Download Minimally Invasive Cardiac Surgery Comes of Age

Inside This Issue
The Young
Helping
the Old? p3
Low LDL & Normal
Blood Pressure
Slows Arterial Plaque
Growth p4
Indications
for Ventricular
Assist Devices
Expanded p6
Remote Monitoring in Heart
Failure p16
Genetic Cause of
Deadly Irregular Heart
Beat Discovered p17
Cardiac
Consult
Heart and Vascular News from Cleveland Clinic | Summer 2009 | Vol. XVIV No. 2
Featured Article
Minimally Invasive
Cardiac Surgery
Comes of Age
- p8
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Dear Colleagues,
Minimally invasive surgery is no longer exotic. Thirteen years ago, Delos M.
Cosgrove, MD, performed the first minimally invasive aortic valve surgery.
In 2008, we performed 462 minimally invasive aortic and mitral valve
procedures, with 0 percent hospital mortality. Cleveland Clinic surgeons
now consider a minimally invasive option first for nearly every patient.
This issue of Cardiac Consult offers a brisk review of Cleveland Clinic’s minimally
invasive thoracic and cardiovascular surgery program. You’ll find mention of the
highly successful valve procedures, along with our robotic surgery program,
Cardiac Consult offers updates on stateof-the-art diagnostic and management
techniques from Cleveland Clinic heart
and vascular specialists. Please direct
correspondence to:
Medical Editors
Christopher Bajzer, MD
A. Marc Gillinov, MD
Sean Lyden, MD
216.448.1026
[email protected]
[email protected]
[email protected]
Managing Editor
Ann Bungo
Marketing Manager
Megan Frankel
video-assisted lobectomies, and new percutaneous techniques.
Art Director
Michael Viars
Medical technology is racing to keep ahead of demand for minimally invasive
alternatives. The appeal is obvious: less pain, fewer complications, shorter hospital
stays. Minimally invasive cardiac surgery is bound to be a hot topic at the big
Photographers
Tom Merce
Steve Travarca
Don Gerda
Russell Lee
The Treatment of Cardiovascular Disease: Legacy & Innovation symposium, being
held here in June. We invite you to join us for this one-time “state of the heart”
global overview of the very latest in cardiac surgery, vascular surgery, cardiovascular medicine, and their related disciplines.
The other articles in this issue of Cardiac Consult reflect the breadth and variety
of our field: new views on ventricular assist devices, lung transplant donation,
remote monitoring in heart failure and more.
We continue to be inspired by the way new technologies advance medicine
and transform lives. As minimally invasive techniques become commonplace,
you’ll find us at the frontier of the next big advance, whatever it may be.
Sincerely,
Christopher Bajzer, MD
Sean Lyden, MD
Associate Director, Peripheral Intervention
Interventional Cardiology
Staff Surgeon,
Vascular Surgery
clevelandclinic.org/heart offers information on new procedures and services, clinical trials, and upcoming CME symposia,
as well as recent issues of Cardiac Consult.
The Sydell and Arnold Miller Family
Heart & Vascular Institute, ranked No. 1
in the nation for cardiac care by U.S.News
& World Report every year since 1995,
accommodates nearly 300,000 patient
visits each year in world-class facilities.
Staff are committed to researching and
applying state-of-the-art diagnostic and
management techniques. Cleveland Clinic
is a not-for-profit, multispecialty academic
medical center.
Cardiac Consult is written for physicians
and should be relied upon for medical
education purposes only. It does not
provide a complete overview of the topics
covered, and should not replace the independent judgment of a physician about the
appropriateness or risks of a procedure
for a given patient.
© The Cleveland Clinic Foundation 2009
A. Marc Gillinov, MD
The Judith Dion Pyle Chair in Heart Valve Research
Thoracic and Cardiovascular Surgery
Page 2 | Cardiac Consult | Summer 09 |
Cleveland Clinic’s toll-free physician referral number is 800.553.5056
The Young Helping the Old?
Can younger or newer stem cells give a regenerative boost to
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donors could help older patients who are recovering from heart
attacks or aortic stenosis.
Marc Penn, MD, PhD
Marc Penn, MD, PhD, Cleveland Clinic Stem Cell Biology and Regenerative 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 differentiDWHSURSHUO\DQGHIÀFLHQWO\
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 transplanted 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
Cleveland Clinic Researchers: Low LDL and Normal
Blood Pressure Slows Arterial Plaque Growth
Low levels of LDL cholesterol coupled with normal blood pressure can
significantly slow the progression of coronary artery disease, according
to a study by Cleveland Clinic researchers.
The study, which was published in the March 31 issue of the Journal of the
American College of Cardiology, is the first to show that aggressive treatment to
lower both cholesterol and blood pressure can slow plaque build-up in patients
with 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 aggressively 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 of
plaque in their arteries. The researchers found that very low
levels of LDL (70 mg/dl or less), in combination with normal
systolic blood pressure (120 or less), significantly slowed
arterial 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 interventional cardiology fellow at Cleveland Clinic. “Optimal control 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 controlled
trial to directly test the clinical benefit of aggressively treating multiple risk factors would
provide further support for this concept.
Researchers from Cleveland Clinic’s departments of Cardiovascular Medicine, Cell
Biology, and Radiology participated in the
study, along with the Cleveland Clinic
Center for Cardiovascular Diagnostics
and Prevention.
Page 4 | Cardiac Consult | Summer 09 |
Cleveland Clinic’s toll-free physician referral number is 800.553.5056
Case Study: Cervical Carotid Aneurysm
Presentation
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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.
Sunita Srivastava, MD
Vascular Surgery
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
of neurologic symptoms such as stroke or TIA with either embolization of aneurysm
contents or thrombosis of the aneurysm.
Figure (2)
6LU$VWOH\&RRSHUUHSRUWHGWKHÀUVWVXFFHVVIXOVXUJLFDOWUHDWPHQWRIH[WUDFUDQLDOFDURWLG
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
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similarly low. Endovascular options also are available, but have not been evaluated for longterm durability and success.
Contact Dr. Sunita Srivastava at 216.445.6939 or [email protected].
REFERENCES
(1) Painter T, Hertzer N, Beven E, O’Hara P. Extracranial carotid aneurysms: report of six cases and
review of the literature. J Vasc Surg 1985;2:312-8.
(2) Moreau P, Albot B, Thevenet A. Surgical
treatment of extracranial internal carotid artery
aneurysms. Ann Vasc Surg 1994;8:404-16.
(3) Knight GC, Hallman GL, Reul GJ, Ott DA,
Cooley DA. Surgical Management of Extracranial
Carotid Artery Aneurysms:Report of 17 Cases.
Texas Heart Inst J 1988;15:91-7.
Visit clevelandclinic.org/heart
(4) McCollum CH, Wheeler WG, Noon GP,
DeBakey ME. Aneurysms of the Extracranial
carotid artery. Twenty one years’ experience.
Am Jour Surg 2005; 196-200.
(8) May J, White GH, Waugh R, Brennan J.
Endoluminal repair of internal carotid artery
aneurysm: a feasible but hazardous procedure.
Jour Vasc Surg. 1997;26:1055-60.
(11) Radak D, Davidovic L, Vukobratov V, Illijevski N, Kostic D, Maksimovic S. Carotid Artery
Aneurysms: Serbian Multicentric Study. Ann Vasc
Surg 2007;21(1):23-9.
(5) Davidovic L, Dusan K, Maksimovic Z,
Markovic D, Dragan VM, Duvnjak S. Carotid artery
aneurysms. Vascular 2004;12:166-70.
(9) Szopinski P, Ciostek P, Kielar P, Myrcha P,
Pleban E, Noszczyk W. A series of 15 patients with
extracranial carotid artery aneurysms:Surgical and
Endovascular treatment. Eur Jour Endovasc Surg
2005;29:256-61.
(12) Attigah N, Kulkens S, Hansmann J, Ringleb
P, Hakimi M, Eckstein H, et al. Sugical Therapy of
Extracranial Carotid Artery Aneurysms:Long term
results over a 24 year period. Eur Jour Endovasc
Surg 2008;37:127-33.
(6) Kaupp H HSJMBJTO. Aneurysms of the extracranial carotid artery. Surgery 1972;72:946-52.
(7) Zwolak R, Whitehouse WJ, Knake J, Bernfeld
B, Zelenock G, Cronenwett J. Atherosclerotic
extracranial carotid artery aneurysms. Jour Vasc
Surg 1984;1:415-22.
(10) Miksic K, Flis V, Kosir G, Pavlovic M,
Tetickovic E. Fusiform and saccular extracranial carotid artery aneurysms. Cardiovasc
Surg 1997;5(2):190-5.
| Cardiac Consult | Summer 09 | Page 5
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
WKHÀUVWGHYLFHVDVDEULGJHWRWUDQVSODQW6LQFHWKDWWLPHDGYDQFHVLQWHFKQLTXH
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.
Gonzalo Gonzalez-Stawinski, MD
“Most individuals with medically refractory heart failure may potentially qualify for VAD therapy,”
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.
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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
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 anticoagulation. 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 encountered 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 moving part, are highly biocompatible and are resistant
to wear and corrosion, making them ideal for permanent use. Cleveland Clinic is studying several
HeartWare (Thoratec) models with extendedlife 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
Cardiac Surgery Comes of Age
A new chapter has been
opened in the history of
cardiac surgery. Minimally
invasive surgery is now
the standard treatment for
an increasing number of
cardiovascular procedures.
As techniques improve,
more and more minimally
invasive procedures are able
to duplicate the outcomes of
conventional surgery, with
fewer complications, and
more rapid recovery time.
Page 8 | Cardiac Consult | Summer 09 |
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Cleveland Clinic’s toll-free physician referral number is 800.553.5056
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 Cardiovascular Surgery at Cleveland Clinic have been pioneers
in evaluating and adopting minimally invasive surgical
techniques. Delos M. Cosgrove, MD, performed the
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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
Mitral Valve Replacement and Repair
Mitral valve repair is the most frequently
performed minimally invasive cardiac
surgery. A. Marc Gillinov, MD, and
Tomislav Mihaljevic, MD, who share a
great deal of experience in all minimally
invasive cardiac procedures (including
robotically assisted), indicate that it
is possible to both repair and replace
valves minimally invasively. However,
they believe that long-term outcomes
are superior with repair, and recommend
repairs in most cases. More minimally
invasive mitral valve repairs have been
performed at Cleveland Clinic than at
any other medical center.
Robotically assisted mitral valve repair
is the least invasive approach to mitral
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valve repair. Robotically assisted procedures are performed endoscopically,
through small ports (rather than formal
Using special instruments, the surgeon
Robotically Assisted Mitral Valve Surgery
incisions) in the right side of the chest.
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Robotically assisted mitral valve surgery
and place an annuloplasty ring, just as
is a type of minimally invasive surgery
in conventional surgery. A partial upper
in which the surgeon uses a specially-
sternotomy includes a 2- to 3-inch skin
designed computer console to control
A Minimally Invasive Approach
Minimally invasive mitral valve repair
can be performed through a 2 to 4-inch
incision and division of the upper portion
surgical instruments on thin robotic arms.
of the sternum, as opposed to the 8- to
The robotic arms are introduced through
10-inch incision of a full sternotomy. The
1- to 2-cm incisions in the right side of the
partial upper sternotomy offers the sur-
chest. The surgeon’s hands control the
geon an excellent view of the mitral valve
movement and placement of the endo-
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.
incision, either a right mini-thoracotomy
or partial upper sternotomy. The surgical
approach or technique for each patient
is based on age, condition, co-morbidities and anatomical considerations.
a skin fold on the right chest, providing an
excellent cosmetic result. The heart is approached between the ribs, providing the
surgeon access to the mitral valve. There
is no sternal incision or spreading of the
ribs required for this surgical technique.
Page 10 | Cardiac Consult | Summer 09 |
These minimally invasive approaches
Robotically assisted mitral valve surgery
provides the surgeon with an undistort-
also can be used when mitral valve
ed, three-dimensional view of the mitral
repair is combined with ablation for
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with the use of a special camera. This
has been instrumental in developing
approach enables surgeons to perform
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complex repairs without the need for
Cleveland Clinic’s toll-free physician referral number is 800.553.5056
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 miniprocedure 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
of this new procedure,” Dr. Sabik says.
division of the sternum or spreading of
built robotic surgical suite, this can be
the ribs, in most cases.
accomplished in less than two minutes.
At the current stage, all patients who have
Cleveland Clinic has excellent results
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
“For an average person who needs two or
three grafts, we can perform the miniCABG procedure instead.”
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 attempts at repairing the mitral valve.
Coronary Artery Bypass Graft Surgery
percutaneously. Some of these techniques
are experimental. Others are part of every-
The traditional coronary artery bypass
Robotic surgery requires specially trained
day clinical practice. For instance, many
graft (CABG) surgery, which was pio-
patients currently receive percutaneous
surgeons and a specially trained operat-
neered at Cleveland Clinic in 1967, is
ing room team. In the rare event that the
valvotomy for stenosis of the mitral, aortic
performed every day at academic medical
robotic approach needs to be switched
or pulmonic valve. In this procedure, ex-
centers and community hospitals alike.
to conventional surgery (fewer than 2
plains interventional cardiologist Samir K.
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
be able to make that switch quickly and
inserted into the femoral artery and guided
a smaller incision and – in some cases –
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to the site of the valve. The balloon is
without the use of a heart-lung machine.
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Visit clevelandclinic.org/heart
| Cardiac Consult | Summer 09 | Page 11
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leaving nothing but a valve that is more
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“There are a lot of patients, especially oldHUSDWLHQWVZKRZHÀQGDUHYHU\ULVN\IRU
balloon is withdrawn. Cleveland Clinic
The mitral valve itself is untouched in
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
feasibility of this treatment.
open heart surgery for various reasons,”
“What surprised many of us in the surgical
says surgeon Lars Svensson, MD, PhD,
profession is that this has worked out very
of Thoracic and Cardiovascular Surgery.
well,” says Dr. Svensson. “Obviously there
“We’ve been able to develop techniques
are higher risks than a routine open heart
that we can approach these valves with-
operation, but it is an option for older or
out having to open the patient’s chest.”
high-risk patients.”
Other percutaneous valve procedures
Another experimental technique is being
are still in the experimental stage.
tested at Cleveland Clinic for the treatment
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of mitral valve regurgitation. A very small,
to study percutaneous aortic valve
specially made metal clip device is deliv-
replacement using a new compressed-
ered via catheter to the mitral valve. The
tissue heart valve. The valve is placed
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on a balloon-mounted catheter and
center of the valve, allowing the blood to
positioned directly over the diseased
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aortic valve. “When we know we are
clip is adjusted until optimal improvement
guided by catheter into the coronary sinus
to a position just alongside the annulus
of the mitral valve, and left there. The
slight rigidity of the bar exerts pressure on
the dilated annulus, pushing it and its atWDFKHGOHDÁHWIRUZDUGWRKHOSUHVWRUHPRUH
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Cleveland Clinic surgeons and cardiologists
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percutaneous valve placement to remedy
the impact of tricuspid regurgitation on
the body using a special device developed
at Cleveland Clinic. This may eventually
provide a means of treating valve disease
caused by radiation treatments to the
chest, which sometimes render the patient
unsuitable for open surgery.
in the right position, we get the heart
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to race faster so it’s not pumping as
valve are observed. When the catheter is
In considering all these techniques, it
much,” says Dr. Svensson. “Then we in-
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should be kept in mind that mortality
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in position, which limits the leakage.
for conventional valve replacement and
Page 12 | Cardiac Consult | Summer 09 |
Cleveland Clinic’s toll-free physician referral number is 800.553.5056
“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
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.
“Small lung cancers and lung cancers
that tend to be more toward the surface
of the lung are the best candidates for
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-
surgery. Traditional thoracotomy may
repair in 2008). This means that experimental minimally invasive alternatives
are most frequently recommended for
patients who are too frail or elderly for
conventional surgery.
Video-assisted Thorascopic Lobectomy
Patients with small, early stage, primary
WXPRUVLQWKHOXQJPD\EHQHÀWIURPD
lobectomy, which removes the tumor along
with the lobe of the lung were it resides. A
conventional lobectomy is performed during a thoracotomy. Cleveland Clinic is now
one of the few centers in the nation that
KDVVLJQLÀFDQWH[SHULHQFHZLWKWKHPLQLmally invasive alternative to this approach.
Video-assisted thoracoscopic surgery
lobectomy (VATS lobectomy) is performed
through three 1-inch incisions and one
harvested and used as a conduit.
The saphenous vein and radial artery are
be more appropriate for some patients
percent for primary isolated mitral valve
The radial artery in the arm may also be
removed by VATS, says David Mason, MD
comparable to those for conventional
lower than the national averages (0.3
or unusable, and for bypass procedures
in the legs for peripheral artery disease.
VATS however most lung cancers can be
The outcomes for VATS lobectomy are
UHSDLUDW&OHYHODQG&OLQLFLVVLJQLÀFDQWO\
artery bypass. Prior to that, the saphen-
tumor and other affected tissue. If an early-
with large tumors, involved lymph
nodes, or prior chest surgery. VATS
techniques are also applied to other
procedures, including wedge resection,
lung biopsy, drainage of pleural effusions, and mediastinal, pericardial and
thymus thoracoscopic procedures.
“Minimally invasive lung surgery is clearly
EHQHÀFLDOWRSDWLHQWVIRUDOPRVWDOOWKRracic diseases that require surgery,” says
Dr. Mason. “However, few surgeons are
trained in these techniques and only a
minority of thoracic surgery procedures are
performed minimally invasively around the
country. At Cleveland Clinic, all thoracic
surgery patients are considered for miniPDOO\LQYDVLYHVXUJHU\ÀUVWDQGH[SHUWLVH
land Clinic surgeons have considerable
experience in performing endoscopic
saphenous vein harvesting and have
expanded its use for lower extremity
bypass. To harvest the saphenous vein,
the surgeon makes a small incision in
the groin and one or two 1-inch incisions in the leg, near the knee. Special
instruments are slid down the inside leg,
alongside the vein. A miniature camera
allows the surgeon to view the vein,
and measure off the length that will be
needed. That length is cut and the vein
is removed through the incision.
In 2005, Cleveland Clinic surgeons
expanded the minimally invasive
approach to include harvesting of radial
arteries. In this procedure, the surgeon
makes a small incision near the wrist
and one near the forearm.
“Applying endoscopic vein harvesting
in these techniques exists. In our experi-
for lower extremity bypass is a bit more
ence, outcomes for cancer cure is identical
challenging than for coronary bypass
to more traumatic techniques and clearly
for a variety of reasons,” says Cleveland
this is not a compromise procedure.”
Clinic vascular surgeon Vikram Kashyap,
0'+RZHYHUWKHVLPLODUEHQHÀWVRI
3- to 4-inch incision in the chest. A
Minimally Invasive Vein Harvesting
thorascope and specially adapted surgical
Cleveland Clinic cardiac surgeons
length of stay can be accomplished for
established the superiority of the internal
these patients.”
instruments are inserted into the incisions.
Guided by the images from the thorascope,
Visit clevelandclinic.org/heart
reduced pain, morbidity and hospital
thoracic artery as a conduit for coronary
| Cardiac Consult | Summer 09 | Page 13
Research Roundup
Highlights of Recent Heart and Vascular Research from Cleveland Clinic
Important Genetic Findings
New Findings in Vascular Surgery
There were two major genetic discoveries from Qing Wang,
Cleveland Clinic Vascular Surgeon Vikram S. Kashyap, MD,
PhD, Department of Molecular Cardiology and Director of
DQGKLVWHDPKDYHPDGHVHYHUDOLPSRUWDQWÀQGLQJV
the Center for Cardiovascular Genetics:
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$%HWWHU$QWLFRDJXODQW
'U.DVK\DSZDVWKHÀUVWWRGHPRQVWUDWHWKHVDIHW\DQGHI-
A year ago, researchers found that a cluster of genetic variants
fectiveness of using the anticoagulant bivalirudin in patients
RQDVSHFLÀFUHJLRQRIFKURPRVRPHLVOLQNHGWRFRURQDU\
undergoing lower extremity bypass. This small study suggests
artery disease (CAD) in white people in northern Europe and
WKDWELYDOLUXGLQLVDEHQHÀFLDODOWHUQDWLYHWRKHSDULQDVDQ
North America. People who have that genetic quirk are more
anticoagulant in lower extremity bypass.
susceptible to developing CAD or having a heart attack. Dr.
Wang and his team have shown the same genetic material also
is associated with coronary artery diseases in the South Korean
SRSXODWLRQ²WKHÀUVWHYLGHQFHRIFURVVUDFHVXVFHSWLELOLW\WR
&$'DVVRFLDWHGZLWKWKHVDPHVSHFLÀFFRPELQDWLRQRIJHQHWLF
YDULDQWV7KLVÀQGLQJFRXOGPHDQEHWWHUJHQHWLFVFUHHQLQJWR
identify people at risk of arterial diseases or heart attacks.
6WHQWDV*RRGDV%\SDVVIRU3HOYLF%ORFNDJHV
Blockage of the large blood vessels in the pelvis (aorta and
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 synthetic tube to bypass the blockage. Less invasive alternatives
are available, but it has not been known for certain how well
*HQHWLF0DUNHUIRU$WULDO)LEULOODWLRQ
they compare to the bypass graft. Now, in a retrospective
7KHGLVFRYHU\WKDWDVSHFLÀFJHQHZKHQPXWDWHGLVOLQNHGWR
review of cases performed at Cleveland Clinic, Dr. Kashyap
GHYDVWDWLQJDEQRUPDOKHDUWUK\WKPFDOOHGDWULDOÀEULOODWLRQFRXOG
has shown that outcomes from percutaneous angioplasty and
lead to new diagnostic tests and treatment options for cardiac
stenting for this condition compare favorably to bypass graft-
patients. Qing K. Wang, PhD found the new gene – NUP155
ing – a step forward for patients who hope to avoid major
– by analyzing the genetics of a family with severe, early-onset
surgery for pelvic blockages.
DWULDOÀEULOODWLRQ$)DQGVXGGHQFDUGLDFGHDWK7KHQHZ
ÀQGLQJPD\SURYLGHDQHZPROHFXODUWDUJHWWRGHYHORSSDWLHQW
tailored treatment strategies to prevent and/or treat the common
IRUPRIDWULDOÀEULOODWLRQ6HHSDJHIRUPRUHGHWDLOV
Using Drugs to Facilitate PCI for Myocardial Infarction
The results of an international clinical trial led by Cleveland
Clinic Cardiologist Stephen A. Ellis, MD, should have high impact on the treatment of patients presenting with heart attacks
caused by blocked coronary arteries. Before the study, it was
ZLGHO\EHOLHYHGWKDWWKHVHSDWLHQWVZRXOGEHQHÀWIURPEHLQJ
given certain blood-thinning agents, either singularly or in
combination, before being taken to a catheterization lab to get
an angioplasty, or other percutaneous intervention (PCI). But
Dr. Ellis’s study showed that administering the drugs before
3&,LQDVSHFLÀFJURXSRISDWLHQWVIDLOHGWRVKRZEHQHÀWDQG
may actually cause harm by promoting bleeding.
Page 14 | Cardiac Consult | Summer 09 |
Cleveland Clinic’s toll-free physician referral number is 800.553.5056
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 STelevation 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
NEW! Acute transfers (acute stroke, STEMI, ICH and acute
aortic syndrome conditons), call 877.379.CODE (2633).
2QHFDOOWRWKLVQXPEHULPPHGLDWHO\ODXQFKHVDÁLJKW²
with no delay-causing dispatch protocols.
Routine transfers, call 216.444.8302 or 800.533.5056
Have the following information ready
‡ Patient name
‡ Date of birth
‡ Cleveland Clinic medical record number
‡Insurance information
‡ Diagnosis and location of patient
‡ Need for telemetry
‡ If the patient has invasive lines, assistive devices or drip;
if the patient is hemodynamically stable
Visit clevelandclinic.org/heart
| Cardiac Consult | Summer 09 | Page 15
Remote Monitoring in Heart Failure
:LWKWKHZLGHVSUHDGLPSODQWDWLRQRIFDUGLDFUHV\QFKURQL]DWLRQWKHUDS\GHÀEULOODWRUV
&57'VDQGLPSODQWDEOHFDUGLRYHUWHUGHÀEULOODWRUV,&'VFDUGLRORJLVWVKDYHHQWHUHG
a new era of remote monitoring. These devices provide a steady stream of data
that 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
DQGWRSURYHWKHEHQHÀWVRIPHGLFDOPDQDJHPHQWE\UHPRWHPRQLWRULQJ
“With the broad application of implanted device therapies, we now
have the unprecedented access
to physiologic data,” says W. H.
Wilson Tang, MD, a cardiologist
and Research Director of the Section of Heart Failure and Cardiac
Transplantation at the Sydell and
W.H. Wilson Tang, MD
Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic.
“This data includes measurements that were originally devised
to monitor device integrity. Now we can take advantage of them
to provide insight into the clinical stability of patients with heart
failure, particularly in between their clinic visits.”
Of particular interest is the ability of devices to measure
changes in impedance in the thoracic cavity. Impedance is
the body’s resistance against an electrical current. “Impedance
was originally a self-check measurement to assess the status of
SDFLQJRUGHÀEULOODWRUOHDGVµVD\V'U7DQJ´3UHYLRXVZRUNKDV
recognized that impedance technology also can indirectly assess
cardiac hemodynamics. Physiological changes may correlate
ZLWKSURJUHVVLYHFKDQJHVDVVRFLDWHGZLWKÁXLGEXLOGXSLQVLGH
the thorax. This detectable change in impedance may occur
weeks before the actual event of hospitalization. The hypothesis
that is currently being tested is whether this early warning can
when downloaded at the time of remote device interrogation
as part of our heart failure disease management program.”
There are some limitations as data from these remote devices
can be variable. “Some patients have big changes and some
patients have small changes,” says Dr. Tang. “Like any diagnostic test, individual measurements need to be interpreted in
the context of the patient’s clinical status. We also don’t know
how frequent we should monitor these data, nor do we have a
universally agreed upon strategy to approach these patients. If
in doubt, we contact the patient to clarify or ask them to come
and see us for follow-up.” The value of this approach has been
supported by the availability of CPT codes for this purpose.
“For now, observing changes in device data can raise suspicion
regarding a patient’s clinical instability,” says Dr. Tang.
The next step is to perform large studies to establish the safety
DQGHIÀFDF\RIUHPRWHPRQLWRULQJLQFOLQLFDOGHFLVLRQPDNLQJ
Bruce Wilkoff, MD, Randall Starling, MD, MPH, and several
members of the Center for Electrical Therapies of Heart Failure
at the Miller Family Heart & Vascular Institute are actively
participating in the design and conduct of prospective clinical
trials to determine the value of these measurements in differHQWGHYLFHSODWIRUPVDQGFRQÀJXUDWLRQVLQWKHWUHDWPHQW
of heart failure.
“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 is
changing drugs or by intensifying counseling.”
leading several of these studies. “Up until now, the treatment
Such measurements have been widely available as part of
complementary data on some CRT-Ds and ICDs, but not for
indications for treatment or alerts. “In fact, when we review
such data in front of our patients, we can even go back and
uncover unreported events,” says Dr. Tang. “It’s a powerful tool
if used appropriately. We have incorporated such information at
the time of clinic visit, as well as systematically reviewed them
Page 16 | Cardiac Consult | Summer 09 |
of heart failure has been reactive, based on a patient feeling
worse. In this generation, we would like to be proactive, using
drugs, counseling, following up closely, and calling the patient.
The advent of broad implantation of these devices in this population allows us to test usefulness of this data in a management
strategy. It’s a tremendous opportunity to advance the treatment of heart failure, perhaps way before patients demanded
the need for hospital admissions.”
Cleveland Clinic’s toll-free physician referral number is 800.553.5056
Genetic Cause of Deadly Irregular
Heart Beat Discovered
7KHGLVFRYHU\WKDWDVSHFLÀFJHQHZKHQPXWDWHGLVOLQNHGWRDWULDOÀEULOODWLRQ$)
could lead to new diagnostic tests and treatment options for cardiac patients.
Qing K. Wang, PhD, Cleveland Clinic Lerner Research Institute’s Department of Molecular Cardiology and Director of the
Center for Cardiovascular Genetics, and his colleagues found
the mutation of the gene NUP155 by analyzing the genetics of
a family with severe, early-onset AF and sudden cardiac death.
AF is the most common rhythm disturbance of the heart found
in the clinical setting. It affects 3 million people in the United
States alone. AF accounts for nearly 15 percent of all strokes and
is also associated with worsening heart failure and increased
mortality. Despite significant advances in AF management,
available treatment options remain far from optimal.
“The new finding may provide a new molecular target to
develop patient-tailored treatment strategies to prevent and/or
treat the common form of atrial fibrillation,” says Dr. Wang.
Each cell in your body contains instructions encoded in your
DNA that are parceled into 23 pairs of chromosomes. Approximately 39,000 genes, which are the instruction booklets containing the DNA, are found dotted along all the chromosomes.
Differences in people come from slight variations in these genes,
which determine everything from hair and eye color to whether
or not a person is more or less susceptible to certain diseases.
The DNA in genes is translated or decoded into another genetic material called RNA in the nucleus of a cell. Then, the
RNA is transported from the nucleus to the liquid inside the
cell called cytosol by a special apparatus called the nuclear
pore complex (NPC). In turn, RNA in the cytosol produces
proteins that are the basic building blocks and workers of
each cell in the body. This conversion – DNA to RNA to
protein – is a tightly regulated process.
NUP155 makes a protein that is a critical component of the
NPC. The NPC acts as a gateway to control the exchange of materials 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
Dr. Wang’s studies revealed that mutant NUP155 causes atrial
fibrillation by altering how RNAs are exported out of the nucleus and how proteins are imported into the nucleus. Specifically,
NUP155 affects the gene/protein called Hsp70, a protein that
can be induced by stress, exercise, surgery, heat shock, and
decreased blood supply to heart tissues.
Hsp70 plays a role in maintaining the proper balance of cardiac
calcium and protecting the structure of heart tissue cells, both
of which are cellular processes important to the maintenance
of heart rhythm. If the level of Hsp70 is low, the heart is not
protected from development of abnormal heart rhythms.
“Identifying a gene linked to AF could lead to new ways to
genetically screen people. For example, individuals in families
with a history of AF could be screened to see if they carry the
mutated NUP155 gene and, therefore, have a greater likelihood of developing AF,” Dr. Wang says. “It also explains a
molecular process or pathway that we might be able to control
with new therapies. These therapies could stop AF from developing in the first place, or treat it after it has been diagnosed.”
Dr. Wang’s research team included Xianqin Zhang, PhD,
Shenghan Chen, PhD, Shin Yoo, Susmita Chakrabarti, Teng
Zhang, PhD, Tie Ke, Carlos Oberti, Sandro L. Yong, Fang
Fang, Lin Li, Lejin Wang, and Qiuyun Chen, all of Molecular
Cardiology, and R. de la Fuente, PhD, Department of Cardiology, Ospedale Italiano Umberto I, in Uruguay.
The research was published recently in Cell ( www.cell.com/
2008; 135(6) pp. 1017-1027). This study was supported by
the American Heart Association, the State of Ohio Wright Center
of Innovation grant and Biomedical Research and Technology
Transfer Partnership Award (BRTT, Ohio’s Third Frontier Project), and the National Basic Research Program of China.
| Cardiac Consult | Summer 09 | Page 17
First Implant of Heartware Ventricular
Assist System at Cleveland Clinic
In March 2009, Nicholas Smedira, MD, a cardiac surgeon with the
0LOOHU)DPLO\+HDUW9DVFXODU,QVWLWXWHSHUIRUPHGWKHÀUVWLPSODQWDWLRQ
of the Heartware® Ventricular Assist System, developed by Heartware
International, at Cleveland Clinic.
Only a handful of the miniaturized circulatory assist devices have been implanted
in the United States to date. The HeartWare® Ventricular Assist System features the
HVAD™ pump, the only full-output pump designed to be implanted next to the heart,
avoiding the abdominal surgery generally required to implant competing devices.
HeartWare has completed an international clinical trial for the device involving five
investigational centres in Europe and Australia. The device is currently the subject of
a 150-patient clinical trial in the United States for a Bridge-to-Transplant indication.
CME Calendar
3K\VLFLDQVDUHZHOFRPHWR
DWWHQGWKHIROORZLQJXSFRPLQJ
V\PSRVLD
A Comprehensive
International Symposium
The Treatment of Cardiovascular
Disease: Legacy & Innovation
June 3-5
InterContinental Hotel &
Bank of America Conference Center
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 Department 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
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.
$OOVDPHGD\YLVLWVZLOOEHFRRUGLQDWHGWKURXJKRXUDSSRLQWPHQWRIÀFH7RDUUDQJHD
same-day visit, call 216.444.6697 or 800.659.7822.
HVI Referrals
To refer cardiology patients, please call
216.444.6697 or 800.553.5056.
To refer surgical patients, call 877.843.2781.
New patients, in most cases, can be seen by
a cardiologist within one week of calling for an
appointment. Most patients requiring surgery
also can be accommodated within one week.
Special Assistance
for Out-of-State Patients
The Cleveland Clinic’s Medical Concierge program is
a complimentary service for patients who travel to
Cleveland Clinic from outside Ohio. Our patient care
representatives facilitate and coordinate the scheduling of multiple medical appointments; provide access
to discounts on airline tickets and hotels, when available; make reservations for hotel or housing accommodations; and arrange leisure activities.
For more information: call 800.223.2273, ext.
55580, visit clevelandclinic.org/services, or email
[email protected].
DrConnect
Make Your Next Report Electronic
DrConnect is an Internet-based service developed to provide
our community physician colleagues real-time electronic
medical record information about the treatment their patients
receive at Cleveland Clinic.
After establishing a DrConnect account with a secure log-in
QDPHDQGSDVVZRUGUHIHUULQJSK\VLFLDQVPD\LGHQWLI\RIÀFH
personnel to receive security rights, allowing DrConnect patient
updates to be immediately integrated into a busy medical
SUDFWLFH·VGDLO\DFWLYLWLHVDQGZRUNÁRZ
Visit clevelandclinic.org/heart
$VLQJOHGDLO\HPDLOQRWLÀFDWLRQFRQWDLQLQJWKH'U&RQQHFW
Web address (URL) gives you one-click access to all newly
released patient-related information, which is presented in
easy-to-navigate “What’s New” screens for quick access and
effective case and time management.
Establishing your own DrConnect account is easy. 1) Log onto
drconnect.clevelandclinic.org. 2) Click on the OnLine Signup
button. 3)6LPSO\ÀOORXW\RXUSK\VLFLDQSDUWLFLSDQWLQIRUPDWLRQ
including choosing a secure password, and submit.
| Cardiac Consult | Summer 09 | Page 19
The Cleveland Clinic Foundation
9500 Euclid Avenue/AC311
Cleveland, OH 44195
Cardiac
Consult
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™.