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  • 1. Inside This Issue The Young Low LDL & Normal Indications Remote Moni- Genetic Cause of Helping Blood Pressure for Ventricular toring in Heart Deadly Irregular Heart the Old? p3 Slows Arterial Plaque Assist Devices Failure p16 Beat Discovered p17 Growth p4 Expanded p6 Cardiac Consult Heart and Vascular News from Cleveland Clinic | Summer 2009 | Vol. XVIV No. 2 Featured Article Minimally Invasive Cardiac Surgery Comes of Age - p8Flashback:
  • 2. Dear Colleagues, Cardiac Consult offers updates on state- of-the-art diagnostic and management techniques from Cleveland Clinic heartMinimally invasive surgery is no longer exotic. Thirteen years ago, Delos M. and vascular specialists. Please directCosgrove, MD, performed the first minimally invasive aortic valve surgery. correspondence to: Medical EditorsIn 2008, we performed 462 minimally invasive aortic and mitral valve Christopher Bajzer, MDprocedures, with 0 percent hospital mortality. Cleveland Clinic surgeons A. Marc Gillinov, MD Sean Lyden, MDnow consider a minimally invasive option first for nearly every patient. 216.448.1026 bajzerc@ccf.org gillinm@ccf.orgThis issue of Cardiac Consult offers a brisk review of Cleveland Clinic’s minimally lydens@ccf.org Managing Editorinvasive thoracic and cardiovascular surgery program. You’ll find mention of the Ann Bungohighly successful valve procedures, along with our robotic surgery program, Marketing Manager Megan Frankelvideo-assisted lobectomies, and new percutaneous techniques. Art Director Michael ViarsMedical technology is racing to keep ahead of demand for minimally invasive Photographers Tom Mercealternatives. The appeal is obvious: less pain, fewer complications, shorter hospital Steve Travarca Don Gerdastays. Minimally invasive cardiac surgery is bound to be a hot topic at the big Russell LeeThe Treatment of Cardiovascular Disease: Legacy & Innovation symposium, beingheld here in June. We invite you to join us for this one-time “state of the heart” clevelandclinic.org/heart offers informa- tion on new procedures and services, clini-global overview of the very latest in cardiac surgery, vascular surgery, cardio- cal trials, and upcoming CME symposia, as well as recent issues of Cardiac Consult.vascular medicine, and their related disciplines. The Sydell and Arnold Miller Family Heart & Vascular Institute, ranked No. 1 in the nation for cardiac care by U.S.NewsThe other articles in this issue of Cardiac Consult reflect the breadth and variety & World Report every year since 1995, accommodates nearly 300,000 patientof our field: new views on ventricular assist devices, lung transplant donation, visits each year in world-class facilities.remote monitoring in heart failure and more. Staff are committed to researching and applying state-of-the-art diagnostic and management techniques. Cleveland Clinic is a not-for-profit, multispecialty academicWe continue to be inspired by the way new technologies advance medicine medical center.and transform lives. As minimally invasive techniques become commonplace, Cardiac Consult is written for physicians and should be relied upon for medicalyou’ll find us at the frontier of the next big advance, whatever it may be. education purposes only. It does not provide a complete overview of the topics covered, and should not replace the inde- pendent judgment of a physician about the appropriateness or risks of a procedureSincerely, for a given patient.Christopher Bajzer, MD Sean Lyden, MD © The Cleveland Clinic Foundation 2009Associate Director, Peripheral Intervention Staff Surgeon,Interventional Cardiology Vascular SurgeryA. Marc Gillinov, MDThe Judith Dion Pyle Chair in Heart Valve ResearchThoracic and Cardiovascular SurgeryPage 2 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
  • 3. The Young Helping the Old? Can younger or newer stem cells give a regenerative boost to donors could help older patients who are recovering from heart Marc Penn, MD, PhD attacks or aortic stenosis. Marc Penn, MD, PhD, Cleveland Clinic Stem Cell Biology and Regenera- tive Medicine and Department of Cardiovascular Medicine, investigates how hearts damaged by heart attacks attract adult stem cells by sending out “homing” signals. Stem cells found in the bone marrow respond to this signal and migrate to the damaged area to become new heart tissue cells. Dr. Penn’s research has expanded to also focus on how aging might affect the homing process and the stem cells’ ability to specialize, or differenti- Dr. Penn induced aortic stenosis in mice. Stem cells from the bone marrow of an older generation of the mice were transplanted into younger mice with the condition. The younger mice didn’t respond well and the condition worsened. However, stem cells from the younger mice’s bone marrow were trans- planted into the older generation — with noticeable improvement to the older mice’s cardiac health. “It would appear that stem cells may tire out over time. There’s evidence that aging does play a role on stem cell function. Now we’re trying to determine if it’s the heart not sending out the message to stem cells, or the stem cells not responding to the signal,” Dr. Penn says. “The heart needs to grow new vessels to nourish the new cells. But if the stem cells aren’t getting to the heart, the heart dilates and the patient develops heart failure in response to aortic stenosis. “We hope that by deciphering the signaling process we will be able to develop new therapies for patients with aortic stenosis and weak hearts.” To coordinate the range of stem cell and regenerative medicine research projects focused on cardiovascular diseases, Dr. Penn organized the Center for Cardiovascular Cell Therapy. The center currently has six clinical trials involving laboratories at Lerner Research Institute and Cleveland Clinic, as well as being a founding partner in the National Institutes of Health’s Cardiovascular Cell Therapy Research Network. Additionally, Dr. Penn directs the Skirball Laboratory for Cardiovascular Cellular Therapeutics and is Director of Cleveland Clinic’s Earl and Doris Bakken Heart-Brain Institute. “The new center and our role in the NIH’s consortium are working to actually bring what we’re learning about cardiovascular cell therapies to patients,” he says.Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 3
  • 4. Cleveland Clinic Researchers: Low LDL and NormalBlood Pressure Slows Arterial Plaque GrowthLow levels of LDL cholesterol coupled with normal blood pressure cansignificantly slow the progression of coronary artery disease, accordingto a study by Cleveland Clinic researchers.The study, which was published in the March 31 issue of the Journal of theAmerican College of Cardiology, is the first to show that aggressive treatment tolower both cholesterol and blood pressure can slow plaque build-up in patientswith a history of coronary artery disease.“The take-home message here is that heart disease is caused by many factors and it’s likely that aggressive management of just one risk factor alone is not the answer,” said Cleveland Clinic cardiologist Stephen J. Nicholls, MD, PhD, a co-author of the paper. “In this study, we looked at aggres- sively controlling multiple risk factors to see if it would have an impact. And it did.”The study examined 3,437 patients with coronary artery disease,using intravascular ultrasound (IVUS) to track the formation ofplaque in their arteries. The researchers found that very lowlevels of LDL (70 mg/dl or less), in combination with normalsystolic blood pressure (120 or less), significantly slowedarterial plaque formation.“What this study shows is that when it comes to blood pressure and cholesterol ‘good’ control isn’t enough,” said lead author Adnan K. Chhatriwalla, MD, an intervention- al cardiology fellow at Cleveland Clinic. “Optimal con- trol should be the goal of treatment because it is shown to have a greater effect on slowing the progression of atherosclerotic plaque.”The authors suggest that a randomized controlledtrial to directly test the clinical benefit of aggres-sively treating multiple risk factors wouldprovide further support for this concept.Researchers from Cleveland Clinic’s depart-ments of Cardiovascular Medicine, CellBiology, and Radiology participated in thestudy, along with the Cleveland ClinicCenter for Cardiovascular Diagnosticsand Prevention.Page 4 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
  • 5. Case Study: Cervical Carotid Aneurysm Presentation Sunita Srivastava, MD Vascular Surgery artery aneurysm found on an incidental CT scan of her sinuses for deviated septum and upper respiratory tract infections. She denies any recent or past trauma and has no history of peripheral aneurysms. Examination and Diagnosis CT scans of the aortic arch to the Circle of Willis and cerebral angiography were performed, resulting in the following images (See Fig 1 and 2.) Due to the proximal extent of the internal carotid artery aneurysm in the neck, an ENT consult also was obtained for potential mandibular manipulation to allow access to the vessels. Treatment The patient underwent resection of the aneurysm with end-to-end anastomosis due to redundancy of the vessels and their large caliber. Surgical pathology was consistent with atherosclerotic aneurysm. Discussion Figure (1) Cervical carotid aneurysms are rare and represent less than 1 percent of all carotid pathologies treated surgically. In the past, mycotic aneurysms were more prevalent and now atherosclerotic aneurysms are more commonly diagnosed. Patients can present with symptoms such as dysphagia, neck swelling, hoarseness and less commonly with bleeding or rupture. The prognosis with nonoperative management is poor with the seqeulae Figure (2) of neurologic symptoms such as stroke or TIA with either embolization of aneurysm contents or thrombosis of the aneurysm. aneurysms with carotid ligation in London in 1808 and the patient did well. Today, standard surgical therapy consists of aneurysmorraphy with patch or interposition bypass with an autologous conduit. This patient had a very redundant internal carotid, so primary resection with end-to-end repair was possible. Results with open surgery are superior to nonoperative similarly low. Endovascular options also are available, but have not been evaluated for long- term durability and success. Contact Dr. Sunita Srivastava at 216.445.6939 or srivass@ccf.org. REFERENCES (4) McCollum CH, Wheeler WG, Noon GP , (8) May J, White GH, Waugh R, Brennan J. (11) Radak D, Davidovic L, Vukobratov V, Il- DeBakey ME. Aneurysms of the Extracranial Endoluminal repair of internal carotid artery lijevski N, Kostic D, Maksimovic S. Carotid Artery (1) Painter T, Hertzer N, Beven E, O’Hara P Ex- . carotid artery. Twenty one years’ experience. aneurysm: a feasible but hazardous procedure. Aneurysms: Serbian Multicentric Study. Ann Vasc tracranial carotid aneurysms: report of six cases and Am Jour Surg 2005; 196-200. Jour Vasc Surg. 1997;26:1055-60. Surg 2007;21(1):23-9. review of the literature. J Vasc Surg 1985;2:312-8. (5) Davidovic L, Dusan K, Maksimovic Z, (9) Szopinski P Ciostek P Kielar P Myrcha P , , , , (12) Attigah N, Kulkens S, Hansmann J, Ringleb (2) Moreau P Albot B, Thevenet A. Surgical , Markovic D, Dragan VM, Duvnjak S. Carotid artery Pleban E, Noszczyk W. A series of 15 patients with P Hakimi M, Eckstein H, et al. Sugical Therapy of , treatment of extracranial internal carotid artery aneurysms. Vascular 2004;12:166-70. extracranial carotid artery aneurysms:Surgical and Extracranial Carotid Artery Aneurysms:Long term aneurysms. Ann Vasc Surg 1994;8:404-16. Endovascular treatment. Eur Jour Endovasc Surg results over a 24 year period. Eur Jour Endovasc (6) Kaupp H HSJMBJTO. Aneurysms of the ex- 2005;29:256-61. Surg 2008;37:127-33. (3) Knight GC, Hallman GL, Reul GJ, Ott DA, tracranial carotid artery. Surgery 1972;72:946-52. Cooley DA. Surgical Management of Extracranial (10) Miksic K, Flis V, Kosir G, Pavlovic M, Carotid Artery Aneurysms:Report of 17 Cases. (7) Zwolak R, Whitehouse WJ, Knake J, Bernfeld Tetickovic E. Fusiform and saccular extracra- Texas Heart Inst J 1988;15:91-7. B, Zelenock G, Cronenwett J. Atherosclerotic nial carotid artery aneurysms. Cardiovasc extracranial carotid artery aneurysms. Jour Vasc Surg 1997;5(2):190-5. Surg 1984;1:415-22.Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 5
  • 6. Indications for VADs Expanded Cleveland Clinic has one of the oldest and largest ventricular assist device (VAD) programs in the United States. In the 1970s, Cleveland Clinic surgeons pioneered and technology have given newer models a wider application. Of the record 49 VADs implanted at Cleveland Clinic in 2008, nine were used as destination therapy, nine as a bridge to decision and 31 as a bridge to transplantation. “Most individuals with medically refractory heart failure may potentially qualify for VAD therapy,”Gonzalo Gonzalez-Stawinski, MD says Cleveland Clinic heart transplant surgeon Gonzalo Gonzalez-Stawinski, MD. Building a better VAD Early VADs were large and cumbersome. Ongoing innovations in technology eventually produced smaller, more powerful devices. By 2000, VADs were more successful than medical therapy for patients with end-stage heart failure, but morbidity remained high. Subsequent advances in design and biocompatibility have resulted in improved safety. “The newer pumps are sturdier, longer-lasting and less prone to infection. We had become good at predicting complications associated with VADs and were having fewer failures. There have been few complications.” Two years ago, changes in Northern Ohio’s organ allocation system reduced the number of donor organs available in the region. Simultaneously, the number of baby boomers with advanced heart failure exploded. Circumstances were ideal for testing a new generation of VADs, and with 30 years’ experience, Cleveland Clinic was poised to meet the need. “The newer pumps are sturdier, longer-lasting and less prone to infection. We had become good at predicting complications associated with VADs and were having fewer failures. There have been few complications,” says Dr. Gonzalez. With a low overall mortality rate of 9.7 percent for VAD patients, Cleveland Clinic was approved by the Centers for Medicare and Medicaid Services and Food and Drug Administration (FDA) to offer this life-saving therapy as a treatment for heart failure. VADs remain a valuable resource for patients awaiting transplantation. Yet a newer, larger group of beneficiaries are patients with heart failure who are deterred by the potential complications of lifetime immunosuppression, but desire a better quality of life. Cleveland Clinic also utilizes VADs as a bridge to medical decision in selected patents, primarily those with acute processes that stun the heart, such as myocarditis. In these patients, a VAD may support the heart during recovery and enable appropriate treatment to be initiated later.Page 6 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
  • 7. More patients with medically refractory heart failure now qualify for VAD therapy A design for every need Cleveland Clinic is one of few institutions worldwide with access to multiple FDA- approved VADs from a variety of leading manufacturers. “This allows us to choose the device that will best suit each patient’s clinical needs,” says Dr. Gonzalez. VADs with pulsatile turbines readily adjust to the body’s metabolic demands, enabling the patient to participate in physical activity. Such VADs are designed to provide circulatory support for one to three years, depending on the model. Second-generation VADs are non-pulsatile, continuous flow pumps. These small, powerful machines are totally implantable. Biocompatible design and materials reduce thromboembolism and require minimum anticoagula- tion. Cleveland Clinic now uses Thoratec’s HeartMate II as bridge to transplantation, and is using the device in a clinical trial of destination therapy in patients who are not considered candidates for transplantation. Although a series of HeartMate II devices built prior to June 2006 was recalled in December 2008 due to cracks in the driveline, Cleveland Clinic never en- countered one of the faulty devices, says Dr. Gonzalez. Thoratec has since changed the design and eliminated the problem that led to the recall. Miniaturized third-generation VADs have a single mov- ing part, are highly biocompatible and are resistant to wear and corrosion, making them ideal for per- manent use. Cleveland Clinic is studying several HeartWare (Thoratec) models with extended- life batteries. These models may be recharged using a household current. The surgeons also are studying the total artificial heart (TAH) as a bridge to transplantation. The safety arm of this study has been completed, and they are now evaluating a portable power source that would enable patients with the device to leave the hospital. For more information To discuss the potential for VAD therapy in a patient with advanced heart failure, please call 877.8-HEART-1 (877.843.2781).Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 7
  • 8. Cardiac Surgery Comes of AgeA new chapter has beenopened in the history ofcardiac surgery. Minimallyinvasive surgery is nowthe standard treatment foran increasing number ofcardiovascular procedures.As techniques improve,more and more minimallyinvasive procedures are ableto duplicate the outcomes ofconventional surgery, withfewer complications, andmore rapid recovery time.Page 8 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
  • 9. T he goal of minimally invasive surgery (MIS) is to complete the surgical task with the minimum of insult to the patient’s body. MIS techniques are usually accomplished without sternotomy, and may not involve stoppage of the heart, or extracorporeal circulation. Smaller incisions offer less opportunity for post-surgical wound infection, and speed recovery times. They are the clear preference of most patients. Surgeons in the Department of Thoracic and Cardiovas- cular Surgery at Cleveland Clinic have been pioneers in evaluating and adopting minimally invasive surgical techniques. Delos M. Cosgrove, MD, performed the international broadcast from Cleveland Clinic in 1996. Cleveland Clinic cardiovascular surgeons, cardiologists and cardiovascular imaging specialists work as a team to prepare for and execute an increasing variety of minimally invasive techniques. This special section of Cardiac Consult offers an overview of Cleveland Clinic’s minimally invasive interventions. We invite you to refer patients for evaluation for minimally invasive cardiac surgery at Cleveland Clinic by calling 216.444.3500 or 877.8HEART1.Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 9
  • 10. Mitral Valve Replacement and RepairMitral valve repair is the most frequentlyperformed minimally invasive cardiacsurgery. A. Marc Gillinov, MD, andTomislav Mihaljevic, MD, who share agreat deal of experience in all minimallyinvasive cardiac procedures (includingrobotically assisted), indicate that itis possible to both repair and replacevalves minimally invasively. However,they believe that long-term outcomesare superior with repair, and recommendrepairs in most cases. More minimallyinvasive mitral valve repairs have beenperformed at Cleveland Clinic than atany other medical center.Robotically assisted mitral valve repairis the least invasive approach to mitralvalve repair. Robotically assisted pro-cedures are performed endoscopically,through small ports (rather than formal Using special instruments, the surgeon Robotically Assisted Mitral Valve Surgeryincisions) in the right side of the chest. Robotically assisted mitral valve surgery and place an annuloplasty ring, just as is a type of minimally invasive surgeryA Minimally Invasive Approach in conventional surgery. A partial upper in which the surgeon uses a specially-Minimally invasive mitral valve repair sternotomy includes a 2- to 3-inch skin designed computer console to controlcan be performed through a 2 to 4-inch incision and division of the upper portion surgical instruments on thin robotic arms.incision, either a right mini-thoracotomy of the sternum, as opposed to the 8- to The robotic arms are introduced throughor partial upper sternotomy. The surgical 10-inch incision of a full sternotomy. The 1- to 2-cm incisions in the right side of theapproach or technique for each patient partial upper sternotomy offers the sur- chest. The surgeon’s hands control theis based on age, condition, co-morbidi- geon an excellent view of the mitral valve movement and placement of the endo-ties and anatomical considerations. and may be an appropriate approach for scopic instruments to open the pericar-The right mini-thoracotomy is performed patients who require combined mitral dium and to perform the procedure.with a 2- to 3-inch skin incision created in valve and aortic valve procedures. Robotically assisted mitral valve surgerya skin fold on the right chest, providing an These minimally invasive approaches provides the surgeon with an undistort-excellent cosmetic result. The heart is ap- also can be used when mitral valve ed, three-dimensional view of the mitralproached between the ribs, providing the repair is combined with ablation forsurgeon access to the mitral valve. There with the use of a special camera. Thisis no sternal incision or spreading of the has been instrumental in developing approach enables surgeons to performribs required for this surgical technique. complex repairs without the need forPage 10 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
  • 11. Joseph F. Sabik, MD, Chairman of Thoracic and Cardiovascular Surgery is now performing a “mini” coronary artery bypass through 3- to 4-inch incisions. The traditional method, by comparison, requires a patient’s sternum to be split. “The mini-procedure offers less pain and a hospital stay that’s shorter by about two days,” says Dr. Sabik. In addition, the surgery is most often done without a blood transfusion. As with the traditional CABG, the mini- procedure uses a healthy artery or vein from the patient’s chest, leg or arm to bypass the clogged artery. Decisions are made on a case-by-case basis, weighing a patient’s size, coronary artery quality and the number of grafts needed. “Many people can take advantage division of the sternum or spreading of built robotic surgical suite, this can be of this new procedure,” Dr. Sabik says. the ribs, in most cases. accomplished in less than two minutes. “For an average person who needs two or three grafts, we can perform the mini- At the current stage, all patients who have Cleveland Clinic has excellent results CABG procedure instead.” leaky mitral valves and or tricuspid valves with minimally invasive mitral valve can be evaluated as a potential patient surgery. In 2008, 53 percent of all Percutaneous Procedures for minimally invasive robotic surgery. It isolated mitral valve procedures done Some cardiac procedures that are usually is even an option for selected patients at Cleveland Clinic were performed done through full exposure or minimally who have already had conventional heart robotically, with 0 percent mortality. invasively, can now also be performed surgery – even after previously failed at- percutaneously. Some of these techniques Coronary Artery Bypass Graft Surgery tempts at repairing the mitral valve. are experimental. Others are part of every- The traditional coronary artery bypass day clinical practice. For instance, many Robotic surgery requires specially trained graft (CABG) surgery, which was pio- patients currently receive percutaneous surgeons and a specially trained operat- neered at Cleveland Clinic in 1967, is valvotomy for stenosis of the mitral, aortic ing room team. In the rare event that the performed every day at academic medical or pulmonic valve. In this procedure, ex- robotic approach needs to be switched centers and community hospitals alike. plains interventional cardiologist Samir K. to conventional surgery (fewer than 2 But recently, surgeons have been success- Kapadia, MD, a balloon-tipped catheter is percent of all cases) the team needs to fully performing this operation through inserted into the femoral artery and guided be able to make that switch quickly and a smaller incision and – in some cases – to the site of the valve. The balloon is without the use of a heart-lung machine.Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 11
  • 12. The mitral valve itself is untouched inleaving nothing but a valve that is more balloon is withdrawn. Cleveland Clinic another experimental percutaneous treat- is participating in a U.S. Food and Drug ment for mitral valve regurgitation. In Administration study to determine the this novel approach, a small metal bar is“There are a lot of patients, especially old- feasibility of this treatment. guided by catheter into the coronary sinus to a position just alongside the annulusopen heart surgery for various reasons,” “What surprised many of us in the surgical of the mitral valve, and left there. Thesays surgeon Lars Svensson, MD, PhD, profession is that this has worked out very slight rigidity of the bar exerts pressure onof Thoracic and Cardiovascular Surgery. well,” says Dr. Svensson. “Obviously there the dilated annulus, pushing it and its at-“We’ve been able to develop techniques are higher risks than a routine open heartthat we can approach these valves with- operation, but it is an option for older orout having to open the patient’s chest.” high-risk patients.” Cleveland Clinic surgeons and cardiologistsOther percutaneous valve procedures Another experimental technique is beingare still in the experimental stage. tested at Cleveland Clinic for the treatment percutaneous valve placement to remedy of mitral valve regurgitation. A very small, the impact of tricuspid regurgitation onto study percutaneous aortic valve specially made metal clip device is deliv- the body using a special device developedreplacement using a new compressed- ered via catheter to the mitral valve. The at Cleveland Clinic. This may eventuallytissue heart valve. The valve is placed provide a means of treating valve diseaseon a balloon-mounted catheter and center of the valve, allowing the blood to caused by radiation treatments to thepositioned directly over the diseased chest, which sometimes render the patientaortic valve. “When we know we are clip is adjusted until optimal improvement unsuitable for open surgery.in the right position, we get the heartto race faster so it’s not pumping as valve are observed. When the catheter is In considering all these techniques, itmuch,” says Dr. Svensson. “Then we in- should be kept in mind that mortality in position, which limits the leakage. for conventional valve replacement andPage 12 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
  • 13. “Minimally invasive lung surgery is clearly beneficial to patients for almost all thoracic diseases that require surgery. However, few surgeons are trained in these techniques and only a minority of thoracic surgery procedures are performed minimally invasively around the country.” - Dr. David Mason the thoracic surgeon cuts and removes the artery bypass. Prior to that, the saphen- tumor and other affected tissue. If an early- ous vein was the preferred conduit for stage cancer tumor is being removed, the this procedure. Today, the saphenous lymph nodes in the mid-chest area also vein continues to be used where the may be removed or biopsied to ensure that internal thoracic artery is inappropriate the cancer has not spread. or unusable, and for bypass procedures in the legs for peripheral artery disease. “Small lung cancers and lung cancers The radial artery in the arm may also be that tend to be more toward the surface harvested and used as a conduit. of the lung are the best candidates for VATS however most lung cancers can be The saphenous vein and radial artery are removed by VATS, says David Mason, MD traditionally harvested through a long in- of the Department of Thoracic and Cardio- cision that is often uncomfortable for the vascular Surgery. “The CT scan should be patient. More and more, however, these able to identify the location of the tumor conduits are being harvested minimally and the likelihood of removal with VATS.” invasively, using an endoscope. Cleve- land Clinic surgeons have considerable The outcomes for VATS lobectomy are experience in performing endoscopic comparable to those for conventional saphenous vein harvesting and have surgery. Traditional thoracotomy may expanded its use for lower extremity be more appropriate for some patients bypass. To harvest the saphenous vein, with large tumors, involved lymph the surgeon makes a small incision in lower than the national averages (0.3 nodes, or prior chest surgery. VATS the groin and one or two 1-inch inci- techniques are also applied to other percent for primary isolated mitral valve sions in the leg, near the knee. Special repair in 2008). This means that experi- procedures, including wedge resection, instruments are slid down the inside leg, lung biopsy, drainage of pleural effu- mental minimally invasive alternatives alongside the vein. A miniature camera are most frequently recommended for sions, and mediastinal, pericardial and allows the surgeon to view the vein, thymus thoracoscopic procedures. patients who are too frail or elderly for and measure off the length that will be conventional surgery. “Minimally invasive lung surgery is clearly needed. That length is cut and the vein - is removed through the incision. Video-assisted Thorascopic Lobectomy racic diseases that require surgery,” says Patients with small, early stage, primary In 2005, Cleveland Clinic surgeons Dr. Mason. “However, few surgeons are expanded the minimally invasive trained in these techniques and only a lobectomy, which removes the tumor along approach to include harvesting of radial minority of thoracic surgery procedures are with the lobe of the lung were it resides. A arteries. In this procedure, the surgeon performed minimally invasively around the conventional lobectomy is performed dur- makes a small incision near the wrist country. At Cleveland Clinic, all thoracic ing a thoracotomy. Cleveland Clinic is now and one near the forearm. surgery patients are considered for mini- one of the few centers in the nation that “Applying endoscopic vein harvesting - in these techniques exists. In our experi- for lower extremity bypass is a bit more mally invasive alternative to this approach. ence, outcomes for cancer cure is identical challenging than for coronary bypass Video-assisted thoracoscopic surgery to more traumatic techniques and clearly for a variety of reasons,” says Cleveland lobectomy (VATS lobectomy) is performed this is not a compromise procedure.” Clinic vascular surgeon Vikram Kashyap, through three 1-inch incisions and one 3- to 4-inch incision in the chest. A Minimally Invasive Vein Harvesting reduced pain, morbidity and hospital thorascope and specially adapted surgical Cleveland Clinic cardiac surgeons length of stay can be accomplished for instruments are inserted into the incisions. established the superiority of the internal these patients.” Guided by the images from the thorascope, thoracic artery as a conduit for coronaryVisit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 13
  • 14. Research RoundupHighlights of Recent Heart and Vascular Research from Cleveland ClinicImportant Genetic Findings New Findings in Vascular SurgeryThere were two major genetic discoveries from Qing Wang, Cleveland Clinic Vascular Surgeon Vikram S. Kashyap, MD,PhD, Department of Molecular Cardiology and Director ofthe Center for Cardiovascular Genetics: -A year ago, researchers found that a cluster of genetic variants fectiveness of using the anticoagulant bivalirudin in patients undergoing lower extremity bypass. This small study suggestsartery disease (CAD) in white people in northern Europe andNorth America. People who have that genetic quirk are more anticoagulant in lower extremity bypass.susceptible to developing CAD or having a heart attack. Dr.Wang and his team have shown the same genetic material also Blockage of the large blood vessels in the pelvis (aorta andis associated with coronary artery diseases in the South Korean iliac arteries) can starve the lower extremities of blood and lead to the need for amputation. Traditionally, this condition is treated with major surgery: the grafting of a y-shaped syn- thetic tube to bypass the blockage. Less invasive alternativesidentify people at risk of arterial diseases or heart attacks. are available, but it has not been known for certain how well they compare to the bypass graft. Now, in a retrospective review of cases performed at Cleveland Clinic, Dr. Kashyap has shown that outcomes from percutaneous angioplasty andlead to new diagnostic tests and treatment options for cardiac stenting for this condition compare favorably to bypass graft-patients. Qing K. Wang, PhD found the new gene – NUP155 ing – a step forward for patients who hope to avoid major– by analyzing the genetics of a family with severe, early-onset surgery for pelvic blockages.tailored treatment strategies to prevent and/or treat the commonUsing Drugs to Facilitate PCI for Myocardial InfarctionThe results of an international clinical trial led by ClevelandClinic Cardiologist Stephen A. Ellis, MD, should have high im-pact on the treatment of patients presenting with heart attackscaused by blocked coronary arteries. Before the study, it wasgiven certain blood-thinning agents, either singularly or incombination, before being taken to a catheterization lab to getan angioplasty, or other percutaneous intervention (PCI). ButDr. Ellis’s study showed that administering the drugs beforemay actually cause harm by promoting bleeding.Page 14 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
  • 15. In the Spotlight Critical Care Transport Cleveland Clinic’s Critical Care Transport team is ready to respond 24/7 to just about any 9-1-1 call, anywhere in the world. Our transport team can start tertiary care during transfer to one of our many facilities, thus improving the outcomes for many serious and complex conditions. Staff Our team is made up of Cleveland Clinic physicians and pediatric intensivists, nurse practitioners, critical care nurses, paramedics and allied health professionals. Each medical team is customized to meet the needs of the patient and is ready at a moment’s notice for regular patient transfers, as well as transfers of highly acute patients with ST- elevation acute MI (STEMI) and acute aortic syndrome. Services Offered 24/7 Adult critical care transport by ground or air by a team experienced in critical care and/or emergency services and trained in transport environment care, 24/7 pediatric critical care transport by ground or air by a team specially trained in neonatal and pediatric intensive care, emergency and transport medicine and flight physiology. More Beds To make sure your patients get the specialized care he or she needs, we now have 24 dedicated Cardiovascular ICU beds with adjacent imaging and cath labs, and a cardiology fellow in attendance, 24/7. In addition, we have a dedicated heart failure ICU and two surgical ICUs (totaling more than 100 Cardiovascular ICU beds). Our Fleet Patients can be transferred to Cleveland Clinic by fully staffed Mobile Intensive Care Units. Our air transport capabilities include a Sikorsky S-76 A++ for our immediate 250-mile radius, and a Beechjet 400A and Hawker 800 for longer distances – both staffed and equipped as “flying ICUs.” For more information, visit clevelandclinic.org/cct. Instructions for Transport Have the following information ready Patient name NEW! Acute transfers (acute stroke, STEMI, ICH and acute Date of birth aortic syndrome conditons), call 877.379.CODE (2633). Cleveland Clinic medical record number Insurance information with no delay-causing dispatch protocols. Diagnosis and location of patient Routine transfers, call 216.444.8302 or 800.533.5056 Need for telemetry If the patient has invasive lines, assistive devices or drip; if the patient is hemodynamically stableVisit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 15
  • 16. Remote Monitoring in Heart Failurea new era of remote monitoring. These devices provide a steady stream of datathat can be remotely monitored to assess and manage patients with heart failure.For cardiologists, the immediate challenge is to access these data in a timely fashion “With the broad application of im- when downloaded at the time of remote device interrogation planted device therapies, we now as part of our heart failure disease management program.” have the unprecedented access There are some limitations as data from these remote devices to physiologic data,” says W. H. can be variable. “Some patients have big changes and some Wilson Tang, MD, a cardiologist patients have small changes,” says Dr. Tang. “Like any diagnos- and Research Director of the Sec- tic test, individual measurements need to be interpreted in tion of Heart Failure and Cardiac the context of the patient’s clinical status. We also don’t know Transplantation at the Sydell and how frequent we should monitor these data, nor do we have a Arnold Miller Family Heart & Vas-W.H. Wilson Tang, MD universally agreed upon strategy to approach these patients. If cular Institute at Cleveland Clinic. in doubt, we contact the patient to clarify or ask them to come“This data includes measurements that were originally devised and see us for follow-up.” The value of this approach has beento monitor device integrity. Now we can take advantage of them supported by the availability of CPT codes for this purpose.to provide insight into the clinical stability of patients with heart “For now, observing changes in device data can raise suspicionfailure, particularly in between their clinic visits.” regarding a patient’s clinical instability,” says Dr. Tang.Of particular interest is the ability of devices to measure The next step is to perform large studies to establish the safetychanges in impedance in the thoracic cavity. Impedance isthe body’s resistance against an electrical current. “Impedance Bruce Wilkoff, MD, Randall Starling, MD, MPH, and severalwas originally a self-check measurement to assess the status of members of the Center for Electrical Therapies of Heart Failure at the Miller Family Heart & Vascular Institute are activelyrecognized that impedance technology also can indirectly assess participating in the design and conduct of prospective clinicalcardiac hemodynamics. Physiological changes may correlate trials to determine the value of these measurements in differ-the thorax. This detectable change in impedance may occur of heart failure.weeks before the actual event of hospitalization. The hypothesisthat is currently being tested is whether this early warning can “We have the challenge of establishing what is the most ap-provide opportunities for early intervention, whether it is by propriate response to these diagnostics,” says Dr. Tang, who ischanging drugs or by intensifying counseling.” leading several of these studies. “Up until now, the treatment of heart failure has been reactive, based on a patient feelingSuch measurements have been widely available as part of worse. In this generation, we would like to be proactive, usingcomplementary data on some CRT-Ds and ICDs, but not for drugs, counseling, following up closely, and calling the patient.indications for treatment or alerts. “In fact, when we review The advent of broad implantation of these devices in this popu-such data in front of our patients, we can even go back and lation allows us to test usefulness of this data in a managementuncover unreported events,” says Dr. Tang. “It’s a powerful tool strategy. It’s a tremendous opportunity to advance the treat-if used appropriately. We have incorporated such information at ment of heart failure, perhaps way before patients demandedthe time of clinic visit, as well as systematically reviewed them the need for hospital admissions.”Page 16 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
  • 17. Genetic Cause of Deadly Irregular Heart Beat Discovered could lead to new diagnostic tests and treatment options for cardiac patients. Qing K. Wang, PhD, Cleveland Clinic Lerner Research Insti- Dr. Wang’s studies revealed that mutant NUP155 causes atrial tute’s Department of Molecular Cardiology and Director of the fibrillation by altering how RNAs are exported out of the nucle- Center for Cardiovascular Genetics, and his colleagues found us and how proteins are imported into the nucleus. Specifically, the mutation of the gene NUP155 by analyzing the genetics of NUP155 affects the gene/protein called Hsp70, a protein that a family with severe, early-onset AF and sudden cardiac death. can be induced by stress, exercise, surgery, heat shock, and decreased blood supply to heart tissues. AF is the most common rhythm disturbance of the heart found in the clinical setting. It affects 3 million people in the United Hsp70 plays a role in maintaining the proper balance of cardiac States alone. AF accounts for nearly 15 percent of all strokes and calcium and protecting the structure of heart tissue cells, both is also associated with worsening heart failure and increased of which are cellular processes important to the maintenance mortality. Despite significant advances in AF management, of heart rhythm. If the level of Hsp70 is low, the heart is not available treatment options remain far from optimal. protected from development of abnormal heart rhythms. “The new finding may provide a new molecular target to “Identifying a gene linked to AF could lead to new ways to develop patient-tailored treatment strategies to prevent and/or genetically screen people. For example, individuals in families treat the common form of atrial fibrillation,” says Dr. Wang. with a history of AF could be screened to see if they carry the mutated NUP155 gene and, therefore, have a greater likeli- Each cell in your body contains instructions encoded in your hood of developing AF,” Dr. Wang says. “It also explains a DNA that are parceled into 23 pairs of chromosomes. Approxi- molecular process or pathway that we might be able to control mately 39,000 genes, which are the instruction booklets con- with new therapies. These therapies could stop AF from devel- taining the DNA, are found dotted along all the chromosomes. oping in the first place, or treat it after it has been diagnosed.” Differences in people come from slight variations in these genes, which determine everything from hair and eye color to whether Dr. Wang’s research team included Xianqin Zhang, PhD, or not a person is more or less susceptible to certain diseases. Shenghan Chen, PhD, Shin Yoo, Susmita Chakrabarti, Teng Zhang, PhD, Tie Ke, Carlos Oberti, Sandro L. Yong, Fang The DNA in genes is translated or decoded into another ge- Fang, Lin Li, Lejin Wang, and Qiuyun Chen, all of Molecular netic material called RNA in the nucleus of a cell. Then, the Cardiology, and R. de la Fuente, PhD, Department of Cardiol- RNA is transported from the nucleus to the liquid inside the ogy, Ospedale Italiano Umberto I, in Uruguay. cell called cytosol by a special apparatus called the nuclear pore complex (NPC). In turn, RNA in the cytosol produces The research was published recently in Cell ( www.cell.com/ proteins that are the basic building blocks and workers of 2008; 135(6) pp. 1017-1027). This study was supported by each cell in the body. This conversion – DNA to RNA to the American Heart Association, the State of Ohio Wright Center protein – is a tightly regulated process. of Innovation grant and Biomedical Research and Technology Transfer Partnership Award (BRTT, Ohio’s Third Frontier Proj- NUP155 makes a protein that is a critical component of the ect), and the National Basic Research Program of China. NPC. The NPC acts as a gateway to control the exchange of ma- terials like RNA and proteins between the cell’s nucleus and the cytosol that surrounds the nucleus. This exchange of RNAs and proteins through a nucleus membrane is essential to numerous functions of the cell.Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 17
  • 18. First Implant of Heartware VentricularAssist System at Cleveland ClinicIn March 2009, Nicholas Smedira, MD, a cardiac surgeon with the CME Calendarof the Heartware® Ventricular Assist System, developed by HeartwareInternational, at Cleveland Clinic.Only a handful of the miniaturized circulatory assist devices have been implanted A Comprehensivein the United States to date. The HeartWare® Ventricular Assist System features the International SymposiumHVAD™ pump, the only full-output pump designed to be implanted next to the heart, The Treatment of Cardiovascularavoiding the abdominal surgery generally required to implant competing devices. Disease: Legacy & Innovation June 3-5HeartWare has completed an international clinical trial for the device involving five InterContinental Hotel &investigational centres in Europe and Australia. The device is currently the subject of Bank of America Conference Centera 150-patient clinical trial in the United States for a Bridge-to-Transplant indication. Cleveland, Ohio Diabetes and the Heart August 6-7 Intercontinental Hotel & Bank of America Conference Center Cleveland, Ohio A Primer in Vascular Disease September 25-26 InterContinental Hotel & Bank of America Conference Center Cleveland, Ohio Congenital Heart Disease in the Adult: The Second Annual Ronald and Helen Ross Symposium October 9 InterContinental Hotel & Bank of America Conference Center Cleveland, Ohio 2009 Heart-Brain Summit October 15-16 Sheraton Chicago Hotel & Towers Chicago For more information about the above events, call the Cleveland Clinic De- partment of Continuing Education at 216.444.5696 or 800.762.8173, or visit clevelandclinicmeded.com.Page 18 | Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056
  • 19. CLE VEL AND CLINIC ACCESS GUIDE Same-day Visits Now Available The Miller Family Heart & Vascular Institute has begun offering same-day appointments for new patients and follow-up visits. Patients who want or need to be seen immediately will be scheduled with a HVI Cardiovascular Medicine staff member. same-day visit, call 216.444.6697 or 800.659.7822. HVI Referrals Special Assistance To refer cardiology patients, please call 216.444.6697 or 800.553.5056. for Out-of-State Patients The Cleveland Clinic’s Medical Concierge program is To refer surgical patients, call 877.843.2781. a complimentary service for patients who travel to New patients, in most cases, can be seen by Cleveland Clinic from outside Ohio. Our patient care a cardiologist within one week of calling for an representatives facilitate and coordinate the schedul- appointment. Most patients requiring surgery also can be accommodated within one week. ing of multiple medical appointments; provide access to discounts on airline tickets and hotels, when avail- able; make reservations for hotel or housing accom- modations; and arrange leisure activities. For more information: call 800.223.2273, ext. 55580, visit clevelandclinic.org/services, or email medicalconcierge@ccf.org. DrConnect Make Your Next Report Electronic DrConnect is an Internet-based service developed to provide our community physician colleagues real-time electronic Web address (URL) gives you one-click access to all newly medical record information about the treatment their patients released patient-related information, which is presented in receive at Cleveland Clinic. easy-to-navigate “What’s New” screens for quick access and effective case and time management. After establishing a DrConnect account with a secure log-in Establishing your own DrConnect account is easy. 1) Log onto personnel to receive security rights, allowing DrConnect patient drconnect.clevelandclinic.org. 2) Click on the OnLine Signup updates to be immediately integrated into a busy medical button. 3) including choosing a secure password, and submit.Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 19
  • 20. The Cleveland Clinic Foundation9500 Euclid Avenue/AC311Cleveland, OH 44195CardiacConsult A Primer in Vascular Disease Save the Date September 25-26, 2009 InterContinental Hotel & Bank of America Conference Center Cleveland, Ohio www.ccfcme.org/Vascular09 This activity has been approved for AMA PRA Category 1 Credit™.