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  1. 1. C O N G E N I T A L C A R D I O L O G Y T O D A Y Timely News and Information for BC/BE Congenital/Structural Cardiologists and Surgeons Intraoperative “Hybrid” Stent Volume 7 / Issue 2 February 2009 North American Edition Delivery Under Direct Vision Using IN THIS ISSUE Endoscopic Guidance Intraoperative “Hybrid” Stent Delivery Under Direct Vision By Ralf J. Holzer, MD MSc; Matt Sisk, RCIS; Using Endoscopic Guidance “...intraoperative ‘Hybrid’ stent Alistair Phillips, MD by Ralf J. Holzer, MD MSc; Matt Sisk, RCIS; Alistair Phillips, MD delivery using direct ~Page 1 visualization and endoscopic Case Report Camp Odayin Allows Children guidance is a fairly simple, with Heart Defects to Have a A 19-year-old female patient was evaluated “Normal” Summer Camp for surgical pulmonary valve replacement. quick, and effective procedure Experience She was born with Tetralogy of Fallot and to allow accurate stent by Brandon Lane Phillips, MD underwent complete repair at about one ~Page 8 year of age, which included patch closure of placement to treat proximal a ventricular septal defect (VSD), as well as pulmonary arterial lesions placement of a transannular right ventricular DEPARTMENTS outflow tract (RVOT) patch. She did not re- in patients who require quire any further surgical or transcatheter interventions and remained cardiovascularly cardiopulmonary bypass Medical News, Products and Information asymptomatic at NYHA class I. However, on surgery for pulmonary valve ~Page 9 echocardiography and serial MRI assess- ments she developed increasing right ventri- or conduit replacement. Close cle (RV) size and reduction in RV function cooperation between surgical because of significant pulmonary insuffi- ciency (PI). and interventional team is essential to facilitate a CONGENITAL CARDIOLOGY TODAY An EKG documented right bundle branch block with a QRS duration of 124ms. MRI successful outcome.” Editorial and Subscription Offices revealed RVEDVi of 103ml/m2 and RVESVi 16 Cove Rd, Ste. 200 of 48ml/m2. The RV ejection fraction (RVEF) Westerly, RI 02891 USA www.CongenitalCardiologyToday.com was 53% (compared to 57% 2 years prior) 2.4m/s). An exercise test revealed VO2 max and the pulmonary regurgitant fraction was of 22ml/kg/min. There were no ischemic © 2009 by Congenital Cardiology 52%. The MRI also documented a stenosis at changes during the exercise test. Today ISSN: 1544-7787 (print); the LPA origin, measuring at its narrowest 1544-0499 (online). Published monthly. All rights reserved. 14mm. A 24-hour Holter recording did not She subsequently underwent combined tran- document any evidence of atrial or ventricular scatheter and EP evaluation in preparation of Statements or opinions expressed in arrhythmias. Based on echocardiography, RV pulmonary valve replacement. This demon- Congenital Cardiology Today reflect pressures were estimated to be normal (TR the views of the authors and spon- strated normal RV pressures (25/9mmHg) sors, and are not necessarily the views of Congenital Cardiology Today. RECRUITMENT ADVERTISING IN RECRUITMENT ADVERTISING FOR Workshop IPC & ISHAC Europe, Asia, Middle East, Australia CONGENITAL CARDIOLOGY TODAY March 22-25, 2009 - • Pediatric Cardiologists Milano Convention Center • Imaging Specialists Milan, Italy • Congenital/Structural • Electrophysiologists www.WorkshopIPC.com Cardiologists • Congenital/Structural Heart • Interventionalists Failure Specialists • Echocardiographers • Cardiac Intensivists Recruitment Ads: 5, 6, 9, 10 For more information and pricing: TCarlsonmd@gmail.com www.CongenitalCardiologyToday.com
  2. 2. Do you or your colleagues have interesting research results, observations, human interest stories, reports of meetings, etc. that you would like to share with the congenital cardiology community? Submit a brief summary of your proposed article to RichardK@CCT.bz The final manuscript may be between 400-4,000 words, contain pictures, graphs, charts and tables. CONGENITAL CARDIOLOGY TODAY www. CongenitalCardiologyToday.com www.CongenitalCardiologyToday.com
  3. 3. CONGENITAL CARDIOLOGY TODAY 3 February 2009 SECTION ON CARDIOLOGY & CARDIAC SURGERY CALL FOR APPLICATIONS 2009-2010 Research Fellowship Award The grant will provide research support for ad- vanced training to a prom- Figure 1. RV angiogram documenting a ising young investigator large dilated right ventricle. The right who has demonstrated pulmonary artery appears to be aptitude for basic science unobstructed while the left pulmonary or clinical science re- artery is not adequately profiled on this search during their pediat- projection. ric cardiology fellowship. Trainees in an accredited U.S. pediatric cardiology or cardiovascular surgical training program are eligible. In making its selection, a special committee will review submitted materials for scientific merit, clarity of presentation, likelihood of Figure 3. Endoscopic evaluation of the productivity by the investigator, and evidence LPA intraoperatively. The top image shows of appropriate academic environment by the the pulmonary artery bifurcation. Of note sponsor. The recipient will receive a grant-in- is the ridge/fold at the LPA origin which is aid of $35,000 and will be invited to present further depicted in the bottom picture (ar- this work at the American Academy of Pediat- rows). rics National Conference and Exhibition in San Francisco in 2010. dimension being 24.8mm, and the LPA at the hilum being 19.7mm. The findings SUBMISSION DEADLINE: FEB. 15, 2009 were discussed with the cardiac surgical team and it was felt that the lesion would For more information or to obtain a copy of be best treated intraoperatively, possibly the application forms, visit: through patch augmentation, but more www.aap.org/sections/cardiology/RFA Figure 2. LPA angiography in LAO-cranial announcements.htm likely through intraoperative stent projection, documenting a kink of the placement. proximal left pulmonary artery. Or write/ call to: The patient was subsequently taken to AAP Section on Cardiology & Cardiac Surgery with a small 4mmHg peak systolic gradi- the operating room and intraoperative 141 Northwest Point Boulevard ent to the LPA. There was no residual L- inspection confirmed a kink of the Elk Grove Village, IL 60007 R shunt. Angiographic evaluation docu- proximal LPA (Figure 3). It was decided lcolegrove@aap.org mented severe pulmonary insufficiency, to proceed with intraoperative stent (800) 433-9016 ext. 7820 a large dilated RV (Figure 1), as well as placement. A Stryker endoscope The Research Fellowship Award is made possi- a fold in the proximal LPA (Figure 2). (Stryker, Kalamazoo, MI) was utilized to ble by an educational grant from the Helen and The LPA at its narrowest at the origin inspect the LPA proximal and distal to the Will Webster Foundation. measured 11.8mm, with the poststenotic kink, as well as to assess the distance to www.CongenitalCardiologyToday.com
  4. 4. February 2009 4 CONGENITAL CARDIOLOGY TODAY Figure 4. Endoscopic evaluation of the left pulmonary artery, documenting the lobar branching. the origin of the left upper lobe branch (Figure 4). Under endoscopic guidance, a standard .035’’ guidewire was placed in the left lower lobe branch pulmonary artery. A Need to Recruit a 26mm Max LD stent was mounted on a 22mm*3cm BiB balloon catheter (NuMED, Pediatric Hopkinton, USA), and the assembly ad- vanced over the guidewire across the Cardiologist? stenotic lesion. Using continuous visualiza- tion with endoscopic guidance, the inner Advertise in Congenital Cardiology balloon was inflated and the stent position Today, the only monthly newsletter adjusted. This was followed by inflation of dedicated to pediatric and congenital the outer balloon. The balloon was deflated cardiologists. and removed and subsequent endoscopic evaluation documented excellent stent Reach the most Board Certified or position with complete relief of the obstruc- Board Eligible pediatric cardiologists tion, and sufficient distance to any lobar throughout the U.S. and Canada. branch pulmonary arteries. Finally, the edges of the stent were ‘crimped’ manually Recruitment advertising includes full to allow a ‘smooth’ entrance into the LPA color in either the North American and avoid any luminal protrusion of stent print edition or the electronic PDF meshwork (Figure 5). International edition. Following intraoperative stent placement, a Available in 1/3 and 1/2 page vertical 21mm bovine pericardial valve was im- Recruitment ad sizes. We can even planted. The patient was separated from create the ad for you at no extra Figure 5. After stent deployment, cardiopulmonary bypass without difficulty charge! endoscopic evaluation documents sufficient and extubated in the operating room. She distance of the stent from lobar branching was discharged home five days following For more information contact: of the LPA (top image). The LPA appears the procedure. to be wide open and the middle images Tony Carlson, Founder shows the stent being ‘crimped’ over the Discussion CONGENITAL CARDIOLOGY crest between LPA and RPA. The bottom TODAY image shows the LPA origin from a Intraoperative ‘Hybrid’ stent delivery is an Tel: +1.301.279.2005 distance, with the vessel being widely important treatment alternative to TCarslonmd@gmail.com patent (note the difference from the transcatheter stent therapy and surgical pre-procedural images). www.CongenitalCardiologyToday.com
  5. 5. CONGENITAL CARDIOLOGY TODAY 5 February 2009 PEDIATRIC CARDIOLOGIST Tucson, Arizona Due to expansion we are seeking a third BC/BE Pediatric Cardiologist to join our Tucson practice. Our practice is part of a 17-member group with offices in the Phoenix and Tucson metropolitan areas. For the Tucson practice we are recruiting a generalist with experience in echocardiography, including trans- esophageal and fetal echo. And, it would be helpful but not essential if one is able to do simple diagnostic catheterizations. In the spring of 2009 we will be moving into a new state-of-art office located a half mile from the main hospital. In addition to our main office, we also see patients in several satellite offices. Figure 6. Advantages and disadvantages of intraoperative ‘Hybrid’ We cover two main private hospitals and one stent delivery under direct visualization and endoscopic guidance, university hospital. when compared to a transcatheter approach. The Phoenix and Tucson practices are both engaged in clinical research and cover teaching rotations for patch angioplasty. Techniques and equipment available to perform residents and medical students. Receive a competitive intraoperative stent placement have expanded considerably [1-4]. income and outstanding benefits including health, life While surgical patch augmentation has distinct advantages to treat and disability insurances, paid malpractice insurance very calcified proximal stenotic lesions, it is less suited to deal with and CME allowance. kinked vessels or external obstructions. The choice between intraop- Tucson has more than 27,000 acres of parks, nearly erative and transcatheter stent placement has to be made individually 40 golf courses and, in addition to boating and fishing, for each specific patient, and is often dependent on operator prefer- is only 35 miles from snow skiing. With the feel of a ence. However, there are very distinct advantages and disadvantages small town, but all the amenities of a major city, of “Hybrid” stent therapy when compared to transcatheter therapy, Tucson is the number one resort destination in the which should guide any individualized approach (Figure 6). Southwest. Intraoperative stent placement can be performed using either direct Arizona Pediatric Cardiology Consultants is an affiliate visualization with endoscopic guidance, which is the preferred treat- of Obstetrix Medical Group, Inc. ment in patients who require cardiopulmonary bypass to address associated lesions, or in the beating heart using intraoperative angio- graphic guidance and direct stent delivery through a sheath inserted For information, please contact into the main pulmonary artery. We recently published a study of 20 Lori Abolafia, Physician Relations Specialist patients who underwent “Hybrid” stent delivery in the pulmonary cir- lori_abolafia@pediatrix.com culation [5], where direct visualization with endoscopic guidance was used in 75% of patients during stent delivery. Pediatrix Medical Group 1301 Concord Terrace In most patients, the decision to perform intraoperative stent deliv- Sunrise, FL 33323 ery does not eliminate the need for a pre-procedural angiographic evaluation. Cardiac catheterization not only provides important he- 800-243-3839 ext. 5209 modynamic information, but also gives accurately calibrated measure- www.obstetrix.com/apcc ments as well as possible landmarks that can be used for stent delivery. www.CongenitalCardiologyToday.com
  6. 6. CONGENITAL CARDIOLOGY TODAY 7 February 2009 arterial branch. It is important to avoid the 2. Zartner P, Cesnjevar R, Singer H, temptation to deploy the stent without a Weyand M. First successful implanta- Matt Sisk, RCIS wire, as the position of the distal end can- tion of a biodegradable metal stent The Heart Center not be reliably assessed during balloon into the left pulmonary artery of a Nationwide Children's Hospital inflation. The tip of the balloon can easily preterm baby.[see comment]. Cathe- 700 Children's Drive slip into a smaller side branch. This may terization & Cardiovascular Interven- Columbus, OH, USA result not only in jailing of other branches, tions 2005;66:590-4. but also potentially lead to vascular injury, if 3. Ing FF. Delivery of stents to target stent and/or balloon are inflated within a lesions: techniques of intraoperative Alistair Phillips, MD small vessel. stent implantation and intraoperative The Heart Center angiograms. [Review] [11 refs]. Pedi- Nationwide Children's Hospital Stents deployed under direct vision can atric Cardiology 2005;26:260-6. Department of Surgery, Ohio State even be shortened manually if the stenotic 4. Bokenkamp R, Blom NA, De Wolf D, University School of Medicine lesion is very short [3], an approach not Francois K, Ottenkamp J, Hazekamp Columbus, OH, USA recommended for transcatheter stent de- MG. Intraoperative stenting of pulmo- livery. Furthermore, after stent deploy- nary arteries. European Journal of LIVE CASES AT THE UPCOMING: ment, the stent edges can be folded/ Cardio-Thoracic Surgery WorkshopIPC & ISHAC crimped by the surgeon (Figure 5), which 2005;27:544-7. March 22-25 - Milan, Italy avoids any luminal protrusion of stent 5. Holzer RJ, Chisolm JL, Hill SL et al. meshwork. This can be a significant bene- "Hybrid" stent delivery in the pulmo- This Case Report article Illustrates a good fit if the stent has to be entered in the fu- nary circulation. Journal of Invasive example of the type of ‘live’ case that Drs. ture using a transcatheter approach. Stent Cardiology 2008;592-8. Ralf Holzer and Alistair Phillips will be per- delivery under direct vision in the operat- 6. Mitropoulos FA, Laks H, Kapadia N et forming at the joint meeting of Workshop ing room is more forgiving vis a vis techni- al. Intraoperative pulmonary artery IPC & ISHAC (International Symposium on cal problems such as balloon rupture or stenting: an alternative technique for the Hybrid Approach to Congenital Heart stent migration, and a suboptimally de- the management of pulmonary artery Disease) in Milan, Italy, this March 22-25, ployed or not fully expanded stent can stenosis. Annals of Thoracic Surgery 2009. usually be removed without great difficulty. 1342;84:1338-41. Even though intraoperative stent place- There will be a total of 23 live cases per- ment can be readily assessed using en- CCT formed by well-known physicians from all doscopy, a completion angiogram prior to over the world at the joint meeting this coming off cardiopulmonary bypass, may year. For more information about attending be helpful to further evaluate the result of Corresponding Author WorkshopIPC & ISHAC visit: intraoperative stent placement. www.WorkshopIPC.com In conclusion, intraoperative ‘Hybrid’ stent You may also watch selected live cases, delivery using direct visualization and en- hosted by Congenital Cardiology Today, doscopic guidance is a fairly simple, quick, from the 2007 and 2008 ISHAC meetings. and effective procedure to allow accurate These include: stent placement to treat proximal pulmo- • NCH Hybrid Catheterization/OR Suites nary arterial lesions in patients who re- • Pulmonary Artery Flow Restrictors quire cardiopulmonary bypass surgery for • Transcatheter Valve pulmonary valve or conduit replacement. • Intra-operative PA Stent Close cooperation between surgical and Ralf J. Holzer, MD, MSc • Perventricular Muscular VSD Device interventional teams is essential to facili- Assistant Director, Cardiac Closure tate a successful outcome. Catheterization & Interventional Therapy • Closure of Septal Defect Using Real Assistant Professor of Pediatrics Time 3D Echo Guidance References Cardiology Division • High Frequency Ultrasound Creation of The Ohio State University ASD 1. Mitropoulos FA, Laks H, Kapadia N et The Heart Center • And more... al. Intraoperative pulmonary artery Nationwide Children's Hospital stenting: an alternative technique for 700 Children's Drive In addition, there are live cases from past the management of pulmonary artery Columbus, OH 43205, USA PICS-AICS and WorkshopIPC meetings. stenosis. Annals of Thoracic Surgery Tel: 614 722-2537; Fax: 614 722-5030 To view these lives cases online, visit: 1342;84:1338-41. ralf.holzer@nationwidechildrens.org www.CHDVideo.com www.CongenitalCardiologyToday.com
  7. 7. February 2009 8 CONGENITAL CARDIOLOGY TODAY Camp Odayin Allows Children with Heart Defects to Have a “Normal” Summer Camp Experience By Brandon Lane Phillips, MD Camp Odayin provides overnight, day and family camps. A typical day at residential camp starts with a Polar Bear swim and is followed by warm up stretches at the flag pole. It’s then off to grab a quick breakfast before the day’s adventures begin. Throughout the morning, campers and staff participate in activities such as: arts and crafts, canoeing, horseback riding, rope challenge course, and archery to name just a few. In the afternoon, all campers partici- pate in waterfront activities. Swimming, lei- surely boat rides, and water skiing are some of the offerings. Each evening meal is fol- lowed by a surprise activity ranging from making s’mores and singing crazy songs by a camp fire to watching your new friends sing (or share whatever special skill they feel they possess) during the talent show. The day is concluded with sharing stories in the cabin before bedtime. Camp Odayin is much like your typical summer camp in a lot of ways, except it is sion of camp. Camp Odayin’s low cost to different in one very important way --- all of families makes it possible for most children the campers have a heart defect. Children who are medically eligible for camp to attend. with cardiac conditions are sometimes ex- cluded from summer camps due to their I am not just a physician, but I am a physi- medical needs. Camp Odayin was specifi- cian who has a congenital heart defect, so I cally created eight years ago to allow chil- know first hand the isolation a child with a dren with heart defects to have a “normal” heart defect can feel. It has always been my summer camp experience while ensuring desire to help my patients with the psycho- their medical needs are met. This past logical aspects of having a medical condi- summer I spent a week with 75 teenage tion. Many of the campers cried when their campers as one of Camp Odayin’s volun- week at camp came to an end. It is obvious teer cardiologists. I was privileged to work that Camp Odayin is a place where they feel with a wonderful team of volunteer counsel- loved and accepted. Since returning from ors and nurses whose main goal was to give camp, I have begun to tell my patients about these kids a week they would never forget. Camp Odayin --- it is another tool I can use to help my patients grow into normal, Many children with chronic medical prob- healthy adults. lems feel isolated --- they think they are the only one with their medical condition. It was To learn more about Camp Odayin, visit interesting watching the campers compare www.campodayin.org or call scars and share experiences. They have a 1.866.9.ODAYIN (1.866.962.2946). very unique bond from the start. It did not take long for them to find old friends or make CCT new ones. Some children with congenital heart defects find it easier to sit on the side- that impressed me most is how these kids lines of life. They choose not to participate encourage each other. The self-confidence in many activities because they have a fear these campers learn at Camp Odayin will of not being able to run as hard or perform serve them well throughout life. Brandon Lane Phillips, MD as well as their peers who do not have car- Instructor-in-Pediatrics, College of diac conditions. Many campers are willing Camp Odayin only requires a $25 registra- Medicine to try activities that they typically would not tion fee of a family to send a child to camp. Fellow, Division of Pediatric Cardiology while at camp. They feel comfortable trying All other expenses of camp are covered by Mayo Clinic activities such as canoeing, horseback rid- donations and fundraisers throughout the ing, archery, or water skiing for the first time year. I have volunteered at other camps for Phillips.Brandon@mayo.edu because they are surrounded by others who children with cardiac defects. Some of them understand their fears. One of the things charge as much as $1,500 for a single ses- www.CongenitalCardiologyToday.com
  8. 8. CONGENITAL CARDIOLOGY TODAY 9 February 2009 Medical News, Product MEDICAL GROUP and Information Epocrates Survey Identifies Trends in Online Resource Use PEDIATRIC Among Physicians A new survey released this November reveals physicians are access- CARDIOLOGISTS ing online clinical resources more than ever, and 75% prefer to obtain information from professional websites rather than through Internet searches. Epocrates, Inc., developer of mobile and online decision PHOENIX: the Perfect Blend of Lifestyle and Work support resources, conducted this nationwide survey to evaluate the impact online resources have on patient communication and care. Known as “the Valley of the Sun,” Phoenix offers numerous cultural, recreational and sporting events along with a strong, vibrant economy. More than 500 physician respondents confirmed that online re- Live in a family-oriented community with excellent school districts and sources help improve patient safety, provide patients up-to-date in- unlimited activities for children. Hike in nearby mountains or play in the formation and even save patients money, which is crucial in this eco- surf along the California coast. Advance your career as part of our nomic climate. The survey found that through online resources, such 17-member group, providing the full spectrum of congenital cardiac as Epocrates Online (www.epocrates.com/online/?CID=PROnline), services in one of the fastest growing metropolitan cities in the nation. physicians are: Arizona Pediatric Cardiology Consultants is seeking three BE/BC Pediatric • Making technology a part of the consultation – Today’s doctors are using technology to check drug dosing, side effects, interactions or Cardiologists to join our rapidly expanding practice in Phoenix: treatment guidelines during patient visits. Nearly 50% of physicians • Generalist: Provide outpatient services in one of our community-based report they most frequently use the Internet during patient consulta- offices; strong interpersonal and clinical skills required. tions, rather than between patient visits or after hours. • Director of Echocardiography: Experience required in all aspects of • Enhancing patient visits – Nearly 90% of physicians strongly agreed or agreed that accessing clinical information online im- echocardiography; must have leadership and research capabilities. proves patient satisfaction and communication. Specifically, physi- • Transplant/Heart Failure Specialist: Pilot a program with the transplant cians reported the use of an online resource helped: surgeons at Phoenix Children’s Hospital and the Mayo Clinic. • increase medication compliance Our practice is recognized as the primary pediatric cardiology group at • decrease pharmacy callbacks Phoenix Children’s Hospital. We provide all inpatient cardiology care, • patients appear more at ease including transthoracic and transesophageal echocardiography, catheter • some patients disclose information physicians would have not interventions, electrophysiology/RFA and MRI procedures. Our group is otherwise known truly unique, providing our practitioners with cutting-edge technology and • Saving money with generics – 70% of physicians have prescribed a academic affiliation in a private practice setting. lower cost or generic medication for a patient in the last month using the drug pricing or coverage features available on Epocrates Online. As one of our clinicians you will also enjoy: Furthermore, one-in-five physicians report saving their patients ■ 401(k) ■ CME allowance money 10 or more times in the four-week period. ■ Professional liability insurance ■ Competitive salaries ■ Comprehensive health/life benefits ■ Relocation assistance Technology is becoming more prevalent in clinical practices, with ■ Clinical research opportunities ■ Stock purchase plan 97% of survey respondents reporting computer access at their prac- tice or institution, and more than 50% working at a wireless facility. For more information regarding this Approximately 75% of physicians report going online more today opportunity, please contact: than a year ago. More than 70% go online for clinical information at least once a day, of which nearly 20% report using web-based re- Lori Abolafia sources five or more times per day. 800.243.3839, extension 5209 Email: lori_abolafia@pediatrix.com Fax: 800.765.9859 www.azkidsheart.com Quintet of Proteins Forms New, Early-Warning Blood Test Arizona Pediatric Cardiology Consultants CARDIOLOGY SPECIALISTS Before Heart Attack Strikes is an affiliate of Pediatrix Cardiology Specialists ™ Newswise — A team of Johns Hopkins biochemists has identified a An Equal Opportunity Employer mixed bag of five key proteins out of thousands secreted into blood www.CongenitalCardiologyToday.com
  9. 9. February 2009 10 CONGENITAL CARDIOLOGY TODAY draining from the heart’s blood vessels that may together or in certain quantities form the basis of a far more accurate early warning test than currently in use of impending heart attack in people with severely reduced blood flow, or ischemia. MEDICAL GROUP The work, involving more than a dozen scientists and taking more PEDIATRIC than a year to perform, is believed to be the largest protein analy- sis ever done at Hopkins. It was based on 76 arterial blood sam- ples from 19 men and women taken immediately before and after CARDIOLOGISTMEDICAL GROUP a period of medically induced ischemia lasting as long as 45 min- utes. Fairfax, Virginia All had ischemia induced through accelerated pacing of the heart’s main chambers. Blood samples were provided by cardi- MEDICAL GROUP ologists at the University of Texas Southwestern. Exciting opportunity available for a BC/BE Pediatric Cardiologist to join a team dedicated to providing quality Key to the researchers’ selection criteria of which proteins to ana- pediatric cardiology care in the Northern Virginia, lyze from among tens of thousands in the blood was what they Maryland, and Washington, D.C. areas. At Child Cardiology call “a pipeline approach.” Associates, we specialize in the care of the fetus, infant, “From the start, we knew that we were looking for rare, almost child and adolescent with congenital and acquired heart unique biomarkers that bore some direct relationship with disease. Many adult patients with congenital heart disease ischemia,” says study senior investigator Jennifer Van Eyk, PhD, choose to continue under our care, where we combine the whose first step was to remove from the analysis common blood roles of diagnostician, teacher, counselor, and consultant. proteins, such as albumin and globulins. That left batches of 400 We maintain admitting privileges in pediatric cardiology at proteins for in-depth measure of any changes before and after Inova Fairfax Hospital for Children, and we are available for ischemia. consultation at all area hospitals, as well as in more than Their analysis, which was presented at the American Heart Asso- 15 satellite locations. Fairfax is located in Northern Virginia ciation’s (AHA) annual Scientific Sessions in New Orleans, found on the outskirts of Washington, D.C. – only a short drive that only the five proteins were present in significantly increased from the Nation’s Capital with its monuments, museums, amounts after ischemia occurred, with at least a doubling in the The John F. Kennedy Center for Performing Arts, plus a blood concentration, compared with those recorded during healthy wide variety of cultural, professional sports and entertain- blood flow. These were lumican, semenogelin, angiogenin, extra- ment opportunities. cellular matrix protein, and so-called long palate, lung and nasal epithelium carcinoma-associated protein 1. Child Cardiology Associates is an affiliate of Pediatrix Medical Group, Inc. Pediatrix offers competitive salaries All of the proteins are believed to originate in the heart, but they and an excellent benefits package including health, disabil- can also be found in other tissues varying from the corneas of the ity, and liability insurances; employee stock purchase eyes (lumican) to semen. Semenogelin, as it is known, has never before been seen in the heart, while others, such as angiogenin, program; 401(k); and CME. are more predictably found in growing blood vessels and muscle tissue, and are actively involved in tissue repair. Little is known For additional information, please contact about the remaining two, which, ironically, have the longest Ron Grattan, Physician Relations Specialist names: extracellular matrix protein, secreted in a rare inflamma- ron_grattan@pediatrix.com tory disease; and long palate, lung and nasal epithelium Pediatrix Medical Group carcinoma-associated protein 1, thought to play a role in innate 1301 Concord Terrace, Sunrise, FL 33323 immunity. 800.243.3839, ext. 5635 The Johns Hopkins biochemists say the presence of all or even a selected set of these proteins in a simple, rapid blood test could Child Cardiology Associates aid emergency paramedics and physicians during the critical 12- 8318 Arlington Boulevard, Suite 250, Fairfax, VA 22031 to 24-hour window before ischemia causes substantial heart tis- sue damage or death from heart attack. www.childcardiology.com www.pediatrix.com www.CongenitalCardiologyToday.com
  10. 10. February 2009 11 . CONGENITAL CARDIOLOGY TODAY . © 2009 by Congenital Cardiology Today (ISSN 1554-7787-print; ISSN 1554-0499- A positive reading on a blood test incor- tack, provide results “too late to take pre- online). Published monthly. All rights re- porating these proteins, they add, could ventive action,” and “after some damage served. provide first responders with advance has already occurred.” Troponin lab tests warning to take urgent action, such as also depend on the heart muscle dying Headquarters using blood thinners like aspirin to pre- first, which can take hours to detect, “So a 9008 Copenhaver Dr. Ste. M vent clotting, or performing cardiac cathe- negative reading is unreliable and can still Potomac, MD 20854 USA terization to check for any more block- mean that an ischemic problem is about to ages in the blood vessels feeding the happen or has already happened,” she Publishing Management heart, which may in turn prompt more says. Tony Carlson, Founder & Editor aggressive treatment. Further actions TCarlsonmd@mac.com could involve angioplasty, in which a bal- In the study, the protein analysis was con- Richard Koulbanis, Publisher & Editor-in-Chief loon device is threaded into the heart’s ducted by mass spectrometry machines RichardK@CCT.bz surrounding blood vessels and then ex- that can measure the presence of proteins John W. Moore, MD, MPH, Medical Editor/ panded to widen the arteries, or even in minute amounts. The machines, oper- Editorial Board surgery. ated six days a week for six months, con- JMoore@RCHSD.org sumed more than 3,700 hours of spectro- Editorial Board “Our results lay the foundation for a first- metric analysis. Teiji Akagi, MD of-a-kind, early-warning system that could Zohair Al Halees, MD save tens of thousands of people on the Researchers next plan to verify the pres- Mazeni Alwi, MD brink of a heart attack,” says Van Eyk, a ence of the five proteins in a larger study Felix Berger, MD professor at the Johns Hopkins University with at least 150 participants, and more Fadi Bitar, MD School of Medicine and its Heart and than 1,000 blood samples. Simultaneously, Jacek Bialkowski, MD Vascular Institute. “People experiencing they plan further analysis of the proteins to Philipp Bonhoeffer, MD chest pain too often come to the emer- map their molecular structures, so that an Mario Carminati, MD gency room, with subsequent electrocar- antibody can be identified to bind to one or Anthony C. Chang, MD, MBA diogram, also called EKG, readings not several of the proteins, laying the basis for John P. Cheatham, MD showing any evidence that a heart attack a blood test for ischemia. And they will Bharat Dalvi, MD, MBBS, DM has occurred, but still leaving open the conduct tests to verify that their study find- Horacio Faella, MD question of whether or not a heart attack ings also apply to ischemia in stroke. Yun-Ching Fu, MD is imminent and about to happen or has Felipe Heusser, MD already happened,” adds Van Eyk, Direc- Funding support for this study was pro- Ziyad M. Hijazi, MD, MPH tor of the Johns Hopkins NHLBI Pro- vided by Inverness. The technology devel- Ralf Holzer, MD teomics Group and the Proteomics Center opment in the study and the “pipeline ap- Marshall Jacobs, MD at Johns Hopkins Bayview Medical Center, proach” were supported by the Johns R. Krishna Kumar, MD, DM, MBBS where the protein analysis took place. Hopkins Bayview Proteomics Center. The Gerald Ross Marx, MD Johns Hopkins NHLBI Proteomics Group Tarek S. Momenah, MBBS, DCH Van Eyk says people frequently have is one of 10 centers funded as part of the Toshio Nakanishi, MD, PhD symptoms of chest pain, shortness of US, seven-year program dedicated to the Carlos A. C. Pedra, MD breath and dizziness, with pale or clammy study of proteomics and understanding the Daniel Penny, MD skin coloring, while arterial blood is con- functions of proteins in the development of James C. Perry, MD stricted but not yet closed. But this myriad cells, tissues and organisms, in both nor- P. Syamasundar Rao, MD of complaints can just as easily be mis- mal and disease processes. Van Eyk has Shakeel A. Qureshi, MD taken for the more everyday, less-serious a patent pending on the protein analysis. Andrew Redington, MD problems of heartburn, stomach cramps or Under an option agreement with The Carlos E. Ruiz, MD, PhD gas. In 2006, the US Centers for Disease Johns Hopkins University, Inverness Medi- Girish S. Shirali, MD Control and Prevention reported more cal Innovations’ Unipath Ltd., in Bedford, Horst Sievert, MD than 12,000 visits to doctors’ offices and United Kingdom, has the right to negotiate Hideshi Tomita, MD emergency rooms by people complaining a license to the patent. Gil Wernovsky, MD of chest pain. Zhuoming Xu, MD, PhD Other Johns Hopkins researchers who William C. L. Yip, MD A new test based on these five proteins, took part in this study were Qin Fu, PhD; Carlos Zabal, MD says Van Eyk, could provide a “more de- Simon Sheng, MSc; Steven Elliott, MSc; finitive answer” to the question “how seri- and Miroslava Stastna, PhD. Additional FREE Subscription ous is it?” much earlier than existing as- support was provided by James de Congenital Cardiology Today is available says for heart attack, such as tests for Lemos, MD, at the University of Texas free to qualified professionals worldwide in troponin proteins I and T. Southwestern. pediatric and congenital cardiology. Interna- tional editions available in electronic PDF file only; North American edition available in Van Eyk says commercially available tests For more information: print. Send an email to Subs@CCT.bz. for cardiac troponin, which is released into www.proteomics.jhu.edu/index.php?id=248 Include your name, title, organization, ad- the blood in telltale patterns for heart at- dress, phone and email. Do you or your colleagues have interesting research results, observations, Contacts and Other Information human interest stories, reports of meetings, etc. that you would like to share For detailed information on author submis- with the congenital cardiology community? sion, sponsorships, editorial, production and sales contact, current and back issues, see Submit a brief summary of your proposed article to Congenital Cardiology Today at: website or send an email to: I N F O @ C C T. b z . RichardK@CCT.bz www.CongenitalCardiologyToday.com