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Transcript
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.