention is the most complex, multidisciplinary, and time-sensitive therapeutic intervention in the world of medicine today. The process is measured in minutes. The outcomes are measured in mortality. Teamwork and smooth transitions are essential. Asante Rogue Regional Medical Center cardiopulmonary and enhanced external — Ivan Rokos, MD counterpulsation (EECP) staff STEMI Systems, May 200714
  • Heart and Vascular Outcomes 2012Annual Volume of Diagnostic Coronary Angiograms Asante Rogue Regional Medical Center Asante Three Rivers Medical Center Asante Rogue Regional Medical Center Cardiovascular Lab at the Cardiovascular Institute Combined Volume Asante Rogue Regional Medical Center cardiac studies staffAnnual Volume of Coronary Interventional Proceduresat Asante Rogue Regional Medical Center 67,200 cardiac procedures have been performed at Asante Rogue Regional Medical Center since 1973. Asante Rogue Regional Medical Center cardiovascular recovery staff 15
  • CORONARY ARTERY DISEASE Coronary Artery DiseaseAsante Rogue Regional Medical Center Cardiovascular Lab at the Cardiovascular InstituteEach year 13 cardiologists and six vascular surgeons perform a high volume of diagnostic cardiac catheterizations, peripheralangiograms, and peripheral vascular interventions at the Asante Rogue Regional Medical Center Cardiovascular Lab.Located in a comfortable, state-of-the-art facility within the outpatient facilities of the Cardiovascular Institute (CVI) onthe Medford campus, our lab allows elective studies to be performed conveniently; total stays average just four hours.Peripheral Intervention Volume Peripheral Angiography Volume Cardiac Catheterization/Coronary Angiography Volume Includes carotid angiography, upper- and lower-extremity angiography, renal angiography, mesenteric angiography, and abdominal angiographyIncludes upper- and lower-extremity angiography, renal angiography,mesenteric angiography, and iliac angiography Peripheral Angiography Complications No stroke, myocardial infarction, Stroke Myocardial Infarction Death or death occurred at the time of coronary angiography/cardiac catheterization from 2007 to 2011.16
  • Heart and Vascular Outcomes 2012Radial Artery AccessThe radial artery is increasingly being used as theaccess site to the arterial system when performingcoronary angiography, cardiac catheterization, andpercutaneous coronary intervention (i.e., coronary We use the Americanstent) procedures. Historically, the brachial and College of Cardiology’sfemoral arteries have served as the points of access tothe arterial system. Radial artery access is associated National Cardiovascular Datawith greater patient comfort, shorter bed rest times, Registry database to trackshorter hospital stays, and less bleeding. If a coronary patient outcomes.intervention is performed via the radial approach,same-day discharge is an option in some circumstances.Femoral artery access is still used for complexcatheterization and interventions, depending onthe patient’s situation. Radial artery access was Cath lab staff at CVIfirst performed on a routine basis at Asante RogueRegional Medical Center in 2009 (the first program Appropriate-Use Criteria forin Southern Oregon) and is now routinely performed Percutaneous Coronary Interventionby five of the cardiologists. Over the past 10 years, there has been a paradigm change in the treatment of patients with coronary artery disease. In the past, if a patient had a 75 percent coronary artery stenosis resulting in symptoms, a cardiologist would have felt compelled to mechanically fix that blockage. We now know it is the patient with A wide range of diagnostic unstable or intractable symptoms who benefits. The and interventional procedures American Heart Association and American College are performed in seven of Cardiology evidence-based treatment guidelines state-of-the-art catheterization have reviewed the large cardiology research trials and have found that revascularization is beneficial in laboratories—five at Asante Rogue patients with acute coronary syndrome (i.e., plaque Regional Medical Center rupture resulting in unstable angina, non-ST-segment and two at CVI. elevation myocardial infarction, or ST-segment elevation myocardial infarction), a high-risk stress test or pressure wire assessment, congestive heartRadial artery hemostasis after removing failure, or debilitating stable angina despite optimalthe radial artery access sheath medical therapy. 17
  • CORONARY ARTERY DISEASE Coronary Artery Disease Stent between fingers Courtesy of Cordis Pressure wire measurement of a hemodynamically significant coronary artery blockage Courtesy of Volcano Drug-eluting stent Courtesy of Fairman Studios Workhorse balloon for angioplasty Courtesy of Boston Scientific Intravascular ultrasound image (cross-sectional view) of a coronary artery with an eccentric atheromatous plaque Courtesy of Volcano Diamond-coated burr that spins at 150,000 revolutions per minute to drill through heavily calcified lesions Courtesy of Boston Scientific18
  • Heart and Vascular Outcomes 2012Fractional Flow Reserve Chronic Total Occlusion: Increasing SuccessMeasurement with a Pressure Wire with Percutaneous Coronary InterventionCoronary anatomy is best assessed by coronaryangiography. If a patient has unstable symptoms and Huntley Barns, 80a severe stenosis, revascularization is clearly indicated. Medford, OregonThere are many other instances in which it is unclearif a specific coronary lesion is the culprit in causing Huntley is a retired pastor who had debilitating exertional anginathe patient’s symptoms. Coronary physiology can despite optimal medical therapy. He had a large 3+ reversible perfusionbe assessed using a pressure wire to measure the defect in the inferior wall. Wall thickening in the inferior wall confirmedfractional flow reserve (FFR), which is the mean viability. Angiography revealed a chronic total occlusion in the mid-rightproximal pressure divided by the mean distal pressure. coronary artery with collateral flow to the distal vessel (figure 1). NewA pressure wire is a 0.014-inch soft coronary wire coronary wire technology and techniques permitted crossing of thewith a pressure transducer on its tip. The pressure tough fibrous cap in the chronic total occlusion with subsequent stentwire transducer is placed distal to the coronary lesion. deployment. A good angiographic result was noted (figure 2), and theThe pressure distal to the coronary lesion is measured patient was discharged home the next day.via the pressure wire, and the pressure proximal to thelesion is measured via the guiding catheter, permittingmeasurement of the pressure gradient (i.e., FFR).Adenosine (a short-acting vasodilator) is then given,and the FFR is measured. A normal fractional flowreserve is 1.0. Clinical outcome studies have shownthat a fractional flow reserve < 0.80 is best treatedwith revascularization (i.e., coronary stent orCABG surgery) and > 0.80 is best treatedwith medical therapy. Pressure wire and intravascular ultrasonography provide additional physiologic and anatomic information regarding coronary artery plaques. figure 1— Chronic total occlusion (> 3 months figure 2— Patent right coronary artery old by definition) in mid-right coronary artery after stent deployment 19
  • CORONARY ARTERY DISEASE Coronary Artery Disease Percutaneous Cardiac Assist Devices: Impella and Tandem Heart For acutely ill patients with failing hearts, temporary cardiac assist devices can mean the difference between life and death. The Impella device is a low-profile pump (impeller) mounted on a pigtail catheter that is advanced across the aortic valve into the left ventricle via femoral artery access. It provides up to 2.5 liters per minute (L/min) of blood flow for cardiac support. The inlet is in the left ventricle, and the outlet is in the ascending aorta. Only the left ventricle can be supported at the moment. This device can be placed solely by the interventional cardiologist and is currently available. The Impella 4.0 L/min device should be available in February 2013. The Tandem Heart device can provide left These devices serve as a bridge to coronary heart support, right heart support, or both and is artery repair (e.g., high-risk percutaneous coronary placed either in the operating room or in the cardiac intervention such as distal left main bifurcation stenting catheterization laboratory. A centrifugal pump is in a patient with low left ventricular ejection fraction used. For right heart support, the inflow cannula is (LVEF) who is not felt to be a candidate for CABG placed in the right atrium and the outflow cannula surgery by the CT surgeons) or to provide time for in the pulmonary artery. For left heart support in the the left ventricle to recover (e.g., acute anterolateral cath lab, the inflow cannula is placed in the left atrium ST-elevation myocardial infarction with cardiogenic via a transseptal puncture, and the outflow cannula shock, metabolic acidosis, and pulmonary edema). is placed in the iliac artery. This device requires a team approach with the interventional cardiologist, the electrophysiologists, and the cardiothoracic surgeons. This device has already been used by the cardiothoracic surgeons and will hopefully be available for use in the cath lab in February 2013. Impella Tandem Heart Courtesy of Abiomed Courtesy of Cardiac Assists20
  • Heart and Vascular Outcomes 2012Impella Use in High-Risk Coronary Stenting Ken Harrison, 55 Yreka, California Ken was admitted with unstable angina and was subsequently diagnosed with a non-ST-elevation myocardial infarction and acute systolic heart failure. Despite optimal medical therapy, he had debilitating angina frequently at rest and simply walking across the room. Coronary angiography revealed a 95 percent stenosis in the distal left main trunk extending into both the left anterior descending and the left circumflex arteries. Given his liver disease, the cardiothoracic surgeons felt he was at prohibitively high risk for coronary artery bypass graft surgery. He then underwent high-risk percutaneous coronary intervention of the distal left main while simultaneously using a percutaneous left heart assist device (Abiomed Impella 2.5) for circulatory support (2.5 L/min). The coronary intervention involved simultaneous kissing-stent deployment into Balloon inflation both the left anterior descending and the left circumflex coronary arteries. Despite the 14F access sheath and the complex nature of the intervention, Ken was discharged home the following day. Six months later he has no angina, is active, and has markedly improved his lifestyle. His liver function has also improved. Inflow port in left ventricle Left mainOutflow port in Left anteriorascending aorta Catheter descending Stent deployment with simultaneous balloon inflation Widely patent left main, left anterior descending, and left circumflex Severe Left stenosis circumflex Impella device in left ventricle Baseline coronary angiogram Approximate location of aortic valve Final angiogram after stent deployment 21
  • CORONARY ARTERY DISEASE Coronary Artery DiseaseEnhanced External Counterpulsation Hypothermia for Cardiac Arrest PatientsFor patients with debilitating chronic angina not Although the mechanism at work is unclear Cardiac arrest (ventricular fibrillation) results inamenable to coronary revascularization (stent or (possibly improved collateral flow), studies have impaired blood flow to the brain. A prolongedbypass surgery), enhanced external counterpulsation repeatedly shown that 60 to 80 percent of patients cardiac arrest (more than five minutes) can cause(EECP) is a well-tolerated, atraumatic, noninvasive experience the following results: brain damage (anoxic encephalopathy). On occasionprocedure that can reduce the symptoms of angina • Reduced frequency and intensity of chest pain the heart can be stabilized, but the patient remainspectoris, presumably by increasing coronary blood • Increased exercise tolerance unresponsive due to inadequate cerebral perfusion.flow to ischemic areas of the heart. • Reduced need for anti-anginal medications Inducing mild hypothermia to a core body temperature (such as nitroglycerin) of 33 degrees C via an external cooling blanket reducesThe EECP device uses a series of compressive cuffs • Improved sense of well-being and quality of life cerebral metabolism and edema and increases thewrapped around the patient’s calves, thighs, and likelihood of making a meaningful neurologic recovery.buttocks and synchronizes their inflation and deflation Patients typically undergo 35 one-hour sessions This treatment has been proven to save one additionalto the cardiac cycle. During diastole the cuffs inflate over a seven-week period and should first be evaluated life for every seven patients treated and is currentlysequentially from the calves proximally, resulting by a cardiologist. We have had 189 such patients since recommended by the American Heart Association.in augmented diastolic central aortic pressure and the program was established in 2003. At Asante Rogue Regional Medical Center,increased coronary perfusion pressure (when coronary 75 patients were treated from November 2006artery flow is maximal). Rapid and simultaneous through December 2011. Thirty-three patientsdecompression of the cuffs at the onset of systole reduces survived, and 11 required rehabilitation care.the systolic pressure and the cardiac workload. 70 percent of patients noted an improvement in distance that Approved by the federal Food and Drug can be walked in six minutes. Administration (FDA) and Medicare Change in Nitroglycerin Use nChange in Chest Pain n Two Weeks a er One Year Later At Completion of Therapy One Year Later Completion of Therapy Large Slight Unchanged Worse Good Slight Unchanged Worse Reduction Reduction Improvement Improvement in Use in Use Courtesy of Abbott Northwestern Hospital22
  • Heart and Vascular Outcomes 2012 Henry Trujillo, 49Cumulative Survival in the Grants Pass, OregonHypothermia and Normothermia Groups Henry is a US Navy veteran and a former truck driver who Hypothermia Normothermia had a sudden cardiac arrest while sleeping. His wife awoke to hear C No Temperature Adjustment him say, “Ahhhh!” before he lost consciousness. His wife initiated cardiopulmonary resuscitation (CPR) and paramedics found him in ventricular fibrillation. Electrical cardioversion was successful, and he required mechanical ventilation. Upon arrival at Asante Rogue Regional Medical Center, Henry was comatose and his 12-lead electrocardiogram (EKG) showed ST-elevation in leads V1 and V2 Survival consistent with myocardial infarction or Brugada syndrome (figure 1). Emergent coronary angiography showed mild luminal irregularities with no spasm, ulceration, or thrombus, confirming Brugada syndrome (sodium channel mutation). The hypothermia protocol was initiated to minimize cerebral edema. Henry’s neurologic function recovered four days later, an intracardiac defibrillator was implanted, and he was discharged home 10 days after his cardiac arrest. DaysSource: The Hypothermia after Cardiac Arrest Study Group,New England Journal of Medicine. 2005;352:225-37.Hypothermia Patient Survivors atAsante Rogue Regional Medical Center Nov through n n n n Dec figure 1—12-lead EKG showed ST-elevation in leads V1 and V2 n with right bundle branch block pattern Average age years Average length of stay days 23
  • Hospital Physicians Hospital Physicians Asante Rogue Regional Medical Center intensivists front row: Petey Laohaburanakit, MD, FCCP; Tamara Dixon, FNP; Matthew Klee, MD; Somnath Ghosh, MD back row: James Stubenrauch, PA-C;, Francisco Paz, MD; Radek Dutkiewicz, MD not pictured: Krish Umapathy, MD Asante Rogue Regional Medical Center hospitalists front row: Nha Le, MD; Erin Brender, MD; EeLin Wan, MD; and Elizabeth Hirni, DO; back row: Jose Mondesi, MD; Ahsan Jaffar, MD; Thu Han Aung, MD; Jonathan Gell, MD; Tim Johnston, MD not pictured: Ahmed T. Ahmed, MD; Tino Bauer, MD; Theresa Chan, MD; Six intensivists at Asante Rogue Regional Agnieszka Dobiecka, MD; Kenneth Sanford, MD; Donna Tribelhorn, MD Medical Center are board certified in critical care medicine; one is additionally board certified in pulmonary medicine. 15 hospitalists provide care for many cardiac patients. All hospitalists are board certified. An intensivist is present in the hospital around-the-clock. Hospitals with an intensivist program are associated with better outcomes and lower mortality rates. 24
  • Arrhythmias Arrhythmias Heart and Vascular Outcomes 2012 Electrophysiology Program Tilt Table Testing Asante Rogue Regional Medical Center’s electrophysiology (EP) program provides comprehensive diagnostic and This simple, noninvasive test is used to evaluate therapeutic management of simple and complex heart rhythm disorders, device management for heart failure, evaluation for neurocardiogenic (vasovagal) physiology as a part and management of syncope, and sudden-death risk assessment and management. Our large procedure volumes, of the evaluation of patients with syncope. The test well-equipped electrophysiology laboratories, and highly experienced electrophysiologists and staff account for the is often used to evaluate patients with recurrent excellent patient outcomes and are comparable to the nation’s highest-rated programs. Both of our electrophysiologists syncope of unknown cause unlikely to be related are certified by the American Board of Internal Medicine in cardiovascular disease and electrophysiology. to pathologic arrhythmia, such as those with structurally normal hearts. Diagnostic Electrophysiology Studies Diagnostic EP studies are routine heart catheterization procedures used to identify and guide the treatment of heart rhythm disorders. Sophisticated, state-of-the-art three-dimensional (3D) electroanatomical mapping systems are used (like a global positioning system for the heart) to guide the clinician’s understanding and treatment of Tilt Table Studies complex arrhythmia mechanisms. Often these diagnostic procedures are done in the same setting as therapeutic Number of intracardiac ablations, pacemaker insertions, and defibrillator implants as indicated. These tests have a complication rate well below 1 percent. Electrophysiology Studies Loop Recorder Implants Electrophysiology Studies Number of Diagnostic 25
  • Arrhythmias ArrhythmiasDonna Wyant, 74 Intracardiac AblationMedford, Oregon Ablations are catheter-based procedures performed to treat aDonna suffered acute systolic heart failure with variety of arrhythmias, including many forms of supraventricular Patients with highly tachycardia, atrial flutter, atrial fibrillation, and some types of symptomatic atrial fibrillationleft ventricular ejection fraction 10 percent. ventricular tachycardia. Radiofrequency energy is used to ablateShe also had severe, central mitral regurgitation who failed anti-arrhythmic arrhythmia foci and reentrant circuits to manage tachyarrhythmias.secondary to her cardiomyopathy. A 12-lead therapy often benefit from Cure rates for many arrhythmias exceed 95 percent, withEKG showed left bundle branch block.Coronary angiography revealed a 90 percent complication rates of usually less than 1 percent. intracardiac ablation therapy.stenosis in her mid-left circumflex arterythat was successfully treated with a coronary Number of Ablation Proceduresstent. Despite coronary revascularizationand maximal medical therapy, her leftventricular ejection had increased to only 15 to20 percent eight months later and she still hadsevere mitral regurgitation. A biventricularpacemaker/intracardiac defibrillator wassubsequently implanted due to persistentsystolic heart failure (LVEF < 35 percent)and bundle branch block resulting in dyssyn-chronous contractility of the left ventricle.Her heart failure subsequently resolved, andan echocardiogram eight months later showednormal left ventricular size and systolicfunction (LVEF 60 percent) and mild mitralregurgitation. Donna is currently asymptomaticfrom a cardiac perspective. From 2000 to 2011, there has been only one procedure-related death (patient with severe ischemic cardiomyopathy and electrical storm [i.e., refractory ventricular tachycardia]). Intracardiac Ablation Complications Death Myocardial Infarction Stroke Tamponade Biventricular pacing/ICD leads in heart Courtesy of Boston Scientific n n n n26
  • Heart and Vascular Outcomes 2012Pulmonary Vein Antral IsolationPulmonary vein antral isolation, also known as atrialfibrillation ablation, is used to treat problematic atrialfibrillation when anti-arrhythmic medications fail. Theprocedure isolates nests of atrial fibrillation–generatingtissue in the posterior part of the left atrium andsometimes the superior vena cava. Mapping systems areused to generate atrial geometry that is then mergedwith CT scans of the posterior atria and the pulmonary figure 1—First step in a substrate map is to reconstruct the left ventricle on our computer. Our software allows for color-codedveins to guide ablation and electrical isolation of areas representation of ventricular voltage. Here purple is normal tissue,of the heart that trigger and sustain atrial fibrillation. and red is dense scar. Colors in between are transitional tissues, whichCure rates vary with the extent of cardiac pathology usually contain the ventricular tachycardia circuits. The pink andand range from 50 to 80 percent. blue dots represent double potentials and mid-diastolic potentials recorded with our mapping/ablation catheter. They are characteristic Gordon Self, 70 of ventricular tachycardia circuits. Talent, Oregon Gordon had a prior anteroapical myocardial infarction, has congestive heart failure, and previously had an implantable cardioverter defibrillator (ICD) placed for prevention of sudden cardiac death. On March 26, 2012, he presented with an “electrical storm” due to incessant ventricular tachycardia at more than 200 beats per minute. His ICD had shocked him 26 times. His condition was refractory to high-dose intravenous amiodarone and lidocaine and a medically induced coma. On the day of the procedure, he had recurrent ventricular tachycardia, requiring a 40-minute code blue. He was added urgently to our schedule for a high-risk ventricular tachycardia ablation. At the electrophysiology lab, his ventricular tachycardia was not hemodynamically tolerated, so he required a substrate map–guided approach (figure 1). This allowed us to identify putative ventricular tachycardia circuits for empiric ablation. The patient then had an extensive lesion set along the identified ventricular tachycardia corridors (figure 2). He was extubated on the following day and discharged from the hospital shortly thereafter. Since the procedure, Gordon has had no recurrent ventricular tachycardia and is doing well. figure 2— Our ablation strategy in unmappable ventricular tachycardia involves applying empiric lesions (red dot) along corridors of transitional tissues, diastolic potentials, and double potentials. These lesions are in diseased, poorly contracting tissue, so they usually do not impair LV function any further. Our endpoint is failure to induce ventricular tachycardia by program electrical stimulation. That was met on this patient. 27
  • Arrhythmias Arrhythmias Gregory Meyer, 65 Central Point, Oregon Gregory had highly symptomatic, longstanding, persistent atrial fibrillation since 2004. He had severe left atrial enlargement at 5.4 centimeters and had already failed therapy with amiodarone and cardioversions. On December 1, 2010, he underwent an operative Maze procedure at another institution without success. He was referred to us for further management. On June 13, 2011, he agreed to undergo a percutaneous atrial fibrillation ablation. At the time of catheter deployment, he was found to have three separate arrhythmia mechanisms coexisting in the left atrium: atrial tachycardia originating from the pulmonary veins (figure 1); perimitral atrial flutter (figure 2); and continuous fibrillatory activity in the posterior wall of the left atrium (figure 3). The radiofrequency ablation strategy involved reconstruction of the left atrium and pulmonary veins in three-dimensional space (figure 4) and making the following lesion sets: antral isolation of the pulmonary veins eliminated the atrial tachycardia; posterior wall isolation using a “box” procedure eliminated the continuous fibrillatory activity (figure 5); and isolation of the mitral annulus from the left inferior pulmonary vein terminated the perimitral flutter and restored sinus rhythm (figure 6). Gregory has remained in normal sinus rhythm since that time and is currently off all antiarrhythmic therapy. figure 1— Atrial tachycardia from the pulmonary veins figure 2— Perimitral annular flutter figure 3— Posterior wall had continuous fibrillatory activity figure 4— Activation map of left annular flutter shows figure 5— Antral isolation of pulmonary veins and figure 6— Mitral isthmus line between mitral valve and activation sequence beginning with red, followed by posterior wall isolation using a “box” procedure left inferior pulmonary vein orange, yellow, green, blue, indigo, and finally violet28
  • Heart and Vascular Outcomes 2012Device Implantation Pacemaker and Implantable Cardioverter Defibrillator VolumesAsante Rogue Regional Medical Center’selectrophysiology laboratory implants the fullrange of cardiac rhythm management devices,including pacemakers, implantable cardioverterdefibrillators, implantable loop recorders, and cardiacresynchronization (biventricular, or Bi-V) devices Total Numberfor the management of heart failure. ICDs havedramatically reduced arrhythmic and all-causemortality in at-risk individuals. Biventricular pacing(with and without an ICD) has become a routine partof managing patients with advanced heart failure.Pacing leads are used to synchronize activation ofthe right and left ventricles to improve contractiledynamics, left ventricular ejection fraction,exercise capacity, and survival. 2010 and 2011 numbers include all patients who received a new device, device revision, device upgrade, or generator replacement. Asante Rogue Regional Medical Center participates There were no device-related in the American College of Device Implantation Complication Rates complications in 2011. Cardiology’s ICD Registry. Percentage of PatientsLead ExtractionsThe effectiveness and the dramatic increase in the useof implanted cardiac devices have resulted in the needfor complex device management and, at times, theremoval of implanted pacing and ICD systems, including Procedure- Infections Hematoma Pneumothorax Lead Chamberleads that have been in place for an extended time. Related Deaths Requiring Dislodgement PerforationLaser lead extraction is used to remove highly fibrosed Re-explorationlead systems from the heart and the vascular system Complication rates are for pacer, biventricular pacer, and ICD implants. For device implants, complication rates are defined as procedure-relatedafter extended use. Although serious intrathoracic mortality, infection, hematoma requiring re-exploration, pneumothorax, lead dislodgment, and chamber perforation.bleeding can occur during lead removal, carefulplanning, monitoring, and technique by experiencedphysicians have led to a high success rate. 29
  • Arrhythmias ArrhythmiasIndications for ICD Therapy1. Cardiac arrest due to ventricular fibrillation (VF) 7. Primary prevention of SCD in patients with Distribution of Device Implantation or ventricular tachycardia (VT) unrelated to a ischemic cardiomyopathy and EF ≤ 35 percent ICDs Pacemakers reversible cause a. Receiving optimal medical therapy2. Sustained VT associated with structural b. At least 40 days after myocardial infarction Bi-V Pacemakers/ICDs Bi-V Pacemakers heart disease c. Life expectancy of at least one year with good3. Syncope of undetermined origin with inducible functional status VT at time of electrophysiologic studies (EPS) d. Class I–III congestive heart failure (CHF)4. Nonsustained VT in patients with ischemic e. Class IV CHF if candidate for biventricular pacing cardiomyopathy, ejection fraction (EF) ≤ 40 8. Primary prevention of SCD in patients with percent, and inducible sustained VT at EPS nonischemic cardiomyopathy and EF ≤ 35 percent5. “Cardiac syncope” in patients with a. Receipt of optimal medical therapy for cardiomyopathy and no explanation of past three to nine months mechanism of syncope after EPS b. Class II–III CHF a. Syncope in setting of cardiomyopathy c. Class IV CHF if candidate for biventricular pacing warrants hospitalization and referral to Based on the 2002 Device Implantation Guidelines and the September arrhythmia specialist 2006 Prevention of Sudden Cardiac Death Guidelines6. Patients with potentially lethal genetic disorders and high-risk characteristics: a. Prolonged QT syndrome Indications for Biventricular Pacing i. Recurrent syncope despite treatment Pacemakers and defibrillators are with beta-blockers 1. Class I–IV heart failure symptoms with left bundle ii. Significant family history of unexplained implanted and managed only by branch block or intraventricular conduction defect sudden cardiac death (SCD), especially with QRS > 120 milliseconds physicians who are certified by if patient has syncope a. Receipt of optimal medical therapy for the Heart Rhythm Society. iii. VF past three to nine months b. Brugada syndrome b. EF ≤ 35 percent i. Syncope with spontaneous Brugada EKG 2. Any patient with significant cardiomyopathy that ii. VF requires sustained ventricular pacing support c. Hypertrophic cardiomyopathy a. Right ventricular apical pacing is known i. Hypertrophy ≥ 30 millimeters to be detrimental in this patient subset ii. Significant family history b. It is reasonable to upgrade a patient from a iii. Nonsustained VT dual-chamber pacing device if EF ≤ 35 percent iv. Syncope and Class III–IV CHF symptoms are present v. Abnormal blood pressure response to exercise 3. Patients with atrial fibrillation who require vi. VT/VF atrioventricular nodal ablation d. Right ventricular dysplasia a. Heart failure symptoms i. Syncope b. Left ventricular dysfunction ii. Significant family history of SCD iii. VT/VF30
  • Heart and Vascular Outcomes 2012New Anticoagulants: Dabigatran, Rivaroxaban, and Apixaban Heart Transplant CareIn patients with atrial fibrillation and a CHADS2 and no clear method for reversing their effectscore ≥ 1, anticoagulation with warfarin (Coumadin), if bleeding occurs. Fresh frozen plasma reverses Mark Huth, MD, PhD, FACC, specializesdabigatran (Pradaxa), rivaroxaban (Xarelto), and the effects of warfarin. Dialysis is required for in the care of patients who have had heartapixaban (not yet FDA approved) should be considered dabigatran. Prothrombin complex concentrates transplants. He earned both his doctorto prevent embolic stroke. are currently being studied. of philosophy and his medical degree and served as an assistant professor of medicineDabigatran is a direct thrombin inhibitor that has at the University of Washington in Seattle.a lower risk of stroke and intracranial hemorrhage Myocardial biopsies are performed to monitorthan warfarin but a similar rate of overall bleeding CHADS2 Risk Criteria Score for rejection. Coronary angiography and(RELY Trial, New England Journal of Medicine intravascular ultrasonography are available Prior stroke, transient ischemic2009;361;1139-51). 2 to monitor coronary allograft vasculopathy. attack, or embolic event Age > 75 years 1Rivaroxaban is a factor Xa inhibitor with a mechanismof action similar to low-molecular-weight heparin. It is Hypertension 1equivalent to warfarin with regard to stroke prevention Diabetes mellitus 1and bleeding risk (ROCKET-AF Trial, New EnglandJournal of Medicine 2011:365:883-91). Heart failure (LVEF < 40%) 1Apixaban is a factor Xa inhibitor that had a lower risk Other high-risk factors requiring anticoagulation includeof stroke and a lower risk of bleeding when compared mitral stenosis and any prosthetic heart valve.with warfarin (ARISTOTLE Trial, New EnglandJournal of Medicine 2011;365:981-92). FDA approval CHADS2 Recommended Therapy tois pending, but it was included in the evidence-based Score Prevent Embolic Strokeguidelines titled “Oral antithrombotic agents for theprevention of stroke in nonvalvular atrial fibrillation: 0 Antiplatelet therapya science advisory for healthcare professionals from Antiplatelet therapy or 1the American Heart Association/American Stroke anticoagulationAssociation” (Stroke 2012:43:00-00). 2 AnticoagulationWhen compared with warfarin, these new ACC/AHA/ESC 2006 guidelines for the managementmedications have the advantage of fewer drug of patients with atrial fibrillation—executive summary: ainteractions and no dietary restrictions, and they do report of the American College of Cardiology/Americannot require international normalized ratio (INR) Heart Association Task Force on Practice Guidelinesmonitoring. Disadvantages include their cost and the European Society of Cardiology Committee for(approximately $8 per day, or $240 per month) Practice Guidelines. Circulation 2006;114:700-52. 31
  • Congenital Heart Disease Congenital Heart Disease Adult Congenital Heart Disease Care of the adult congenital heart disease (ACHD) patient is a rapidly growing subspecialty of cardiology. These patients are survivors of childhood congenital heart operations and interventional procedures and include those adults who have undiagnosed cardiac disease of a congenital origin. Based on conservative estimates of 800,000 such patients in the United States, it is estimated that there are 12,000 Oregonians with ACHD. Care of these patients is highly complex and can Brian Morrison, MD, FACC, specializes in the care often involve multiple specialties. Unique issues during of ACHD patients. He trained at the internationally non-cardiac surgery, general medical care, and high-risk known UCLA Adult Congenital Heart Disease obstetrical care are some of the concerns addressed Center—the first and one of the largest of its kind by ACHD specialists. in the United States. He has served as an assistant clinical professor at the OHSU Division of Pediatric At Asante Rogue Regional Medical Center, Cardiology for the past 12 years and has spoken and in conjunction with the Pediatric and Adult at national meetings. Congenital Cardiac Units at Oregon Health & Science University, we are able to deliver state-of-the-art care with multimodality imaging, electrophysiological evaluation and treatment, outpatient follow-up, and There are five cardiac surgical care. Other issues addressed by the ACHD section include preparticipation screening for echosonographers who young athletes, patients with Marfan syndrome, and are board certified in pediatric other inherited diseases of the cardiovascular system. echocardiography. Pediatric Echocardiography Volumes— Asante Rogue Regional Medical Center32
  • Cardiac Surgery Cardiac Surgery Heart and Vascular Outcomes 2012 Cardiothoracic Surgery The cardiothoracic program at Asante Rogue Regional Medical Center has been in existence for more than 35 years, during which time our surgeons have performed more than 16,000 cardiac operations. Excellence in cardiothoracic surgery requires an integrated team effort. It represents the collective experience gained over the many years of the program as well as a continuing commitment to The cardiac surgical innovation and expertise provided by physicians, operating-room staff, Coronary Care Unit (CCU) nurses, and support staff. A team program was established of four cardiothoracic surgeons, each of whom individually performs more than 100 operations per year, along with their cardiac anesthesia 35 years ago. colleagues performs approximately 500 cardiac operations each year. Excellence in postoperative care is achieved by a team of highly experienced CCU nurses, who along with intensivists and cardiologists have cared for thousands of cardiac patients. Cardiac Surgeries Performed · –Year Total Number of Surgeries Performed Distribution of Cardiac Procedures The open heart surgery team has seven people with 30 or more years of experience. In 2010 and 2011, 95 percent of first-time CABG surgery Coronary Artery Aortic Valve Mitral Valve Mitral Valve Transmyocardial patients (475/501) received Bypass Gra Total Replacement Replacement Repair Total Revascularization an internal mammary graft. AVR Total MVR Total Isolated Isolated Isolated Surgical Atrial Fibrillation CABG AVR MVR Ablation Maze 33
  • Cardiac Surgery Cardiac Surgery Coronary Artery Bypass Graft CABG Mortality Rate for First Operation Asante Rogue Regional Medical Center Society of Thoracic Surgery Comparable Hospital Benchmark n n n n n n n n n n n n Preston Mitchell, 95 Medford, Oregon Mortality Rate for Second Third or Fourth CABG Surgery Reoperation Preston is a photographer and an Asante Rogue Regional Medical Center STS Benchmark active musician who had syncope as a result of ventricular tachycardia. Physical examination showed a healthy-appearing man. Echocardiography was unremarkable, including normal biventricular size and systolic function and normal valvular function. Coronary angiography showed an 80 percent stenosis in the distal left main involving the origin of both the left anterior descending and the left circumflex arteries. Pressure wire assessment showed that these lesions n n n n n n n n n n were clearly hemodynamically significant (FFR = 0.79). Because Preston’s health was quite good despite his being 92 years old, Mortality Rate by Age for Open Heart Surgery – he underwent two-vessel coronary artery bypass graft surgery. He made a full recovery and is still playing the string bass in the symphony at age 95. – – – – – – – – – n n n n n n n n n 34
  • 2012 Heart and Vascular OutcomesAsante Valve ClinicPatients with valvular heart disease managed by Southern Oregon Cardiology, LLC, are automatically enrolledin the Asante Valve Clinic if they have moderate to severe aortic stenosis, severe aortic regurgitation, or severe mitralregurgitation. The nurse coordinator tracks these patients via a database to ensure that they are evaluated on a regularbasis and that appropriate follow-up care is maintained.The American Heart Association and American College of Cardiology Valvular Heart Disease Guidelines recommendannual clinical evaluation and echocardiography for patients with moderate to severe aortic stenosis, severe aorticregurgitation, and severe mitral regurgitation (Journal of the American College of Cardiology 2008;52:e1-e142). Of note,patients with mild aortic stenosis are recommended to have an echocardiogram every three years. Aortic Stenosis Moderate Mean gradient 25–40 mm Hg Aortic valve area 1.0–1.5 cm2 Severe Mean gradient > 40 mm Hg Aortic valve area < 1.0 cm2 Aortic Regurgitation Severe 3–4+ on 0–4 severity scale Mitral Regurgitation Severe 3–4+ on 0–4 severity scaleFor symptomatic patients with aortic stenosis, the Percutaneous balloon aortic valvuloplasty is available atstandard approach is surgical aortic valve replacement. Asante Rogue Regional Medical Center. TranscatheterFor patients considered at increased risk for open heart aortic valve replacement is performed by cardiologists atsurgery, treatment options include: Oregon Health & Science University in Portland, with • Transcatheter aortic valve replacement (TAVR) whom we have an excellent working relationship. The • Palliation with percutaneous balloon aortic pre-TAVR evaluation is performed by cardiologists from valvuloplasty the Asante Valve Clinic and typically involves cardiac • Comfort care catheterization with an aortic valve study, coronary angiography, CT angiography of the iliac/commonManagement of these patients is discussed at the femoral arteries, STS risk scoring, percutaneous coronarycardiology conference each Wednesday morning, with intervention (i.e., coronary stenting) if necessary, andcardiologists and cardiothoracic surgeons in attendance. percutaneous balloon aortic valvuloplasty if necessary.The optimal treatment strategy is chosen for eachpatient in a manner similar to Tumor Board Review Contact Southern Oregon Cardiology, LLC,for oncology patients. at (541) 282-6606 if you would like to enroll a patient in the Asante Valve Clinic. 35
  • Cardiac Surgery Cardiac Surgery Valve Procedures Valve Procedure Volume Minimally Invasive Valve Procedures The minimally invasive thoracoscopic video- assisted mitral/tricuspid valve procedure allows valve repair or replacement to be performed without sternotomy. Asante Rogue Regional Medical Center cardiac surgeons use this technique primarily for patients who require mitral valve replacement, mitral valve repair for degenerative prolapse, or tricuspid valve repair. Minimally invasive surgery offers a better cosmetic outcome and can reduce pain, likelihood of infection, and length of hospital stay. Flail mitral valve leaflet Severe regurgitant jet Repaired valve; no regurgitation Left atrium Valve leaflet tips do not coapt Doppler signal showing the severely leaky valve Valve after repair (leaflets touch; no mitral regurgitation) Transesophageal echo Left ventricle Transesophageal echo Transesophageal echo 36
  • Heart and Vascular Outcomes 2012 Scott Wolf, 64 Chiloquin, OregonMinimally Invasive Valve Procedure Volume Scott suffered with progressive dyspnea and was subsequently noted to have a large left atrial mass that obstructed mitral inflow. He also had a small atrial septal defect. Resection of the large left atrial mass and closure of the atrial septal defect was made via a small right inframammary incision (i.e., minimally invasive open heart surgery). Pathology confirmed the mass to be a left atrial myxoma. Scott made a good recovery and is currently doing well. Large left atrial mass Right ventricle Mitral valve Right atrium Left ventricle Left atriumStandard sternotomy Small thoracic incision Transesophageal echocardiography shows After surgical resection a large mass in the left atrium impairing flow across the mitral valve Vascular accessStandard sternotomy on left; minimally invasiveapproach for mitral valve repair on rightCourtesy of Edwards Lifesciences 37
  • Cardiac Surgery Cardiac Surgery Prosthetic Heart Valves Anterior mitral 3D Echocardiography valve leaflet Chordal rupture on the Real-time, three-dimensional P2 segment of the posterior Posterior mitral echocardiography is primarily used mitral valve leaflet valve leaflet in patients with valvular heart disease undergoing transesophageal echocardiog- raphy. The most frequent and beneficial use is in patients undergoing mitral valve repair. The cardiologists and the cardiac anesthesiologists are both trained in this Pericardial tissue valve (bioprosthetic) modality. The cardiologists evaluate the Courtesy of Edwards Lifesciences patient prior to surgery. During the operation, the cardiac anesthesiologists provide helpful feedback to the cardiothoracic surgeons to obtain the best possible repair. St. Jude Medical mechanical valve 3D transesophageal echo of the mitral valve Courtesy of St. Jude Medical Intraoperative transesophageal Posterior mitral echocardiography is performed Left atrium valve leaflet routinely on patients undergoing Eccentric anteriorly directed mitral regurgitant jet Left ventricle valve surgery at Asante Rogue Regional Medical Center. Implanted mechanical aortic and mitral valves There are eight board-certified Courtesy of CarboMedics cardiac anesthesiologists trained in transesophageal echocardiography. Porcine tissue valve (bioprosthetic) Courtesy of Medtronic 2D transesophageal echo with and without color Doppler 38
  • 2012 Heart and Vascular Outcomes Distribution of Primary Valve Procedures n Isolated Mitral Valve Repair Mortality Rate Asante Rogue Regional Medical Center STS Benchmark Risk-Adjusted Rate* n n n n n n n n n *Note: STS did not calculate risk adjustment on this population until 2008. Isolated Aortic Valve Repair/Replacement Isolated Mitral Valve Repair/Replacement Isolated Mitral Valve Replacement Mortality Rate Aortic Valve Repair/Replacement CABG Mitral Valve Repair/Replacement CABG Asante Rogue Regional Medical Center STS Benchmark Risk-Adjusted Rate Aortic/Mitral Valve Repair/Replacement CABG Other Valve ProceduresSTS Risk AdjustmentThe purpose of the risk adjustment is to allow STSdatabase participants to compare their performancewith those of other participants (e.g., overall STS, n n n n n n n n nlike participants, region, or state). By accounting forand controlling patient risk factors that are present Isolated Aortic Valve Replacement Mortality Rateprior to surgery, risk adjustment “levels the playingfield” as best as possible. Comparing unadjusted event Asante Rogue Regional Medical Center STS Benchmark Risk-Adjusted Raterates would unfairly penalize participants who performoperations on higher-risk patients. Risk adjustmentmore accurately represents a participant’s performancerelative to that of a reference group presented withthe same patient population. STS overall surgical benchmark: STS national database combined n n n n n n n n n results (per surgical category) from more than 900 participants. 39
  • Cardiac Surgery Cardiac Surgery Endovascular Treatment of Thoracic Aortic Aneurysm Until recently, treatment of a descending thoracic aortic aneurysm required an open and morbid surgical procedure associated with a significant risk of paraplegia. A new endovascular approach is safer and less invasive and involves accessing the femoral artery, advancing a stent graft to the descending thoracic aorta, and deploying the stent graft across the aneurysm to seal it off. Patients often go home in one to two days. Wanda Talley, 86 Klamath Falls, Oregon Asante Rogue Regional Medical Center Wanda suffered from a massive thoracic open heart surgery team aortic aneurysm. In the past this would have been an untreatable problem for a woman of her age. Using minimally invasive Thoracic Aorta Procedure Volumes endograft stent technology, available at Asante Rogue Regional Medical Center, Open Surgery of Ascending Aorta Aortic Arch and/or Descending Thoracic Aorta surgeons repaired the aneurysm, leaving Endovascular Stent Gra of Descending Thoracic Aorta only a small incision in the groin. Asante Rogue Regional Medical Center’s hybrid operating room was developed with the technology to complete such complex procedures. Wanda continues to enjoy spending time with her daughter, Sheryl, and family. 40
  • Heart and Vascular Outcomes 2012Transmyocardial RevascularizationTransmyocardial revascularization (TMR) is an Transmyocardial Revascularization Procedure Volumeoption for patients with stable angina refractoryto medical treatment and not amenable to standardcoronary revascularization. A carbon dioxide laseris used to fire single, high-energy pulses to createsmooth, straight microchannels in the wall of the leftventricle. TMR is occasionally used in conjunctionwith standard CABG to treat an area of myocardiumthat cannot be revascularized with bypass grafts orstents. Clinical trials have demonstrated TMR tobe a safe and effective means of obtaining long-termrelief of angina, improved heart muscle perfusion,and improved quality of life. This technology was Asante Rogue Regional Medical Centerintroduced at Asante Rogue Regional Medical Cardiac Intensive Care Unit staffCenter in 2001.Atrial Fibrillation Maze ProcedureMaze Procedure Volume The Maze procedure uses a cryoablation technique to create lines of nonconducting scar tissue at the pulmonary vein orifices and within the walls of the atria to prevent the propagation of electrical excitation originating in the pulmonary veins into the atria and the sustained disorganized electrical activity within the atria which lead to initiation of sustained atrial fibrillation. The procedure is appropriate for individuals with highly symptomatic atrial fibrillation who have failed conventional therapy. Asante Rogue Regional Medical Center Heart Center staff 41
  • Vascular Surgery Vascular Surgery Comprehensive Vascular Care Six board-certified vascular surgeons provide Peripheral Angiography Volume around-the-clock elective and emergent care for Inpatient and Outpatient a wide spectrum of peripheral vascular disorders. Outpatient angiography and peripheral vascular interventions are performed in the outpatient angiography suite within CVI. Complex surgical reconstructive procedures, including a high-volume endovascular program for the management of abdominal aortic aneurysms, are performed within the region’s only state-of-the-art dedicated endovascular angiographic operating room located at Asante Rogue Regional Medical Center. Vascular surgeons, cardiothoracic surgeons, and cardiologists provide an integrated approach to the management of complex thoracic and abdominal aortic disease, combining thoracotomy and endovascular approaches to the management of thoracoabdominal aortic aneurysms and acute aortic dissections. Vascular surgeons, interventional cardiologists, and neurologists work together to provide a Includes carotid angiography, renal angiography, mesenteric angiography, upper- and lower-extremity angiography, comprehensive management of carotid artery and abdominal angiography. disease, using either surgical endarterectomy or percutaneous stent procedures. Iliac arteries Aneurysm Aorta Six board-certified vascular surgeons provide around-the-clock coverage. Stent graft Stent graft placed across aneurysm, effectively sealing it off Courtesy of Medtronic The peripheral vasculature Courtesy of Abbott Vascular42
  • Heart and Vascular Outcomes 2012 Femoral artery accessAbdominalaortic aneurysm Open surgical repair of abdominal aortic aneurysm Endovascular approach via Courtesy of Medtronic the femoral arteries (less invasive) Courtesy of Medtronic Elective Endovascular Stent Gra Repair In-Hospital Mortality RateAbdominal aortic aneurysmCourtesy of Medtronic n n n n n n n n nElective Abdominal Aortic Aneurysm Surgical Volume Total Repairs Open Surgical Repair Endovascular Stent Gra Repair Leapfrog recommends that annual hospital volumes for abdominal aortic aneurysm repair be more than 50 per year. 43
  • Vascular Surgery Vascular Surgery Carotid Endarterectomy While the patient is under general anesthesia, an incision is made in the skin over the carotid artery. The carotid artery is clamped and incised, and the atherosclerotic plaque is removed (endarterectomy). This is similar to removing the inner layers of an onion. The artery and the skin are then surgically closed. Isolated Carotid Endarterectomy In-Hospital Death and Stroke Rates Death StrokeGordon Karnes, 79Klamath, CaliforniaGordon suffered from progressive anddebilitating exertional angina and dyspnea. n n n n n n n n nHe was subsequently noted to have severeaortic stenosis with peak gradient 93 mm Hg,mean gradient 55 mm Hg, and calculatedvalve area 0.9 cm2. Coronary angiography Total Carotid Artery Revascularization Proceduresrevealed a 99 percent stenosis in the mid-leftanterior descending, a 95 percent stenosis in the Isolated Carotid Endarterectomy Simultaneous Carotid Endarterectomy and Cardiac Surgery Carotid Stentmid-left circumflex, and a 60 percent stenosisat the origin of the posterior descending artery.Routine preoperative carotid artery ultraso-nography was abnormal and led to carotidangiography, which revealed a 98 percentstenosis in the proximal right internal carotidartery and a 75 percent stenosis in the proximalleft internal carotid artery. The patient had nohistory of transient ischemic attack or stroke.He underwent high-risk simultaneous rightcarotid endarterectomy, aortic valve replace-ment, and four-vessel coronary artery bypassgraft surgery. The surgical team procedurewent very well, and the patient made a goodrecovery. Gordon is currently active andfeeling well more than one year later. Carotid stent program began in 2005.44
  • 2012 Heart and Vascular OutcomesNatural History of Carotid DiseaseRisk of Ipsilateral StrokeSymptomatic patients—transient Stent across Blood flowischemic attack (TIA)/stroke: carotid artery to brain • 70 to 99 percent stenosis: 13.0 percent per year plaque • 50 to 69 percent stenosis: 4.4 percent per yearAsymptomatic patients: • > 60 percent stenosis: 2 to 3 percent per yearSource: NASCET, NASCET II, ACAS, and ACST trials. Filter trapsWho Should Be Considered Equipment particles fromfor Carotid Stenting? placed via plaque butHigh-risk surgical patient: femoral artery permits in leg blood flow • Symptomatic patient with ≥ 50 percent stenosis • Asymptomatic patient with ≥ 80 percent stenosis InternalCriteria for Increased Surgical Risk carotid artery • Congestive heart failure class III/IV and/or Carotid stent deployed; filter not yet retrieved left ventricular ejection fraction < 30 percent Courtesy of Abbott Vascular • Open heart surgery indicated • Recent myocardial infarction • Unstable angina • Severe pulmonary disease Current CMS Coverage for Carotid Stents • Contralateral carotid occlusion • Symptomatic patients with ≥ 70 percent carotid • Contralateral laryngeal nerve palsy stenosis at high risk for carotid endarterectomy • Irradiated neck • Previous carotid endarterectomy with recurrent stenosis • High cervical internal carotid artery lesions • Common carotid lesions below the clavicle • Severe tandem lesions 45
  • Vascular Surgery Vascular Surgery Carotid Stent Volume 124 carotid stent procedures have been performed at Asante Rogue Regional Medical Center since 2005. Asante Rogue Regional Medical Center awarded American Heart Association Get With The Guidelines® for Stroke in 2012. The region’s only state-of-the-art dedicated Carotid Stenting in High-Risk Surgical Patients n endovascular angiographic operating room is located at Asante Rogue Regional Medical Center. -Day Outcomes Patients at Normal Surgical Risk: NIH–Sponsored CREST Trial Asante Rogue Regional Medical Center was one of 110 centers in North America chosen to participate in the National Institutes of Health–sponsored CREST trial. This study randomized normal-risk surgical Death Stroke Stroke Myocardial patients with carotid artery disease to carotid Major Minor Infarction endarterectomy versus carotid stenting with distal National Institutes of Health (NIH) stroke scale emboli protection. The screening process for treating performed before and after each procedure. physicians is rigorous; only experienced physicians with an excellent track record are chosen. Eleven patients participated in the study, and nine received carotid stents. All patients did well, with no death, stroke, or myocardial infarction.46
  • imaging Imaging Heart and Vascular Outcomes 2012 Noninvasive Diagnostic Testing Asante Rogue Regional Medical Center offers a Treadmill stress testing provides electrocardiogram full spectrum of noninvasive diagnostic testing for assessment for exercise-induced ischemia or arrhythmias, cardiovascular diseases: including chronotropic competence. Treadmill testing • Echocardiography (transthoracic, is used predominantly for patients who are able to transesophageal, pediatric) exercise and have a normal baseline EKG. • Treadmill stress testing • Nuclear stress testing • Multigated acquisition (MUGA) scans • Holter/event monitors • Tilt table testing Echocardiography Volumes—Asante Rogue Regional • Vascular imaging Medical Center Asante Three Rivers Medical Center Asante Rogue Valley Cardiac Studies and • Cardiac magnetic resonance imaging (MRI) Asante Three Rivers Cardiac Studies • CT coronary angiography (CTCA) • Coronary calcium score Echo Transesophageal Echo Treadmill stress testing Pediatric Echo Stress Echo Echocardiography is a noninvasive ultrasonographic assessment of cardiac structure and function, including evaluation of ischemic and nonischemic ventricular dysfunction, cardiomyopathy, valvular heart disease, and congenital malformations. Invasive transesophageal assessment is also performed in the inpatient and outpatient settings, as well as intraoperative assessment of cardiothoracic surgical procedures. 6,891 stress tests were performed at Asante Rogue Regional Medical Center and Asante Three Rivers Medical Center in 2011. Transesophageal echo is available around-the-clock at Asante Asante Rogue Regional Medical Center Rogue Regional Medical Center. echocardiography imaging staff 47
  • imaging Imaging An event monitor is worn for approximately one month. When a patient has symptoms (such as palpitations, light-headedness, or dizziness), the patient pushes a button to record the heart rhythm. This information is then transmitted over the telephone to the physician for review. Tilt table testing is a noninvasive assessment for vasovagal (neurocardiogenic) syncope. Vascular imaging consists of ultrasonographic Nuclear stress testing assessment of carotid and peripheral vascular disease, including atherosclerotic blockage, aneurysm formation, and deep venous thrombosis. Asante Rogue Regional Medical Center Nuclear stress testing allows a noninvasive assessment nuclear imaging staff of coronary blood flow and cardiac function; it is Cardiac MRI is used to evaluate for arrhythmogenic performed with exercise or pharmacologic stress right ventricular dysplasia, constrictive pericarditis, protocols. It is useful in assessment of ischemia with and myocardial viability following infarction. a baseline abnormal EKG, a nonspecific or possibly false-positive treadmill result, moderate probability for coronary artery disease, localization of ischemia in known coronary artery disease, or risk Peripheral Vascular Imaging Volumes— stratification after a cardiac event. Asante Rogue Regional Medical Center and Asante Three Rivers Medical Center MUGA scans are used for evaluation of right and left ventricular systolic performance. Arterial Ultrasound of Arms and Legs Carotid Artery Ultrasound A Holter monitor continuously records a patient’s Venous Ultrasound of Legs heart rhythm for 24 hours. The patient notes any symptoms, which allows correlation of the heart rhythm to any concerning symptoms. Cardiologists trained in: Asante Rogue Regional Medical Center Transesophageal 7 vascular imaging staff echocardiography Nuclear stress tests 12 Cardiac CT 5 48
  • Heart and Vascular Outcomes 2012Cardiac CTCoronary calcium score is a screening heart scan CT coronary angiography consists of high-resolutionused to detect calcium deposits found in atherosclerotic 3D pictures of the moving heart and great vessels thatplaque in the coronary arteries. The calcium score is are used to determine whether a patient has significantthen used to evaluate risk of future coronary heart coronary atherosclerosis or any structural abnormalitydisease and events. of the heart and the surrounding structures.Coronary arterial calcification is part of the developmentof atherosclerosis (hardening of the arteries), occursalmost exclusively in atherosclerotic arteries, and isabsent in the normal vessel wall. A score of 0 implies 64-slice CT scanners area low likelihood of coronary obstruction but cannot available at Asante Roguetotally exclude the presence of atherosclerosis. A high Regional Medical Center and Asantescore indicates a significant plaque burden and an Three Rivers Medical Center.increased relative risk of future heart and vascular Lightspeed VCT Courtesy of GE Healthcareevents. It should be understood that calcification doesnot imply significant obstruction, nor is it site specificfor a stenotic lesion; rather, it indicates the extent ofatherosclerosis throughout the coronary arteries. Coronary Artery Calcium Score Medicare Coverage for CTCA – – > • Patients with acute chest pain presenting in an emergency room (or equivalent) when necessary Cumulative Incidence of Coronary Events to rapidly differentiate among reasonably probable aortic, pulmonary, and/or coronary etiologies • First-line testing for coronary artery disease in nondiabetic patients with intermediate risk factors presenting in an emergency room (or equivalent) with chest pain syndrome or other symptoms strongly suggestive of coronary disease, and who have normal or borderline enzymes and EKGs, when negative findings will result in avoiding invasive coronary angiography • Equivocal or suspected inaccurate stress (or stress imaging) test in patients with low to intermediate risk factors when a negative CTCA will result in Years to Event avoiding invasive coronary angiography • Clinical findings strongly suggestive of Source: Detrano R, Guerci AD, Carr JJ, et al. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. a congenital anomaly of the coronary vessels New England Journal of Medicine. 2008;358:1336-45. or great vessels3D cardiac CT imageCourtesy of GE Healthcare 49
  • Preventive cardiology Preventive Cardiology Cardiac Rehabilitation, Preventive emotional health is evaluated, and appropriate support Medicine, and Cardiac Education and counseling are offered. Educational lectures for patients and their families are given weekly on a variety Diagnosing and treating a cardiac condition are of topics, including diet, exercise, medications, cardiac only the first steps in returning a person to the physiology, and stress reduction. maximal level of function. Multiple studies have shown that participation in a formal program of Goals of the Asante Cardiac Rehab program include: cardiac rehabilitation (rehab) is the most cost- • Determining the level at which a patient effective way to return cardiac patients to a full active may safely exercise life. Rehab programs improve exercise capacity • Educating patients about cardiac anatomy (by an average of 50 percent) and decrease mortality and function in health and in illness (by as much as 25 percent). They also teach patients • Developing the habit of regular exercise while and their families how to stay healthy in the future. improving endurance and a sense of well-being Prevention of cardiovascular disease is an important • Facilitating smoking cessationChad Teresi, 64 part of our mission. • Helping both patient and family understand theJacksonville, Oregon elements of a healthy diet and weight control Asante Rogue Regional Medical Center has had a • Helping patients understand their medicationsChad is a retired police officer who suffered vigorous rehab program since 1998, and Asante Three and the need for medication compliancefrom chest discomfort, dyspnea, and fevers Rivers Medical Center’s program is even older. Bothfor four weeks. Physical examination revealed programs are certified by the American Association Eligibility for participation in Asante Cardiac Rehabbounding pulses, holodiastolic murmur along of Cardiovascular and Pulmonary Rehabilitation. Medicare and most other insurers cover patientsthe right sterna border, and a Duroziez sign. The programs are directed by cardiologists and staffed who in the previous year had any of the following:Transesophageal echocardiography showed by multidisciplinary teams. Exercise prescriptions stable angina pectoris, myocardial infarction, coronarythree aortic valve vegetations with 3+ are developed for each participant and include both artery stenting, bypass surgery, valve surgery, orregurgitation on a 0–4 severity scale. He was monitored exercise and extensive education. The patient’s heart transplantation.diagnosed with culture-negative endocarditisdue to an antibiotic-treated tooth abscess. Achievements of the Asante Center RehabHe subsequently underwent debridement program during 2010 and 2011 include:of an aortic root abscess and replacement • 250 patients participated each year.of the aortic valve. He made a good recovery • 95 percent of patients said they were either satisfiedand participated in the cardiac rehabilitation or very satisfied with their rehab experience.program, where he quit smoking tobacco, • 97 percent of patients were on a heart-healthy diet.increased his exercise capacity from 2.8 • 85 percent of patients were exercising at home.metabollic equivalents (METs) (strolling slowly) • Medication compliance was excellent. Of theto 7.0 METs (jogging). His calf claudication patients appropriate for therapy, 98 percent werealso resolved over time with the exercise. taking statins, 100 percent were taking aspirin,Chad is greatly enjoying life after making and 98 percent were taking beta-blockers.many changes to his lifestyle. • Patients demonstrated significant improvements in functional capacity, sense of vitality, social functioning, emotional well-being, and level Asante Rogue Regional Medical Center of pain. Cardiac Rehabilitation staff50
  • Heart and Vascular Outcomes 2012 Cardiac rehabilitation is recommended Cardiac Educators by the American Heart Association and Asante Rogue Regional Medical Center has a group the American College of Cardiology. of Cardiac Clinical Case Managers who visit with patients both before and after cardiac surgery. They also see patients who have experienced heart failure, angina, myocardial infarction, coronary artery stenting, Asante Rogue Regional Medical Center or required pacemaker or defibrillator implantation. and Asante Three Rivers Medical Center Many of these educators also work in the Cardiac are both certified by the American Rehab program. The educators teach patients about their illness using a variety of teaching aids, including Association of Cardiovascular and actual stents, artificial valves, and pacemakers. The Pulmonary Rehabilitation. primary purpose of their visits is to be sure that patients understand their situation and have an opportunityAsante Rogue Regional Medical Center to ask questions of an expert in a nonthreateningCardiac Clinical Case Managers environment. We believe that education is key to good 92 percent of participants patient outcomes in both the short and long term. noted improvement in 3,360 Cardiac Rehab patients at Asante strength and endurance. Some Comments from PatientsRogue Regional Medical Center since 1998 “Fantastic staff and program…professional and friendly…I owe them everything.” 220 patients at Asante Rogue Regional Medical Center in 2011 87 percent of patients have “Felt like part of the family.” good blood pressure control at the 155 patients at Asante Three Rivers completion of the program. “Not only good for one’s health but also for your Medical Center in 2011 emotional well-being…don’t change a thing.” “A sincere and unequivocal thank-you for all you did 87 percent of patients report continued for me during the past three months. You helped me 95 percent of Cardiac Rehab patients physically, emotionally, and intellectually; you created were very satisfied with their experience. home exercise compliance. an environment of hope and optimism. Your work is deeply appreciated.” 97 percent of previous smokers were smoke-free at the conclusion Asante Rogue Regional Medical Center Asante Three Rivers Medical Center of their Cardiac Rehab program. Cardiac Rehabilitation Cardiac Rehabilitation Third Floor Northwest 520 SW Ramsey Avenue, Suite 103 2825 East Barnett Road Grants Pass, OR 97527 Cardiac Rehab is an effective way to Medford, OR 97504 (541) 472-7474 reduce morbidity and mortality. (541) 789-4466 51
  • Therapies on the horizon Therapies on the HorizonCryptogenic Stroke and Patent Foramen Ovale Resistant Hypertension:Paradoxical embolization via a patent foramen ovale events in the intention-to-treat arms). However, Renal Artery Radiofrequency Ablation(PFO) is a very infrequent but known cause of stroke. secondary endpoint analysis looks encouraging. Final We all know that the kidneys are important inA question is whether closing the foramen ovale reduces recommendations should be forthcoming in 2013. blood pressure regulation. For patients with resistantthe risk of recurrent stroke. Everyone has a PFO in hypertension defined as persistent hypertensionutero, and it closes shortly after birth in approximately Current recommendations are as follows: despite maximal dose of three antihypertensive75 percent of people. In the remaining 25 percent, • For cryptogenic stroke in patients < 55 years medications, bilateral renal artery denervation looksthis “door” in the atrial septum remains open to some old, a careful evaluation is recommended and quite promising. It can be performed using andegree. In young patients with stroke (age < 55 years), may include brain MRI with diffusion-weighted endovascular catheter that delivers radiofrequencyit has been observed that patients with a PFO have imaging, head/neck magnetic resonance angiogram energy to the luminal surface of the renal artery.an increased risk of recurrent stroke. (MRA) or cervicocerebral angiography, carotid The Symplicity HTN-2 trial showed a 32 mm Hg ultrasonography, transesophageal echocardiography, reduction in systolic blood pressure and a 12 mm HgPercutaneous closure devices have been designed to Holter monitor, hypercoagulable screen, urine reduction in diastolic blood pressure at 18 months.close the PFO, but the American Stroke Association, toxicology screen, and lower-extremity The Symplicity HTN-3 trial will randomize patientsAmerican Heart Association, American Association venous ultrasound. to renal denervation versus a sham procedure toof Neurologists, American College of Cardiology, • A typical hypercoagulable evaluation includes remove any placebo effect. This device is not yetand Food and Drug Administration issued a statement factor V Leiden, antithrombin III, protein S and approved by the FDA.recommending the completion of randomized clinical C, antinuclear antibody, lupus inhibitor panel,trials to determine if there is a clinical benefit for homocysteine, prothrombin gene mutation,first-time stroke patients ( Journal of the American methylene tetrahydrofolate reductase mutation,College of Cardiology 2009;53:2014-18). and erythrocyte sedimentation rate. • Antiplatelet therapy with aspirin or clopidogrelThe recently published CLOSURE-1 study enrolled is the standard of care except in patients with909 patients with cryptogenic stroke and found no atrial fibrillation, hypercoagulable state, orreduction in the rate of recurrent transient ischemic thromboembolic disease (e.g., pulmonaryattack or stroke with the STARFlex PFO closure device embolism, deep-venous thrombosis) who(New England Journal of Medicine 2012;366:991-99). require anticoagulation with warfarin,For 80 percent of patients with a recurrent stroke, dabigatran, or rivaroxaban.an explanation other than paradoxical embolism • For PFO patients with recurrent transient ischemicwas found. attack or stroke despite optimal medical therapy, percutaneous PFO closure is recommended. ThereThe RESPECT and PC trials were presented in is no evidence of benefit, but the FDA has issuedOctober 2012 at the Transcatheter Cardiovascular a Humanitarian Device Exemption for this use.Therapeutics conference but have not yet beenpublished in a peer-reviewed journal. These studies If percutaneous PFO closure is required, we havewere randomized clinical trials of the Amplatzer PFO the training and the hospital privileges to performclosure device versus medical therapy in first-time the procedure. We follow the recommendations madestroke patients. Neither trial met the primary end by American Heart Association, American Strokepoint of the study (i.e., reduction in embolic Association, Food and Drug Administration, and our professional societies.52
  • Heart and Vascular Outcomes 2012Atrial Fibrillation: Preventing StrokeUsing a Left Atrial Appendage Occluder Close Working Relationship withThe most feared outcome of atrial fibrillation is Oregon Health & Science Universityembolic stroke. The left atrial appendage is typically There are certain cardiac procedures that are required infrequently. We believe patients requiring suchthe site for thrombus formation. Left atrial appendage procedures should be referred to a major university medical center that performs these on a regular basis.occluders (i.e., plugs) can be delivered from the Fortunately, we have a close working relationship with the cardiologists at the Oregon Health & Scienceinferior vena cava through the atrial septum via a University in Portland, Oregon. Dr. Brian Morrison of Southern Oregon Cardiology, LLC, travels totransseptal puncture. In the PROTECT-AF study Portland every month to teach cardiology fellows and see patients in the OHSU Adult Congenital Heart(Lancet 2009;374:534-42), patients with atrial Disease clinic. Oregon Health & Science University received a $125 million grant from Nike’s Phil Knightfibrillation were randomized to warfarin versus a left in September 2012 to establish the OHSU Cardiovascular Institute. A patient’s evaluation always begins inatrial appendage occluder. For patients who received Southern Oregon, but patients may require the following procedures, all of which are offered at Oregonthe left atrial appendage occluder, warfarin was stopped Health & Science University:after 30 days and both groups were followed foran average of three years. The left atrial appendage • Heart transplantation • Percutaneous closure of atrial septal defectoccluder had a higher risk of adverse safety events at or patent ductus arteriosusthe time of implantation, such as pericardial effusion • Transcatheter aortic valve replacement either(4.8 percent), device embolization (0.6 percent), and through the arteries in the groin or using a • Percutaneous closure of perivalvular leakstroke (1.1 percent). Despite these early risks, the left small incision through the ribs involving a prosthetic heart valveatrial appendage occluder group had a lower rate ofstroke. As mandated by the FDA, a second clinical • Percutaneous pulmonic valve replacement • Cardiac MRI for congenital heart disease,trial is under way to better clarify whether the benefits with the Melody Valve sarcoidosis, hemochromatosis, amyloidosis,of the left atrial appendage occluder outweigh the and other conditionsrisks. Other occlusion devices are being studied.If the left atrial appendage occluder is approved, it isunclear whether it will be available only for patientswho are unable to take anticoagulation therapy(e.g., warfarin) or for all atrial fibrillation patientsat increased risk of stroke. 53
  • Physician Biographies Physician Biographies Asante Cardiovascular and Thoracic Surgery Charles Carmeci, MD, FACS David L. Folsom, MD, FACS Roger V. Hall, MD, FACS Cardiovascular and Thoracic Surgery Cardiovascular and Thoracic Surgery Cardiovascular and Thoracic Surgery Specialties: Coronary artery bypass graft surgery, Specialties: Coronary artery bypass graft surgery, Specialties: Coronary artery bypass surgery with valve surgery, thoracic aortic aneurysm repair, valve surgery, thoracic aortic aneurysm repair, extensive experience in thoracic aortic aneurysm repair, minimally invasive valve surgery, thoracic oncology, minimally invasive valve surgery, thoracic oncology, re-do surgery, valve surgery, thoracic oncology minimally invasive thoracic surgery, thoracic aortic minimally invasive thoracic surgery Medical Degree: University of Utah aneurysm surgery, stent grafts Medical Degree: University of Utah Internship/Residency: General Surgery at Medical Degree: Medical College of Virginia Internship/Residency: General Surgery at Madigan Army Medical Center Internship/Residency: General Surgery at Case Western Reserve University Cardiothoracic Surgery Fellowship: Letterman Stanford University Medical Center Cardiothoracic Surgery Fellowship: Case Western Army Medical Center Cardiothoracic Surgery Fellowship: University Reserve University Board Certification: American Board of Surgery, of Wisconsin Board Certification: American Board of Surgery, American Board of Thoracic Surgery (recertified 2006) Board Certification: American Board of Surgery, American Board of Thoracic Surgery Honors/Awards: Past President, Medical American Board of Thoracic Surgery Honors/Awards: Chairman, Department Staff at Asante Rogue Regional Medical Center; Honors/Awards: Graduated with honors from of Surgery at Asante Rogue Regional Medical Past Chairman, Department of Surgery at Asante George Washington University (undergraduate Center 2002–2005; Allen Research Fellow at Rogue Regional Medical Center degree) and Medical College of Virginia Wade Park VA Medical Center Office: Medford Office: Medford Office: Medford 54
  • Heart and Vascular Outcomes 2012 Southern Oregon Cardiology, LLCGeorge R. Wilkinson, MD, FACS Jon R. Brower, MD, FACC Kent W. Dauterman, MD, FACC, FSCAICardiovascular and Thoracic Surgery Cardiology CardiologySpecialties: Cardiovascular and thoracic Specialties: Consultative cardiology, echocardiography, Specialties: Consultative and interventionalsurgery, valve repair, off-pump surgery, transesophageal echocardiography, nuclear cardiology, cardiology including carotid stenting, radial arterycomplete aortic reconstruction coronary angiography access, cardiac assist devices (Impella), balloonMedical Degree: University of Iowa Medical Degree: University of Arizona aortic valvuloplastyInternship/Residency: General Surgery at Internship/Residency: Neurology and Internal Medical Degree: Johns Hopkins School of MedicineTripler Army Medical Center Medicine at University of Arizona Internship/Residency and Chief Residency:Cardiothoracic Surgery Fellowship: Letterman Cardiology Fellowship: University of Arizona University of California, San FranciscoArmy Medical Center Board Certification: Internal Medicine, Cardiology Fellowship: University of California,Board Certification: American Board of Cardiovascular Disease San FranciscoThoracic Surgery Honors/Awards: Residency Excellence in Interventional Cardiovascular Fellowship:Honors/Awards: Clinical Associate Professor of Teaching (three years) Cleveland ClinicSurgery, Uniformed Services Medical School Clinic: Medford, Grants Pass, Brookings Board Certification: Cardiovascular Medicine,Office: Medford Interventional Cardiology Honors/Awards: Valedictorian, College of Arts and Sciences, University of Toledo; Top Three Graduate, Johns Hopkins School of Medicine Dr. Dauterman served as a Peace Corps public health volunteer in Zaïre. Research: Served as the local principal investigator for the NIH-sponsored CREST trial and CAPTURE I and II, and CHOICE carotid stent registries Clinic: Medford, Grants Pass, Brookings 55
  • Physician Biographies Physician Biographies Southern Oregon Cardiology, LLC Brian W. Gross, MD, FACC Mark M. Huth, MD, PhD, FACC Todd S. Kotler, MD, FACC Cardiology Cardiology Cardiology Specialties: Consultative and interventional Specialties: General cardiology, heart failure, heart Specialties: Consultative cardiology, interventional cardiology, heart catheterization, echocardiography, transplant, echocardiography, nuclear cardiology, cardiology, general cardiology, nuclear cardiology nuclear imaging coronary angiography Medical Degree: Stanford University School Medical Degree: University of Rochester School Medical and Doctoral Degrees: Louisiana of Medicine of Medicine and Dentistry, New York State University Internship/Residency: Internal Medicine at Internship/Residency: Dartmouth Medical School, Internship/Residency: Louisiana State University University of California, Los Angeles (UCLA) New Hampshire Cardiology Fellowship: University of Washington Cardiology Fellowship: Cedars-Sinai Medical Cardiology Fellowship: University of Washington Postdoctoral Fellowship: Physiology at University Center, UCLA Board Certification: Internal Medicine, of Washington Board Certification: Internal Medicine, Cardiology, Cardiovascular Medicine, Interventional Cardiology Board Certification: Internal Medicine, Cardiology Interventional Cardiology Honors/Awards: Carpenter Award 2012; Oregon Honors/Awards: Honors in physiology from Honors/Awards: Highest honors from University American College of Cardiology Leadership Award, Rutgers University (undergraduate); Outstanding of California, Santa Cruz (undergraduate) May 2009; Washington Research Award (American Intern and Resident of the Year; Chairman of the Clinic: Medford, Grants Pass, Brookings Heart Association), Intern and Resident of the Year; American College of Cardiology’s Oregon GAP Oregon Fire Chief’s Award–Meritorious Service Project in Congestive Heart Failure Award; All American Selection to the All New England Soccer Team Dr. Huth served as an assistant professor at the University of Washington, Division of Cardiology. Dr. Gross served as an assistant professor at the University of Washington, Division of Cardiology. Clinic: Medford, Grants Pass, Brookings Clinic: Medford, Grants Pass, Brookings 56
  • Heart and Vascular Outcomes 2012Kenneth M. Lightheart, MD, FACC David J. Martin, MD, FACC Mark G. Moran, MD, FACC, FSCAICardiology Cardiology CardiologySpecialties: Consultative cardiology, transesophageal Specialties: Electrophysiology, intracardiac Specialties: Interventional cardiology, pacemakerechocardiography, nuclear cardiology, coronary ablation, pacemakers, defibrillators, invasive and and defibrillator implantation and follow-up, invasiveangiography, cardiac CT noninvasive cardiology and noninvasive cardiology, nuclear cardiologyMedical Degree: Oregon Health & Science University Medical Degree: Dartmouth Medical School Medical Degree: University of California,Internship: Internal Medicine at Legacy Internship/Residency: Internal Medicine at Los Angeles (UCLA)Portland Hospitals Cedars-Sinai Medical Center, UCLA Internship/Residency: UCLA Medical CenterResidency: Internal Medicine at David Grant Cardiology Fellowship: Cedars-Sinai Medical Center Cardiology Fellowship: UCLA Medical CenterMedical Center, Travis Air Force Base, California Board Certification: Clinical Cardiac Board Certification: Internal Medicine, Cardiology,Cardiology Fellowship: Wilford Hall Medical Electrophysiology, Cardiovascular Disease Interventional Cardiology; Testamur NASPExAM;Center, Lackland Air Force Base, Texas Honors/Awards: Alpha Omega Alpha Honor Society Certified Cardiac Device Specialist IBHREBoard Certification: Internal Medicine, Cardiology, in medical school, Phi Beta Kappa Honors/Awards: California Heart AssociationNuclear Cardiology Clinic: Medford, Brookings Research Fellow; bachelor’s degree in biology withHonors/Awards: Summa cum laude from Brigham highest honors from University of California, SantaYoung University, cum laude from Oregon Health & Cruz; Department of Medicine Intern of the Year,Science University, Alpha Omega Alpha Honor Society UCLA Medical Center; Fellow Society for Cardiacin medical school, Housestaff Scientific Research Angiography and InterventionsSecond Place Award Clinic: Medford, Grants Pass, BrookingsClinic: Medford, Grants Pass, Brookings 57
  • Physician Biographies Physician Biographies Southern Oregon Cardiology, LLC Brian J. Morrison, MD, FACC Bruce Patterson, MD, FACC Eric A. Pena, MD, FACC Cardiology Cardiology Cardiology Specialties: Consultative cardiology, pediatric Specialties: Consultative and preventative cardiology, Specialties: Cardiology, electrophysiology and adult congenital heart disease echocardiography, transesophageal echocardiography, Medical Degree: University of South Florida Medical Degree: University of Illinois, Chicago nuclear cardiology, coronary angiography Internship/Residency: Emory University, Internship/Residency: Internal Medicine at University Medical Degree: University of Pennsylvania Atlanta, Georgia of Colorado Health Sciences Center, Denver Internship/Residency: Internal Medicine at Brigham Cardiology Fellowship: Emory University Cardiology Fellowship: Massachusetts General and Women’s Hospital, Harvard Medical School Board Certification: Cardiology, Electrophysiology Hospital, Harvard Medical School Cardiology Fellowship: Boston University Medical Center Honors/Awards: Chief Medical Resident Board Certification: Cardiology Board Certification: Internal Medicine, Cardiology Dr. Pena has served on the faculty of the Heart Rhythm Honors/Awards: Grove Outstanding Senior Award Society’s International Meeting for the past three years. Finalist, University of Illinois College of Medicine; Honors/Awards: Cook Memorial Prize in Economics Outstanding Resident Teaching Award, University at Pomona College, California; President, Alpha Omega Research: Primary investigator or co-investigator of Colorado Health Sciences Center; Affiliate Alpha Honor Society, University of Pennsylvania in many PIVOTAL clinical trials, Miracle ICD, Associate Professor of Pediatrics at Oregon Health School of Medicine Companion trial, PAVE trial, and MADIT CRT trial & Science University Dr. Patterson earned his master’s degree from the Clinic: Medford, Brookings Dr. Morrison’s training included a senior clinical Princeton Theological Seminary in New Jersey. research fellowship at Boston Children’s Hospital. Clinic: Medford, Grants Pass, Brookings He also spent one year as an instructor and a staff physician at the Adult Congenital Heart Disease Center at the University of California, Los Angeles. Clinic: Medford, Grants Pass, Brookings 58
  • Heart and Vascular Outcomes 2012Bradley E. Personius, MD, FACC Stephen J. Schnugg, MD, FACC Richard A. Schaefer, MD, FACCCardiology Cardiology Medical Director of the Process Improvement in Cardiac Care Team andSpecialties: Consultative and preventative cardiology, Specialties: Consultative cardiology, interventionaltransesophageal echocardiography, pacemakers, complex cardiology, cardiac catheterization, echocardiography of the Cardiac Rehabilitation program atlipid disorders, cardiac CT, nuclear cardiology, Asante Rogue Regional Medical Center Medical Degree: University of California,cardiac catheterization Los Angeles Now retired from consultative and invasiveMedical Degree: Loma Linda University Internship/Residency: Internal Medicine at cardiology, Dr. Schaefer received his bachelor’sSchool of Medicine Wadsworth VA Medical Center degree with distinction and departmentalInternship/Residency: Internal Medicine at Wilford honors from Stanford University and his Cardiology Fellowship: Wadsworth VA medical degree from the University ofHall Medical Center, Lackland Air Force Base, Texas Medical Center Rochester School of Medicine and Dentistry.Cardiology Fellowship: Wilford Hall Medical Center Board Certification: Internal Medicine, Cardiology, He completed his internship and first-yearBoard Certification: Internal Medicine, Cardiology, Interventional Cardiology residency at Strong Memorial Hospital ofCardiac Device Specialist Clinic: Medford, Grants Pass, Brookings the University of Rochester and his second-Clinic: Medford, Grants Pass, Brookings year residency and Cardiology Fellowship at Oregon Health Sciences University. He served as president of the Oregon Chapter of the American College of Cardiology from 1991 to 1994. Dr. Schaefer’s board certification was in Internal Medicine and Cardiology. He published scientific articles on hearing in insects, measurement of cardiac function, cardiac auscultation and the mechanism of heart murmurs, and techniques for pericar- diocentesis and coronary angiography. 59
  • Physician Biographies Physician Biographies Oregon Surgical Specialists, PC Special thanks to Juan M. Castillo, MD, FACS Mark A. Eaton, MD, FACS Karen Bales, Christal Paetz, Vascular, General, and Bariatric Surgery Vascular, General, and Bariatric Surgery and Paula Granger from the Specialties: Vascular, endovascular, bariatric, and Specialties: Vascular, endovascular, bariatric, and Performance Improvement general surgery, including laparoscopic surgery; general surgery, including laparoscopic surgery; Department at Asante Rogue certified in da Vinci robotic-assisted surgery certified in da Vinci robotic-assisted surgery Regional Medical Center Medical Degree: New York University Medical Degree: University of New Mexico for their hard work and Medical Center Internship/Residency: General Surgery at commitment to this project. Internship/Residency: General Surgery at University of Texas Southwestern Medical Center University of Texas Southwestern Medical Center and Parkland Memorial Hospital and Parkland Memorial Hospital Vascular Surgery Fellowship: University of Tennessee Vascular Surgery Fellowship: New York University Board Certification: General Surgery, Medical Center Vascular Surgery Board Certification: General Surgery, Honors/Awards: Alpha Omega Alpha Honor Society Vascular Surgery in medical school; Trauma Director, Asante Rogue Honors/Awards: Honors program at New York Regional Medical Center University Medical Center; Chairman, Committee Fluent in English and Spanish on Cancer by American College of Surgeons for Asante Rogue Regional Medical Center and Research: Subinvestigator in PIVOTAL small Providence Medford Medical Center; Chief of Staff, aneurysm study, Endologix large neck aneurysm Asante Rogue Regional Medical Center study, and CREST carotid stent studies Fluent in English and Spanish Office: Medford Research: Subinvestigator in PIVOTAL small aneurysm study, Endologix large neck aneurysm study, and CREST carotid stent studies Office: Medford 60
  • Heart and Vascular Outcomes 2012William E. Faught, MD, FACS Nancy O’Neal, MD, FACS Mitchell M. Plummer, MDVascular and General Surgery General Surgery Vascular and General SurgerySpecialties: General, vascular, and endovascular Specialties: General surgery, including laparoscopic, Specialties: Vascular, endovascular thoracicsurgery, including laparoscopic surgery breast, and oncologic surgery; certified in da Vinci and abdominal aortic aneurysm repair, limb salvage,Medical Degree: Southern Illinois University robotic-assisted surgery and general surgeryInternship/Residency: General Surgery at Medical Degree: University of Texas Southwestern Medical Degree: University of Kentucky CollegeUniversity of Utah Medical School, Dallas of Medicine, LexingtonVascular Surgery Fellowship: Southern Internship/Residency: General Surgery at Internship/Residency: General and VascularIllinois University University of Texas Southwestern Medical Center Surgery at University of Texas Southwestern Medical and Parkland Memorial Hospital Center, Dallas (UTSW)Board Certification: General Surgery,Vascular Surgery Board Certification: General Surgery Vascular Surgery Fellowship: UTSWHonors/Awards: Alpha Omega Alpha Honor Society Office: Medford Board Certification: General Surgery, Vascular Surgeryin medical school Honors/Awards: Graduation with high distinction,Research: Subinvestigator in PIVOTAL small University of Kentucky College of Medicine, Lexington;aneurysm study, Endologix large neck aneurysm active member of the American College of Surgerystudy, and CREST carotid stent studies and the Society of Vascular Surgery.Office: Medford Dr. Plummer was an assistant professor in the Division of Vascular and Endovascular Surgery, training fellows and residents in advanced vascular techniques at UTSW. Research: Numerous clinical research projects at UTSW Office: Medford 61
  • Physician Biographies Physician Biographies Oregon Surgical Specialists, PC David L. Street, MD, FACS David K. Traul, MD, FACS Vascular, General, and Bariatric Surgery Vascular, General, and Bariatric Surgery Specialties: Vascular, endovascular, bariatric, and Specialties: Vascular, endovascular, bariatric, and general surgery, including laparoscopic surgery general surgery, including laparoscopic surgery; certified in da Vinci robotic-assisted surgery Oregon Surgical Specialists, PC, staff Medical Degree: University of California, Davis Internship/Residency: General Surgery at Medical Degree: Medical College of Wisconsin University of California, Davis Internship/Residency: General Surgery at Vascular Surgery Fellowship: University of Rochester Medical College of Wisconsin School of Medicine and Dentistry Vascular Surgery Fellowship: Cleveland Clinic Board Certification: General Surgery, Board Certification: General Surgery, Vascular Surgery Vascular Surgery Honors/Awards: Graduation with distinction, Honors/Awards: Best Junior Surgical Resident Point Loma College Research: Primary investigator in PIVOTAL Research: Primary investigator in Endologix small aneurysm study and subinvestigator in large neck aneurysm study and CAPTURE II CHOICE, CAPTURE I and II, and CREST carotid stent study; subinvestigator in PIVOTAL carotid stent studies small aneurysm study and CREST carotid stent study; Office: Medford and subinvestigator in CHOICE, CAPTURE I and II, and CREST carotid stent studies Office: Medford Asante Cardiovascular and Thoracic Surgery staff 62
  • Heart and Vascular Outcomes 2012Contact InformationAsante Rogue Regional Medical Center . . . . . . . . . . . . . . . . . . . . . . . . . (541) 789-7000 Asante Rogue Regional Medical Center Cardiovascular LabTransfer Admit Center (Admissions Hotline) . . . . . . . . . . . . . . . . . . . . . . . . . (541) 789-BEDS (2337) at the Cardiovascular Institute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 282-6660 Toll-free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (855) 789-BEDS (2337) 520 Medical Center Drive, Suite 150 asante.org Medford, OR 97504 2825 East Barnett Road Fax: (541) 282-6661 Medford, OR 97504 Southern Oregon Cardiology, LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 282-6606Cardiac Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 789-4466 Jon R. Brower, MD, FACC Toll-free: (800) 283-0423Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 789-7132 Kent W. Dauterman, MD, FACC, FSCAI socardiology.comEmergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 789-7100 Brian W. Gross, MD, FACC TDD Hearing-Impaired Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 789-7104 Mark M. Huth, MD, PhD, FACC Medford OfficeImaging Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 789-4322 Todd S. Kotler, MD, FACC 520 Medical Center Drive, Suite 200Lifeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 789-4440 Kenneth M. Lightheart, MD, FACC Medford, OR 97504Nurse Supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 951-0097 David J. Martin, MD, FACC Phone: (541) 282-6606 Mark G. Moran, MD, FACC, FSCAI Fax: (541) 282-6601Asante Three Rivers Medical Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 472-7000 Brian J. Morrison, MD, FACC 500 SW Ramsey Avenue Bruce Patterson, MD, FACC Grants Pass Office Grants Pass, OR 97527 Eric A. Pena, MD, FACC 520 SW Ramsey Avenue, Suite 101 Bradley E. Personius, MD, FACC Grants Pass, OR 97527Asante Cardiovascular and Thoracic Surgery . . . . . . . . . . . . . . . (541) 789-5710 Stephen J. Schnugg, MD, FACC Phone: (541) 472-7800Charles Carmeci, MD, FACS asante.org Fax: (541) 472-7801David L. Folsom, MD, FACS 520 Center Drive, Suite 201Roger V. Hall, MD, FACS Medford, OR 97504George R. Wilkinson, MD, FACS Fax: (541) 789-5711Oregon Surgical Specialists, PC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (541) 282-6680Juan M. Castillo, MD, FACS oregonsurgical.comMark A. Eaton, MD, FACS 520 Medical Center Drive, Suite 300William E. Faught, MD, FACS Medford, OR 97504Nancy O’Neal, MD, FACS Fax: (541) 282-6681Mitchell M. Plummer, MD surgery@oregonsurgical.comDavid L. Street, MD, FACSDavid K. Traul, MD, FACS Southern Oregon Cardiology, LLC, staff 63
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