Advancing Cardiovascular, Thoracic and Pulmonary Care in Our Region. Winter 2021 I Volume 2
Dear Colleague, As you will discover in this latest edition of our newsletter, Excela Health continues to expand and enhance its capabilities in cardiovascular, thoracic and pulmonary care in the region. Most notable is the recent addition of a hybrid operating room at Westmoreland Hospital. Our cover article by Dr. Nevin Baker details this development and the concurrent introduction of Transcatheter Aortic Valve Replacement here in the County. This represents another major step by Excela in providing local residents advanced, tertiary and quaternary care in a setting convenient to them and their loved ones. You’ll learn about significant developments in minimally invasive cardiac and lung surgery that are occurring at Excela. You will also note our burgeoning sleep disorders program and increasing depth in the treatment of peripheral artery disease. We’ll also introduce you to the latest additions to our medical staff along with a synopsis of their education, training and other credentials. The area’s best and brightest clinicians continue to gravitate to Excela as a place to practice.
Transcatheter Aortic Valve Replacement Now Performed In Westmoreland County Aortic stenosis is the most common adult valvular abnormality encountered in clinical practice. It is also the most common heart valve replaced worldwide. Current AHA/ACC guidelines recommend aortic valve replacement for the majority of patients with severe symptomatic aortic stenosis. These symptoms can include, but are not limited to, shortness of breath, angina, fatigue, syncope and palpitations. Most demonstrated symptoms are evidence of heart damage related to their valve disease. Without aortic valve replacement, severe aortic stenosis is a life-threatening disease and carries a poor short-term prognosis. Clinical evidence demonstrates that patients with symptomatic, severe aortic stenosis may have a survival rate as low as 50% within two years of symptom development. Traditional methods of valve replacement have involved open heart surgery. Over a period of years, the landscape has significantly changed with regard to options for patients with symptomatic severe aortic stenosis. CONTINUED ...
By any measure, Excela Health is accelerating and elevating its position as one of the premier health systems in western Pennsylvania. We appreciate your confidence in our capabilities and thank you for the partnerships we have developed in the care of your patients.
In This Edition: n n n n n
Sincerely, James Adisey, MD, FACC Medical Director, Heart, Lung and Vascular 1
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Transcatheter Aortic Valve Replacement Now Performed In Westmoreland County Minimally Invasive Cardiac Surgery (MICS) at Excela Health Robotic Pulmonary Segmentectomy at Excela Health Managing Sleep Apnea During COVID-19 Vascular Surgery at Excela Health New Appointments Fast Facts: Quality at Excela Health Cardiovascular Services, Referring Patients Awards and Accolades
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Transcatheter Aortic Valve Replacement Now Performed In Westmoreland County (continued) While the standard of care has been surgical aortic valve replacement (SAVR), the role of Transcatheter aortic valve replacement (TAVR) is evolving and offers an alternative approach for many patients. TAVR is a minimally invasive, percutaneous approach for aortic valve replacement. Typically, the valve is implanted through the femoral artery following placement of a large-bore access site sheath. Rarely is surgical cutdown necessary for this approach. Alternative arterial access such as carotid, axillary, or subclavian artery also have been used. Excela has chosen the Edwards Sapien 3 Ultra (S3 Ultra) valve due to its proven safety and efficacy. The valve tissue is made from bovine pericardium, similar to that of surgically implanted valves. There is a geometric open-cell scaffold which surrounds the valve and a sealing outer “skirt” at the base of the valve. The valve is crimped upon a delivery balloon catheter system outside of the body, then advanced through the existing large bore arterial access sheath and across the aortic valve. Fluoroscopic landmarks and aortic root injection allow for proper valve alignment. After confirming proper location, the balloon catheter delivery system is used to expand the scaffolding system and the valve is implanted.
TAVR has been associated with arrhythmic complications including high degree heart block and atrial fibrillation. Advances in TAVR technology have allowed for a more deliverable device with less risk of valve embolization or perivalvular leak/aortic insufficiency. It has become a Class I indication (recommended) for patients with severe valvular heart disease to be evaluated by a multidisciplinary Heart Valve Team. Thus, the Excela Health Structural Heart Program upholds a multidisciplinary approach to the treatment of patients with aortic valve stenosis. The purpose of the Heart Team is to use a patient-centered approach when determining treatment for severe aortic stenosis. As a multidisciplinary team, we review cardiac imaging, coronary angiography, CT scans along with clinical history during our multidisciplinary valve conference. Your patient’s clinical information will be reviewed by our team of cardiothoracic surgeons, interventional cardiologists, cardiovascular imagers, cardiac anesthesiologists, and nurse navigators. Our Structural Heart Program continually strives to provide unprecedented, collaborative care. Our structural heart nurse navigator will ensure your patients are scheduled for an appointment, their questions are answered, and you, as the referring provider, remain informed. If the decision is made to proceed with TAVR, you will be kept up-to-date throughout the process of scheduling and post-procedure discharge. Patients identified as having symptomatic, severe aortic valve stenosis should be evaluated by a cardiologist who can then refer for evaluation by the multidisciplinary physicians within the Heart, Lung & Vascular Institute at Excela Health.
Juan J. Chahin, MD, FACC, FSCAI; Vinod S. Kudagi, MD; Hiroyuki Tsukui, MD, PhD; Nevin C. Baker, DO, FACC, FSCAI; Amanda Urosek, BSN, RN; Mitsugu Ogawa, MD
If you have any further questions, please do not hesitate to contact our structural heart nurse navigator Amanda Urosek at 724-961-0357. We continually look forward to providing your patients with all the cardiovascular tools and talent we have to offer, right here in Westmoreland County.
The procedure is considered elective in the majority of cases, and patients can expect, on average, a 48-hour stay in the hospital following an uncomplicated procedure. Potential risks with TAVR include bleeding or damaging blood vessels, which may require blood transfusion or surgical repair. In addition, similar to SAVR, there is risk of stroke or heart attack. 2
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Minimally Invasive Cardiac Surgery (MICS) at Excela Health Heart surgery is a major complex procedure. However, with the evolution of new technologies, it has become less invasive and provides clinical options that are of material benefit to both the surgical team and the patient. These advances are now available through a very robust and accomplished cardiac surgery program at Westmoreland Hospital. Traditionally, heart surgery has been performed through an incision of about eight inches down the middle of the chest (Fig 1). Since the sternum is also completely divided, it takes time for the bones to heal. This, in turn, gives rise to an elongated period of time to fully return to daily life (driving, carrying heavy loads, etc.). Additionally, rare complications such as mediastinitis can occur, which can be an emotional burden on the patient from a cosmetic standpoint as well.
The skin incision is about 2.5 inches in length and preserves the sternum, creating the following advantages: n Less infection n Less anesthesia time n Less bleeding and blood transfusion n Faster recovery and discharge n Faster return to full function n Cosmetic advantages The introduction of MICS allows for the same surgical outcomes as traditional methods, made possible by advances in heart- lung machine technology, the introduction of specialized MICS tools (Fig 3), and the use of endoscopes to improve visibility (Fig 4).
Fig 3 MICS instruments allow access to the heart through small incision
Fig 1 Traditional median full sternotomy
We are pleased to announce that at Excela Health Westmoreland Hospital, our cardiac surgery team has been providing MICS procedures since September 2019. We perform valve repair and replacement for patients with valvular diseases such as aortic stenosis and mitral regurgitation through a small, partial sternal incision or a small, right intercostal thoracotomy (Fig 2).
FIg 2 Right mini-thoracotomy for mitral valve procedure
Fig 4 Mitral valve repair using endoscope with excellent visibility
In addition, we have been occluding the left atrial appendage with the Atriclip device in patients who are not suitable for the trans-catheter Watchman procedure, with a left thoracoscopic approach using three incisions .5 to 1 inch in length. This procedure provides an attractive MICS intervention for certain afib patients desiring to eliminate their need for a lifetime regimen of blood thinners. Not all patients are suitable for a MICS procedure depending on the body habitus, complexity of the cardiac procedure, and other clinical factors. Thorough pre-operative examinations and selection of patients have resulted in superb outcomes of cardiac surgery at Excela in both our MICS and traditional approaches. CONTINUED ...
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Minimally Invasive Cardiac Surgery (MICS) at Excela Health (continued) The goal of the cardiac surgery program at Excela is a simple one; combine the latest technology and superior technique in a fashion that results in outstanding clinical results, shorter recovery times, less post-operative pain and less risk for infection for our patients — and yours.
Michael Culig, MD, Director Hiroyuki Tsukui, MD, PhD, Associate Director Cardiac Surgery
the lobe that has the cancer is removed, and the rest of the lobe is spared. During robotic pulmonary segmentectomy the tumor is removed along with a smaller portion of adjacent lung, associated pulmonary artery blood vessels and regional lymph nodes. This procedure can be performed minimally invasively through several small incisions using robotic surgical techniques. This procedure is best reserved for tumors that are less than 2 cm in size. Data show that patients with COPD may be excellent candidates and shortness of breath after surgery may not worsen. 1.0 cm nodule in the superior segment of the left lower lobe
Robotic Pulmonary Segmentectomy at Excela Health The management of the more than 230,000 patients in the United States who develop lung cancer is evolving with improvements in chemotherapy, immunotherapy and targeted therapy. However, for most patients who develop early lung cancer, surgical resection remains the mainstay of treatment and offers the best opportunity for long-term cure. Traditionally, surgery for lung cancer involves removal of a significant portion of the lung called a lobe. Unfortunately, many patients with lung cancer also have COPD or emphysema. Undergoing lobectomy for these patients can lead to significant increases in dyspnea and reduction in quality of life.
Surgical resection options for lung cancer
Robotic pulmonary segmentectomy is an advanced robotic thoracic surgical procedure that is only offered in specialty centers with comprehensive thoracic surgical programs such as that found within our System.
Indocyanine green fluorescence (ICG) to display the segmental blood supply of the lung during robotic segmentectomy Operative team performing a robotic segmentectomy
At Excela Health we are able to offer a procedure known as robotic pulmonary segmentectomy for many patients who are diagnosed with early lung cancer. During the procedure only the segment of 4
Last year alone, nearly 600 thoracic surgical procedures were performed at Excela. Many of these procedures were done for the diagnosis, evaluation and management of patients with lung cancer. CONTINUED ...
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Robotic Pulmonary Segmentectomy at Excela Health (continued) In my role as medical director of thoracic surgery and director of the robotic surgical program at Excela, I have performed more than 100 pulmonary segmentectomies. Interestingly, the procedure dates back to the surgical treatment of Tuberculosis. What is new, however, is the ability for surgeons to be able to perform these procedures using minimally invasive techniques. Many of our patients stay only one day in the hospital after the procedure. We also know that for many patients segmentectomy offers long-term survival equivalent to lobectomy. The Excela Advanced Lung Center and The Center for Lung and Thoracic Disease see more than 4,500 patients per year. To make a referral for patients with pulmonary nodules, suspected lung cancer or esophageal disease, please call 724-689-0520.
Michael Szwerc, MD, FACS Medical Director, Robotic Surgery Director of Center for Lung and Thoracic Disease
Thoracic and Pulmonary Services • Robotic assisted lung resection • Robotic assisted esophageal resection • Robotic/Laparoscopic assisted Paraesophageal Hernia Repair • Robotic assisted Nissen/Toupet/Dor fundoplication • Endoscopic sympathectomy for hyperhidrosis • Thoracic outlet procedures • Bronchoscopy with EBUS biopsy • Navigational Bronchoscopy • Video Mediastinoscopy • Tracheal surgery • Esophageal, bronchial, tracheal stenting • Chest wall resection and reconstruction • Management of pleural effusions • Pulmonary nodule management • Lung cancer screening • Robotic assisted Heller myotomy for achalasia • Mesothelioma surgery • Chemotherapy ports • Diaphragmatic plication/repair of diaphragmatic hernia • Esophageal diverticulectomy • Management of pneumothorax • Management of mediastinal masses • Robotic assisted thymectomy
Managing Sleep Apnea During COVID-19 Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, affecting up to 10-15% of men and 4-6% of women in the United States. In patients with OSA, repeated collapse of the upper airway during sleep can result in airflow interruptions, intermittent oxygen desaturation, and fragmented nonrestorative sleep. Untreated OSA has been associated with increased morbidity and mortality, with negative effects on hypertension, coronary artery disease, arrhythmias, heart attack, pulmonary hypertension, diabetes mellitus, and other cardiovascular and metabolic disease. It has been adversely associated with depression, mood disorders, cognitive function, driving safety, and overall quality of life. Evaluation and treatment often require a sleep study to confirm diagnosis and titrate positive pressure therapy. The management of sleep apnea has been a challenge during the COVID-19 pandemic, primarily due to concerns of increased risk of transmission during a sleep study and aerosol generating procedures. As the case rate of COVID-19 rises, many sleep studies have been postponed or cancelled. However, recent data suggest that OSA may be an independent risk factor for worse clinical outcomes in patients with COVID-19 infection (Sleep Medicine Reviews, Feb 2021), highlighting the importance of addressing sleep apnea in high-risk patient populations.
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Managing Sleep Apnea During COVID-19 (continued) The Excela Health Advanced Sleep Center has implemented a number of new protocols and upgrades for COVID-19 that meet or exceed guidelines set forth by the American Academy of Sleep Medicine. These risk mitigation strategies ensure continued care of our sleep patients, while optimizing safety for patients and staff. n Negative pressure rooms: Excela Health is the only facility in the region that has outfitted sleep lab rooms with negative pressure technology to decrease the spread of airborne pathogens. Typically available only in a hospital setting, negative pressure ventilation has been retrofitted in the rooms at our Latrobe sleep lab facility. n Enhanced screening: Patients undergo screening for COVD-19 at three separate timepoints: 1) at the time of scheduling the appointment, 2) during a reminder call 24-48 hours prior to their sleep study, and 3) upon arrival to the sleep lab. Patients identified as high risk for COVID-19 infection are rescheduled and referred for evaluation and self-quarantine. n Individualized, staggered check-in: Patients are met individually at the entrance to the sleep lab and undergo a temperature check. Each patient completes registration and set-up for their sleep study before the next patient is brought in to minimize risk of exposure, separating patients in space and time. n Personal Protective Equipment (PPE) and Enhanced Cleaning Protocols: Sleep technicians are fully equipped with PPE to ensure safety for patients and staff. Enhanced cleaning protocols are used for each room before and after every patient.
Another option for many patients is a home sleep test (HST). HST units consist of multiple sensors (nasal canula for airflow, chest belt for respiratory effort and pulse oximeter) that can be used to diagnose OSA. Done in the comfort of a patient’s own home, HSTs offer accurate and convenient sleep testing, while minimizing risk of COVID-19 exposure.
The Excela Health Advanced Sleep Center has augmented its program for home sleep testing. Additional HST units are now available and patient access has been enhanced. After evaluation by a sleep physician or other medical provider, a patient or family member can schedule an appointment to pick up equipment. Education and instruction are provided by the sleep staff at that time. Units are worn for one or two nights, then returned for data upload and physician review. To meet the needs of an increasing number of sleep patient referrals, additional board-certified sleep physicians and nurse practitioners have also been hired to join our existing team of providers. Teleheath and in-person visits are available for patient convenience. Despite the impact of the COVID-19 on patient care, Excela Health will continue to provide the best possible care for sleep patients.
Euhan John Lee, MD Medical Director, Center for Sleep and Breathing Disorders Excela Health
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Vascular Surgery at Excela Health The Vascular surgery program at Excela Health has grown exponentially in recent years, with expanding capabilities to treat a spectrum of conditions and increased case complexity. With the addition of a hybrid operating room, Excela can now also provide the significant advantages and benefits derived through intraoperative imaging to both the surgical team and the patient. Since our inception in 2015, we have treated more than 6,000 patients, constituting a steady and material growth in utilization. Care for the vascular patient often begins at our IAC (Intersocietal Accrediation Commission) accredited Vascular Labs. Here we can offer non-invasive extracranial cerebrovascular, peripheral artery and peripheral venous testing. Realizing that effective treatment of vascular disease is multi-faceted, our program places a premium on collaboration starting with a patient’s primary care physician and including other clinicians in such specialties as cardiovascular medicine, neurology, physical medicine and rehabilitation and imaging. We offer expertise and experience in treating a wide range of vascular conditions including: n Abdominal aortic aneurysms n Carotid artery disease n Dialysis access n Lower extremity arterial and diabetic-related wounds
n Peripheral artery disease n Renal artery stenosis n Varicose veins We take great pride in the quality of our program, which is reflected in our outcomes. For example, in our series of endovascular aortic aneurysm repairs, our 30-day mortality stands at 0.5% and morbidity for myocardial infarction, chronic heart failure or stroke is .05%. Regarding venous disease, while compression is our first step in treatment, we perform radiofrequency ablation, stab phlebectomy and sclerotherapy in the care of these patients. The vascular program at Excela combines tertiary level services and care with the convenience of being provided in a community setting. Given the demographic profile of the vascular patient, our combination of quality and accessibility should prove attractive for those needing assessment and/or treatment.
Elizabeth Detschelt, MD, FACS Director of Vascular Surgery
New Appointments Parminder Sharma, MD Cardiology Education Undergraduate DAV College Gurunanak DEV University Jalandhar, Punjab, India MD Government Medical College Gurunanak DEV University Amritsar, Punjab, India 7
Training • St. Francis Medical Center Residency Internal Medicine Certifications • American Board of Internal Medicine • American Board of Internal Medicine Cardiovascular Disease • Certification Board of Nuclear Cardiology Nuclear Cardiology • ACLS
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New Appointments Mitsugu Ogawa, MD Cardiothoracic Surgery Education MD Kyoto Prefectural University of Medicine PhD Kyoto Prefectural University of Medicine; Graduate School of Medical Science Training • Kyoto Prefectural University of Medicine Internship • Kyoto Second Red Cross Hospital Residency • John Hunter Hospital, Australia Fellowship • Royal North Shore Hospital, Australia Fellowship • Barnes Jewish Hospital, Washington University School of Medicine, St louis, MI Heart Transplant and Mechanical Circulatory Assist Device Fellowship • Brigham and Women’s Hospital, Harvard Medical School, Boston, MA Advanced Adult Cardiac Surgery Fellowship Certifications • Japanese Board of Surgery • USMLE STEP 3
Training • University of Pittsburgh School of Medicine Residency • University of Pittsburgh Medical Center Fellowship • University of Pittsburgh Medical Center Fellowship Certifications • American Board of Internal Medicine Sleep Medicine-Subspecialty • American Board of Internal Medicine Pulmonary Disease-Subspecialty • American Board of Internal Medicine Critical Care Medicine-Subspecialty
Fast Facts: Quality at Excela Health • Door to Balloon – 54 minutes (Top 75th percentile of all hospitals, outperforming like hospitals by 4 minutes) • Transfer Door to Balloon – 87 minutes (Top 75th percentile of all hospitals, outperforming like hospitals by 18 minutes) • Transfer from Outside Hospital Door to Westmoreland’s Door – 60 minutes (Top 75th percentile of all hospitals, outperforming like hospitals by 14 minutes) • TPCI Risk Adjusted Mortality for STEMI Patients – 4.1% (Top 75th percentile of all hospitals, outperforming US registry by 1.93%)
Euhan John Lee, MD Pulmonary and Critical Care Medicine Education Undergraduate Harvard University (Cambridge, MA) MD UMDNJ-University Hospital (Newark, NJ)
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Cardiovascular Services at Excela Health • Abdominal Aortic Aneurysm Treatment • Anti-Arrhythmia Surgery • Atrial Fibrillation Surgical Ablation • Cardiac Ablation • Cardiac and Pulmonary Rehabilitation • Cardiac Catheterization • Cardiac Imaging including cardiac MRI, intravascular ultrasound, and CT angiography using our 64-slice CT scanner • Cardiac Valve Repair/Replacement • Coronary and Peripheral Angioplasty • Coronary Artery Bypass Grafting • Deep Vein Thrombosis Care • Echocardiogram and Stress Echocardiogram • EKG • Electrophysiology • Endovascular Surgery • Event and Holter Monitoring • Extracorporeal Membrane Oxygenation (ECMO) • Heart Failure Clinic • Minimally Invasive/Keyhole Aortic Valve Surgery • Minimally Invasive Cardiac Surgery (MICS) • Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)/Keyhole Bypass Surgery • Minimally Invasive/Keyhole Mitral Valve Surgery • MUGA Scan • Nuclear Stress Testing • Off Pump CABG/Beating Heart Surgery • Pacemaker Clinic • Pacemaker/Defibrillator Implantation • Preventive Cardiology • Thoracic Aortic Aneurysm Surgery • Tilt Table Testing • Treatment of Carotid Artery and Peripheral Artery Disease
Referring Your Patients • Excela Health Medical Group physicians may refer to any of our specialist through Allscripts. • Non-EHMG physicians may refer by fax to these locations: • EHMG Cardiology - Latrobe Office: 724-539-6320 Fax: 724-539-6333 • EHMG Cardiology - Frick Office: 724-547-3858 Fax: 7245470737 • EHMG Cardiology - Norwin Office: 724-861-7939 • EHMG Thoracic Surgery and ALC - Greenburg/Frick/Norwin Office: 724-689-0520 Fax: 724-689-0522 • Excela Advanced Lung Center Office: 724-689-1440 Fax: 724-689-1442
Addresses for all locations available at ExcelaHealth.org
Awards and Accolades • American Heart Association “Get With The Guidelines” Gold Plus Award to both Westmoreland and Latrobe Hospitals • American Heart Association “Get With The Guidelines” Silver Plus Award to Frick Hospital
• U.S. News and World Report High Performing Hospitals, Heart Failure and COPD
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• American Heart Association “Get With The Guidelines” Heart Failure Quality Achievement Award
• Highmark Blue Cross Blue Shield Blue Distinction Center Plus for Cardiac Care
• Bronze Recognition through American Heart Association “Mission Lifeline” Award
• The Excela Advanced Vein Center is one of only seven IAC accredited vein center sites in the state of Pennsylvania.
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