Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 Flashback::RUOG·VÀUVWPLQLPDOO\LQYDVLYHDRUWLF YDOYHVXUJHU\SHUIRUPHGDW&OHYHODQG&OLQLFLQ 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 ROGHUWLVVXHV"5HVHDUFKHUVDUHÀQGLQJWKDWVWHPFHOOVIURP\RXQJHU 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 $\HDUROGIHPDOHZLWKKLVWRU\RIK\SHUWHQVLRQK\SHUOLSLGHPLDDWULDOÀEULOODWLRQ DQGSUHYLRXVULJKWKHPLVSKHULF&9$ZLWKQRUHVLGXDOGHÀFLWVSUHVHQWVZLWKDULJKWFDURWLG 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 PDQDJHPHQW7KHLQFLGHQFHRIVWURNHLVSHUFHQWWRSHUFHQWDQGFUDQLDOQHUYHGHÀFLWVDUH 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. :KRTXDOLÀHVIRU9$' 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 | 'HORV0&RVJURYH0'QRZ&(2DQG3UHVLGHQWRI &OHYHODQG&OLQLFSLFWXUHGKHUHLQZLWKFDUGLDF VXUJHU\WHDPSLRQHHUHGPLQLPDOO\LQYDVLYHVXUJLFDO WHFKQLTXHVWRLPSURYHWKHHIÀFDF\DQGUHGXFH WKHULVNVRIVXUJLFDOWUHDWPHQWIRUFRURQDU\DUWHU\ GLVHDVHDQGYDOYHGLVRUGHUV 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 ZRUOG·VÀUVWPLQLPDOO\LQYDVLYHDRUWLFYDOYHVXUJHU\LQDQ 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 )DVWIRUZDUG\HDUV0RUHWKDQKDOIRIDOOLVRODWHGPLWUDO YDOYHVXUJHULHVDW&OHYHODQG&OLQLFDUHGRQHURERWLFDOO\ 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. FDQUHSDLUDQGUHVKDSHWKHYDOYHOHDÁHWV 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 YDOYHOHDÁHWVDQGVXEYDOYXODUVWUXFWXUHV DWULDOÀEULOODWLRQVD\V'U*LOOLQRYZKR with the use of a special camera. This has been instrumental in developing approach enables surgeons to perform WHFKQLTXHVWRWUHDWDWULDOÀEULOODWLRQ 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 – HIÀFLHQWO\,Q&OHYHODQG&OLQLF·VSXUSRVH to the site of the valve. The balloon is without the use of a heart-lung machine. LQÁDWHGLQVLGHWKHYDOYH´XQVWLFNLQJµWKH Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 | Page 11 7RGD\ SHUFXWDQHRXV SURFHGXUHVDUHD YDOXDEOHRSWLRQ IRUKLJKULVN SDWLHQWV FDOFLÀHGOHDÁHWV7KHEDOORRQLVZLWKGUDZQ WRWKHQDWLYHWLVVXHDQGWKHGHÁDWHG leaving nothing but a valve that is more RSHQDQGHIÀFLHQW “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 &OHYHODQG&OLQLFZDVDPRQJWKHÀUVW 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 FOLSVKROGWKHÁDSVWRJHWKHUDWURXJKO\WKH on a balloon-mounted catheter and center of the valve, allowing the blood to positioned directly over the diseased ÁRZWRHLWKHUVLGHRILW3ODFHPHQWRIWKH 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 QRUPDOYDOYHOHDÁHWDOLJQPHQW Cleveland Clinic surgeons and cardiologists ZHUHWKHÀUVWWRSHUIRUPDQH[SHULPHQWDO 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 LQEORRGÁRZDQGSUHVVXUHVWKURXJKWKH 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- ZLWKGUDZQWKHFOLSKROGVWKHYDOYHÁDSV should be kept in mind that mortality ÁDWHWKHEDOORRQµ7KHYDOYHLVVHFXUHG 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: &URVV5DFH*HQHWLF/LQNWR$UWHULDO'LVHDVHV+HDUW$WWDFNV $%HWWHU$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™.