Download NON-SURGICAL APPROACH TO ATRIAL SEPTAL DEFECT

Qa
ask the experts
&
Aside from auscultation, what are
the best testing modalities for diagnosing valvular (mitral, aortic, etc.)
dysfunction?
The stethoscope is rapidly approaching
obsolescence. The gold standard for evaluating valvular dysfunction is cardiac ultrasound, which can be performed with a
transducer placed on the anterior chest
wall, or if more detailed information is necessary, can be placed on an endoscopic
tube so that clear unobstructed views of
the heart can be obtained.
Using these tests, you can not only see the
structures, but you can evaluate whether
any abnormalities of blood flow across the
valve are present.
Is CKMB (creatine kinase isoenzyme
MB) the best laboratory test for
diagnosing myocardial infarction?
A battery of tests, including CKMB, should
always be used to evaluate patients with
suspected MI. Myoglobin is an extremely
sensitive test and becomes positive very
rapidly, but it is very nonspecific. It may
raise your suspicions and affect your
immediate treatment of that patient. CKMB
is a highly reliable test but takes four-tosix hours to become positive. The third test
is the troponin test. Tropinin I is helpful,
and although it is late in elevating after
heart damage, it remains elevated for fourto-six days, whereas the other tests return
to baseline relatively quickly. Cardiac enzymes should always be done in sequence
so the clinician does not rely on one positive or negative set of tests. Rather, it is
best to make a diagnosis based on trends in
their rise and fall.
Lourdes
VOLUME 1 • NUMBER 1 • AUGUST 2006
Lourdes
64-Slice Scanner Eases
Detection of Heart Disease
Our Lady of Lourdes Medical Center has a
vital piece of new technology that allows cardiologists to detect heart and coronary artery
disease without invasive catheterizations.
Lourdes is the first hospital in the
Delaware Valley to install the Siemens 64slice Computed Tomography scanner, the
SOMATOM Sensation 64. The scanner captures three-dimensional images with sharpness and clarity previously only possible
through an invasive exam, at unbelievable
speed.
Consider that it takes the 64-slice scanner
only:
• 5 seconds (less than an easy breath to
hold) to search for pulmonary emboli;
• 5-8 seconds to evaluate plaque within
carotid arteries;
• 10 seconds for coronary artery imaging,
including distal segments and multiple arterial branches;
• 20 seconds to take images of the entire
chest;
• About 30 seconds to scan the whole
body, in search for a blood clot, for example,
that has become the source of emboli.
“This new scanner is as close to having Xray vision as you can get,” said Kathleen V.
lourdes wellness
center
Lourdes Wellness Center in Collingswood
offers ongoing programs in yoga, meditation,
exercise and stress reduction, as well as integrative family practice care, located in
Collingswood, NJ.
For more information,
call 856-869-3125.
CardiologyLog
The New Jersey Heart
Institute at Lourdes, one
of the largest providers of
inpatient cardiac services
in the entire Delaware
Greatrex, M.D., acting Chief of Radiology at
Lourdes. “In just seconds, we can get complete images of a patient’s heart, brain or
lungs. We are able to move those images
around for a 360-degree view of the organ,
blood vessel or tissue, and within a few minutes, we are able to diagnose heart disease
and cancer, without the need for surgery.”
Jan Weber, M.D., Chief of Cardiology at
Our Lady of Lourdes Medical Center and
Medical Director of the New Jersey Heart
Institute at Lourdes, said the effective use of
the 64-slice scanner is yet another example of
the rapidly growing collaboration between
the Cardiology and Radiology services.
“A CT scan is painless, fast and relatively
risk-free, and is a major breakthrough in our
battle against cardiac disease,” Dr. Weber
said.
To refer a patient to receive a 64-slice
scan, call 856-757-3829. To request a
brochure on the scanner — or a supply of
brochures to display in your office,
call 1-888-LOURDES.
PAID
at our lady of lourdes
medical center
1600 Haddon Avenue
Camden, NJ 08103
888-LOURDES (888-568-7337)
www.lourdesnet.org
Medical Editor: Jan Weber, M.D., F.A.C.C.
Marketing Director: Carol Lynn Daly
Writer/Editor: Josh Bernstein
CardiologyLog is intended to provide physicians with news and information that will
assist them in their everyday practice.
Please direct any comments or suggestions to
our Marketing Director at the above address
or to: [email protected].
nearly 100 cardiologists
and cardiovascular surgeons. From diagnostics
to treatment to rehabilitation, NJHI provides services for every stage of cardiac care, including
catheterization, angioplasty, open-heart surgery
as well as arrhythmia
diagnosis and treatment.
The cardiac catheterizaMemorial Hospital Cherry Hill is managed by
cardiologists from the
NJHI.
• For more information,
NON-PROFIT ORG
U.S. POSTAGE
1600 Haddon Avenue
Camden, NJ 08103
PERMIT #36
BELLMAR, NJ 08031
Non-Surgical Approach to
Atrial Septal Defect
Valley, is staffed with
tion lab at Kennedy
CardiologyLog
is published by
A PUBLICATION OF THE NEW JERSEY HEART INSTITUTE AT LOURDES
call the New Jersey
Heart Institute at
Lourdes at
856-365-4072.
• For physician referral,
call 1-888-LOURDES
(1-888-568-7337).
While the standard method for treating atrial
septal defect (ASD) has traditionally been openheart surgery, newer, minimally invasive approaches have emerged to change the entire outlook on
this condition.
This approach involves the combined use of
fluoroscopy and 3-D intravascular ultrasound to
visualize the defect. A catheter is then advanced
through the defect, and a flat semi-rigid occlusive
plate is deployed on each side of the ASD. The
plates are drawn together to create a synthetic wall
that permanently seals the defect.
ASDs, which are seen in 30-to-40 percent of all
adult congenital heart disease patients, can be
asymptomatic, but can cause complications such as
right-sided heart failure and heart rhythm abnormalities. Patients have a shortened life expectancy
and a greater risk of stroke. Previously, the only
options were open heart surgery or watchful waiting given the extreme risk of surgery.
According to Manoj Khandelwal, M.D., F.A.C.C.,
Lourdes Interventional Cardiologist and member of
Associated Cardiovascular Consultants, P.A., this
minimally invasive technique is less traumatic to
the patient, causes less pain and has fewer postoperative complications than the traditional surgical
approach. (See page three for a case study of a
Lourdes patient treated with transcatheter closure of
ASD.) Patients treated with this new approach are
generally in the hospital for about one day, which
is quite a dramatic change from the three-day stay
associated with the traditional surgical approach.
“We are also finding the surgery has had a surprisingly positive outcome for patients who previously had suffered from chronic headache," Dr.
Khandelwal noted. This is most likely a result of
substances entering the left side of the heart that in
the absence of the ASD would have been cleared by
the lungs.
Candidates for transcatheter closure of ASD
include those with echocardiographic evidence of
an ASD as well as clinical evidence of right ventric-
At Lourdes, interventional cardiologists are successfully
employing a minimally invasive approach to treat patients
who peviously would have required open heart surgery or
avoided treatment, given the risks.
ular volume overload. This procedure is also indicated in individuals who have previously undergone a
fenestrated fontan procedure but who subsequently
require closure of the fenestration. Contraindications include persons with bleeding disorders, lack
of sufficient tissue to secure the device and infection. Risks include arrhythmia, brachial plexus
injury, embolus, endocarditis and stroke.
Most patients can resume normal activities within one month, and should avoid strenuous activity
for at least that period.
For more information on this procedure, or to
refer a patient, contact Jan Platt at the New Jersey
Heart Institute: 856-365-4072.
case study
…CardiologyLog…
clinical
pearls
First do no harm.
Many types of complementary and
alternative forms of therapy, now being
studied by the National Institutes of
Health’s National Center of Complementary and Alternative Medicine
(NCCAM), demonstrate that there are a
number of therapies that patients find
helpful in easing stress and developing
more healthful lifestyles. A number of
clinical studies have looked into the use
of alternative therapy specifically for
heart disease. Two recent studies that
are of particular interest looked at CAM
and its effect on heart disease.
One study looked specifically at the
effects of long-term stress reduction in
individuals 55 and over with systemic
hypertension. Researchers reviewed all
cause- and cause-specific mortality for
202 participants who had high blood
pressure and who had participated in
two separate, randomized, controlled
trials that included transcendental meditation (TM) and other stress-reducing
behavioral interventions. Compared to
controls, the TM group showed a 23
percent decrease in all-cause mortality,
and a 30 percent decrease for cardiovascular mortality. The researchers concluded that a stress-reducing program used
as adjuvant therapy to improve hypertension may contribute to decreased
mortality in older subjects.
Source: Schneider RH, Alexander CN,
Staggers F, Rainforth M, Salerno JW, Hartz A,
Ardndt S, Barnes VA, Nidich SI. Long-term
effects of stress reduction on mortality in
persons > or = 55 years of age with systemic hypertension. Am J Cardio 2005 May
1,95(9):1060-4.
Complementary Therapies.
Canadian researchers reviewed the literature to provide a systematic evaluation
of complementary therapies, such as T’ai
Chi, exercise, and transcendental meditation, as a supplement to traditional
cardiac rehabilitation for low-to-moderate risk individuals. They concluded that
these therapies may be useful while
other forms of therapy, such as
acupuncture, require further evidence.
Source: Arthur HM, Patterson C, Stone JA.
The role of complementary and alternatiave
therapies in cardiac rehabilitation: a systematic evaluation. Eur J Cardiovasc Prev
Rehabil 2006 Feb: 13(1) 3-9.
Lourdes Approved for Carotid
Stenting
The New Jersey Heart Institute at Lourdes
(NJHI) is among a select number of hospitals
approved by the Centers for Medicare and
Medicaid Services (CMS) for coverage of
patients requiring treatment for the prevention
of stroke using carotid stenting. Since earning
approval, over 90 procedures have been performed. Outcomes have been excellent, with
success and safety records that are superior to
those predicted from prior studies.
Lourdes was among the first institutions to
participate in the carotid stent’s post-approval
CAPTURE trial and is currently participating in
the trial’s extension, CAPTURE II. In addition,
the NJHI at Lourdes just received IRB approval
to begin a carotid stenting protocol using a
device produced by another manufacturer.
“Additional device options will allow the program to grow dramatically,” explains NJHI
Director Jan Weber, M.D. In addition, Dr. Weber
notes that several additional interventional cardiologists are in the process of obtaining credentialing so that Lourdes may expand this
service further.
Carotid stenting can be can safely performed
in patients who would not be considered for
open repair because of prohibitively high risk
or because of other medical conditions.
Candidates for carotid stenting surgery include
individuals who have had:
update: coverage for
cardiac rehabilitation
The Centers for Medicare and Medicaid Services
(CMS) have expanded the diagnoses for which cardiac rehabilitation may be approved for coverage.
Lourdes’ Cardiac Rehabilitation program provides a
comprehensive monitored cardiac rehab for patients
who have had:
• Stent placement (new!)
• Valve repair (new!)
• Heart transplant (new!)
• Stable angina
• Post CABG
• Post MI
This expansion of coverage demonstrates that CMS
has now followed the lead of other commercial
insurers. It represents the realization that whether
the solution is surgical intervention or intervention
in the cath lab, all heart disease deserves risk factor
modification in a supportive, medically supervised
setting.
• Prior radiation treatment to the neck;
• A previous open surgical procedure with
scarring;
• A blockage that is hidden behind the
jaw bone making the area surgically inaccessible;
• Severe atherosclerotic disease that would
significantly increase the probability of a
potentially lethal complication if surgery were
chosen.
Generally, candidates for a carotid stent
undergo carotid Doppler ultrasound or cerebral
angiography to assess the degree of reduced
blood flow. Pre-procedure evaluations include
echocardiogram and a transesophageal ultrasound. Patients are usually seen in the cath lab
to ensure that there are no other defects that
would prohibit surgery.
For more information on this procedure, or
to refer a patient, contact Jan Platt at the New
Jersey Heart Institute: 856-365-4072.
Up Against the Wall?
Abdominal Aortic Stent Graphs
Lourdes cardiologists are employing
endovascular stent grafts for the treatment of
abdominal aortic aneurysm (AAA). This procedure, which is an alternative to open surgical
repair, results in less blood loss, less trauma
and a shortened hospital stay. For patients who
would not otherwise meet the criteria for standard surgery, this technique is an important
option.
“It is truly a blessing to be able to treat
patients with this life-threatening condition for
whom no options were available in the past
and achieve such excellent outcomes,” comments Lourdes Interventional Cardiologist
Ronald Cohen, D.O., who performs the AAA
endograph as a member of Cardiovascular
Associates of the Delaware Valley.
The new procedure involves the use of a
coiled metal spring covered with a goretex-like
cloth that is compressed flat and threaded
through a catheter to the site of the aneurysm.
When the stent is at the appropriate location,
the coil is allowed to open, like an umbrella,
forming a tight bond against the wall of the
aorta and cutting off the blood supply to the
aneurysm. When it assumes its fully opened
position against the vessel wall, it creates a
new channel. The weakened area clots and
turns to fibrin.
Abdominal aortic stent graphs are of benefit
Atrial Septal Defect
The patient is an 82-year-old woman
who for 20 years carried a diagnosis of
having a “hole in the heart.” She had a
complex medical history, including four
negative breast biopsies, cardiovascular
attacks (CVAs) five and 10 years previously, implantation of a VVI pacemaker,
emergent abdominal surgery after a
complication from a colonoscopy, paroxysmal atrial fibrillation, hiatal hernia,
diverticulitis and restless leg syndrome.
The patient stated that for five years,
she experienced shortness of breath
with exertion. For the last month, she
noted increased dyspnea with even minimal exertion. A trip to the bathroom
made her short of breath and required
rest for resolution. However, she denied
any paroxysmal nocturnal dyspnea
(PND), edema, orthopnea or chest pain.
In early April 2005, the patient was
admitted to a nearby facility for exacerbation of her shortness of breath.
Pulmonary evaluation revealed no significant lung disease. A CT scan showed
no evidence of interstitial lung disease,
and a ventilation-perfusion (VQ) scan
showed no evidence of a pulmonary
embolism.
A transthoracic echocardiogram
revealed normal left ventricular function, moderate-to-severe pulmonary
hypertension, right ventricular hypokinesis, mild aortic insufficiency, borderline prolapse of the mitral valve, and
diastolic dysfunction. An atrial septal
defect was noted. Transesophageal
echocardiogram was attempted but
aborted because of the development of
acute hypoxemia. The patient was able
to ambulate with oxygen saturation
above 80 percent. Home oxygen was
recommended. The RV ejection fraction
was 9 percent. The LV ejection fraction
was 57 percent. The patient was re-anticoagulated and discharged.
Upon further examination, Lourdes’
interventional cardiologist Manoj
Khandelwal, M.D., F.A.C.C., concluded
the patient’s symptoms were consistent
with atrial septal defect, with RV dilatation and a significant left-to-right
shunt. Dr. Khandelwal recommended
atrial septal defect closure utilizing a
percutaneous device.
Later that same month, the patient
underwent ASD closure via both
femoral veins at Our Lady of Lourdes
Medical Center in Camden.
No significant step-off was identified.
The right atrial pressure was 12 and
right ventricular pressure was 66/12.
The pulmonary artery pressure was
59/24 and the left atrial mean pressure
was 20.
The ASD was successfully closed
with an Amplatzer® Septal Occluder #20
mm device (AGA Medical Corporation).
The atrial septum had a “Swiss cheese”
appearance, and multiple defects were
identified, but apparently all defects
were sealed with the device. However,
there appeared to be a minimal residual
shunt at the inferior aspect. Literature
suggested that the majority of these
shunts would resolve over time with
subsequent endothelialization of the
device.
An echocardiogram taken in January
2006 demonstrated continued severe
to patients for whom the risk of surgery would
outweigh the benefits. These include the
extreme elderly, persons with severe pulmonary
or severe heart disease or other debilitating
condition.
Since most patients present with no symptoms, most physicians follow patients every six
months with ultrasound. An initial abdominal
CT is used to obtain very precise measurements
of aneurysm length and diameter and its relation to other major arteries that branch off
from the aneurysm. At Lourdes, the following
Amplatzer® Septal Occluder
©AGA Medical Corporation
right ventricular systolic dysfunction
and RV dilatations, which are likely due
to long-standing cor pulmonale and
volume overload from the un-repaired
ASD. The ASD appears well closed after
the implantation of the Amplatzer®
device. The patient does have mildly
decreased left ventricular systolic function, mild-to-moderate mitral regurgitation and aortic insufficiency.
By February 2006, the patient reported she could perform routine activities
without difficulty, though she does
require supplemental oxygen on occasion. She also takes Lasix daily.
To date, the patient continues to do
well, with stable vital signs.
For more information on the
treatment of ASD via this procedure,
contact Jan Platt at the New Jersey
Heart Institute: 856-365-4072.
guidelines are employed to determine when it is
necessary to intervene:
• Evidence of active dissection;
• Abdominal pain described as “tearing” in
nature;
• Aneurysm greater than 5.5 cm in diameter;
• Significant increase in the diameter of the
aneurysm between ultrasound studies.
For more information on this procedure, or
to refer a patient, contact Jan Platt at the New
Jersey Heart Institute: 856-365-4072.