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NewYork-Presbyterian Cardiac and Vascular Services
2016 OUTCOMES
AND QUALITY REPORT
NewYork-Presbyterian Cardiac and Vascular Services
2016 OUTCOMES
AND QUALITY REPORT
Welcome
1
About NewYork-Presbyterian
4
Cardiac and Vascular Services Leadership
6
Clinical Reports
Ischemic Heart Disease
8
Advanced Heart Failure
13
Pulmonary Hypertension
20
Rhythm Disorders
24
Adult Congenital Heart Disease
28
Hypertrophic Cardiomyopathy
32
Cardio-Oncology
33
Valve Disease
34
Aortic Disease
42
Cerebrovascular Disease
48
Peripheral Vascular Disease
50
Cardiovascular Imaging
52
Preventive Cardiology
54
Behavioral Cardiology
55
NewYork-Presbyterian OnDemand
56
For More Information or to Make a Referral
[email protected]
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Welcome
Dear Colleague:
During the past year, NewYork-Presbyterian – in partnership with Columbia
University Medical Center and Weill Cornell Medicine – continued to build on
the strengths of its many clinical and scientific endeavors in cardiac and vascular
services with the fundamental goal of improving outcomes for patients. Our
physicians and surgeons are world-renowned leaders in their fields, and our
programs are among the largest and most comprehensive in the country.
Patients routinely come to NewYork-Presbyterian for treatment of the most
complex heart diseases and disorders, confident that we can help, and we do.
We are very fortunate to have a cohort of clinicians and investigators who work
closely together in developing new medications, devices, surgical techniques,
and minimally invasive approaches that are changing the landscape of care for
heart and vascular disease.
Dr. Steven J. Corwin
NewYork-Presbyterian is proud to serve patients who seek out our expertise and
experience in cardiac care from not only our metropolitan area, but who also
travel from across the country and around the world.
In the following report, I invite you to learn about NewYork-Presbyterian’s
significant role in advancing clinical and research innovations in the field.
Sincerely,
Steven J. Corwin, MD
President and Chief Executive Officer
NewYork-Presbyterian
“Patients routinely come
to NewYork-Presbyterian
for treatment of the most
complex heart diseases and
disorders, confident that we
can help, and we do.”
Dr. Steven J. Corwin
2016 OUTCOMES AND QUALITY REPORT
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1
Welcome
Dear Colleague:
Columbia University Medical Center takes pride in partnering with NewYork-Presbyterian
and Weill Cornell Medicine to advance care for patients with cardiovascular disease. Together, our cardiac programs currently rank No. 1 in New York City and No. 3 in the nation.
Our expert cardiologists and cardiac and vascular surgeons have been at the forefront of
the major clinical trials that have led to advances in coronary angioplasty and stenting.
For example, every drug-eluting stent now available in the United States was approved
through trials conducted by Columbia interventional cardiologists. Columbia was the first
center in the nation to perform coronary interventional procedures using “robotic PCI,”
which places stents and opens blockages using a precision-guided robotic system.
Our doctors have performed more than 2,000 transcatheter aortic valve replacements
Dr. Lee Goldman
through the groin instead of by major chest surgery – the nation’s highest volume – and
almost half of the interventional cardiologists who perform the procedure have been
trained by Columbia experts. We have the world’s largest heart failure and transplantation
“Columbia University Medical
Center takes pride in partnering
with NewYork-Presbyterian
and Weill Cornell Medicine to
advance care for patients with
cardiovascular disease.”
Dr. Lee Goldman
program and a national referral center for catheter ablations to treat heart arrhythmias.
For children with congenital heart disease, Columbia doctors developed surgical techniques
now used throughout the world, including the pioneering use of 3-D printing to help guide
surgeries in the smallest of infants.
Our progress is attributable, in large part, to the highly specialized skills and experience
of our multidisciplinary cardiac and vascular teams. It is our great privilege to be part of a
major clinical and academic endeavor that has such a depth and breadth of expertise in
cardiovascular disease.
Sincerely,
Lee Goldman, MD
Executive Vice President, Dean of the Faculties of
Health Sciences and Medicine, and Chief Executive
Columbia University Medical Center
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Dear Colleague:
Weill Cornell Medicine’s partnerships with NewYork-Presbyterian and Columbia University
Medical Center are central to the work we do and enable us to achieve the best possible
outcomes for patients. Our powerful collaborations in clinical care, biomedical research, and education ensure that cardiac patients receive world-class treatment, backed by the
latest findings and performed by the most highly trained specialists.
At Weill Cornell Medicine, our cardiologists and our cardiac and thoracic surgeons are leaders in
their field. They are refining surgical techniques, pioneering minimally invasive approaches and
robotic surgery, and developing novel strategies for prevention and diagnosis. Working with
colleagues across disciplines and at our partner institutions, they are propelling research forward
and enhancing our understanding of how cardiovascular disease develops and progresses.
Patients in New York and around the country are benefitting from these advances, as well as
Dr. Augustine M.K. Choi
from the training provided by our faculty to the next generation of physicians and surgeons.
Weill Cornell Medicine is especially proud of the survival and quality of life outcomes achieved by our cardiac care teams, working in conjunction with NewYork-Presbyterian and
colleagues at Columbia. Together we are committed to reducing morbidity and mortality
from cardiovascular disease and to developing innovative, personalized strategies to
enhance the care of cardiac patients worldwide.
Sincerely,
“Our powerful collaborations
in clinical care, biomedical
research, and education ensure
that cardiac patients receive
world-class treatment.”
Dr. Augustine M.K. Choi
Augustine M.K. Choi, MD
Stephen and Suzanne Weiss Dean
Weill Cornell Medicine
2016 OUTCOMES AND QUALITY REPORT
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About NewYork-Presbyterian
“The growth of our cardiac and vascular
programs is closely linked to the
development of NewYork-Presbyterian’s
integrated academic healthcare network.
Over the last three years, our institution has
doubled in size. Today, patients throughout
the region can receive the highest quality
of care in their own communities.”
OUR LOCATIONS
NewYork-Presbyterian Hospital Campuses
NYP/The Allen Hospital
NYP/Columbia University Medical Center
NYP/Lower Manhattan Hospital
NYP/Morgan Stanley Children’s Hospital
NYP/Weill Cornell Medical Center
NYP/Westchester Division
NewYork-Presbyterian Regional Hospital Network
NYP/Brooklyn Methodist Hospital
NYP/Hudson Valley Hospital
NYP/Lawrence Hospital
NYP/Queens
WESTCHESTER
COUNTY
Dr. Laura L. Forese
Executive Vice President and
Chief Operating Officer
NewYork-Presbyterian
BRONX
HUD
SO
N
RIVER
NEW
JERSEY
M A N HATTA N
QUEENS
B R O O K LY N
Dr. Laura L. Forese
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
NewYork-Presbyterian
Cardiology and Heart Surgery
ranks #3 in the nation.
GEOGRAPHICAL REACH OF CARDIAC AND VASCULAR PROGRAMS – NORTHEAST
NewYork-Presbyterian is one of the nation’s most
comprehensive healthcare delivery networks,
focused on providing innovative and compassionate
care to patients in the New York metropolitan area
and around the globe. In collaboration with two
renowned medical school partners, Columbia University College of Physicians and Surgeons and
Weill Cornell Medicine, NewYork-Presbyterian is consistently recognized as a leader in medical education,
groundbreaking research, and clinical innovation.
NewYork-Presbyterian has four major divisions:
NewYork-Presbyterian Hospital is ranked #1 in the
New York metropolitan area by U.S. News and World
Report and repeatedly named to the magazine’s
Honor Roll of best hospitals in the nation.
NewYork-Presbyterian Regional Hospital Network is comprised of leading hospitals in and around
New York and delivers high quality care to patients
throughout the region.
NewYork-Presbyterian Physician Services connects medical experts with patients in their communities.
We are proud to serve a diverse
local, regional, national, and
international population. In 2015,
NewYork-Presbyterian physicians
saw more than 23,000 patients
for cardiac and vascular care.
NewYork-Presbyterian Community and Population
Health features the Hospital’s ambulatory care
network sites, community care initiatives, and
healthcare quality programs.
NewYork-Presbyterian is one of the largest healthcare providers in the U.S. Each year, nearly 29,000
NewYork-Presbyterian professionals deliver exceptional care to more than two million patients.
www.nyp.org
2016 OUTCOMES AND QUALITY REPORT
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Cardiac and Vascular Services
Leadership
Dr. Michael A. Borger
Dr. Richard M. Green
Dr. Darren B. Schneider
Dr. Yoshifumi Naka
Dr. Michael Argenziano
Dr. Arash Salemi
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Cardiac and Vascular Services
Leadership
In our second annual Outcomes and Quality Report, we are
pleased to continue to bring you highlights of our diverse cardiac
and vascular programs. Here you will read about the innovative
endeavors that our cardiologists, cardiac electrophysiologists,
interventional cardiologists, and cardiovascular surgeons are pursuing
to maximize the outcomes of even the most complex cases.
We also share metrics that clearly demonstrate that the integrated
efforts of NewYork-Presbyterian physicians and surgeons are
making important inroads in all facets of cardiac and vascular
diseases, and most importantly, in the outcomes of patients who
suffer with them.
Michael Argenziano, MD
Chief, Adult Cardiac Surgery
NewYork-Presbyterian/
Columbia University Medical Center
Leonard N. Girardi, MD
Cardiothoracic Surgeon-in-Chief
NewYork-Presbyterian/
Weill Cornell Medical Center
Emile A. Bacha, MD
Chief, Division of Cardiac,
Thoracic, and Vascular Surgery
NewYork-Presbyterian/
Columbia University Medical Center
Richard M. Green, MD
Associate Chief,
Division of Cardiac, Thoracic,
and Vascular Surgery
NewYork-Presbyterian/
Columbia University Medical Center
Michael A. Borger, MD
Director, Aortic Surgery
Director,
Cardiovascular Institute
NewYork-Presbyterian/
Columbia University Medical Center
Karl H. Krieger, MD
Vice Chairman, Department of
Cardiothoracic Surgery
NewYork-Presbyterian/
Weill Cornell Medical Center
Our accomplishments are rooted in the close collaborations among
our specialists, who develop strategies for each patient’s care based
on insights from a multidisciplinary perspective. This enables us to
determine which approach – medical, interventional, or surgical or a
combination thereof – is best suited for the patient. We have pushed
the field forward by working together.
With a shared goal of improving the lives of patients, the faculty of NewYork-Presbyterian, Columbia University Medical Center, and Weill Cornell Medicine are committed to extending the boundaries of
what is possible in diagnosis, management, and treatment of cardiac
and vascular disease.
Martin B. Leon, MD
Director, Center for
Interventional Vascular Therapy
NewYork-Presbyterian/
Columbia University Medical Center
Arash Salemi, MD
Surgical Director,
William Acquavella Heart Valve Center
NewYork-Presbyterian/
Weill Cornell Medical Center
Bruce B. Lerman, MD
Chief, Maurice R. and
Corinne P. Greenberg
Division of Cardiology
NewYork-Presbyterian/
Weill Cornell Medical Center
Darren B. Schneider, MD
Chief, Division of Vascular
and Endovascular Surgery
NewYork-Presbyterian/
Weill Cornell Medical Center
Yoshifumi Naka, MD, PhD
Director,
Cardiac Transplantation
and Mechanical Circulatory
Support Program
NewYork-Presbyterian/
Columbia University Medical Center
Dr. Bruce B. Lerman
Dr. Allan Schwartz
Dr. Emile A. Bacha
Dr. Martin B. Leon
Dr. Karl H. Krieger
Allan Schwartz, MD
Chief, Division of Cardiology
NewYork-Presbyterian/
Columbia University Medical Center
Craig R. Smith, MD
Surgeon-in-Chief
NewYork-Presbyterian/
Columbia University Medical Center
Dr. Craig R. Smith
Dr. Leonard N. Girardi
Clinical Reports
CARDIAC AND VASCULAR DISEASE
From medical management to device
development and new ways of
applying interventional and surgical
approaches, NewYork-Presbyterian is
committed to elevating the fields of
cardiac and vascular disease.
2016 OUTCOMES AND QUALITY REPORT
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ISCHEMIC HEART DISEASE
INNOVATIONS IN ISCHEMIC HEART DISEASE
NewYork-Presbyterian cares for patients with
some of the most complex ischemic heart disease
who have very few treatment options.
The Hospital’s mortality rate for patients with
heart attack is 22% lower than the national average.
Left Main Coronary Artery Disease Our interventional cardiologists and cardiac
surgeons were lead investigators for a landmark international study of 1,900 patients
establishing that drug-eluting stents are as safe and effective as surgery for most
patients with left main coronary artery disease (LMCAD) of low-to-intermediate
complexity. Findings from the EXCEL (Evaluation of XIENCE versus Coronary Artery
Bypass Surgery for Effectiveness of Left Main Revascularization) trial were published
online in 2016 in The New England Journal of Medicine.
Bioabsorbable Stents In July 2016, the FDA approved the first fully absorbable stent
to treat coronary artery disease. The stent was studied in a clinical trial of more
than 2,000 patients led by our physicians and conducted nationwide. The study
compared the absorbable stent with a drug-eluting metallic stent and found them
clinically comparable. The bioresorbable vascular scaffold system releases the drug
everolimus to limit the growth of scar tissue and it
gradually becomes integrated as part of the vessel wall
in approximately three years.
BASELINE 6 MONTHS 2 YEARS 5 YEARS
Absorb GT1™ Absorbable Vascular Scaffold System.
(Courtesy of Abbott Vascular)
Myocardial infarction caused by a stenosis of the right coronary artery
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Acute Myocardial Infarction
Left Ventricular Aneurysm Exclusion Our physicians are participating in a major clinical
trial evaluating the first minimally invasive catheter-based treatment for ischemic
heart failure following a heart attack. The Parachute®
ventricular partitioning device is used to partition damaged, non-functional heart muscle from the healthy,
functional segment to decrease the overall volume of
the left ventricle and as a result increase the power
of the ventricular contraction. The hope is that the
technique will lead to less readmission and translate
to reduced mortality.
STEMI Performance Measures
2015
Proportion of patients prescribed an
ACE-I or ARB for LVSD at discharge
95.0%
90.2%
Proportion of patients prescribed a
beta-blocker at discharge
100.0%
97.5%
94.0%
93.6%
100.0%
96.7%
Overall AMI performance composite
96.0%
95.0%
Proportion of patients prescribed a
statin at discharge
100.0%
99.2%
97.0%
96.1%
Evaluation of LV systolic function
Our physicians have particular expertise in managing Complex Higher-Risk and
Indicated Patients (CHIP), including those with chronic total occlusions, patients with
poor left ventricular function who require hemodynamic support in order to undergo
procedures, as well as patients with complex coronary disease and other comorbid
conditions, including renal insufficiency. In fact, we have one of the most robust chronic
total occlusion programs in the country with several hundred cases treated each year.
NewYork-Presbyterian’s angiographic
success rate for stented lesions,
excluding chronic total occlusions, is 99.7%.
ACC-NCDR
Hospitals
Discharge AMI performance composite
EXPERT MANAGEMENT OF HIGHER-RISK PATIENTS
Our physicians are facilitating widespread cognitive and technical expertise in these
areas through the creation of a CHIP national interventional training program,
which trains physicians around the country in these newer approaches, and with
their recent position paper published in Circulation (August 2, 2016): “Treatment of
Higher-Risk Patients with an Indication for Revascularization: Evolution within the
Field of Contemporary Percutaneous Coronary Intervention.”
NewYorkPresbyterian
Proportion of STEMI patients receiving
primary PCI within 90 minutes
Source: American College of Cardiology National Cardiovascular Data Registry (ACTION Registry®-GWTG™) /
Institutional Outcomes Report 2015
Percutaneous Coronary Intervention
Mortality Rate
2015
All Adverse Events*
2015
5%
5%
4%
4%
3%
3% ACC-NCDR Hospitals
2%
2% NewYork-Presbyterian
1%
1%
0%
NewYork-Presbyterian ACC- NCDR Hospitals
0%
ACC-NC
NewYor
NewYork-Presbyterian ACC- NCDR Hospitals
* Composite of adverse events – death, emergency
CABG, stroke, repeat target vessel revascularization
(continued on page 10)
Source: American College of Cardiology National
Cardiovascular Data Registry (ACC-NCDR)
CathPCI Registry Institutional Outcomes Report 2015
2016 OUTCOMES AND QUALITY REPORT
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ISCHEMIC HEART DISEASE
EXPERT MANAGEMENT OF HIGHER-RISK PATIENTS
Percutaneous Coronary Intervention
(continued from page 9)
Risk Factors of Patients Undergoing PCI
2015
NewYorkPresbyterian
ACC-NCDR
Hospitals
Age ≥75
26.1%
23.4%
Prior Myocardial Infarction >7 days
32.9%
30.4%
Prior Heart Failure
18.4%
14.7%
Diabetes Mellitus
40.7%
39.3%
6.0%
2.8%
20.3%
17.6%
Currently on Dialysis
Prior Coronary Artery Bypass Grafting
Source: American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)
CathPCI Registry
Institutional Outcomes Report 2015
PCI Complications
2015
NewYorkPresbyterian
ACC-NCDR
Hospitals
Hematoma >10 cm at Access Site within 72 hrs
0.1%
0.1%
Cardiogenic Shock
0.9%
1.5%
Cerebrovascular Accident/Stroke
0.5%
0.3%
Heart Failure
0.9%
1.4%
Myocardial Infarction
1.4%
1.8%
Renal Failure/Dialysis
0.3%
0.4%
Source: American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)
CathPCI Registry
Institutional Outcomes Report 2015
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Emphasizing Cardiac Testing in Appropriate Patients Our physicians also have
reported on the underutilization of specific cardiac testing in high-risk populations,
such as those with heart failure. They have found that the current emphasis on
reducing the number of procedures and tests for healthier patients may have
resulted in underutilization of care for sicker patients (such as those with congestive
heart failure). Their analysis showed that patients hospitalized with heart failure
are frequently not adequately tested and therefore may not be able to benefit from
evidence-based therapies.
Use of Intravascular Imaging and Physiology As part of the management advancing
the care of patients with complex coronary artery disease, our physicians frequently
employ cutting-edge technologies for intravascular imaging and physiology during the care of these patients. Several high-impact clinical trials in this area have been completed or are underway under the leadership of our physicians. As an example
of the commitment to using these technologies to impact patient care, our
physicians have pioneered an approach to revascularize patients with advanced
kidney disease without the use of intravenous contrast through the use of
intravascular ultrasound, optical coherence tomography, and pressure-guided
assessments of lesion severity.
High-Risk Revascularization Patients with coronary artery disease today are
older and sicker, with more advanced disease and fewer treatment options due
to comorbidities. Many patients who are referred to NewYork-Presbyterian are
considered “high risk” because of advanced age, complex coronary disease, and/or
previous heart surgery, multiple stenting, or other catheter interventions. While the
number of bypass surgeries performed nationally has decreased dramatically, CABG
is still the best overall operation for patients with diabetes, left main or triple vessel
disease. We have one of the finest programs in the nation for high-risk coronary
revascularization as well as its various iterations, including off-pump coronary
bypass, and minimally invasive coronary bypass with and without robotic assistance.
Our expertise and experience in hybrid revascularization enables us to provide a
combination of therapies to patients with complicated, extensive coronary artery
disease. This may include, for example, off-pump or minimally invasive coronary bypass for certain vessels, and stents or other catheter-
based techniques for other vessels. The approach is tailored to each patient based on their specific anatomy, allowing the benefits of the best surgical and interventional procedures now available.
Coronary Artery Bypass Grafting
Volume
2015
n=894
36%
n=322
Among 1,194 hospitals in the United States,
NewYork-Presbyterian’s mortality was better
than the national average for CABG.
Bilateral Internal Mammary Arteries for CABG A nationally accepted measure
of the quality and sophistication of a cardiac surgery program is the proportion
of coronary bypass operations performed with internal mammary arteries (IMA),
which have greater longevity than vein bypasses. While the use of one IMA is a
standard expectation for CABG, the use of two IMAs – bilateral IMA – provides even
better outcomes, but is much less common due to its technical complexity. In fact,
while nationally only 6 percent of all coronary bypass operations are performed
with bilateral IMA, at NewYork-Presbyterian bilateral IMA are used in approximately
70 percent of cases, placing our program among the top in the country. For those
patients who may not qualify for bilateral mammary artery grafting, we offer radial
artery grafts as an alternative. We have shown superior survival in patients in whom
radial arteries were utilized instead of saphenous vein grafts.
Cardiogenic Shock Team Despite advances in the treatment of coronary artery
disease and in the technology of mechanical circulatory support devices, patients
with myocardial infarction complicated by cardiogenic shock still have mortality
rates in the range of 40 to 50 percent. Collaboration between multiple specialties is
the key to better outcomes for these patients. To this end, NewYork-Presbyterian has
established a multidisciplinary Cardiogenic Shock Team representing cardiothoracic
surgery, interventional cardiology, advanced heart failure, and critical care specialties
with availability of mechanical circulatory support 24/7.
64%
n=572
Isolated CABG
CABG Concomitant
Source: NewYork-Presbyterian
30-Day Mortality Rate
July 1, 2012 - June 30, 2015
5%
4%
3%
National Death Rate
NewYork-Presbyterian
2%
1%
0%
NewYork-Presbyterian
National
Source: Hospital Compare (of 1,194 hospitals in the U.S.)
Isolated CABG Complications Rate
2013 - 2015
Acute Renal Failure - New Onset Dialysis
1.0%
Postoperative Stroke Rate
1.7%
30 Days Readmission - Unplanned
8.5%
Source: Vizient Clinical Data Base/Resource Manager™ used
by permission of Vizient. All rights reserved.
2016 OUTCOMES AND QUALITY REPORT
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ISCHEMIC HEART DISEASE
Selected Clinical Trials
Selected Publications
ABSORB III Trial This prospective randomized, multicenter trial supports
the U.S. premarket approval of the Absorb™ Bioresorbable Vascular
Scaffold System.
Stone GW, Sabik JF, Serruys PW, Simonton CA, Généreux P, Puskas J, Kandzari
DE, Morice MC, et al; EXCEL Trial Investigators. Everolimus-eluting stents
or bypass surgery for left main coronary artery disease. The New England
Journal of Medicine. 2016 Dec 8;375(23):2223-35.
ABSORB IV Trial This trial continues to evaluate the safety and
effectiveness as well as the potential short and long-term benefits
of the Vascular Absorb™ and the Absorb GT1™ BVS System, as
compared to the control stent XIENCE.
IDEAS Trial: Innovative Discharge Education for Acute Coronary
Syndrome and Stable Heart Disease Patients The purpose of this
study is to assess the impact of patient-derived discharge interventions on quality of life, medication compliance, and readmission rates
for STEMI, NSTEMI, and ACS patients who are discharged rapidly from
the hospital. The study includes the opportunity for patients to
review their own angiogram.
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Al’Aref SJ, Wong SC, Swaminathan RV, McNair P, Feldman DN, Kim LK, Singh
HS, Bergman G, Minutello RM. Analysis of reperfusion time trends in patients
with ST-elevation myocardial infarction across New York State from 2004 to
2012. International Journal of Cardiology. 2017 Apr 1;232:140-46.
ISCHEMIA: International Study of Comparative Health Effectiveness
with Medical and Invasive Approaches This trial will determine the
best management strategy for patients with at least moderate ischemia
on stress imaging. Patients will be assigned to cardiac catheterization
followed by revascularization plus optimal medical therapy (OMT) or
to OMT, with cardiac catheterization and revascularization reserved for
those who fail OMT.
Puskas JD, Halkos ME, DeRose JJ, Bagiella E, Miller MA, Overbey J, Bonatti J,
Srinivas VS, Vesely M, Sutter F, Lynch J, Kirkwood K, Shapiro TA, Boudoulas
KD, Crestanello J, Gehrig T, Smith P, Ragosta M, Hoff SJ, Zhao D, Gelijns AC, Szeto WY, Weisz G, Argenziano M, Vassiliades T, Liberman H, Matthai W,
Ascheim DD. Hybrid coronary revascularization for the treatment of
multivessel coronary artery disease: A multicenter observational study.
Journal of the American College of Cardiology. 2016 Jul 26;68(4):356-65.
PARACHUTE IV: A Pivotal Trial of the Parachute Implant System This trial
will evaluate the Parachute implant in approximately 560 patients with
ischemic heart failure in up to 80 centers in the U.S. The event-driven
primary endpoint includes all-cause mortality and hospitalization for
worsening heart failure.
Kim LK, Looser P, Swaminathan RV, Minutello RM, Wong SC, Girardi L,
Feldman DN. Outcomes in patients undergoing coronary artery bypass graft surgery in the United States based on hospital volume, 2007 to 2011.
Journal of Thoracic and Cardiovascular Surgery. 2016 Jun;151(6):1686-92.
SHIELD II: Supporting Patients Undergoing High-Risk PCI This study
will evaluate the HeartMate PHP System, a temporary (<6 hours), highflow percutaneous left ventricular support device system indicated for
use during high-risk PCI performed in patients with severe coronary
artery disease and depressed left ventricular ejection fraction.
12
Kirtane AJ, Doshi D, Leon MB, Lasala JM, Ohman EM, O’Neill WW, Shroff A,
Cohen MG, Palacios IF, Beohar N, Uriel N, Kapur NK, Karmpaliotis D, Lombardi
W, Dangas GD, Parikh MA, Stone GW, Moses JW. Treatment of higher-risk
patients with an indication for revascularization: Evolution within the field
of contemporary percutaneous coronary intervention. Circulation. 2016 Aug 2;134(5):422-31.
NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Benedetto U, Gaudino M, Ng C, Biondi-Zoccai G, D’Ascenzo F, Frati G,
Girardi LN, Angelini GD, Taggart DP. Coronary surgery is superior to drug
eluting stents in multivessel disease. Systematic review and meta-analysis
of contemporary randomized controlled trials. International Journal of
Cardiology. 2016 May 1;210:19-24.
ADVANCED HEART FAILURE
MANAGEMENT OF COMPLEX CARDIAC DISEASE
NewYork-Presbyterian’s advanced heart failure programs offer a continuum of care
for patients in all stages of heart failure – from medical management to ventricular
support and heart transplantation. Our patients present with advanced cardiac
disease with myriad causes and comorbidities. These include genetic abnormalities,
diastolic heart failure, ischemic or hypertrophic cardiomyopathy, valvular disease,
and heart attack.
At the core of these programs are multidisciplinary teams with highly specialized
expertise in assessment and management of these complicated cases. Team members include specialists in gastroenterology, pulmonology, infectious disease, and cardiac anesthesia. These collaborations, coupled with meticulous perioperative, postoperative, and ongoing care, speak to our outstanding outcomes, including mortality rates
lower than the national average.
CardioMEMS NewYork-Presbyterian is now incorporating CardioMEMS™ into its
comprehensive management approach to the care of patients with heart failure.
The cutting-edge tool allows continuous monitoring of a patient’s pulmonary
pressure, facilitating early recognition of fluid accumulation and early intervention
or medication adjustment before a patient becomes severely symptomatic
necessitating an ED visit or hospital admission.
The CardioMEMS™ Heart Failure System is the first and only FDA-approved heart
failure monitoring system proven to significantly reduce hospital admissions and
improve quality of life in NYHA class III patients. The hemodynamic monitoring system is implanted into a distal branch of the descending pulmonary artery. The patient is instructed to transmit daily
pressure readings – pressure trend
information and individual pulmonary
artery pressure waveforms – that are
immediately available to physicians for
review.
Advanced Heart Failure
Mortality Rate
July 1, 2012 - June 30, 2015
20%
National
NewYork-Presbyterian
15%
10%
5%
0%
NewYork-Presbyterian
National
Source: Centers for Medicaid and Medicare Services /
medicare.gov/hospitalcompare
NewYork-Presbyterian has a
91% inpatient survival rate in patients
undergoing care for advanced heart failure
and a 30-day mortality rate
28% lower than the national average.
CardioMEMS (Courtesy of St. Jude Medical)
2016 OUTCOMES AND QUALITY REPORT
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ADVANCED HEART FAILURE
CONTINUING PROGRESS IN LVAD DEVELOPMENT
Ventricular Assist Devices
For more than 25 years, NewYork-Presbyterian has
been a pioneer in the field of ventricular support
for advanced heart failure management.
Volume
2011 - 2015
200
150
100
50
0
2011
2012
2013
2014
2015
Source: NewYork-Presbyterian
Ventricular Assist Device Implants
Volume Distribution
2015
n=159
18%
n=29
42%
n=66
40%
n=64
In 2015, our surgeons performed more than 150 left ventricular assist device (LVAD)
procedures – one of the largest volumes nationwide – with survival rates that exceed
the national average. They have played an integral role in the development of many groundbreaking devices, including several LVADs, such as HeartMate I and II, and most recently, NewYork-Presbyterian was one of the major sites for patient enrollment in
the MOMENTUM 3 trial evaluating HeartMate 3.
MOMENTUM 3, which was the largest LVAD clinical study to date, tested this newest
generation pump in more than 1,000 patients nationwide. The goal was to evaluate
survival free from device replacement and debilitating stroke over a six-month period.
The unique design of HeartMate 3 minimizes blood trauma and provides patients with
an artificial pulse of 30 beats per minute.
The newer generation device features a centrifugal-flow durable left ventricular
assist system that utilizes fully magnetically levitated technology engineered to
lower adverse event rates, especially thrombosis. While HeartMate II is composed of
an axial continuous-flow pump, HeartMate 3 uses a miniaturized centrifugal flow
device and fewer moving parts, which help with surgical placement. At the end of
the study’s six-month observation period, there were no significant differences
in the rates of death or disabling stroke, and
reoperation for pump malfunction or the need
for urgent transplantation was less frequent in
the centrifugal pump group.
Short Term
Destination Therapy
Bridge-to-Transplant
Source: NewYork-Presbyterian
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
HeartMate 3 (Courtesy of St. Jude Medical)
Ventricular Assist Devices
Patient Profiles
INTERMACS*
June 23, 2006 - December 31, 2015
Adverse Events*
June 23, 2006 - December 31, 2015
NewYorkPresbyterian
INTERMACS
Level 1 Critical Cardiogenic Shock
11.7%
17.1%
Level 2 Progressive Decline
57.8%
37.2%
Level 3 Stable but Inotrope Dependent
25.0%
28.8%
5.5%
16.7%
Levels 4-7
*INTERMACS is the United States National Registry for patients receiving durable mechanical
circulatory support device therapy to treat advanced heart failure.
Source: INTERMACS Quality Assurance Quarterly Report (Q4 2015)
NewYorkPresbyterian
INTERMACS
Neurological Dysfunction
3.10%
4.00%
Renal Dysfunction
1.90%
2.40%
Respiratory Failure
2.90%
3.90%
Pump/Related-Drive Line Infections
(after the first 3 months)
0.75%
1.44%
Pump/Related-Drive Line Infections
(during the first 3 months)
1.39%
1.43%
13.10%
13.60%
27.30%
38.00%
Bleeding
Rehospitalization
*Table includes overall counts and percentages for each type of adverse event
reported at Hospital site and INTERMACS overall. Source: INTERMACS Quality Assurance Quarterly Report (Q4 2015)
All Long-Term Implants Post-Implant Survival
June 23, 2006 - December 31, 2015
Bridge-to-Transplant Survival
June 23, 2006 - December 31, 2015
Destination Therapy Survival
June 23, 2006 - December 31, 2015
100%
100%
100%
80%
80%
80%
60%
60%
60%
40%
40%
40%
20%
20%
20%
0%
1 Year
3 Years
NewYork-Presbyterian
5 Years
INTERMACS
Source: INTERMACS Quality Assurance Quarterly Report (Q4 2015)
0%
1 Year
3 Years
NewYork-Presbyterian
5 Years
INTERMACS
Source: INTERMACS Quality Assurance Quarterly Report (Q4 2015)
0%
1 Year
3 Years
NewYork-Presbyterian
5 Years
INTERMACS
Source: INTERMACS Quality Assurance Quarterly Report (Q4 2015)
2016 INNOVATIONS AND QUALITY REPORT
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15
ADVANCED HEART FAILURE
EXCELLENCE IN ADULT ECMO
PLATINUM
In 2016, NewYork-Presbyterian’s
Adult ECMO Program was designated
a Platinum Center of Excellence in
Life Support by the Extracorporeal Life
Support Organization (ELSO). This is the
first time Platinum Level status has ever
been awarded. NewYork-Presbyterian is
one of only three adult centers worldwide
to achieve this designation.
The mission of NewYork-Presbyterian’s ECMO (Extracorporeal Membrane Oxygenation)
program is to sustain life and provide the Hospital’s clinical team with the tools that
support the most critical situations. The use of this evolving technology enables
physicians to provide immediate cardiopulmonary support while resting the
damaged native heart and lungs, improve perfusion and oxygenation of end organs,
and allow ample time for diagnosis, treatment, and recovery from the primary injury
or disease. At the same time, our clinicians strive to advance ECMO technology and
novel applications to treat adult patients with life-threatening illness, while balancing
ethical considerations and cost/benefit factors.
NewYork-Presbyterian has one of the largest medical ECMO programs in the world
for adult respiratory failure. In 2016, the Extracorporeal Life Support Organization
(ELSO) designated NewYork-Presbyterian’s Adult ECMO Program as a Platinum Center
of Excellence in Life Support. This is the first time ELSO has ever awarded Platinum
Level status, and NewYork-Presbyterian is one of only three adult centers worldwide
to achieve this designation. Over the past five years there has been a significant
increase in ECMO usage at NewYork-Presbyterian, due, in part, to referrals from other
hospitals. Our ECMO team is available 24/7 for referrals and patient transfers.
Innovative Hybrid Configurations Our clinicians have particular expertise in
hybrid configurations that can provide differential support for various forms of
cardiopulmonary failure. For example, for patients supported with venovenous
ECMO who develop hemodynamic compromise, an arterial limb can be added
(venovenous-arterial ECMO) to offer additional circulatory support. For patients on
venoarterial ECMO who develop concomitant
respiratory failure in the setting of some
residual cardiac function, an oxygenated
reinfusion limb can be added to the internal
jugular vein (venoarterial-venous ECMO) to
improve oxygen delivery to the cerebral and
coronary circulation.
Venoarterial ECMO cannulation
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
ADULT ECMO
CASE STUDY: PERIPHERAL VENOARTERIAL-ECMO AND LVAD
A 72-year-old man presented with severe dyspnea one week after an
episode of excruciating arm pain for which he had not sought medical
attention. An electrocardiogram showed evidence of an anterior myocardial infarction (MI), and coronary angiography revealed complete
occlusion of the left anterior descending artery. Echocardiography revealed anterior wall akinesis, a left ventricular ejection fraction (LVEF) of
30%, and a large anterior ventricular septal rupture, a complication of MI
that carries mortality as high as 80%. An intra-aortic balloon pump (IABP)
was inserted, and the patient was transferred to NewYork-Presbyterian.
Given the size of the septal defect and the temporal proximity to the
Intraoperative image of large
anterior ventricular septal rupture
myocardial infarction, urgent surgical repair was deferred because of
the anticipated friability of the septal tissue. However, despite IABP
support, the patient developed worsening shock with hypotension and renal failure. Peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted with cannulas in the
right internal jugular vein and right axillary artery. This configuration provided robust hemodynamic
support, while allowing the patient to participate in ambulatory rehabilitation and prevent the complications of being bedbound for weeks while awaiting surgery.
The patient was supported for two weeks with VA-ECMO, at which point the septal defect was deemed
repairable, having completed the process of necrosis. With primary closure of the septal defect, further
decline in LVEF was anticipated. Extensive discussions were held with the patient and his wife prior
to surgery, and the patient consented to placement of a left ventricular assist device. Intraoperative
transesophageal echocardiography revealed a large, 2 cm defect (shunt fraction 3.8). Through an
anterior ventriculotomy the defect was found in the
mid septum, surrounded by firm fibrotic tissue that
allowed patch closure. A durable LVAD was inserted
after the septal defect had been repaired, and the
patient was transported to the recovery unit. He was
extubated on postoperative day one. Transthoracic
echocardiogram performed one week later showed no
residual interventricular shunt and he was discharged
to a rehabilitation facility. He is alive and well now
living at home more than one year after his MI without
experiencing any hospitalizations in the interim.
Volume
2011 - 2015
200
150
100
50
0
2011
2012
2013
2014
2015
Source: NewYork-Presbyterian
ECMO by Type
2015
n=177
49.7%
n=88 cases
50.3%
n=89 cases
Respiratory ECMO
Cardiac ECMO
Source: NewYork-Presbyterian
Transthoracic echocardiogram
2016 OUTCOMES AND QUALITY REPORT
|
17
ADVANCED HEART FAILURE
Founded over a quarter of a century
ago, the heart transplant program at
NewYork-Presbyterian has long been
a premier center, with a transplant
volume that is among the highest in
the country. More than 2,300 adult and
pediatric heart transplants have been
performed here since 1988.
Heart Transplant
Volume
2011 - 2015
100
80
60
40
20
0
2011
2012
2013
2014
2015
Source: NewYork-Presbyterian
18
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
HEART TRANSPLANT
NewYork-Presbyterian has one of the largest and most active advanced therapy
and heart transplant programs in the United States. Our surgeons and cardiologists
have a distinguished history of advancing the standards of care and the survival
rates of patients through innovative surgical techniques, applying basic research in
immunosuppression to the clinical setting, and by inventing and perfecting lifesustaining cardiac assist devices that prolong life while waiting for organ availability
or as a destination therapy for patients – including infants and small children – who
are not eligible for transplantation.
Extended Donor Organs Heart transplant surgery remains limited to the most
severe cases due, in part, to a shortage of donor hearts, which must pass through
a stringent screening process. Moreover, there are many patients who – because
of complicating health issues or age restrictions – are not eligible to be included on
the transplant waiting list, yet are in need of a transplant. To address these issues,
the heart transplant team at NewYork-Presbyterian expanded the usual criteria
by which donor hearts are accepted, and these alternate waiting list strategies for
heart transplantation are helping to maximize the use of extended donor organs.
As a result, waiting times to transplantation are lower here than at other centers in
the region, and the ability to transplant sooner translates into better post-transplant
outcomes.
The heart transplant program has implemented extended criteria protocols for both
organ donors and transplant recipients. Today, extended donor organs are utilized
routinely and may be offered to patients over age 65, as well as to patients formerly
considered too compromised to undergo transplantation. These extended criteria
protocols are significantly widening the availability of organs and providing the
option of transplantation with superior results to patients who would otherwise be
denied transplant.
Heart Transplant
Patient Survival
15%
80%
12%
60%
9%
40%
6%
20%
3%
1 Month
n=108
1 Year
n=108
NewYork-Presbyterian
Goyal P, Sterling MR, Beecy AN, Ruffino JT, Mehta
SS, Jones EC, Lachs MS, Horn EM. Patterns of
scheduled follow-up appointments following
hospitalization for heart failure: Insights from an
urban medical center in the United States. Clinical
Interventions in Aging. 2016 Sep 26;11:1325-32.
In-Hospital Mortality Rate
100%
0%
Selected Publications
3 Years
n=148
National
1 month (adjusted) January 1, 2013 - June 30, 2015
1 year (adjusted) January 1, 2013 - June 30, 2015
3 years (adjusted) July 1, 2010 - December 31, 2012
0%
2013
2014
Observed
0%
2015
Expected*
*Expected mortality was determined using UHC risk-adjustment methodology.
Source: Vizient Clinical Data Base/Resource Manager™ used
by permission of Vizient. All rights reserved.
Source: Scientific Registry of Transplant Recipients / srtr.org
Selected Clinical Trials
CIRT: Cardiovascular Inflammation Reduction Trial This NIH trial is investigating whether lowdose methotrexate reduces heart attacks, strokes, or death in people with type 2 diabetes or
metabolic syndrome who have had a heart attack or multiple coronary blockages.
COAPT Trial: Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for
Heart Failure Patients with Functional MR This study will evaluate the safety and effectiveness
of the MitraClip System for the treatment of moderate-to-severe or severe functional mitral
regurgitation in symptomatic heart failure subjects not appropriate for mitral valve surgery.
MOMENTUM 3 Continued Access Protocol This study will continue to evaluate the safety and
clinical performance of the HeartMate 3 Left Ventricular Assist System for the treatment of
advanced, refractory left ventricular heart failure.
PARACHUTE IV: Percutaneous Ventricular Restoration in Chronic Heart Failure This randomized
multicenter trial, which is designed to evaluate the Parachute implant, will enroll approximately
560 patients with ischemic heart failure in up to 80 centers in the U.S. The event-driven primary
endpoint includes all-cause mortality and hospitalization for worsening heart failure. (Phase III)
Vest AR, Kennel PJ, Maldonado D, Young JB,
Mountis MM, Naka Y, Colombo PC, Mancini DM, Starling RC, Schulze PC. Recovery of serum
cholesterol predicts survival after left ventricular assist device implantation. Circulation: Heart
Failure. 2016 Sep;9(9).
Willey JZ, Gavalas MV, Trinh PN, Yuzefpolskaya M,
Reshad Garan A, Levin AP, Takeda K, Takayama H, Fried J, Naka Y, Topkara VK, Colombo PC. Outcomes after stroke complicating left ventricular assist device.
The Journal of Heart and Lung Transplantation.
2016 Aug;35(8):1003-9.
Topkara VK, Garan AR, Fine B, Godier-Furnémont
AF, Breskin A, Cagliostro B, Yuzefpolskaya M, Takeda K, Takayama H, Mancini DM, Naka Y, Colombo PC.
Myocardial recovery in patients receiving contemporary left ventricular assist devices: Results from
the interagency registry for mechanically assisted
circulatory support (INTERMACS). Circulation: Heart
Failure. 2016 Jul;9(7).
Goyal P, Almarzooq ZI, Horn EM, Karas MG, Sobol I, Swaminathan RV, Feldman DN, Minutello RM,
Singh HS, Bergman GW, Wong SC, Kim LK. Characteristics of hospitalizations for heart failure with
preserved ejection fraction. American Journal of
Medicine. 2016 Jun;129(6):635.e15-26.
TAVR UNLOAD: Transcatheter Aortic Valve Replacement for Advanced Heart Failure The objective
of this study is to determine the safety and efficacy of transcatheter aortic valve replacement
via a transfemoral approach in heart failure patients with moderate aortic stenosis as compared
with optimal heart failure therapy.
2016 OUTCOMES AND QUALITY REPORT
|
19
PULMONARY HYPERTENSION
PROGRESS IN PULMONARY HYPERTENSION
Our physicians offer rare expertise in the multidisciplinary management of the
most complex multifactorial pulmonary hypertension across the spectrum of
all ages. These include idiopathic and heritable pulmonary hypertension, and
pulmonary hypertension related to diseases of the connective tissue, congenital
heart and left heart disease, and lung, hematological, oncologic, and renal and
hepatic diseases.
As one of the largest chronic thromboembolic pulmonary hypertension
(CTEPH) centers in the country, NewYork-Presbyterian is home to the only
regional multidisciplinary program for CTEPH, managing the most complex
patients in partnership with one of the largest accredited Pulmonary Hypertension Centers in the world. By offering advanced medical, interventional,
and surgical management of pulmonary hypertension and vascular disease,
including catheter-directed fibrinolytic therapy, balloon pulmonary angioplasty (BPA), pulmonary embolectomy and pulmonary thromboendarterectomy
(PTE), our center enables patients to access the entire spectrum of treatment
options. Our chronic thromboembolic pulmonary hypertension and pulmonary thromboendarterectomy program is one of the largest in the country
linked to an accredited Pulmonary Hypertension Center of Comprehensive
Care, and we have performed more than 120 pulmonary thromboendarterectomy surgeries with excellent outcomes.
Pursuing Critical Research The pulmonary hypertension programs established
at NewYork-Presbyterian more than 30 years ago have been at the forefront
of clinical advances made possible by researchers at Columbia University
Medical Center and Weill Cornell Medicine. They have long been leaders in the
field of genetic discovery in cardiovascular disease and, notably, pulmonary
arterial hypertension, having reported the very first mutation associated with
inherited forms of pulmonary hypertension. More recently, researchers here
have identified three novel genes for pulmonary hypertension using linkage
analysis, association studies, comparative genomic hybridization, and whole
exome/genome sequencing and RNA sequencing.
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
NewYork-Presbyterian’s Pulmonary Hypertension
Centers are now accredited by the Pulmonary
Hypertension Association as Pulmonary
Hypertension Centers of Comprehensive Care.
Columbia and Weill Cornell faculty have also participated in the major clinical trials for the development of new drug treatments for pulmonary hypertension,
and are currently pursuing studies of newer oral and inhaled therapies, including
intravenous Flolan®. They are also serving as collaborators in the National Heart,
Lung, and Blood Institute-sponsored Pulmonary Vascular Disease Phenomics
(PVDOMICS) study. This study will assemble a cohort of patients across the World
Health Organization groups 1 through 5 in order to redefine classifications of
pulmonary hypertension based on pathobiologic mechanisms.
CTEPH Registry Columbia University Medical Center participates in the
CTEPH Registry, a national registry to further our understanding of the natural
history of incident cases of chronic thromboembolic pulmonary hypertension
and interventions, including pulmonary thromboendarterectomy.
PAH Biobank NewYork-Presbyterian is an enrolling center for the National
Biological Sample and Data Repository for Pulmonary Arterial Hypertension
– also known as the PAH Biobank, a National Institutes of Health/National
Heart, Lung, and Blood Institute-funded resource of biological samples,
genetic data, and clinical data for the PAH research community. Its goal is to
further PAH research by providing the largest cohort of WHO Group 1 PAH
biological specimens and data for researchers to use in their studies.
Prevalence of Hypertension in Patients with Multiple Myeloma Weill Cornell
researchers are undertaking a retrospective data analysis of patients with
symptomatic untreated multiple myeloma currently undergoing evaluation of
induction chemotherapies.
CASE STUDY: HEREDITARY PULMONARY ARTERIAL HYPERTENSION
A 52-year-old woman with hereditary pulmonary arterial hypertension (HPAH),
initially diagnosed in 1998, was treated with subcutaneous remodulin, letairis,
and revatio, with a previous history of atrial septostomy (2006 and 2007), and
most recently metoprolol due to palpitations, PVCs and a hyperdynamic state.
Her medical history also includes ulcerative colitis and pancreatic and ovarian
cysts, and recent repeat genetic testing was positive for von Hippel Lindau
disease without known association with HPAH. She underwent her routine
monitoring, including right heart catheterization every two to three years,
CPET and cardiac MRI monitoring of her right ventricle yearly (Figure 1), and
follow-up of aneurysmal pulmonary artery dilatation and severe pulmonary
insufficiency. Over the years, her catheterization revealed a mPAP 56mm Hg in 1996, 73 in 2007; she was an acute nonresponder; and most recently her RA
3 PA 65/24/40 PA sat 74% PCW 8 normal coronaries. Her most recent cardiopulmonary stress test was a VO2 20.3 ml/kg/min (76%) R 0.91 VE/VCO2 35.2,
and 6 minute walk test of 600 meters.
Figure
1: Pulmonary arterial remodeling as demonstrated on contrast enhanced magnetic
resonance angiography (MRA). Note diffuse PA dilation involving the main and branch
pulmonary arteries (images shown in Inf-Sup [left], and AP [right] orientations)
Thus, given acceptable hemodynamics, well-preserved functional status, and
with a progressively increasing PA aneurysm, severe pulmonic insufficiency, and
concern of RV outflow obstruction with RV septal bulge, she was referred for
elective repair. Initial surgery included longitudinal opening of the pulmonic artery from just above the pulmonary valve out into the left hilum. The aneurysm
was large enough that both the left upper lobe and intermediate branches of the
pulmonary artery were actually within the mediastinal cavity. Extension of this
incision showed aneurysmal dilatation out to the right upper lobe pulmonary artery
as well. Trileaflet pulmonary valve was resected and replaced with a 23mm valve. A large portion of the pulmonary artery was then removed along the
anterior surface of both right and left main pulmonary arteries, as well as the
main pulmonary artery itself with initial thoughts of preservation of native PA
compliance and responsiveness to vasodilators. Intraoperative TEE did not show any RV outflow obstruction. However, later
that evening she went into RV failure and was taken back to the OR for
repair of pulmonary artery aneurysm with a 30mm woven Dacron graft and
insertion of a right ventricular assist device. She progressed well over the
next five days and her native ventricular function improved dramatically.
Plans were for explantation of the RVAD but then she was more urgently
taken back with diminished RVAD flows due to some acute outflow kinking;
she tolerated explantation of her RVAD well.
Pathology of the explanted pulmonary artery showed medial degeneration
and medial necrosis with fibrosis and lymphoplasmacytic inflammation of
the outer portion of the adventitia. No intimal or medial inflammation is
present (Figure 2).
Figure
2: Image A is a section of
A
pulmonary
artery stained with
hematoxylin
and eosin showing
cystic medial degeneration with
pools of mucopolysaccharide in
the media (long arrows). The outer
layer
of adventitia has fibrosis with
lymphoplasmacytic
inflammation
(short
arrows, magnification 40X).
Image
B is an elastic stain showing
fragmentation of the elastic fibers in the area highlighted by the rectangle (magnification
200X). Image C shows the adventitial inflammation at higher magnification (400X).
C
B
She is now doing well, following an initial course of inpatient rehabilitation
is less hyperdynamic, and is exercising regularly on a treadmill and doing
well. Repeat clinical testing will be done in the context of the PVDOMICS.
Extended genetic studies re the particular genetic abnormality of HPAH are
being sought out and she will require routine monitoring for VHL disease.
2016 OUTCOMES AND QUALITY REPORT
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21
PULMONARY HYPERTENSION
CASE STUDY: CTEPH AND PREGNANCY
A 28-year-old pregnant woman with a history of multiple DVTs presented at
15 weeks gestation to a local emergency department with acute shortness
of breath and mild hemoptysis. She had progressive dyspnea and cough
over the next 4 weeks and presented again at 19 weeks gestation with
dyspnea, cough, and hypoxia. Her oxygen saturation level was 92% on 4 L
nasal cannula. A transthoracic echocardiogram demonstrated signs of severe
pulmonary hypertension, and a chest CT with angiography had findings
consistent with chronic thromboembolic pulmonary hypertension (CTEPH).
The patient was transferred to NewYork-Presbyterian for specialized
management of her CTEPH and high-risk pregnancy. She underwent a
ventilation/perfusion scan, which was also consistent with the diagnosis
of CTEPH. Despite the known high risk of pregnancy and pulmonary
hypertension, the patient decided to proceed with the pregnancy. A
multidisciplinary team with experts from high risk obstetrics, pulmonary
hypertension, extracorporeal membrane oxygenation, thoracic surgery,
critical care, obstetric anesthesia, hematology, neonatology, and psychiatry
managed the patient through the remainder of her pregnancy.
The patient was admitted to the ICU and treated with a number of advanced
targeted pulmonary hypertension medications, including continuous
intravenous epoprostenol. She developed severe hemoptysis and underwent
urgent embolization of the bronchial artery collaterals. The patient had
recurrent large-volume hemoptysis at 27 weeks gestation and underwent
re-embolization. Her cough was suppressed, and she continued on targeted
PAH therapies and heparin. There was serious concern about recurrence
on the required anticoagulation for CTEPH, as well as many discussions
about the optimal timing of delivery in light of maternal and fetal risks. The
decision was made to deliver at 30 weeks gestation. General anesthesia and
intubation were accomplished uneventfully for repeat cesarean section. The
thoracic surgical team inserted guide wires into the right femoral artery and
right femoral vein to facilitate emergent ECMO cannulation if needed.
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Maternal intraoperative hemodynamic and respiratory status were
unremarkable. The infant had some early respiratory difficulties, but soon
improved and was discharged home with no residual medical problems. The
patient was extubated in the OR and sent to the medical intensive care unit,
where the expert ECMO teams are based.
Despite maximal medical therapy for pulmonary arterial hypertension,
the patient remained very symptomatic and dependent on supplemental
oxygen. A repeat right heart catheterization with selective pulmonary
angiograms was performed. Hemodynamic characteristics confirmed
severe PAH, and angiogram findings were consistent with bilateral chronic
thromboembolic disease (Figure 1).
The pulmonary hypertension and thoracic surgery teams scheduled PTE
when the patient’s condition was deemed stable at 6 weeks postpartum.
Hemodynamics demonstrated normalization of the pulmonary arterial
pressure in the immediate postoperative period without any operative
complications (surgical specimen shown in Figure 2). The patient was
discharged home on postoperative day 9 off all targeted PH medications
and off oxygen. The patient remains asymptomatic and continues to do well
with anticoagulation therapy. Her child remains in excellent health.
Figure 1
Figure 2
Reference Article Rosenzweig EB, Biscotti M, Cleary K, Smiley R, Bacchetta MD.
Chronic thromboembolic pulmonary hypertension, pregnancy, and a pulmonary
endarterectomy: A rare challenge. Pulmonary Circulation. 2016 Sep;6(3):384-88.
Selected Publications
Selected Clinical Trials
BEAT: Beraprost-314d Added-on to Tyvaso® This study will assess the efficacy
and safety of BPS-314d-MR when added on to inhaled treprostinil (Tyvaso®) in
patients with pulmonary arterial hypertension. (Phase III)
LARIAT: Bardoxolone Methyl Evaluation for Pulmonary Hypertension This
study assesses bardoxolone methyl relative to placebo in patients with pulmonary
hypertension to determine the recommended dose range, evaluate the change from
baseline in a 6-minute walk distance, and determine the effect of bardoxolone
methyl in pulmonary hypertension. (Phase II)
Macitentan for Pulmonary Hypertension after LVAD Implantation This study is
evaluating the effect of macitentan 10 mg on pulmonary vascular resistance as
compared to placebo in subjects with pulmonary hypertension after left ventricular
assist device (LVAD) implantation. (Phase IV)
PVDOMICS: Defining the Future Fingerprints of Pulmonary Vascular Disease
This prospective study is designed to lead to new understanding of patients
with pulmonary hypertension and right heart dysfunction, based on molecular,
clinical, hemodynamic, dynamic, and radiographic characteristics. Development of
new classifications will be a product of association of these in-depth phenotypic
descriptions with specific molecular mechanisms of pathogenesis. The protocol
will be implemented to lead to identification of both sub-phenotypes of lung
vascular disease and to biomarkers of disease that may be useful for early
diagnosis or for assessment of interventions to prevent or treat this condition.
Rituximab for Systemic Sclerosis-Associated Pulmonary Arterial Hypertension This trial will determine if rituximab has a marked beneficial effect on clinical
disease progression, with minimal toxicity, in patients with SSc-PAH when
compared to placebo. (Phase II)
TROPHY 1: Treatment of Pulmonary Hypertension – U.S. Study The objective
of this multicenter, nonrandomized study is to assess the safety, performance
and initial effectiveness of the TIVUS™ System when used for pulmonary artery
denervation through subjective and objective change in clinical parameters and
hemodynamic evaluation. (Not yet open for recruitment)
Rosenzweig EB, Chicotka S, Bacchetta M. Right ventricular assist device use in ventricular failure due to pulmonary arterial
hypertension: Lessons learned. The Journal of Heart and Lung
Transplantation. 2016 Oct;35(10):1272-74.
Krishnan U, Horn EM. A contemporary approach to pulmonary
arterial hypertension. Current Atherosclerosis Reports. 2016 Sep;18(9):58.
Zamanian RT, Levine DJ, Bourge RC, DeSouza SA, Rosenzweig EB,
Alnuaimat H, Burger C, Mathai SC, Leedom N, DeAngelis K, Lim
A, De Marco T. An observational study of inhaled treprostinil
respiratory-related safety in patients with pulmonary arterial
hypertension. Pulmonary Circulation. 2016 Sep;6(3):329-37.
Clark CB, Horn EM. Group 2 pulmonary hypertension: Pulmonary venous hypertension: epidemiology and pathophysiology.
Cardiology Clinics. 2016 Aug;34(3):401-11.
Evans JD, Girerd B, Montani D, Wang XJ, Galiè N, Austin ED,
Elliott G, Asano K, Grünig E, Yan Y, Jing ZC, Manes A, Palazzini
M, Wheeler LA, Nakayama I, Satoh T, Eichstaedt C, Hinderhofer
K, Wolf M, Rosenzweig EB, Chung WK, et al. BMPR2 mutations
and survival in pulmonary arterial hypertension: An individual
participant data meta-analysis. The Lancet. Respiratory Medicine.
2016 Feb;4(2):129-37.
Al-Naamani N, Palevsky HI, Lederer DJ, Horn EM, Mathai SC,
Roberts KE, Tracy RP, Hassoun PM, Girgis RE, Shimbo D, Post WS,
Kawut SM; ASA-STAT Study Group. Prognostic significance of
biomarkers in pulmonary arterial hypertension. Annals of the
American Thoracic Society. 2016 Jan;13(1):25-30.
Chiu JS, Zuckerman WA, Turner ME, Richmond ME, Kerstein D, Krishnan U, Torres A, Vincent JA, Rosenzweig EB. Balloon atrial
septostomy in pulmonary arterial hypertension: Effect on
survival and associated outcomes. The Journal of Heart and
Lung Transplantation. 2015 Mar;34(3):376-80.
2016 OUTCOMES AND QUALITY REPORT
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23
RHYTHM DISORDERS
OPTIMIZING ELECTROPHYSIOLOGY PROCEDURES
Patients with non-standard arrhythmias
and anatomical anomalies, such as
those with congenital heart disease, are
routinely referred to NewYork-Presbyterian
where the resources exist for providing
treatment that requires sophisticated
technology and specialized personnel
experienced in the field of rhythm disorders.
Electrophysiology Procedures
2015
n=2,970
2%
n=83
36%
n=1,064
28%
n=824
34%
n=999
Weill Cornell Medicine researchers have been at the forefront of studying leadless
pacemakers, which represent the newest device that can be offered to selected
patients with constant atrial fibrillation with erratic rhythms. The miniaturized
device, which is smaller than the size of a AAA battery, is placed with a steerable
catheter directly into the right ventricle via the femoral vein. The wireless device
reduces the risk of infection and removes the risk of wire compromise or damage.
Subcutaneous defibrillators are benefitting patients with heart abnormalities that
would make it very difficult, if not impossible, to have the standard devices implanted
surgically. Researchers at Columbia University Medical Center are major participants
in the PRAETORIAN trial evaluating subcutaneous versus transvenous implantable
cardioverter defibrillator therapy.
Columbia University Medical Center researchers are also investigating a number of
other avenues to optimize various aspects of electrophysiology procedures. These
include evaluating signal analysis to better perform ablation procedures, particularly
in patients with atrial fibrillation and atrial flutter; refining MRI to tailor how images
are collected for electrophysiology procedures; exploring how to improve data collection from electrograms, such as automating analysis for quicker accessibility and
interpretation of large volumes of data; and working with Columbia’s Engineering
Department to develop novel ways to image the heart to identify origins of arrhythmias
using only echocardiograms.
ADVANCES IN ABLATION TECHNIQUES
Ablations
Pacemakers
Lead Extractions
Implantable Cardioverter Defibrillators
Source: NewYork-Presbyterian
24
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Advances in technology continue to drive progress in the field of electrophysiology.
Most recently this includes the ability to visualize what occurs in the heart electrically
in addition to anatomically. This is particularly key in caring for adult congenital heart
disease patients who often present with arrhythmia complications related to their
extreme anatomical abnormalities. For example, patients with transposition of the
great arteries and prior Mustard procedures have major differences in their cardiac
anatomy and access to their atrial chambers for the treatment of atrial flutters. What
lesions did the patient have and what surgical procedures were performed to correct
them? Were artificial grafts used in the chambers of the heart? This information
needs to be taken into consideration when deciding how to reach the abnormal
electrical circuits to be ablated. It may require trans-baffle punctures in patients who
have undergone Mustard procedures. Treatment therefore involves considerable
coordination for the ablation therapy, interfacing with adult congenital heart disease
experts, cardiologists with expertise in imaging techniques, and often with the
surgeons who performed the patient’s earlier procedures.
At NewYork-Presbyterian, patients benefit from this collaboration and care by
physicians who have developed, studied, and continue to refine these procedures.
They employ CT imaging and MRI to visualize the heart’s chambers prior to the
procedure and intracardiac echocardiograms that provide real-time assessment and
assist in navigation of the catheters. Advanced technology and skill and experience of
practitioners have greatly decreased complications, increased success rates of these
procedures, and importantly, broadened the audience of patients who can benefit.
Mapping and Tracking Arrhythmias Prior to recent technological advances, the
complex and often transient nature of atrial fibrillation made mapping and tracking
its spillover of electrical impulses impossible. NewYork-Presbyterian has one of
the largest case volumes in the U.S. for ablation of ventricular tachycardia with
remote navigation. The magnetic-based system allows for very precise and accurate
movements of the catheters. With the use of a joystick, physicians can manipulate
the magnets to change the orientation and direction of the catheters, enabling entry
into crevices that are extraordinarily challenging to reach manually. The technology
has enhanced treatments for certain types of unusual arrhythmias that until now
were unsuccessful because of the lack of accessibility to certain areas of the heart.
Electroanatomic mapping
of atrial fibrillation
Device Volume by Type
2011 - 2015
1,000
800
600
400
200
0
2011
2012
2013
Pacemakers
2014
2015
ICDs
Source: NewYork-Presbyterian
Lead Extraction Volume
2011 - 2015
100
80
60
40
20
0
2011
2012
2013
2014
2015
Source: NewYork-Presbyterian
Atrial Fibrillation Ablation Complications Rate
2015
Pericardial Effusion/Tamponade
0.84%
Transient Ischemic Attack/Cerebrovascular Accident
0.47%
Myocardial Infarction
0.00%
Transfusion
0.00%
Source: NewYork-Presbyterian
2016 OUTCOMES AND QUALITY REPORT
|
25
RHYTHM DISORDERS
ADVANCES IN ABLATION TECHNIQUES
Catheter Ablations Volume
2011 - 2015
(continued from page 25)
In electroanatomic mapping, one magnet is located in the tip of the catheter and
another is positioned beneath the cath lab table. This allows physicians to know
at any time where the catheter is in three-dimensional space, enabling them to
mark any area where there is a suspicion of electrical activity that could be helping
to maintain or trigger the AF. Through a combination of touching the endocardial
surface with the catheter and integrating this information with the intracardiac
echo, as well as a pre-procedure CT scan, the left atrium is reconstructed in a threedimensional form.
1,200
1,000
800
600
400
200
0
2011
2012
2013
2014
2015
Source: NewYork-Presbyterian
Catheter Ablations by
Type of Arrhythmia
2015
n=1,064
45%
n=475
40%
n=426
12%
n=128
3%
n=35
Atrial Fibrillation
Supraventricular Tachycardia
Ventricular Tachycardia
Atrioventricular Node
Source: NewYork-Presbyterian
26
|
NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Contact Force-Sensing (CF-sensing) Catheters Our physicians are using the latest
catheters that provide information on the force that is being placed on the heart
during the ablation procedure to help determine whether the contact is suitable for
delivering an effective ablation lesion. Newer ablation catheters allow physicians to
assess whether adequate contact has been established with atrial tissue at the tip
of the catheter. Prior to the availability of the CF-sensing catheter, there was a 20 to
30 percent recurrence rate following atrial fibrillation ablations. The force-sensing
technology helps to overcome the challenge of drawing a complete line of block in a
great many different areas in the atrium. A gap in the line of block can jeopardize the
entire treatment. The CF-sensing catheter helps to ensure a complete lesion at each
site of the ablation.
Rotor Modulation Guided Procedures In order for an arrhythmia to be sustained,
there needs to be a substrate or perpetuator that allows atrial fibrillation to continue.
This is particularly relevant for patients with persistent atrial fibrillation. The
electrophysiological substrate is believed to be related to rapidly spinning rotors.
These perpetuators are often located in the left atrium; however, in as many as 25 percent of patients, the right atrium may participate. A novel diagnostic catheter
and mapping approach is enabling our physicians to pinpoint these rotors, which
cannot be observed with the naked eye. Extensive computerized processing of
electrical information highlights the coordinates of the rotors in a three-dimensional
projection so that the ablation catheter can be directed toward those regions.
Weill Cornell Medicine researchers are principal investigators for the multicenter
REAFFIRM study, which is evaluating rotor ablation followed by conventional ablation
versus conventional ablation alone for the treatment of persistent atrial fibrillation.
Weill Cornell is the only site in New York participating in this study.
Ablations without Fluoroscopy Our electrophysiologists are also pioneers in performing ablations on atrial fibrillation without fluoroscopy, reducing the time by 20 to 40
minutes for these complex procedures. Today, our physicians perform about 90 percent of ablation procedures for atrial fibrillation and 100 percent for atrial flutter without
any fluoroscopy. They have accomplished this through novel integration of the
existing technologies of intracardiac three-dimensional echocardiography with local
3-D electroanatomic mapping that has facilitated visualization of the heart and the
ability to track the catheter in such a way that was previously not possible.
For ablations of ventricular tachycardia, which involves the most intensive fluoroscopic
use – particularly in patients with structural heart disease – remote navigation is also
used, but with less than five minutes of fluoroscopy. A multicenter clinical trial is now
under development for the evaluation of a remote navigation system protocol for
ablation of ventricular tachycardia due to structural heart disease.
Selected Clinical Trials
PRAETORIAN: Comparison of Subcutaneous and Transvenous Implantable
Cardioverter Defibrillator Therapy This randomized controlled trial will
outline the advantages and disadvantages of the subcutaneous implantable
cardioverter-defibrillator compared to the transvenous ICD.
REAFFIRM: Atrial Fibrillation Treatment with Focal Impulse and Rotor
Modulation Guided Procedures This study is designed to assess the safety and
effectiveness of focal impulse and rotor modulation procedures followed by
conventional ablation, including PVI versus a standard PVI procedure, for the
treatment of persistent atrial fibrillation.
SENSE Trial: Sensing Atrial High Rate Episodes with Implantable Cardioverter
Defibrillators The primary aim of this trial is to assess the efficacy of an
implantable cardioverter-defibrillator lead with dedicated atrial sensing dipoles
in detecting atrial high rate episodes.
Selected Publications
Bunting E, Lambrakos L, Kemper P, Whang W, Garan H, Konofagou
E. Imaging the propagation of the electromechanical wave in heart
failure patients with cardiac resynchronization therapy. Pacing and
Clinical Electrophysiology. 2017 Jan;40(1):35-45.
Ciaccio EJ, Coromilas J, Wit AL, Peters NS, Garan H. Formation of functional conduction block during the onset of reentrant ventricular tachycardia. Circulation: Arrhythmia and Electrophysiology. 2016 Dec;9(12).
Ip JE, Cheung JW, Liu CF, Thomas G, Markowitz SM, Lerman BB.
Ablating the imperceptible: A novel application of para-hisian pacing.
Pacing and Clinical Electrophysiology. 2016 Nov;39(11):1285-88.
Ip JE, Cheung JW, Liu CF, Lerman BB. Loss of biventricular pacing: When common problems have unusual remedies. Pacing and Clinical
Electrophysiology. 2016 Aug;39(8):876-79.
Ip JE, Lerman BB. Validation of device algorithm to differentiate pacemaker-mediated tachycardia from tachycardia due to atrial tracking.
Heart Rhythm. 2016 Aug;13(8):1612-17.
Liu CF, Cheung JW, Ip JE, Thomas G, Yang H, Sharma S, Markowitz SM,
Lerman BB. Unifying algorithm for mechanistic diagnosis of atrial tachycardia. Circulation: Arrhythmia and Electrophysiology. 2016 Aug;9(8).
Hickey KT, Hauser NR, Valente LE, Riga TC, Frulla AP, Masterson Creber
R, Whang W, Garan H, Jia H, Sciacca RR, Wang DY. A single-center randomized, controlled trial investigating the efficacy of a mHealth ECG
technology intervention to improve the detection of atrial fibrillation:
The iHEART study protocol. BMC Cardiovascular Disorders. 2016 Jul 16;
16:152.
Biviano AB, Nazif T, Dizon J, Garan H, Fleitman J, Hassan D, Kapadia S,
Babaliaros V, Xu K, Parvataneni R, Rodes-Cabau J, Szeto WY, Fearon WF,
Dvir D, Dewey T, Williams M, Mack MJ, Webb JG, Miller DC, Smith CR,
Leon MB, Kodali S. Atrial fibrillation is associated with increased mortality in patients undergoing transcatheter aortic valve replacement:
Insights from the placement of aortic transcatheter valve (PARTNER)
trial. Circulation: Cardiovascular Interventions. 2016 Jan;9(1):e002766.
2016 OUTCOMES AND QUALITY REPORT
|
27
ADULT CONGENITAL HEART DISEASE
COMPREHENSIVE CARE FOR ADULT CONGENITAL HEART DISEASE
It is expected that by the year 2020 more adults than children will need openheart procedures to correct congenital heart defects. At NewYork-Presbyterian,
cardiologists, interventional cardiologists, cardiac surgeons, and cardiac imaging
specialists have come together to establish major programs in adult congenital
heart disease. They continue to develop the burgeoning field to ensure that
this growing adult population is treated by highly trained heart specialists who
understand the unique physiological, anatomical, and clinical features of congenital
heart disease at all ages.
NewYork-Presbyterian is one of the few programs in the
country with the depth and breadth of expertise to address
the multiple and complex anatomical abnormalities
that can present in adult congenital heart disease.
NewYork-Presbyterian has a long history of addressing the complex needs of
patients with adult congenital heart disease, having formed one of the first such
programs in 1987. A collective effort among adult and pediatric specialists, our
programs follow adult patients with a wide spectrum of congenital heart problems.
These include cardiac defects often first discovered in adulthood, such as atrial
septal defects and bicuspid aortic valve disease; complex birth anomalies that may
have already required multiple surgeries in childhood, such as tetralogy of Fallot,
transposition of the great arteries, coarctation of the aorta, and single ventricle
anatomy or Fontan circulation, as well as a large group of congenital heart patients
with pulmonary hypertension and Eisenmenger’s physiology.
Each year, cardiac surgeons with NewYork-Presybterian’s Congenital Heart Center perform more than 700 cardiac operations, including some 25 heart transplants, 175 newborn heart repairs, and 100 adult congenital heart repairs.
(continued on page 30)
Angiogram of a ventricular septal defect
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Adult Congenital Heart Surgery
2015
CASE STUDY:
ORTHOTOPIC BICAVAL HEART TRANSPLANT
25
20
15
10
5
0
Anomalous Aortic
Aortic Origin Surgery
of Coronary
Artery Surgery
Aortic
Valve
Surgery
Conduit
Heart
Transplant
Mitral
Valve
Surgery
Other Pulmonary Pulmonic
Cardiac
Artery
Valve
Surgery* Reconstruction Surgery
Tricuspid Ventricular
Valve
Septal
Surgery
Defect
*Other cardiac surgery: Fontan Procedure, Coarctation Repair, ECMO, Partial Anomalous Pulmonary Venous Connection,
Double-Chambered Right Ventricle Repair, PMI, Tetralogy of Fallot, Mediastinal Procedure, Transposition of the Great Arteries
Source: Society of Thoracic Surgeons (STS) National Database 2015
Interventions by Type
2015
n=396
40%
n=159
32%
n=127
28%
n=110
Atrial Septal Defect Repair
2015
200
150
100
50
0
Catheter
Atrial Septal
Defect Repair
Surgical
Atrial Septal
Defect Repair
Source: NewYork-Presbyterian
Catheter Interventions
Surgical Interventions
Electrophysiologic Implants
Source: NewYork-Presbyterian
A 33-year-old male had a history of L-transposition of great
arteries with ventricular septal defect, pulmonary atresia,
mesocardia, and aneurysmal left ward ascending aorta. He had multiple cardiac surgeries: first a right classic Blalock-
Taussig shunt in the neonatal period, then a modified
Blalock-Taussig shunt at 1 year of age, then a left modified
Blalock-Taussig shunt at 3 years of age, then a “physiologic repair” with VSD patch closure and 19mm homograft conduit between the left ventricle and the pulmonary arteries
at 9 years of age, and finally the implantation of a pacemaker
for heart block. He also had a history of atrial fibrillation and
pulmonary embolism (on coumadin). He then developed a
heart failure on his systemic right ventricle.
He was admitted to NewYork-Presbyterian and required
femoral intra-aortic balloon pump and multiple ionotropes
for hemodynamic support. The patient was listed for heart
transplant. This heart transplant was high-risk given his clinical status, his anatomy (pulmonary artery on the right, aorta
on the left, related to the L-transposition of great arteries), his
multiple cardiac surgeries and sternotomies, and the presence
of a highly calcified LV-PA homograft behind the sternum.
The patient underwent a complex orthotopic bicaval heart
transplant with extraction of LV-PA conduit, patch plasty of
the pulmonary artery confluence, aortoplasty to be able to
connect the donor vessels (normal anatomy) and recipient
vessels (ccTGA anatomy), and extraction of pacemaker generator and leads. Discharge echocardiography and right heart
catheterization with endomyocardial biopsy showed a good
biventricular function, with normal right heart pressures and
biopsy showing ISHLT Grade 0 at the time of discharge.
2016 OUTCOMES AND QUALITY REPORT
|
29
ADULT CONGENITAL HEART DISEASE
COMPREHENSIVE CARE FOR ADULT CONGENITAL HEART DISEASE
Meeting Surgical Challenges With major successes in the surgical, medical, and
critical care of infants with congenital heart disease, these patients are living into
adulthood. However, as adults, many require reoperations. For example, adults who
have had surgery for hypoplastic left heart syndrome as children face an uncertain
future in terms of the right ventricle. Some of these patients can have very complex
anatomy as adults. When they require further surgery, whether it is a corrective
surgery, valve replacement, or a transplant, their physiology and anatomy are so
complicated that they should be operated on by pediatric and congenital cardiac
surgeons. NewYork-Presbyterian cardiac surgeons are very versatile in pediatric
congenital heart surgery, enabling them to address these different types of patients
as adults with their unique anatomy and physiology.
Selected Clinical Trials
ADVANCE ASO AMPLATZER™ Atrial Septal Occluder
Post Market Surveillance This prospective, multicenter,
case-cohort study aims to identify potential risk factors
associated with the occurrence of erosion due to
implantation of the AMPLATZER™ Septal Occluder.
Portico™: Resheathable Transcatheter Aortic Valve System
U.S. IDE Trial This prospective, multicenter, randomized,
controlled clinical study is designed to evaluate the safety
and effectiveness of the SJM Portico Transcatheter Heart
Valve and Delivery Systems (Portico) via transfemoral and
alternative delivery methods.
TRACTOR: Ticagrelor Therapy for RefrACTORy Migraine This pilot study evaluates treatment of 40 patients with
right to left shunt to assess the hypothesis that P2Y,
G protein-coupled 12 (P2Y12) inhibition with Brilinta/
ticagrelor (90 mg PO twice a day) reduces episodic and/or
chronic migraine headache symptoms. (Phase IV)
Congenital bicuspid disease is one condition seen frequently in adults because the
valves replaced early on are prone to deterioration. Bicuspid valves create turbulent
flow and because of that the wear on them is greater than with a normal tricuspid
valve. These patients present with varying degrees of symptomatic aortic stenosis
down the line. The vast majority are classified Sievers 1, which represents a partial
raphe between two of the three native aortic valve cusps. Less common would be
a complete fusion between two of the three cusps, and the least common form
would be two cusps and no evidence of a third cusp whatsoever. Bicuspid valves
generally fail earlier than their tricuspid counterparts, typically in middle-age.
In addition to correcting these challenging conditions with standard open-heart
surgery, our surgeons are pursuing alternative technologies and techniques that
include the Portico™ resheathable transcatheter aortic
valve system. Weill Cornell Medicine is a major participant
in the Portico™ clinical trial evaluating this transcatheter,
self-expanding, nitinol-based valve. The valve, which is
retrievable and repositionable, is used for patients with all
forms of aortic stenosis, including those who have varying
degrees of congenital malformations.
Portico™ transcatheter aortic heart valve (Courtesy of St. Jude Medical)
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Rapid Growth of Interventional Procedures While medical and surgical therapies for
congenital heart disease have made significant strides in recent years, the field of interventional cardiology has, at the same time, experienced rapid growth. NewYorkPresbyterian’s interventional cardiologists have particular expertise in performing
structural interventions for adults with uncorrected congenital heart defects,
including patent foramen ovale (PFO) and atrial septal defects.
Selected Publications
Patients considered for PFO closure are primarily those with cryptogenic stroke,
ranging in age from their teens to early sixties. Every patient who is a candidate for
PFO closure is assessed carefully with multiple diagnostic modalities to ensure that
they do not have other cardiac or vascular defects that could give rise to stroke. They
are evaluated for rhythm disorders, coagulation abnormalities, and other structural
and vascular defects, to make sure that they are truly cryptogenic and that there are
no contraindications to receiving a device.
Lewis MJ, Hecht E, Ginns J, Benton J, Prince M, Rosenbaum MS.
Serial cardiac MRIs in adult Fontan patients detect progressive
hepatic enlargement and congestion. Congenital Heart Disease.
2016 Nov 28. [Epub ahead of print]
Over the past 15 years, PFO closure has been performed using off-label devices
approved for atrial septal defects. As of October 2016, the FDA has approved the
AMPLATZER™ PFO Occluder as the first device in the U.S.
officially indicated for PFO closure in cryptogenic stroke. Longterm data from the pivotal RESPECT trial showed a 45 percent
relative risk reduction of recurrent ischemic stroke with device
closure compared to medical therapy alone.
AMPLATZER™ septal occluder
(Courtesy of St. Jude Medical)
NewYork-Presbyterian’s interventional cardiologists
have particular expertise in performing
structural interventions for adults with
uncorrected congenital heart defects, including
patent foramen ovale and atrial septal defects.
Singh HS, Benson L, Osten M, Horlick E. Cardiac Catheterization
in Adult Congenital Heart Disease. Diagnosis and Management
of Adult Congenital Heart Disease. Ed. M.A. Gatzoulis, G.D.
Webb, and P.E.F. Daubeney. Philadelphia, Elseiver. [Expected in
print April 2017]
Lewis M, Ginns J, Schulze C, Lippel M, Chai P, Bacha E, Mancini D, Rosenbaum M, Farr M. Outcomes of adult patients with congenital heart disease following heart transplantation: The impact
of disease type, prior thoracic surgeries and bystander organ
dysfunction. Journal of Cardiac Failure. 2016 Jul;22(7):578-82.
Vida VL, Bacha E, Stellin G. Evolving hybrid approaches: The
preservation of the ‘neglected’ pulmonary valve function
in patients with congenital heart disease. Expert Review of
Cardiovascular Therapy. 2016 Jul;14(7):793-98.
Lee TM, Bacha EA. Copy number variants in congenital heart
disease: A new risk factor impacting outcomes? The Journal of
Thoracic and Cardiovascular Surgery. 2016 Apr;151(4):1152-53.
Lewis MJ, Ginns JN, Ye S, Chai P, Quaegebeur JM, Bacha E,
Rosenbaum MS. Postoperative tricuspid regurgitation after
adult congenital heart surgery is associated with adverse
clinical outcomes. The Journal of Thoracic and Cardiovascular
Surgery. 2016 Feb;151(2):460-65.
2016 OUTCOMES AND QUALITY REPORT
|
31
HYPERTROPHIC CARDIOMYOPATHY
NewYork-Presbyterian’s hypertrophic
cardiomyopathy program has the depth
and breadth of experience to provide
seamless care for patients at every age
and at every stage of this disease.
NewYork-Presbyterian’s hypertrophic cardiomyopathy (HCM) program
brings together expertise in adult and pediatric cardiology, imaging, cardiac
interventional techniques, and surgery to address this common cardiac
disorder affecting one in 500 people. Our clinicians care for patients with
HCM and their families at every stage of the disease. This includes the
screening and assessment of first-degree relatives for HCM-related genes.
With funding from the National Institute on Aging, Columbia University
Medical Center researchers are exploring the higher prevalence of
cardiovascular disease that leads to manifestations of HCM in the elderly.
Our HCM program manages patients with medications; a personalized program of exercise, diet, and nutrition; and interventions ranging from implantable
cardioverter defibrillators to septal ablation or surgical myectomy. In the
rare situation when a patient progresses to end-stage HCM, we are able to
offer heart transplantation.
Innovations in Surgical Approaches Septal myectomy has been considered
the gold standard for the treatment of severe, medically refractory symptoms
resulting from left ventricular outflow tract obstruction. The classic surgical approach is the Morrow procedure, which involves gaining access to the ventricular septum by way of an aortotomy across the aortic valve. Limitations of this procedure are a midline sternotomy and a prolonged postoperative
recovery.
Cardiothoracic surgeons at NewYork-Presbyterian/Weill Cornell have recently performed robot-assisted septal myectomy for HCM. This minimally invasive
32
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
approach, rather than going through the aortic valve, takes a more direct
path by entering from the right chest and going through the mitral valve to
resect the septum. While there is not yet enough evidence to confirm that
outcomes from the robotic approach are better than the Morrow procedure,
our surgeons have reported excellent results to date.
Stem Cell Research Columbia researchers are utilizing a form of personalized
stem cells that can be derived from a patient’s skin sample in order to develop
human cardiomyocyte models of genetic heart disease, including HCM. While
researchers know a good deal about the genes that are defective in HCM
patients, there is little known about the downstream events that lead to
hypertrophy of the heart muscle and the predisposition for sudden cardiac death. Skin samples taken from patients with HCM will permit the researchers to directly study patients’ heart cells in the laboratory. These studies may lead to new insights in the pathogenesis of HCM at the cellular and molecular
level, potentially resulting in novel treatment for this debilitating disease.
Novel Markers of Prognosis Weill Cornell Medicine researchers are seeking
to develop a predictive model of cardiovascular outcomes in HCM by using
exploratory data mining methods to identify demographic, clinical, and
novel cardiovascular magnetic resonance imaging, genetic, and biomarker
variables associated with the outcomes. They are also developing a score
from the predictive model that can be used to assess risk given a patient’s
combination of risk factors, thus establishing the evidence base to develop a
clinical trial designed to reduce morbidity and mortality in HCM.
Selected Publications
SinTakayama H, Chung WK, Maurer MS, Ginns JN. Hypertrophic
cardiomyopathy: New approaches and a time to reappraise older
approaches. The Journal of Thoracic and Cardiovascular Surgery. 2016
Oct;152(4):983-88.
CARDIO-ONCOLOGY
NewYork-Presbyterian physicians are skilled in
developing treatment strategies for cardiovascular
toxicities associated with cancer therapies
and also provide comprehensive care
for patients with existing cardiovascular issues
who have been newly diagnosed with cancer.
NewYork-Presbyterian’s program in cardio-oncology brings together experts
in clinical cardiology, clinical oncology, cardiovascular imaging, cardiac
surgery, and cardiac pathology. This broad expertise and experience is
enhanced by access to the most advanced medical therapies and cuttingedge surgical technologies currently available.
Our cardio-oncology program provides care for patients who may experience cardiac side effects from traditional cancer therapies. Many of the
commonly used new biologic agents have known cardiotoxic effects. Our
physicians are skilled in developing treatment strategies for cardiovascular
toxicities associated with cancer therapies. We also provide comprehensive
care for patients with existing cardiovascular issues who have been newly
diagnosed with cancer, working closely with the oncology team to identify chemotherapy agents that are safer for the heart. A major goal of the cardio-
oncology program is to enable patients to remain on chemotherapy while
minimizing cardiac damage.
NewYork-Presbyterian’s cardio-oncology program provides:
• Inpatient and outpatient consultations for patients with cancer
Researchers at Columbia University Medical Center and Weill Cornell Medicine are focused on identifying mechanisms for cancer-related cardiac disease
and improving cardiovascular outcomes in cancer patients.
Cardiac Tumor Program Cardiac tumors are a rare but serious condition
that require a specialized center to achieve optimal patient outcomes.
NewYork-Presbyterian’s program is one of only a few such programs in the
region dedicated to caring for patients with a cardiac mass. Patients with
tumors unresponsive to chemotherapy or radiation therapy are frequently
referred to our program for care. There are two broad categories of patients
who present with cardiac tumors: those who have primary cardiac tumors
and those who have other tumors within the chest that invade the heart
or great vessels. Our cardiothoracic surgeons have particular expertise in
performing great vessel resection and reconstruction.
Our patients also benefit from access to the most advanced medical therapies
and surgical technologies, as well as the latest oncology clinical trials for
primary tumors or metastatic disease of the heart.
Lipoma in a left cardiac ventricle
• Adult cancer survivors clinic
• Childhood cancer survivors clinic
2016 OUTCOMES AND QUALITY REPORT
|
33
VALVE DISEASE
NewYork-Presbyterian has established leading programs in the treatment of valve
disease through multidisciplinary approaches that include surgical, interventional,
and hybrid options. Columbia University Medical Center and Weill Cornell Medicine
clinicians across cardiovascular specialties are at the vanguard of landmark clinical
trials in the development, evaluation, and refinement of novel, less-invasive
techniques for repairing and replacing damaged aortic, mitral, and tricuspid valves.
Valve Procedures
Volume
2011 - 2015
2,500
2,000
1,500
1,000
500
0
2011
2012
2013
2014
2015
Source: NewYork-Presbyterian
NewYork-Presbyterian physicians have performed
more than 2,000 TAVR procedures since 2005. Our
TAVR program is now among the top volume centers
in the United States, with over 550 cases in 2015, and
70% of our patients are discharged in two days or less.
TRANSFORMATIVE AORTIC VALVE PROCEDURES
Procedures by Location
2015
n=2,321
27%
n=617
65%
n=1,505
Aortic Valve
Tricuspid Valve
Mitral Valve
Pulmonic Valve
Source: NewYork-Presbyterian
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
7%
n=154
2%
n=45
Aortic stenosis is a life-threatening condition that is present in more than 3 percent
of the population, and the average age at presentation is 75 – a time when comorbidities
often prevent patients from tolerating surgical therapies. Therefore, much of the focus
on treatment of aortic valve disease and aortic stenosis has moved toward minimally
invasive treatment, as well as expanding indications for any patients at high risk for
surgery who may benefit from less-invasive approaches in which the paramount
advantage is quick recovery.
Surgical valve replacement continues to be an important option for patients. These include patients with aortic stenosis, especially for younger patients, those
with bicuspid aortic valves, and those requiring concomitant cardiac procedures.
Determining which of several surgical approaches, including minimally invasive
incisions, as well as the type of prosthetic heart valve to be implanted – mechanical
or biologic – is facilitated by discussions among the heart team (cardiologists and
surgeons) weighing the pros and cons of each approach. These include tradeoffs
between the superior longevity of mechanical valves and the avoidance of lifelong
blood thinners with biologic valves. Valve Procedures
Procedures by Approach
2015
In-Hospital Mortality Rate
2015
Surgical Site Infection Rate
2011 - 2015
2,000
5%
1.0%
1,500
4%
0.8%
1,000
3%
0.6%
500
2%
0.4%
1%
0.2%
0
Transcatheter
Open Surgery
0%
Source: NewYork-Presbyterian
Isolated Open
Valve Surgery
Observed
All Open
Valve Surgery
0.0%
2011
2012
NewYork-Presbyterian
Expected*
2013
2014
Observed
2015
Surgical Site Infection
Standardized Infection Ratio = Observed/Expected
*Expected mortality was determined using
Vizient risk-adjustment methodology.
Source: National Healthcare Safety Network/
Department of Infection Prevention and Control
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
Aortic Valve Surgery
Aortic Valve Open Procedures Volume
2011 - 2015
1,200
In-Hospital Mortality Rate
2015
7%
1,000
800
6%
Stroke
1.8%
5%
Renal Failure - New Onset Dialysis
0.0%
30 Days Readmission - Unplanned
5.6%
Postoperative Infection
0.3%
4%
600
3%
400
2%
1%
200
0
0%
2011
2012
2013
2014
2015
Source: NewYork-Presbyterian
Isolated Aortic Valve Complications Rate
2015
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
Isolated Aortic
Valve Surgery
Aortic Valve
Replacement +
CABG
Observed
Aortic Valve
Replacement +
Mitral Valve Replacement
Expected*
*Expected mortality was determined using Vizient risk-adjustment methodology.
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
2016 OUTCOMES AND QUALITY REPORT
|
35
VALVE DISEASE
Transcatheter Valve Procedures
Volume
2011 - 2015
600
500
400
300
200
100
0
2011
2012
2013
2014
The TAVR Revolution Over the past decade, transcatheter aortic valve replacement
(TAVR) has undergone a tremendous evolution led by Columbia University Medical
Center researchers in surgery and interventional cardiology. This started in 2007
with the pioneering work of the PARTNER 1 trial, which established TAVR as the
standard of care for inoperable patients and as an alternative to surgery in high-risk
patients. The success of this trial set the stage for PARTNER 2, also led by Columbia
physicians, which focused on healthier patients in their 70s and 80s at intermediate
risk for surgery. These studies resulted in FDA approval of TAVR for intermediate
risk patients in 2016, as well as approval of a third generation transcatheter heart
valve, the Edwards SAPIEN 3 prosthesis. These major achievements have resulted
in a paradigm shift in the treatment of aortic stenosis. Today, TAVR has become an
important component of patient discussions, and our interventionalists and surgeons
speak with patients together to present all options in an open and unbiased manner.
2015
Source: NewYork-Presbyterian
The PARTNER Trial Journey
Transcatheter Valve Procedures
by Access
2015
n=567
15%
n=83
1%
n=7 1%
n=4
83%
n=473
Aortic
Mitral
Pulmonary
Tricuspid
Source: NewYork-Presbyterian
36
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Over the past decade, Columbia researchers, as part of a joint effort of surgeons and interventionalists,
have conducted a major series of clinical trials – the PARTNER Trials – with great success evaluating
catheter-based treatment of aortic valve disease. This work has resulted in close to 200 publications over
the past few years, including several in The New England Journal of Medicine and The Lancet, detailing
the significant outcomes of these clinical trials.
The newer generation TAVR devices are much smaller. The procedures can be
performed while the patient is awake. The rates of major vascular and bleeding
complications are much lower. And while the longevity of the valve replacement is still
under study, patients often prefer this technology because the hospital stay is only
one to two days and recovery is much quicker than with open surgery. With over a
10-year history of experience in TAVR – the longest in the nation – Columbia researchers
have now begun to study the longevity of valve replacement in patients who have had
the procedure.
PARTNER 3 for Low-Risk Patients The success of the PARTNER 1 and 2 trials in
higher-risk patients laid the groundwork for the current PARTNER 3 multicenter
study, which will compare TAVR using the SAPIEN 3 balloon-expandable platform
with surgical valve replacement in patients with symptomatic, severe aortic stenosis
who are at low operative risk. Columbia serves as a principal investigator for the
trial, which will begin to enroll approximately 1,200 patients across 50 sites. The
subjects will be age 65 or older with a Society of Thoracic Surgeons risk score of less
than 4 percent. The noninferiority trial has a primary endpoint comprising a one-year composite of death, stroke, or rehospitalization.
Embolic Prevention During TAVR About three to six percent of TAVR patients
experience a stroke caused by embolic debris that becomes dislodged when the
valve is replaced. Columbia researchers served as lead authors of an international
study demonstrating that transcatheter cerebral embolic protection (TCEP) is safe,
provides effective capture of embolic debris, and does not change neurocognitive
function for TAVR patients. The SENTINEL trial enrolled 363 patients at 19 hospitals
and is currently the largest randomized trial to examine the safety and efficacy of
using neuroprotection during TAVR.
Transcatheter Valve Repair
In-Hospital Mortality Rate
2015
5%
4%
3%
2%
1%
0%
TAVR - Transfemoral
Observed
MitraClip
Expected*
*Expected mortality was determined using
Vizient risk-adjustment methodology.
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
TAVR - Transfemoral
Complications Rate
2015
Postoperative Stroke
0.7%
Renal Failure - New Onset Dialysis
0.0%
30 Days Readmission - Unplanned
4.7%
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
2016 OUTCOMES AND QUALITY REPORT
|
37
VALVE DISEASE
MULTIPLE OPTIONS FOR MITRAL VALVE DISEASE
great success. This is due in large part to a high volume of isolated mitral
valve procedures performed by our surgeons. With increasing evidence
that mitral valve repair has superior outcomes to replacement, the surgical
treatment of mitral valve disease, particularly for mitral valve prolapse, is
becoming more of a specialty operation best performed at high-volume
academic medical centers.
As with many areas of cardiac disease, the state-of-the-art treatment of
mitral valve disease today is multidisciplinary and involves medical therapies,
surgical treatments, and transcatheter procedures. NewYork-Presbyterian’s
mitral valve centers offer patients a range of treatment options not available
just a few years ago. They continue to shift the surgical approach from
replacement to repair and from open surgery to minimal access methods –
including the less invasive mini-thoracotomy and robotic procedures – with
Minimally Invasive Mitral Valve Surgery Surgeons at NewYork-Presbyterian
have been performing minimally invasive mitral valve surgery since 1998,
and participated in the first clinical trials of robotic mitral valve repair over
15 years ago. The most common minimally invasive approach utilized by
our surgeons is a right mini-thoracotomy, which utilizes a three to four
inch incision between the ribs without cutting the breastbone, and allows
mitral valve repair or replacement, as well as associated procedures such as
tricuspid valve repair, atrial septal defect repair, and the Maze procedure for
atrial fibrillation. To date, our surgeons have performed over 1,500 mitral
valve operations via this minimally invasive approach and have taught this
technique to hundreds of surgeons from all over the world.
NewYork-Presbyterian is one of the nation’s
leading centers for mitral valve repair, which
is much more difficult and challenging than
mitral valve replacement, but provides
a better, more durable solution for most patients.
Mitral Valve Surgery
Mitral Valve Open Surgery Volume
2011 - 2015
In-Hospital Mortality Rate
2011 - 2015
600
6%
500
5%
400
4%
300
3%
200
2%
100
1%
0
2011
2012
2013
2014
2015
Source: NewYork-Presbyterian
0%
0%
Mitral Valve Repair
Isolated
Mitral Valve**
Observed
|
NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Postoperative Stroke
1.7%
Renal Failure - New Onset Dialysis
1.3%
30 Days Readmission - Unplanned
7.6%
Postoperative Infection
0.9%
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
Mitral Valve Repair
+ CABG
Expected*
*Expected mortality was determined using Vizient risk-adjustment methodology.
**Isolated mitral valve includes both mitral valve repair and replacement.
38
Isolated Mitral Valve Complications Rate
2015
The Evolving Role of Robotics The Hospital’s cardiac robotic surgery program, one
of the few in the country, continues to evolve with a surgical team led by a cardiac
surgeon with more than 15 years of experience in performing, evaluating, and
refining a wide range of totally robotic cardiac surgical procedures. The program
incorporates the newest iteration of robotics technology – da Vinci Xi® – for mitral valve
reconstructions. While the earlier versions of the da Vinci robot involved a fairly
large incision, the newest version has eight-millimeter ports. The da Vinci Xi surgical
system employs instruments that are as dexterous as a surgeon’s hands, but
considerably smaller, and a 3-D camera that provides vividly clear visuals.
The minimally invasive approach performed through small incisions on the right side
of the chest produces shorter hospitalizations of two to three days, less morbidity
postoperatively, and less pain and suffering. Considered the least invasive approach
of the mitral valve procedures, robotic surgery is typically found to be most beneficial in distant, small cavities or contained areas such as the left atrium where the mitral
valve sits. The robot really excels in these situations, making it possible to take the
camera into that small space and have the same degree of freedom as if the surgeon’s
hands were physically in that space.
CASE STUDY: ROBOTIC ENDOSCOPIC SURGERY
A 45-year-old man had increasing shortness of breath. He
went to his doctor who heard a murmur and sent him to
a cardiologist. An echocardiogram showed severe mitral
regurgitation. At first, his cardiologist recommended a surgeon
who would do the surgery in the traditional way through
the sternum (sternotomy). But the patient decided to search
the internet and found that there was a good alternative:
totally endoscopic
robotic mitral valve
repair available at
NewYork-Presbyterian.
His cardiologist
encouraged him to
explore all options.
After a consultation in
the office, the patient
proceeded with robotic endoscopic surgery. The procedure
went well and was performed with only tiny incisions. The
valve was repaired successfully and the patient went home
three days after surgery. He returned to work in three weeks,
much earlier than would be expected after sternotomy.
This patient’s case highlights many important issues. For one,
surgery in general is becoming much less invasive because
patients value that and there are now ways to maintain and
even improve on quality outcomes. The robotic surgical system
makes it possible to do mitral valve repair through incredibly
tiny incisions, as was done with this patient. (continued on page 40)
The procedure involves placing four pencil sized (8mm) ports
and one thumb-sized port (15mm) in the right chest. A
completely catheter-based system is used to go on the heartlung machine and stop the heart. NewYork-Presbyterian has
one of the few programs in the country to perform these
procedures through such small incisions.
2016 OUTCOMES AND QUALITY REPORT
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39
VALVE DISEASE
MitraClip
The Next Quantum Leap NewYork-Presbyterian is positioned at the cutting
edge of the next generation of techniques to manage patients with severe
and various forms of mitral valve disease. Collaboration among our surgeons
and interventionalists are already paving the way toward a new chapter in
percutaneous mitral valve replacement. The approach will essentially be
the mitral version of transcatheter aortic valve replacement. Experimental
evaluation of these devices has already begun, and four new early studies will
soon begin enrolling patients for repair or replacement of the mitral valve
using transcatheter techniques.
Complications Rate
2015
Postoperative Stroke
1.3%
Renal Failure - New Onset Dialysis
0.0%
30 Days Readmission - Unplanned
4.0%
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
New Technology for Mitral Regurgitation Patients with significant sympto-
matic degenerative mitral regurgitation who are not candidates for surgery are
benefitting from a new catheter-based treatment called MitraClip, patented
by physicians at NewYork-Presbyterian. The very low-risk procedure creates a
tissue bridge between the anterior and posterior leaflets using one or two clips
that are deployed through a trans-septal approach. A clip, which is mounted
on the end of a catheter, is advanced through a vein from the groin into the
left atrium. The clip is opened and advanced across the mitral valve. While the
heart is beating, the ends of the clip latch onto the flaps of the valve pinning
the leaflets together. The resulting bow-tie-shaped opening permits blood
flow when the heart relaxes, but prevents leakage or back flow when the heart
contracts. The MitraClip is now commercially available for high-risk patients
with degenerative mitral disease, and is under evaluation – in the COAPT multicenter trial – for patients with functional mitral disease.
Catheter-based
placement of MitraClip
40
|
NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Surgery without Bypass NewYork-Presbyterian/Columbia is a principal
investigator center for a multicenter international study evaluating
standard mitral valve repair surgery versus surgical repair using Gore-Tex
neochordae via the apex of the left ventricle in all risk patients with mitral
valve regurgitation. The Gore-Tex neochordae approach does not involve
cardiopulmonary bypass, enabling surgeons to correct a patient’s mitral valve
prolapse under normal physiologic beating-heart conditions.
TREATMENT FOR THE TRICUSPID VALVE
Tricuspid regurgitation is a very common condition afflicting about 1.6 million
people in the United States alone. However, because tricuspid valve disease
often presents in combination with right heart dysfunction, liver disease, or in
patients with prior cardiac procedures, tricuspid valve surgery has been associated
with a significant mortality rate. NewYork-Presbyterian physicians are leading
major programs to treat patients with tricuspid regurgitation via catheterbased techniques. Columbia researchers are leading a national trial of TriAlign,
an innovative catheter-based device for repair of the triscupid valve. Through a
transjugular approach, a pledgeted suture is used to cinch the valve, making the
leaflets close more fully, and thereby reducing the leak. Researchers at Columbia
are also evaluating the Edwards FORMA transcatheter valve system, another
minimally invasive way to repair the tricuspid valve. Using a catheter, physicians
place a foam-filled polymer balloon “filler” in the area of the leakage. The patient’s
leaflets coapt on the balloon and this reduces regurgitation.
Selected Publications
Selected Clinical Trials
COAPT Trial The purpose of the COAPT trial is to confirm the
safety and effectiveness of the MitraClip® System for the
treatment of moderate-to-severe or severe functional mitral
regurgitation in symptomatic heart failure subjects. (Phase III)
Concurrent Tricuspid Valve Repair During Mitral Surgery This study will determine whether repairing a tricuspid valve in
patients with mild-to-moderate tricuspid regurgitation at the
time of planned mitral valve surgery will improve heart health.
(Phase II)
INTREPID The purpose of this early feasibility study is to
evaluate the safety and initial performance of the Medtronic
Intrepid Transcatheter Heart Valve for treatment of mitral
valve disease.
PARTNER 3: SAPIEN 3 Transcatheter Heart This study will
establish the safety and effectiveness of the Edwards SAPIEN 3
transcatheter heart valve in patients with severe, calcific aortic
stenosis who are at low operative risk for standard aortic valve
replacement. (Phase III)
ReChord This trial will assess the effectiveness of the study
device in subjects undergoing mitral valve repair without
cardiopulmonary bypass compared to standard surgical
techniques with cardiopulmonary bypass.
REFLECT Trial: Cerebral Protection TAVI This study will
assess the safety and efficacy of the TriGuard™ HDH embolic
deflection device in patients undergoing TAVI. (Phase II/III)
SCOUT: Mitralign Percutaneous Tricuspid Valve Annuloplasty
System This study will assess the early safety and performance of the Mitralign Percutaneous Tricuspid Valve
Annuloplasty System for symptomatic chronic functional
tricuspid regurgitation.
Tricuspid Transcatheter Repair This early feasibility study will
measure clinical outcomes and effectiveness of the Edwards
FORMA Tricuspid Transcatheter Repair System.
de Biasi AR, Wong SC, Minutello RM, Voudris K, Worku B, Girardi LN, Salemi A. Short- and mid-term results after transapical transcatheter aortic valve replacement
in nonagenarians. Journal of Cardiovascular Surgery (Torino). 2017 Feb;58(1):99-104.
Lau C, Gaudino M, Mazza A, Munjal M, Girardi LN. Reoperative aortic valve replacement
in a previous biologic composite valve graft. Annals of Thoracic Surgery. 2016 Nov;
102(5):e477-e480.
McCarthy JR, Guy TS. Totally endoscopic robotic mitral valve surgery. AORN Journal.
2016 Oct;104(4):293-306.
Pagnesi M, Martino EA, Chiarito M, Mangieri A, Jabbour RJ, Van Mieghem NM,
Kodali SK, et al. Silent cerebral injury after transcatheter aortic valve implantation
and the preventive role of embolic protection devices: A systematic review and
meta-analysis. International Journal of Cardiology. 2016 Oct 15;221:97-106.
Eudailey K, Hamid N, Hahn RT, Kodali S, Gray W, George I. MitraClip followed by
surgical aortic valve replacement: Hybrid techniques for regurgitant aortic and
mitral valve disease. Annals of Thoracic Surgery. 2016 Aug;102(2):e83-5.
Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, et al; PARTNER 2
Investigators. Transcatheter or surgical aortic-valve replacement in intermediaterisk patients. The New England Journal of Medicine. 2016 Apr 28;374(17):1609-20.
Leontyev S, Davierwala PM, Krögh G, Feder S, Oberbach A, Bakhtiary F, Misfeld M,
Borger MA, Mohr FW. Early and late outcomes of complex aortic root surgery in
patients with aortic root abscesses. European Journal of Cardiothoracic Surgery.
2016 Feb;49(2):447-54; discussion 454-55.
Worku B, de Biasi AR, Gulkarov I, Wong SC, Salemi A. Transapical mitral valve-in-valve implantation for patients in cardiogenic shock. Annals of Thoracic Surgery. 2015;
99(5):e103-5. Argenziano M, Skipper E, Heimansohn D, Letsou G, Woo YJ, Kron I, Alexander J,
Cleveland J, Kong B, Davidson M, Vassiliades T, Krieger K, et al; for the EVEREST
Investigators. Surgical revision after percutaneous mitral repair with the MitraClip
device. The Annals of Thoracic Surgery. 2010 Jan:89(1):72-80.
Nifong LW, Chitwood WR, Pappas PS, Smith CR, Argenziano M, Starnes VA, Shah PM.
Robotic mitral valve surgery: A United States multicenter trial. The Journal of Thoracic
and Cardiovascular Surgery. 2005 Jun;129(6):1395-1404.
2016 OUTCOMES AND QUALITY REPORT
|
41
AORTIC DISEASE
With increasing experience and research
that has demonstrated proven durability
of aortic root valve-sparing surgery,
NewYork-Presbyterian surgeons are
making these procedures available to a
greater number of patients who can benefit.
Aneurysm size, valve dysfunction, and age
are no longer exclusionary criteria.
Aortic Procedures
Volume
2011 - 2015
600
500
400
300
200
100
0
2011
2012
2013
2014
2015
Source: NewYork-Presbyterian
42
|
NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
ADVANCING TREATMENT FOR AORTIC DISEASE
NewYork-Presbyterian’s cardiac and vascular surgeons have extensive experience and
expertise in the management of aortic diseases, including endovascular and surgical
approaches for valve replacement and repair, thoracic and abdominal aortic aneurysms,
and aortic dissection. They are supported by expert heart teams, comprised of cardiologists, radiologists, perfusionists, and nursing, that are key to our successful outcomes.
Aortic Root Aneurysms In the past, patients with an ascending aortic aneurysm
with fairly leaky aortic valves, or whose aorta was on the larger side (approaching
six centimeters), were not considered candidates for valve-sparing surgery with
the concern that the valves would likely fail. Today, with increasing experience,
our surgeons are now offering these procedures to a greater pool of patients and
performing them on a regular basis. Through their participation in clinical trials for
valve-sparing surgery, in particular those involving patients with Marfan’s syndrome,
our surgeons are finding that the operations are quite durable across a broad
spectrum of the disease – from patients with healthy valves and smaller aneurysms
to those who present with more complex circumstances, including aortic dissection. Aortic Root Replacement A study undertaken by Weill Cornell Medicine’s Department of Cardiothoracic Surgery looked at aortic root replacement in 890 consecutive patients
over a 17-year period who were operated on at NewYork-Presbyterian/Weill Cornell
Medical Center. The results demonstrated that in high volume aortic centers, aortic
root replacement (mechanical or composite valved graft, and valve-sparing reconstruction) can be performed with low perioperative risk. Operative mortality was 0.2 percent (0% in the valve-sparing reconstruction group), and the incidence of major postoperative complications was less than 0.5 percent. The researchers noted
that although the mechanical composite valved graft remains the gold standard for
durability, the biologic composite valved graft and valve-sparing reconstruction are
excellent options for those who cannot take or want to avoid long-term anticoagulation.
Custom Grafts More than half of patients treated by our cardiac and vascular
surgeons have had some prior aortic surgery, whether an endovascular stent graft
or an open surgical repair. Aneurysm disease can be progressive and other parts of
the aorta start to dilate with the original repair failing or the aorta failing above that
repair, further increasing the complexity of disease. The majority of these patients
require custom-designed grafts. Utilizing sophisticated CT imaging, our surgeons create
three-dimensional models to precisely design a stent graft built to the anatomical
specifications of each individual patient.
Aortic Procedures
Procedure Volume by Type
2015
High-Risk Surgical Cases NewYork-Presbyterian vascular surgeons are pursuing the development of endovascular devices for the treatment of aortic aneurysms in patients at
high risk for surgery. They are currently enrolling patients in an FDA-approved clinical trial
of custom-designed stent grafts for the treatment of thoracoabdominal aortic aneurysms.
No stent graft treatment is currently commercially available for these patients, many
of whom are over the age of 80. The minimally invasive stent graft device will allow
physicians to treat thoracoabdominal aortic aneurysms without the large incisions of
traditional open surgery, sparing patients the risk of major complications.
n=515
27%
n=141
70%
n=358
Iliac Branch Endoprosthesis NewYork-Presbyterian served as lead investigators of
the just completed multicenter nationwide trial of the Gore® Excluder® Iliac Branch
Endoprosthesis, the first off-the-shelf aortic branch device approved in the country
and the only device indicated for the endovascular treatment of common iliac artery
aneurysms or aortoiliac aneurysms. Results of the five-year trial in which more than
565 patients were treated will be published shortly.
Suprarenal Abdominal Aorta Well-established endovascular techniques are available
for the descending aorta and for the infrarenal abdominal aorta. Surgeons at NewYorkPresbyterian are now in the stages of development of endovascular approaches for the
suprarenal abdominal aorta. Treating aneurysm disease of the ascending aorta and the
aortic arch with endovascular approaches present some engineering challenges, and first
generation devices are now being tested in clinical trials.
Following the Genetic Link Weill Cornell Medicine researchers are investigating the
genetic linkage in younger individuals or individuals with a family history that may have
a genetic predisposition for their aneurysm disease. Their findings have implications for
specific medication therapies that are shown to be effective for preventing aneurysm
disease in patients with certain hereditary aneurysm conditions such as Marfan’s. In
addition, the information guides screening, as they may be harboring an aneurysm that
is asymptomatic and could put them at risk for a catastrophic occurrence.
3%
n=16
Open Surgery
Endovascular
Hybrid
Source: NewYork-Presbyterian
Procedure by Location Distribution
2015
100%
80%
60%
40%
20%
0%
Thoracoabdominal
Ascending/Arch/Descending
Descending
Ascending/Arch
Abdominal
Source: NewYork-Presbyterian
2016 OUTCOMES AND QUALITY REPORT
|
43
AORTIC DISEASE
Open Thoracic Aortic Repair
Selected Clinical Trials
Endovascular Thoracoabdominal Aortic
Aneurysm Repair (TAAA IDE) This prospective,
nonrandomized, single-center, single-arm
study will assess the feasibility and safety
of endovascular stent-graft implantation
using a standard configuration branched and
fenestrated stent graft or physician-specified
branched and fenestrated stent grafts
for treatment of thoracoabdominal aortic
aneurysms involving the mesenteric and renal
arteries in patients at high risk for open surgery.
N-TA^3CT: Non-Invasive Treatment of
Abdominal Aortic Aneurysm The primary aim
of this study is to determine if doxycycline
will inhibit by at least 40 percent the increase
in greatest transverse diameter of small
abdominal aortic aneurysms (3.5-5.0 cm in
men, 3.5-4.5 cm in women) over a 24-month
period of observation in comparison to a
placebo-treated control group. (Phase II)
PRESERVE-Zenith® Iliac Branch System Clinical
Extended Study This trial evaluates the
safety and effectiveness of the Zenith Branch
Endovascular Graft-Iliac Bifurcation System,
which is made up of two devices – the Zenith®
Branch Endovascular Graft-Iliac Bifurcation
and the ConnectSX™ covered stent – in the
treatment of aorto-iliac and iliac aneurysms.
44
|
NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Ascending Aorta and Aortic Arch
In-Hospital Complications Rate
2015
Volume
2011 - 2015
500
400
300
Acute Renal Failure - Early Onset Dialysis
1.0%
Deep Sternal Wound Infection
0.0%
Postoperative Stroke
200
100
0
1.7%
Source: NewYork-Presbyterian
2011
2012
2013
2014
2015
Source: NewYork-Presbyterian
Valve Sparing
In-Hospital Mortality Rate
2015
In-Hospital Mortality Rate
2015
5%
10%
4%
8%
3%
6%
2%
4%
1%
2%
0%
0%
Thoracic Aortic Repair
Observed
Expected*
0%
0%
Elective
Observed
Urgent/Emergent
Expected*
*Expected mortality was determined using Vizient
risk-adjustment methodology.
*Expected mortality was determined using Vizient
risk-adjustment methodology.
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
CASE STUDY:
THORACIC ENDOVASCULAR AORTIC REPAIR
A 36-year-old male presented with increasing shortness of breath, as well as a several week history of fever and night sweats. Investigations revealed streptococcus viridans endocarditis with severe aortic regurgitation, as well as a large aortic root
abscess. His past medical history was significant for aortic coarctation repair at the
age of 5. Preoperative CT examination revealed a 6.0 cm
aneurysm of the descending aorta (Figure 1).
Figure 1: CT angiogram revealing a large, saccular
aneurysm of the descending aorta s/p coarctation
repair. The patient presented with endocarditis
and aortic root abscess formation.
The patient underwent replacement of the aortic root and ascending aorta with a
“BioRoot” (i.e. pericardial valve sewn into a Gelweave graft), as well as autologous
pericardial patch reconstruction of the aortic annulus and intervalvular body.
His postoperative course was uncomplicated. Once the antibiotic therapy was
completed, the patient underwent thoracic endovascular aortic repair (TEVAR) of the
descending aorta with left subclavian-carotid bypass. The perioperative course was
uncomplicated and the patient was discharged home on day 3. He is alive and well
one year postoperatively with an unremarkable follow-up
CT scan (Figure 2).
Figure 2: Follow-up CT examination reveals complete
exclusion of the aneurysm and a patent carotid-subclavian
bypass. The green object is an Amplatzer device that was
used to occlude the proximal left subclavian artery.
Selected Publications
Gaudino M, Weltert L, Munjal M, Lau C, Elsayed M, Salica A, Gambardella I, Mills E, De Paulis R, Girardi LN; Cornell
International Consortium for Aortic Surgery (CICAS). Early
clinical outcome after aortic root replacement using a
biological composite valved graft with and without neosinuses. European Journal of Cardiothoracic Surgery. 2017 Feb 1;
51(2):316-21.
Girardi LN, Lau C, Munjal M, Elsayed M, Gambardella I, Ohmes LB, Gaudino M. Impact of preoperative pulmonary
function on outcomes after open repair of descending and
thoracoabdominal aortic aneurysms. Journal of Thoracic and
Cardiovascular Surgery. 2017 Feb;153(2):S22-S29.e2.
Girdauskas E, Rouman M, Disha K, Fey B, Dubslaff G, von
Kodolitsch Y, Reichenspurner H, Borger MA, Kuntze T.
Morphologic and functional markers of aortopathy in
patients with bicuspid aortic valve insufficiency versus
stenosis. Annals of Thoracic Surgery. 2017 Jan;103(1):49-57.
Lau C, Gaudino M, Mazza A, Munjal M, Girardi LN.
Reoperative aortic valve replacement in a previous biologic
composite valve graft. Annals of Thoracic Surgery. 2016
Nov;102(5):e477-e480.
Guglielmetti L, Nazif T, Sorabella R, Akkoc D, Kantor A, Gomez A,
Wang C, Takayama H, Dizon J, Borger M, George I. Bicuspid
aortic valve increases risk of permanent pacemaker implant
following aortic root replacement. European Journal of
Cardiothoracic Surgery. 2016 Sep;50(3):497-503.
Girdauskas E, Owais T, Fey B, Kuntze F, LaStephens EH, Borger MA. Getting to the root of the matter: management
of the aortic root in Type A aortic dissection. European
Journal of Cardiothoracic Surgery. 2016 Aug;50(2):230-31.
(continued on page 47)
2016 OUTCOMES AND QUALITY REPORT
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45
AORTIC DISEASE
Endovascular Procedures
CASE STUDY: TYPE B AORTIC DISSECTION
A 44-year-old male with a history of hypertension presented to an
outside hospital with acute onset tearing chest and back pain. A CT scan revealed an acute type B aortic dissection extending from
the left subclavian artery to the iliac arteries. He was managed
medically with antihypertensive medications and discharged home.
He presented to NewYork-Presbyterian four days later with acute
worsening of chest pain radiating to the neck and back. He had severe hypertension that required multiple different antihypertensive
medications to control. He had persistent pain as well. An endovascular stent graft was placed in his descending thoracic aorta, covering
the primary tear of the dissection. His pain resolved and his blood
pressure was better controlled with fewer medications.
Volume
2011 - 2015
200
160
120
80
40
0
2011
2012
Procedure Volume by Type
2015
n=141
2014
2015
Source: NewYork-Presbyterian
Procedure by Location Distribution
2015
100%
28%
n=39
59%
n=84
2013
80%
13%
n=18
60%
40%
Thoracic
Thoracoabdominal
Abdominal
20%
Endovascular Aortic Repair
Complex Aortic Repair*
Thoracic Endovascular Aortic Repair
0%
*Complex aortic repair: usage of fenestated and
branched stent grafts and thoracoabdominal repairs
Source: NewYork-Presbyterian
46
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Source: NewYork-Presbyterian
Endovascular Abdominal Aortic Repair (EVAR)
Selected Publications
(continued from page 45)
Procedure Volume by Location
2015
Girdauskas E, Rouman M, Disha K, Fey B, Dubslaff G,
Theis B, Petersen I, Gutberlet M, Borger MA, Kuntze T. Functional aortic root parameters and expression
of aortopathy in bicuspid versus tricuspid aortic
valve stenosis. Journal of the American College of
Cardiology: JACC. 2016. Apr 19;67(15):1786-96.
n=84
4%
n=4
20%
n=17
39%
n=33
3%
n=2
Leontyev S, Haag F, Davierwala PM, Lehmkuhl L, Borger MA, Etz CD, Misfeld M, Gutberlet M, Mohr FW. Postoperative changes in the distal residual aorta after surgery for acute type a aortic dissection: Impact of false lumen patency and size of descending
aorta. Journal of Thoracic and Cardiovascular Surgery.
2016 Apr 25. [Epub ahead of print]
34%
n=28
Infrarenal
Iliac
Iliac, Infrarenal
Suprarenal
Iliac, Juxtarenal
Iliac, Suprarenal
Juxtarenal
Pararenal
Source: NewYork-Presbyterian
In-Hospital Complications Rate
2015
Acute Renal Failure - Early Onset Dialysis
0.0%
39%
Deep Sternal Wound Infection
n=33
0.0%
Postoperative Stroke
0.0%
30 Days Readmission - Unplanned
2.4%
Source: NewYork-Presbyterian
In-Hospital Mortality Rate
2015
Worku B, Gulkarov I, Mack CA, Girardi LN, Salemi A. Ascending aortic aneurysm repair and surgical ablation for atrial fibrillation. Journal of Cardiothoracic
Surgery. 2015 Nov 26;10:174.
34%
10%
n=28
8%
6%
20%
n=17
4%
2%
0%
Sorabella RA, Wu YS, Bader A, Kim MJ, Smith CR,
Takayama H, Borger MA, George I. Aortic root replacement in octogenarians offers acceptable perioperative and late outcomes. Annals of Thoracic Surgery.
2016 Mar;101(3):967-72.
0%
0%
Elective
All EVAR
Observed
0%
Emergenct/Urgent
Expected*
*Expected mortality was determined using Vizient risk-adjustment methodology.
Gaudino M, Lau C, Munjal M, Avgerinos D, Girardi LN. Contemporary outcomes of surgery for aortic root
aneurysms: A propensity-matched comparison of valve-sparing and composite valve graft replacement. Journal of Thoracic and Cardiovascular Surgery. 2015
Nov;150(5):1120-29.
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
2016 OUTCOMES AND QUALITY REPORT
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47
CEREBROVASCULAR DISEASE
CAROTID ARTERY DISEASE
Selected Clinical Trials
CREST-2: Carotid Revascularization and Medical
Management for Asymptomatic Carotid Stenosis Trial Weill Cornell Medicine and Columbia University Medical
Center are participating in the NIH-funded multicenter
CREST-2 study of carotid treatment for patients with
asymptomatic carotid atherosclerotic stenosis. The study
compares a combination of carotid endarterectomy and
intensive medical management to intensive medical
management alone, and carotid artery stenting combined
with intensive medical management to intensive medical
management alone, in two separate arms. Columbia and
Weill Cornell are the only sites in New York City participating
in CREST-2.
Selected Publications
Siracuse JJ, Epelboym I, Li B, Hoque R, Catz D, Morrissey NJ. External carotid artery stenosis after internal and common carotid stenting. Annals of Vascular Surgery. 2015 Apr;29(3):
443-46.
48
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
NewYork-Presbyterian’s vascular and endovascular surgery centers are among the
highest volume programs in New York State, providing traditional vascular procedures as well as innovative and minimally invasive endovascular therapies. Our
specialists offer comprehensive treatments for carotid artery disease and cerebrovascular disease to prevent stroke, including medical management, endarterectomy, and
more minimally invasive carotid artery stenting. We emphasize less invasive treatments that shorten recovery time and improve patient outcomes. Our physicians
are performing fewer carotid interventions, largely for patients with asymptomatic
disease, because they believe that medical therapy in many cases may be preferable.
NewYork-Presbyterian’s vascular and
endovascular surgery centers are among the
highest volume programs in New York State.
Our endovascular specialists provide expertise in screening and surveillance with
noninvasive tests, including carotid ultrasound, CT angiography, and MR angiography.
Patients benefit from our state-of-the-art endovascular operating room suites that combine robotics and 3-D imaging, enabling us to safely perform the most advanced endovascular treatments available today.
Transcarotid Revascularization (TCAR) NewYork-Presbyterian physicians are helping
to develop a nationwide multicenter clinical trial and registry studies designed to
monitor the safety and effectiveness of stents placed directly into the carotid artery
while reversing blood flow within the carotid artery to reduce stroke risk. Surgeons
access the carotid artery through a mini incision at the base of the neck using local
anesthetic rather than accessing the artery remotely with catheters from the groin,
thereby avoiding the risks of entering through complex aortic arch anatomy. The
remainder of the procedure is performed with a stenting technique, providing
embolic protection. Our surgeons still apply advanced stenting technology, but more
safely in that they can control blood flow in the artery and prevent debris, fragments,
or embolization to the brain that can cause stroke.
Carotid Artery Procedures
Volume
2011 - 2015
n=1,015
250
200
1.5%
1.0%
30%
n=303
150
100
0.5%
0.0%
70%
n=712
50
0
In-Hospital Mortality Rate
2015
Procedure Volume by Type
2011 - 2015
2011
2012
2013
2014
0%
0%
Carotid Artery
Stenting
Observed
2015
Carotid Artery
Endarterectomy
Expected*
*Expected mortality was determined using
Vizient risk-adjustment methodology.
Source: NewYork-Presbyterian
Carotid Artery Endarterectomy
Source: Vizient Clinical Data Base/Resource ManagerTM
used by permission of Vizient. All rights reserved.
Carotid Artery Stenting
Source: NewYork-Presbyterian
Adverse Events
Perioperative through 30 Days Post-Procedure
2015
Myocardial Infarction
Stroke
Death
10%
10%
10%
8%
8%
8%
6%
6%
6%
4%
4%
4%
2%
0%
0%
CAS
Asymptomatic
0%
CAS
Symptomatic
NewYork-Presbyterian
2%
0%
CAE
Asymptomatic
Benchmark
CAE
Symptomatic
0%
2%
0%
CAS
Asymptomatic
CAS
Symptomatic
NewYork-Presbyterian
CAE
Asymptomatic
Benchmark
CAE
Symptomatic
0%
0%
CAS
Asymptomatic
0%
0%
CAS
Symptomatic
NewYork-Presbyterian
CAE
Asymptomatic
CAE
Symptomatic
Benchmark
CAS: Carotid Artery Stenting
CAE: Carotid Artery Endarterectomy
Source: NewYork-Presbyterian
Benchmark Source: Joint Commission on Accreditation of Healthcare Organizations; Advanced Disease-Specific Care Certification Requirements for Comprehensive Stroke Center (CSC) 2015
2016 OUTCOMES AND QUALITY REPORT
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49
PERIPHERAL VASCULAR DISEASE
COMPREHENSIVE CARE FOR PERIPHERAL VASCULAR DISEASE
NewYork-Presbyterian brings together vascular specialists in cardiology, radiology,
and vascular surgery for the management of patients with peripheral vascular
disease. For lower extremity disease, patients receive targeted therapies to manage
limb-threatening ischemia, non-healing wounds, pain with walking, and diabetes.
We provide medical management, as well as catheter-based minimally invasive
procedures, and surgical bypass, with minimally invasive revascularization techniques
utilized whenever possible.
Program for Advanced Limb Preservation NewYork-Presbyterian specializes in
treating lower extremity wounds in patients at high risk for amputation, particularly
those with diabetes and peripheral artery disease. Patients with diabetes oftentimes
have multiple medical conditions and severe vascular disease that lead to tissue
breakdown and the formation of wounds and ulcers, development of pain at rest,
and gangrene in the foot, toes, or limb. Our physicians are skilled in emergent
revascularization for these patients, as well as managing their myriad and complex
comorbidities, including heart disease and renal failure.
Through the Program for Advanced Limb Preservation, an interdisciplinary team of
vascular specialists, podiatrists, plastic surgeons, and other experts is dedicated solely to
healing wounds and preventing amputations in patients with diabetes, PAD, and other
vascular problems. The program is New York City’s only tertiary limb salvage program
providing comprehensive diagnostic evaluation, advanced wound care treatments, including hyperbaric oxygen therapy, surgical and minimally invasive vascular procedures,
reconstructive foot surgery, and investigational treatments such as stem cell therapy.
Vascular Diagnostic Laboratory NewYork-Presbyterian’s Vascular Diagnostic
Laboratory provides advanced diagnosis, treatment, and prevention approaches for
diseases of the vascular or circulatory system. Comprised of three dedicated labs
and two advanced treatment rooms for minimally invasive procedures, the Vascular
Diagnostic Laboratory performs a wide array of noninvasive vascular studies. Among
the testing modalities are carotid duplex ultrasound, aortic ultrasound, venous
ultrasound, vein mapping, arterial duplex imaging of upper and lower extremities,
digital photoplethysmography, and thoracic outlet syndrome evaluation.
Peripheral vascular disease
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
Peripheral Vascular Procedures
Selected Clinical Trials
Peripheral Arterial Revascularization Procedures
2011 - 2015
2,000
1,500
1,000
500
0
2011
2012
Endovascular
2013
Bypass
2014
2015
BEST-CLI: Best Endovascular versus Best Surgical Therapy
Critical Limb Ischemia This study compares the effectiveness of the best available surgical treatment with the best
available endovascular treatment in adults with critical
limb ischemia who are eligible for both treatment options.
WISE LE: Evaluation of WIRION™ EPS in Lower Extremities
Arteries This study seeks to demonstrate the safety and
performance of the WIRION EPS in patients undergoing
lower extremity atherectomy for peripheral arterial disease.
Endarterectomy
Source: NewYork-Presbyterian
Selected Publications
Lower Extremities Peripheral
Interventions by Technique
2015
Vascular Laboratory
Volume by Type
2015
n=2,364
n=30,102
100%
80%
29%
n=683
58%
n=1,367
13%
n=314
60%
40%
20%
0%
Venous Duplex
Arterial Duplex
Physiological Testing
Angioplasty
Stent
Atherectomy
Source: NewYork-Presbyterian
Source: NewYork-Presbyterian
Salzler GG, Graham A, Connolly PH, Schneider DB, Meltzer
AJ. Safety and effectiveness of adjunctive intra-arterial
abciximab in the management of acute limb ischemia.
Annals of Vascular Surgery. 2016 Jan;30:66-71.
Meltzer AJ, Sedrakyan A, Isaacs A, Connolly PH, Schneider
DB; Vascular Study Group of Greater New York. Comparative effectiveness of peripheral vascular intervention
versus surgical bypass for critical limb ischemia in the Vascular Study Group of Greater New York. Journal of
Vascular Surgery. 2016 Nov;64(5):1320-1326.e2.
Connolly PH, Meltzer AJ, Spector JA, Schneider DB. Indocyanine green angiography aids in prediction of limb salvage
in vascular trauma. Annals of Vascular Surgery. 2015
Oct;29(7):1453.e1-4.
Jones DW, Siracuse JJ, Graham A, Connolly PH, Sedrakyan
A, Schneider DB, Meltzer AJ. Safety and effectiveness of
endovascular therapy for claudication in octogenarians.
Annuals of Vascular Disease. 2015 Jan;29(1):34-41.
2016 OUTCOMES AND QUALITY REPORT
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51
CARDIOVASCULAR IMAGING
NewYork-Presbyterian is home to dedicated
adult cardiovascular imaging programs
that are among the largest in the world.
Our cardiovascular imaging specialists
continually investigate and develop
emerging technologies and
techniques in this burgeoning field.
Non-ischemic fibrosis (NIF) on cardiac magnetic resonance has been linked to poor
prognosis. A study by Weill Cornell Medicine researchers examining a broad cohort of
patients with right ventricular (RV) dysfunction supports the concept that NIF is linked to
adverse RV chamber remodeling. Shown here are representative examples of each RV
dimension; all were measured during both end-diastole and end-systole.
Reference Article Kim J, Medicherla CB, Ma CL, Feher A, Kukar N, Geevarghese A,
Goyal P, Horn E, Devereux RB, Weinsaft JW. Association of right ventricular
pressure and volume overload with non-ischemic septal fibrosis on cardiac
magnetic resonance. PLoS One. 2016 Jan 22;11(1): e0147349.
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
MEETING CHALLENGES IN CARDIAC IMAGING
Imaging specialists at NewYork-Presbyterian employ a multidisciplinary, multi-modality
approach to the detection and treatment of heart disease, including ischemic, valvular, and congenital heart disease, and thoracic disorders. Our cardiovascular imaging programs bring together cardiologists with training in advanced cardiac imaging and radiologists who, in addition to the traditional cardiac imaging tools, apply MRI, CT,
and PET imaging in new and novel ways, including combining these techniques with
other cutting-edge diagnostic tests to improve detection and guidance for treatment.
Imaging in Adult Congenital Heart Disease Emerging imaging technologies are
affording a better understanding of the anatomic and physiologic aspects of
congenital heart disease in adults. MRI provides incredibly high spatial resolution
imaging for both cardiac function and cardiac morphology, but also looks specifically
at physiologic aspects of both left and right ventricular function, as well as valvular
flow function and anatomy – all within a single, multifaceted examination. Unlike
other cardiovascular imaging modalities, MRI can wed these abilities and multifaceted
imaging approaches to the direct assessment of myocardial tissue characteristics,
which is especially applicable to patients with adult congenital heart disease. In
these patients, our cardiologists are interested in long-term sequential monitoring
of cardiovascular performance. Increasingly, our physicians are gathering data that
not only show where the MRI can detect changes, but also how the changes that are
detected are prognostically significant, helping, for example, to better stratify those
patients who will need surgery or to predict who will have arrhythmic events.
For patients who cannot have an MRI scan due to having a pacemaker or a defibrillator, our physicians are also using 320-slice cardiac CT in a novel way to evaluate the
function of the patient’s heart. Using gated CT, they have been able to reduce the
radiation exposure by about 80 percent while still achieving very high resolution
images of heart function, valves, and vessels.
An Emphasis on Early Identification Our imaging specialists have a particular interest
in improving methods for early identification of heart disease in women, ethnic
minorities, and young patients with a family history of premature heart disease. Their
expertise includes coronary artery calcium scoring for asymptomatic individuals at
high risk of disease, and cardiac PET that allows visualization of microvascular circulation
that can cause chest pain in patients whose larger arteries are free of disease.
Coronary Calcification Test A study by Weill Cornell researchers has demonstrated
that the coronary artery calcification test, a five minute procedure that examines
the total amount of calcified plaque buildup in the heart arteries, can be used to
accurately predict the likelihood of heart attack or death over a 15-year period. With
this information, physicians can intervene earlier and more aggressively if the noninvasive scan shows a patient is at risk for heart disease but not yet having symptoms.
Diagnosing ATTR-CA A type of heart failure caused by a build-up of amyloid can be
accurately diagnosed and prognosticated with an imaging technique, eliminating the
need for a biopsy in select patients, according to a multicenter study led by researchers
at Columbia University Medical Center. The technique may also detect transthyretinrelated cardiac amyloidosis (ATTR-CA) before it progresses to advanced heart failure.
The diagnostic tool evaluated in the study, technetium pyrophosphate planar cardiac
imaging, is derived from bone scintigraphy, a form of single-photon emission computed
tomography that is conventionally used to detect bone cancer. The imaging scans were
compared to tissue biopsy results, the gold standard for diagnosing ATTR-CA.
Tc 99m pyrophosphate scan of patient without
amyloidosis (left), and with amyloidosis (right)
(Courtesy of Dr. Adam Castano)
Reference Article Castano A, Haq M, Narotsky DL, Goldsmith J, Weinberg RL, Morgenstern R,
Pozniakoff T, Ruberg FL, Miller EJ, Berk JL, Dispenzieri A, Grogan M, Johnson G, Bokhari S, Maurer
MS. Multicenter study of planar technetium 99m pyrophosphate cardiac imaging: Predicting
survival for patients with ATTR cardiac amyloidosis. JAMA Cardiology. 2016 Nov 1;1(8):880-89.
Selected Publications
Khalique OK, Pulerwitz TC, Halliburton SS, Kodali SK, Hahn RT, Nazif TM, Vahl TP, George I, Leon MB, D’Souza B, Einstein AJ. Practical considerations for optimizing cardiac computed tomography protocols
for comprehensive acquisition prior to transcatheter aortic valve
replacement. Journal of Cardiovascular Computed Tomography.
2016 Sep-Oct;10(5):364-74.
Kim J, Srinivasan A, Seoane T, Di Franco A, Peskin CS, McQueen DM,
Paul TK, Feher A, Geevarghese A, Rozenstrauch M, Devereux RB,
Weinsaft JW. Echocardiographic linear dimensions for assessment
of right ventricular chamber volume as demonstrated by cardiac
magnetic resonance. Journal of the American Society of Echocardiography. 2016 Sep;29(9):861-70.
Roleder T, Karimi Galougahi K, Chin CY, Bhatti NK, Brilakis E, Nazif
TM, Kirtane AJ, Karmpaliotis D, Wojakowski W, Leon MB, Mintz GS,
Maehara A, Stone GW, Ali ZA. Utility of near-infrared spectroscopy
for detection of thin-cap neoatherosclerosis. European Heart Journal Cardiovascular Imaging. 2016 Sep 27. [Epub ahead of print]
Pulerwitz TC, Khalique OK, Nazif TN, Rozenshtein A, Pearson GD,
Hahn RT, Vahl TP, Kodali SK, George I, Leon MB, D’Souza B, Po MJ,
Einstein AJ. Very low intravenous contrast volume protocol for
computed tomography angiography providing comprehensive
cardiac and vascular assessment prior to transcatheter aortic valve
replacement in patients with chronic kidney disease. Journal of
Cardiovascular Computed Tomography. 2016 Jul-Aug;10(4):316-21.
Weinsaft JW, Kim J, Medicherla CB, Ma CL, Codella NC, Kukar N,
Alaref S, Kim RJ, Devereux RB. Echocardiographic algorithm for
post-myocardial infarction LV thrombus: A gatekeeper for thrombus evaluation by delayed enhancement CMR. JACC: Cardiovascular
Imaging. 2016 May;9(5):505-15.
Zemedkun M, LaBounty TM, Bergman G, Wong SC, Lin FY, Reynolds D, Gomez M, Dunning AM, Leipsic J, Min JK. Effectiveness of a low
contrast load CT angiography protocol in octogenarians and non-
agenarians being evaluated for transcatheter aortic valve replacement.
Clinical Imaging. 2015 Sep-Oct;39(5):815-19.
2016 OUTCOMES AND QUALITY REPORT
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53
PREVENTIVE CARDIOLOGY
Sleep and Heart Disease in Women Columbia researchers have launched
a study to learn if inadequate sleep increases the risk of heart disease
in women. With funding from the American Heart Association, they are
enrolling 500 women between the ages of 20 and 79 to examine sleep
patterns and other potential risk factors, including menopause and caregiving
and relationship stressors. They will also look at molecular changes that occur
with restricted sleep and how those changes raise the risk of heart disease.
particularly among those overweight and physically inactive. Strategies to encourage healthy lifestyles and reduce CVD risk factors among this vulnerable at-risk
population are vital.
Women’s Heart Alliance The Women’s Heart Alliance is a collaboration between
the Barbra Streisand Women’s Heart Center at Cedars-Sinai Heart Institute
and the Ronald O. Perelman Heart Institute at NewYork-Presbyterian/
Weill Cornell Medical Center. Education and advocacy efforts have included
participation in the Women in the World Summit focused on heart disease
outcomes and meetings on Capitol Hill to discuss legislation on equitable
representation of heart disease in women in medical research.
Individuals Uniquely at Risk Weill Cornell researchers are identifying individuals at
risk for heart disease due to lipid disorders, family history of heart disease at young
ages, inflammatory disorders, and premature menopause. They also have found
that women who have survived cancer may not be screened as rigorously for heart
disease because of the intense focus on their cancer. Importantly, imaging for breast
cancer staging can potentially identify calcium in the arteries, and those women so
identified should be referred to a cardiologist for preventive therapies.
HeartSmarts In 2016, NewYork-Presbyterian/Weill Cornell marked the fifth
anniversary of its HeartSmarts program, which aims to reduce the incidence
of cardiovascular disease through education in underserved communities. In
collaboration with churches and wellness ministries, the program has created
a coalition of more than 80 lay health ambassadors who utilize a faith-based
curriculum to increase knowledge of cardiovascular health and heart disease
prevention. A recent study by Weill Cornell Medicine researchers demonstrated that a 12-week HeartSmarts program resulted in significant reductions in
participant averages for systolic and diastolic blood pressure, weight, and BMI.
Heart Health in Action Launched more than a decade ago, Columbia’s Heart
Health in Action program is designed to improve awareness and knowledge of
cardiovascular disease among a high-risk population of urban minority women. Since its inception, more than 1,000 women ranging from age 19 to 90 have
been assessed for their cardiovascular disease (CVD) knowledge and screened
for metabolic syndrome, including hypertension, an abnormal lipid profile, high
blood sugar, and increased waist size. A major goal of the program is to help
participants take steps to reduce weight and increase physical activity. Columbia
researchers recently evaluated a segment of the population – women 18 to 49 –
for cardiovascular disease risk burden and found the majority were at high risk,
PCSK9 and Cardiac Prevention Weill Cornell Medicine researchers are evaluating the
use of PCSK9 inhibitors to control the number of low-density lipoprotein receptors
that play a critical role in regulating blood cholesterol levels in individuals who
cannot tolerate statins or who may not be achieving their goals on statin therapy.
Selected Publications
Tettey NS, Duran PA, Andersen HS, Boutin-Foster C. Evaluation of
HeartSmarts, a faith-based cardiovascular health education program.
Journal of Religion and Health. 2017 Feb;56(1):320-28.
Giardina EV, Paul TK, Hayes D, Sciacca RR. Cardiovascular disease risk
among young urban women. Journal of Women’s Health. (Larchmont).
2016 Nov;25(11):1139-46.
Tettey NS, Duran PA, Andersen HS, Washington N, Boutin-Foster C. It’s Like Backing up Science with Scripture: Lessons learned from the implementation of HeartSmarts, a faith-based cardiovascular disease health
education program. Journal of Religion and Health. 2016 Jun;55(3):1078-88.
Paul TK, Sciacca RR, Bier ML, Rodriguez J, Song S, Giardina EGV. Intergenerational misperception of size among overweight and obese families. Journal
of General Internal Medicine. 2015 Jan;30(1):43-50.
Flink L, Sciacca RR, Bier ML, Rodriguez J, Giardina EGV. Women at high risk
for cardiovascular disease lack basic cardiovascular disease knowledge.
Clinical Cardiology. 2013;36(3):133-38.
Giardina EGV, et al. Cardiovascular disease knowledge and weight
perception among Hispanic and non-Hispanic white women. Journal of
Women’s Health. 2013;22:1009-15.
54
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
BEHAVIORAL CARDIOLOGY
Columbia University Medical Center is making important contributions to cardiovascular behavioral medicine research with a team of highly skilled interdisciplinary
professionals – internists, cardiologists, psychologists, and quantitative faculty. They
are engaged in research studies investigating:
• Behavioral and biological factors that explain the relationship between psychological factors and heart disease
• Ways to treat depression in those with established heart disease
• Modifiable emergency department and patient-level factors that can improve
care, reduce recurrence, and minimize rehospitalization
• Mechanisms connecting psychological, emotional, and physical health
• Psychosocial factors and biological mechanisms that contribute to hypertension
• Alternative approaches to diagnosing and treating hypertension
Their scientific investigations will increase the understanding of the mechanisms
involved in cardiovascular diseases. With recognition of the importance of behavioral,
psychological, societal, and lifestyle factors, they will be able to improve management
of the risks of hypertension and heart disease. Current research endeavors include:
REACH: Reactions to Acute Care and Hospitalization This study is designed to
identify emergency department factors associated with poor long-term psychiatric
and medical prognosis after cardiac events.
Post-Hospital Syndrome This study aims to determine best hospital practices for
reducing readmission risk in cardiac patients.
CODIACS Quality of Life This study seeks to determine the quality-adjusted life year
benefits and healthcare costs of following the American Heart Association’s advisory for depression screening and subsequent comprehensive treatment of depression in
cardiac patients.
PUME This study is examining the acute effects of provoked anger, depressed
mood, and anxiety on vascular endothelial cell health.
Ambulatory Blood Pressure Monitoring Implementation This study involves the
development and testing of an intervention to increase uptake of the U.S. Preventive
Services Task Force hypertension screening guidelines in diverse primary care settings.
Selected Publications
Schwartz JE, Wang YC, Shimbo D, Muntner P, Moran A, Krakoff LR.
Prevalence of masked hypertension among U.S. adults with nonelevated clinic blood pressure. American Journal of Epidemiology.
2017 Jan 18. [Epub ahead of print]
Kronish IM, Moise N, McGinn T, et al. An electronic adherence
measurement intervention to reduce clinical inertia in the
treatment of uncontrolled hypertension: The MATCH Cluster
Randomized Clinical Trial. Journal of General Internal Medicine. 2016 Nov;31(11):1294-1300.
Haerizadeh M, Moise M, Chang BP, Edmondson D, Kronish I.
Depression and doctor-patient communication in the emergency
department. General Hospital Psychiatry. 2016 Sep-Oct;42:49-53.
Kronish IM, Ross JS, Zhao H, Muntner P. The impact of hospitalization for acute myocardial infarction on adherence to statins among
older adults. Circulation: Cardiovascular Quality and Outcomes. 2016
Jul;9(4):364-71.
Sumner JA, Kubzanksy LD, Kabrhel C, et al. Associations of trauma
exposure and posttraumatic stress symptoms with venous thrombo-
embolism over 22 years in women. Journal of the American Heart
Association. 2016 May 12;5(5).
Muntner P, Booth JN, 3rd, Shimbo D, Schwartz JE. Is white-coat
hypertension associated with increased cardiovascular and mortality
risk? Journal of Hypertension. 2016;34(8):1655-58.
Shimbo D, Barrett Bowling C, Levitan EB, et al. Short-term risk of
serious fall injuries in older adults initiating and intensifying treatment
with antihypertensive medication. Circulation: Cardiovascular Quality
and Outcomes. 2016;9(3):222-29.
Suls J, Green P, Davidson KW. A biobehavioral framework to address the emerging challenge of multi-morbidity. Psychosomatic Medicine.
2016;78(3):281-89.
Sundquist K, Chang BP, Parsons F, Dalrymple N, Edmondson D, Sumner
JA. Treatment rates for PTSD and depression in recently hospitalized
cardiac patients. Journal of Psychosomatic Research. 2016;86:60-62.
2016 OUTCOMES AND QUALITY REPORT
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55
NYP OnDemand
In July 2016, NewYork-Presbyterian introduced NYP OnDemand, a suite of digital health services designed
to improve and expand patient care in new and innovative ways. NYP OnDemand was created by
members of the Department of Information Technology under the direction of Daniel Barchi, Senior
Vice President and Chief Information Officer, and Peter M. Fleischut, MD, Chief Innovation Officer, in
concert with the Hospital’s clinical team.
“At NewYork-Presbyterian,
we are looking to redefine the
intersection of technology
and healthcare, and our
new digital health platform
is our way of strengthening
traditional telehealth services.”
Dr. Steven J. Corwin
President and CEO
NewYork-Presbyterian
NYP OnDemand is comprised of telehealth services for both patients and healthcare providers and
includes:
Second Opinion Patients can receive detailed written second opinions on their diagnosis or treatment
from world-renowned specialists at Columbia University Medical Center and Weill Cornell Medicine
through a secure, easily accessible online service.
Digital Emergency At NewYork-Presbyterian/Weill Cornell Medical Center, patients visiting the Emergency
Department with non-life threatening illnesses and injuries can have a live video visit with an Emergency
Medicine physician. The first program of its kind in New York, the program has reduced ED admission to
discharge time from 2.5 hours to less than 35 minutes.
Urgent Care Adults in New York State can have a live video visit with a Weill Cornell Medicine Emergency
Medicine physician from their phone, tablet, or desktop. Patients can receive care for non-life threatening
illnesses and injuries such as the flu, a sore throat, or allergies, all from the comfort of home.
Virtual Visit Patients can have a live video visit with their medical professional from their phone, tablet,
or desktop, saving time and making these visits more convenient. Inter-Hospital Consult Providers across NewYork-Presbyterian’s hospital sites can collaborate on cases
and provide their specialty insight to patients and their colleagues. NewYork-Presbyterian’s Inter-Hospital
Consult programs include Telestroke, Telepediatrics, and a Mobile Stroke Treatment Unit.
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NEWYORK-PRESBYTERIAN CARDIAC AND VASCULAR SERVICES
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New York, NY 10032
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Weill Cornell Medical Center
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New York, NY 10065