Heart & Cardiovascular - Fall 2016

A Semiannual Publication of Augusta University Heart and Cardiovascular Services

Heart & Cardiovascular

FALL 2016

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FALL 2016

LETTER FROM THE EDITOR

HEART & CARDIOVASCULAR

It is strange how six months passed by so quickly! We just published our spring newsletter, and already it’s time for the fall issue! We value and crave your support as Augusta University Heart and Cardiovascular Services moves forward to our institution’s bicentennial.

The past six months have been outstanding, and the upcoming six months promise to bring many other notable events to the academic and clinical calendar of our Heart and Cardiovascular Services.

In April 2016, with the assistance of the Kimmerling Foundation Fund, we were able to launch the first Cardiovascular Graduate Mixer at the ACC National Scientific Sessions at McCormick Place in Chicago. This event was a hit, with the room being completely full and positive energy flowing as networking took place. It appeared as though this is an event whose time had come. We were able to meet with colleagues who had graduated more than a decade ago from the Medical College of Georgia at Augusta University (MCG). This event inspired us to develop a robust

Cardiovascular Graduate Alumni Association at MCG.

Vincent Robinson, MD, FACC, FRCP(C) Co-Director, Nuclear Cardiology Director, Cardiology Fellowship Professor & Garrison Distinguished Chair,

Our next event was a two-day, CME-accredited conference Sept. 3-4,

Cardiovascular Medicine

2016. This event featured a wide range of faculty at Augusta University Heart and Cardiovascular Services who presented new innovations in clinical care being practiced within Augusta University’s health system. Our graduates from across the country also presented, showing where the skills they developed at MCG have taken them – all the way to leadership of tertiary cardiovascular programs throughout the country. Graduate speakers came in from Atlanta, Memphis and Tampa. I believe this event will provide graduates and current cardiology fellows with a palpable reminder of the great value of our Cardiovascular Disease Training Program at Augusta University. We believe this will allow for significant networking and camaraderie.

We look forward to seeing graduates, faculty, current trainees, friends and stakeholders at our next Cardiovascular Mixer at the ACC in Washington, D.C., in March 2017. Also, please do not forget to mark August 19-20, 2017, on your calendar for the Second Kimmerling Faculty and Graduate Showcase meeting, which will offer an excellent overview of clinical and research activities at Augusta University and beyond.

First Cardiovascular Graduate Mixer at the ACC National Scientific Sessions at McCormick Place in Chicago.

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In This Issue FALL 2016

INTRODUCTION____________________________ 2-7 NEW PHYSICIANS___________________________ 7 CARDIOVASCULAR RESEARCH: UNLOCKING THE DOOR TO FUTURE THERAPIES_________________________ 8 LIFELONG STRATEGY FOR PATIENTS WITH CONGENITAL HEART DISEASE_________ 10 DIVERSITY IN CARDIOLOGY: MCG CARDIOLOGY FELLOWSHIP TRAINING PROGRAM RECEIVES THE 2016 DIVERSITY IN CARDIOLOGY AWARD____________________ 11 CARDIOVASCULAR DISEASE FELLOWSHIP TRAINING_____________________ 12

Heart & Cardiovascular is produced semiannually

THE ROLE OF INTRAOPERATIVE TEE IN COMPLEX CARDIOTHORACIC PROCEDURES______________________________ 13

by Augusta University Heart and Cardiovascular Services and the Augusta University Division of Communications and Marketing. Please direct

COMPLEX TRANSRADIAL CORONARY INTERVENTION: ADAPTING TRANSRADIAL TECHNIQUES TO COMPLEX LESIONS AND HIGHER-RISK PATIENTS________ 14

comments or questions to 706-721-4997.

GRAND ROUNDS CALENDAR________________ 15 SAVE THE DATE_____________________________ 16

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MESSAGE FROM CARDIOTHORACIC SURGERY

Dear Readers, Augusta University’s health system is a tertiary care center, and most of our referrals are for highly complex cases with highly acute patients, many of whom come from out of state. While their hospital care is often challenging, their post-discharge management can be equally daunting.

In order to facilitate their post-discharge recovery, we are putting in place a highly integrated team of discharge planning nurses, home health care personnel and social workers to work with our clinic and referring physicians’ offices. We will be sending more information to you regarding the process, but, in the meantime, any suggestions or advice is most welcome.

Other accomplishments are as follows: • We have been recognized once again as the “bloodless surgery” site for open heart surgery by the Jehovah’s Witness community. We are fortunate to have a highly dedicated team of professionals from various fields who strive to minimize the use of blood and blood products.

M. Vinayak Kamath, MD

Robert G. Ellison Distinguished Chair of Cardiothoracic Surgery, Professor and Chief, Cardiothoracic Surgery 706-721-3226

• We are partnering with area educational and community

kamath@augusta.edu

institutions to offer lectures and talks on topics ranging from CPR to post-cardiac intervention care. If your group wishes to host one of our specialists as a speaker, please let us know.

• In understanding that no patient is an island, we are focusing more extensively on needs of the patients’ caregivers.

Discharge planning now includes detailed counseling to family members regarding the assistance available in their respective communities.

We welcome the new interns and residents into our fold. They remind us of the reasons we are here – to teach tomorrow’s health care professionals and provide our patients with the latest treatments and technology.

We would also like to bring to our readers’ attention that some cases of nontuberculous M. chimaera have been reported across the country in patients following open heart surgery. The infection usually manifests itself over months and years as endocarditis, pulmonary infiltrates or disseminated sepsis. We have not encountered any such cases at Augusta University Health. If you suspect your patient may have M. chimaera infection after having open heart surgery, please contact the respective hospital for further information, or visit cdc.gov/media/releases/2016/p1013contaminated-devices-.html.

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MESSAGE FROM ADULT CARDIOLOGY

Dear Readers, As interim division chief, I am pleased to update you on the activities of the cardiology service at Augusta University’s health system and the Division of Cardiology at the Medical College of Georgia at Augusta University (MCG). We have continued to strive for excellence in clinical care, teaching and research.

Neal L. Weintraub, MD

Interim Chief, Division of Cardiology,

We are proud to welcome a new interventional cardiologist to our team. Dr. Jacob Misenheimer has joined us after completing a oneyear fellowship program at the University of North Carolina at Chapel

Professor and GRA Kupperman Eminent Scholar in Cardiovascular Medicine, Associate Director of the Vascular Biology Center for Translational Research

Hill in interventional cardiology. Dr. Misenheimer graduated from the General Cardiology Fellowship Program at MCG in June 2015.

He has a strong interest in education and research. Dr. Misenheimer has been published in both Catheterization and Cardiovascular Interventions and Cardiovascular Diagnosis and Therapy.

We are also proud to welcome a new electrophysiologist to our team. Like Dr. Misenheimer, Dr. Haitham Hreibe is one of our own, having completed the General Cardiology Fellowship Program at MCG in 2009. After completing electrophysiology (EP) fellowship training at the University of Florida in 2010, he took a position as a staff electrophysiologist with Blair Medical Associates, an affiliate of the University of Pittsburgh Medical Center, where he served as a clinical instructor of medicine. Dr. Hreibe has published a number of manuscripts in journals such as the American Heart Journal and the American Journal of Cardiology. With Dr. Hreibe’s recruitment, the EP service will be able to meet the needs of Georgians for complex EP care and provide the most up-to-date training for our fellows.

In particular, our basic research programs have achieved remarkable success over the past year, and I am pleased to highlight some of the recent research developments and other happenings in our division.

We welcomed a new researcher, Dr. Eric Belin de Chantemèle. Belin de Chantemèle received a doctorate in cardiovascular physiology from Université Claude Bernard Lyon 1 in Lyon, France. After completing postdoctoral fellowship training in the Laboratory of Integrated Neurovascular Biology at Angers Medical School in Angers, France, he moved to Augusta, where he served as a postdoctoral fellow in the Vascular Biology Center under the mentorship of Dr. David Stepp. Belin de Chantemèle joined the Physiology Department as an assistant professor in 2011, and he now works in the Department of Medicine’s Cardiology Division as an associate professor. His laboratory, housed in the Vascular Biology Center, studies the impact of obesity on cardiovascular function and disease states such as hypertension. He is the recipient of an R01 grant from the National Institutes of Health (NIH).

Dr. Yaoliang Tang, a physician-scientist who focuses on stem cell therapeutics in animal models, is heading our collaborative team that has received two new R01 grants from the NIH. Additionally, Tang has received a third R01 plus an American Heart Association Grant in Aid. This is a remarkable achievement and a testament to the impact Tang’s 6 112472 - HEART AND CARDIO FALL 2016.indd 6

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,

us

research has on the exciting field of stem cell biology. These grants, coupled with my own two R01 grants in the field of obesity/cardiovascular disease, make the Division of Cardiology at MCG perhaps the most highly funded research division in the nation for its size. We are delighted to collaborate with clinical and translational researchers to advance our discoveries into practice. In addition, we provide a fertile training ground for the next generation of cardiovascular researchers.

Once again, the division was proud to host its annual graduation gala to celebrate the accomplishments of our fellows and wish them the best for the next stage of their careers. The success of our fellowship program can be measured year after year in so many ways, from their performance on in-service exams and the cardiovascular boards to their placement in high-powered advanced training programs and faculty/staff positions. This year, our training program is the recipient of the Spirit of the Heart Diversity in Cardiology Award from the Association of Black Cardiologists. This award recognizes academic institutions that strive to reduce health disparities and advance equity in health care and is a testament to the success we have achieved in recruiting African-Americans and other underrepresented minorities to our program. We are grateful to our director, Dr. Vincent J.B. Robinson, for his stewardship of the program, and to Dr. Sean Javaheri, associate program director, who has transformed the teaching conferences and made it his mission to improve the quality of clinical training for every fellow.

We are proud to call ourselves the Division of Cardiology at Augusta University. Working together, we deliver the highest caliber patient-centered care, train the next generation of cardiologists and conduct research that will transform cardiovascular health for decades to come. We truly appreciate your strong support and look forward to even greater success in the future.

NEW FACULTY

Haitham Hreibe, MD, FHRS Cardiac Electrophysiologist

Jacob Misenheimer, MD Interventional Cardiologist

• Board certified in: • Clinical Cardiac Electrophysiology • Cardiovascular Disease • Internal Medicine

• Board certified in: • Cardiovascular Disease • Internal Medicine

Dr. Hreibe is available to see patients at the following locations: • Cardiovascular Center on 15th Street, 937 15th St., Augusta, GA 30912 • Cardiovascular Center on Chafee Avenue, 1003 Chafee Ave., Augusta, GA 30912 • Wills Memorial Hospital, 120 Gordon St., Washington, GA 30672 Dr. Hreibe may be reached at 706-7217815 or 706-721-2426.

For an appointment, call 706-721-2426.

Research focus: the role of protein tyrosine phosphatase in the control the cardiovascular function

Dr. Misenheimer is available to see patients at the following locations: • Cardiovascular Center on 15th Street, 937 15th St., Augusta, GA 30912 • Washington County Regional Medical Center, 610 Sparta Road, Sandersville, GA 31082

Currently the principal investigator on two research projects: 1. “Aldosterone Contribution to Leptinmediated Hypertension in Obese Females” 2. “Leptin-induced, Adipocyte-derived Adlosterone Secretion: A New Risk Factor for Metabolic and Cardiovascular Complications”

Dr. Misenheimer may be reached at 706721-2328 or 706-721-2426.

For an appointment, call 706-721-2426.

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Eric J. Belin de Chantemèle, D.Sc, FAHA Research Faculty Member, Vascular Biology Center

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FALL 2016

Neal L. Weintraub, MD

Interim Chief, Division of Cardiology,

Professor and GRA Kupperman Eminent

CLINICAL RESEARCH

Scholar in Cardiovascular Medicine, Associate Director of the Vascular Biology Center for Translational Research

Cardiovascular Research:

Unlocking the door to future therapies The impact of scientific research on the practice of cardiology is stunning. For example, the recognition of the role of blood clot formation in heart attacks has led to the use of aspirin and other blood-thinning agents to prevent heart damage, while the discovery of the key enzyme involved in cholesterol production paved the way for the development of powerful medicines that lower cholesterol levels and reduce the burden of coronary artery disease. Clearly, patients with heart disease are living longer and better than ever because of these discoveries.

Nevertheless, heart disease remains the No. 1 killer of men and women in the United States.

This is why researchers in the Division of Cardiology at the Medical College of Georgia (MCG) are redoubling their efforts to make breakthrough discoveries in order to conquer heart disease once and for all. Over the past several years, we have established a strong program in basic cardiovascular research within the Vascular Biology Center (VBC), a multidisciplinary center that houses an internationally recognized team of experts with the skills and know-how to tackle the most complex problems facing cardiovascular scientists and clinicians today. The VBC brings us all together with the common purpose of understanding how cardiovascular disease develops and identifying new and better treatments for our patients.

Over the past several decades, the United States has

treatment strategies. For this reason, the Division

seen an alarming trend in the prevalence of obesity.

of Cardiology at MCG developed a robust research

Being obese or overweight is now the second-leading

program focused on the prime culprit in obesity: the fat

cause of preventable death in the United States, close

cells, themselves. Clinicians have recognized for some

behind tobacco use. The majority of the 300,000

time that not all obese patients are alike; in fact, their

deaths per year attributable to the obesity epidemic in

risk of developing disease seems to correspond to the

the U.S. are caused by cardiovascular disease. And the

pattern of fat tissue expansion.

southeastern U.S. is a literal “hotbed” of obesity, with more than 65 percent of Georgians considered to be

For example, fat tissue expansion in the buttocks

obese or overweight.

(“pear shape”) is much healthier than expansion in the waist area (“apple shape”), the latter being strongly

Efforts to treat obesity through improvements in dietary

associated with cardiovascular disease risk. In addition,

and exercise habits have largely failed, emphasizing

patients and clinicians alike recognize that once fat

the need to untangle the linkages between obesity and

tissue builds up, it is very difficult to lose and keep off.

cardiovascular disease in order to develop effective

It is almost as if the body develops a memory of exactly

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how much fat mass has accumulated and seeks to maintain it despite our best efforts. Our lab has been hot on the trail of solving these and other mysteries of obesity-related cardiovascular disease.

In collaboration with our surgical colleagues, we have discovered a gene, termed HDAC9, that is expressed in fat cells and appears to be a prime candidate and a potential target for treatment of obesity. Fueled by a recent $1.8 million grant from the National Institutes of Health (NIH), we are working in earnest to unravel the links between HDAC9 and cardiovascular disease, which appear to be far more complex and significant than we originally envisioned.

Figure 1 Fat tissue expansion in the buttocks (“pear shape”) is much healthier than expansion in the waist area (“apple shape”), the latter being strongly associated with cardiovascular disease risk.

For example, it turns out that HDAC9 is also expressed in blood vessels and is implicated in thoracic aortic aneurysm disease, a condition that causes up to 10,000 deaths annually in the U.S., typically striking down healthy people

The Cardiology Division at MCG has a powerful stem

in the prime of their lives. Because of our expertise and

cell research group, headed by Dr. Yaoliang Tang, whose

unique capabilities to study HDAC9 and a longstanding

mission is to unlock the secrets of stem cells and develop

track record of research in aneurysm disease, our

newer, better therapeutic approaches. His research

laboratory is assisting researchers at Harvard University

is focusing on how stem cells talk to each other via a

to determine how HDAC9 is involved in thoracic aortic

molecular pathway known as Notch signaling and how

aneurysm and other diseases of the aorta.

to “rewire” aging stem cells to improve their function via manipulating an enzyme called EZH2. Tang has recently

Once the heart is damaged due to heart attack, infection,

been awarded two NIH R01 grants worth nearly $4.5

etc., it tends to become progressively weaker over time,

million to conduct this important research. Notably, his

leading to a condition known as congestive heart failure

collaborators include Dr. Adam Berman, who heads up

(CHF). The prognosis of CHF is dismal: nearly half of

the innovative clinical trials of stem cell therapy in patients

the patients with this disorder will die within five years

with CHF. The integration of basic science and clinical

of the initial diagnosis. Although advances in medical

research is sure to help advance patient care and improve

therapy and support devices have helped, we desperately

outcomes in the future for patients with CHF.

need newer approaches to help the heart heal itself.

Researchers have known for some time that the heart

All this is happening right here at Augusta University.

contains stem cells that foster its growth and development

We are proud that our research program serves as an

but become depleted in injured heart tissue and cannot

inspiration for advancing patient care and a platform for

promote repair. Implanting stem cells into the hearts of

training the next generation of physicians and scientists.

patients with CHF has shown promise in early clinical trials,

We greatly appreciate your support in standing with us as

but much more research is needed to optimize this form of

we strive to achieve even greater success in the future.

therapy.

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CLINICAL RESEARCH

Lifelong strategy for patients with congenital heart disease

Anastasios C. Polimenakos, MD, FACS, FACC Director, Pediatric and Congenital Heart Surgery

Congenital heart defects are the most common birth

now successfully addressed. An estimated 85 percent

defects. Of all congenital conditions, heart defects

of patients born with congenital heart disease in the

account for the highest resource utilization among

United States are projected to survive into adulthood.

U.S. pediatric hospitalizations. In the earliest era of

The number of adults with congenital heart disease now

cardiac surgery, operations on children with congenital

exceeds the number of children with the condition.

cardiac malformations were landmark achievements that heralded the birth of pediatric heart subspecialties. What

These astonishing improvements in saving and

followed was a period of remarkable evolutionary steps

prolonging the lives of those born with congenital heart

in understanding the circulatory physiology, abnormal

disease come with the price of the lifelong challenges

morphology and functional consequences of structural

that accompany the longevity. Clearly, both short-term

congenital heart disease.

and long-term outcomes have improved substantially and continue to improve for even the most challenging forms

Innovative interventions have saved and prolonged lives,

of congenital heart disease. It is nonetheless apparent

enhancing quality of life as well for those with congenital

that long-term survival may require not only multiple

heart disease. The rapid progress in surgical therapy

surgeries, but catheter-based interventions to relieve

has been just one element of a broader picture that also

obstructions, implant devices, and treat dysrhythmias.

includes less-invasive and more-informative diagnostic

Managing adults with congenital heart disease will

modalities, catheter-based interventions, “hybrid�

require support at a national level.

collaborative strategies, the emergence of pediatric cardiac critical care and the evolution of multidisciplinary

The success story of saving and prolonging the lives

efforts with cell biologists and translational research

of those born with congenital heart disease requires

scientists.

acknowledgment of lifelong implications for the patients’ well-being. We must adapt to ensure that congenital

Congenital heart defects are now surgically corrected as

heart disease patients of all ages have access to

soon as possible after birth, avoiding the consequences

appropriate professional expertise and care.

of impaired circulation. Malformations once widely considered to be uniformly fatal (hypoplastic left heart syndrome and related anomalies, for instance) are

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TRAINING PROGRAM

completed a one-year interventional

Diversity in Cardiology:

cardiology fellowship at the CedarsSinai Medical Center UCLA. This allowed him to become one of the

MCG Cardiology Fellowship Training Program receives the 2016 Diversity in Cardiology Award The Medical College of Georgia at Augusta University’s (MCG)

most highly trained TAVR specialists for that year in the new procedure pioneered in the United States at Cedars-Sinai Medical Center. He has gone on to initiate the TAVR program

Dr. Mulugeta Fissha

at the University of Tennessee Health

Dr. Fissha trained in cardiovascular

Science Center. He has recently been

Cardiovascular Disease Training

diseases at MCG from July 1, 2007,

Program received notification from

to June 30, 2010. Fissha has the

the Association of Black Cardiologists

distinction of having obtained a

that the program was the recipient

certificate in clinical translational

of the ABC Diversity in Cardiology

science while training at MCG. He

Award for 2016. The prestigious

subsequently went on to complete

award has been received by many

his interventional cardiology training

of the preeminent cardiovascular

at the Newark Beth Israel Medical

divisions in our country. Previous

Center.

promoted to associate professor in that institution.

Dr. Almois Mohamad

Dr. Mohamad trained in

University, Emory University, Johns

MCG from July 1, 2009, to June 30, 2012. During his final year, he served as chief cardiology fellow.

recipients include Brigham and Women’s Hospital in Boston, Duke

cardiovascular diseases at the

He has presented his research work

Dr. Uzoma Ibebuogu

Dr. Ibebuogu completed his internal

Hopkins University, Ohio State

medicine residency at MCG before

University, the State University of

matching into the Cardiovascular

New York (SUNY) Downstate Health

Disease Training Program from July

Sciences Center, the University of

1, 2007, to June 20, 2010. During

Iowa and Vanderbilt University. Dr.

the training program, he won

Vincent J.B. Robinson, program

several accolades for his research.

director for the past 14 years,

He was second runner-up for the

accepted the award on behalf of the

Young Cardiovascular Researcher

program at the black tie dinner Oct.

in Clinical Research for his research

1, 2016, in New York City.

in congestive heart failure.

nationally at the American College of Cardiology meeting in March 2011. He is employed at the Jackson Cardiology Associates Professional Association in Jackson, Mississippi.

He practices in interventional cardiology, having completed his interventional cardiology fellowship at Tulane University from July 2012 to June 2013. (continued on page 12)

He received his prize at the The award not only seeks to

Annual Scientific Sessions of the

see enrollment of minorities in

American College of Cardiology

cardiovascular disease training

in March 2009. In March 2010, he

programs but also looks at the

returned with his project on the

trajectory of these graduates once

use of the D-dimer tests to detect

they leave the training program. The

atrial thrombosis and was second

minority graduates from the MCG

nationally for the best research

Cardiovascular Training Program

poster competition at the

have had a spectacular trajectory of

American College of Cardiology

success upon graduation. Some of

meeting in March 2010. After

the graduates are listed below with

graduating from the General

their achievements.

Cardiology Program, Ibebuogu 11

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Dr. Robinson receives the ABC Diversity in Cardiology Award for 2016 on behalf of the Cardiovascular Disease Training Program at MCG. Presented by Lammar Rucker. augustahealth.org/cardio

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Dr. Mbu Mongwa FALL 2016

Dr. Mongwa trained in cardiovascular diseases at MCG from July 1, 2005, to June 30, 2008. Mongwa subsequently completed the electrophysiology fellowship at SUNY Downstate in New York. He has

HEART & CARDIOVASCULAR

been employed at the Carle Clinic on the main campus in Urbana, Illinois. Mongwa functions as the cardiac electrophysiologist and

First Cardiovascular Graduate Mixer at the ACC National Scientific Sessions at McCormick Place in Chicago.

congestive heart failure specialist at the Carle Clinic.

Dr. Eze D. Uche

Dr. Uche trained in cardiovascular diseases at MCG from July 1, 1994, to June 30, 1997. Uche has a thriving private practice in Leesburg, Florida. Uche is trained in pharmacy and holds a Doctor of Pharmacy.

Among our current cardiovascular disease trainees, there are two outstanding minority fellows: Drs. Albert Sey and Michael Ibe. These individuals seek to follow in the illustrious path of their groundbreaking mentors. The Cardiovascular Disease Training Program is delighted to support the mission of Augusta University, which is an equal opportunity institution.

Cardiovascular Disease Fellowship Training

Vincent Robinson, MD, FACC,

Sean Javaheri, DO, FACC, FSCAI

Director, Adult Cardiology

Fellowship Training Program

FRCP(C)

Associate Director, Adult Cardiology

Fellowship Training Program

Zahid Amin, MD

Director, Pediatric Cardiology Fellowship Training Program

2016-2019 FELLOWS New Adult Cardiology Fellows

Christina Dookhan, MBBS Jackson Memorial Hospital/University of Miami Miller School of Medicine in Miami, Florida

Abhishek Garg, MBBS Medical College of Georgia at Augusta University in Augusta, Georgia

Gurpreet Johal, MD Oregon Health and Science University in Portland, Oregon

Tarun Sharma, MD St. John Hospital and Medical Center in Detroit, Michigan

New Pediatric Cardiology Fellows Dennis VanLoozen, MD Medical College of Georgia at Augusta University in Augusta, Georgia

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t the ns at cago.

CLINICAL RESEARCH

Shvetank Agarwal, MD, FASE Associate Professor and Section Chief of Cardiothoracic Anesthesia

The role of intraoperative TEE in complex cardiothoracic procedures

Case #1: A 54-year-old male with rheumatic mitral valve disease and considerable mitral annular calcification underwent a mechanical mitral valve replacement. On coming off bypass, a moderate to severe paravalvular leak was noted, which seemed to swirl around in the left atrium to the extent that determining its origin was almost impossible. Sequential 2D and 3D color Doppler views helped to identify the exact spot, which was around 9 o’clock position, just next to the left atrial appendage, which was successfully repaired by the surgeon in the second bypass run. (See figure 1 on page 15.)

Case #2: A 21-year-old female came for a percutaneous repair of a perimembraneous ventricular septal defect (pmVSD). These defects are usually not amenable to percutaneous repairs because of their close proximity to the tricuspid and aortic valves and also because the occluder device specifically designed for this defect has not yet been approved by the U.S. Food and Drug Administration (FDA).

In this patient, the defect was aneurysmal, which made it suitable for this approach, and a decision was made by the interventional cardiologist to use the PDA duct occluder, which is FDA approved in the U.S. A close communication was required throughout the procedure, including proper sizing of the defect, as too large an occluder would interfere with the functioning of the aortic valve leaflets and a too-small device would leave a residual leak or could dislodge and embolize. 2D and 3D TEE was used to guide the placement of the Judkins right catheter and the retrograde glidewire across the pmVSD and then finally an 10X8 Amplatzer Duct Occluder as it was deployed. A thorough post-deployment TEE showed a well-placed device without any residual shunt and no impingement of the aortic or tricuspid valvular apparatus. (See figure 2 on page 15.)

Use of TEE in the OR did not become commonplace until the late 1980s, when high-frequency transducers became available. Since then, its use has grown considerably in the modern cardiac ORs. Our perioperative TEE-trained cardiac anesthesiologists regularly use TEE in the OR for a multitude of reasons, including to provide diagnostic information that could not be obtained preoperatively, prompt diagnosis of myocardial ischemia, confirmation of the adequacy of valve reconstruction and other surgical repairs, determination of intraoperative complications and other hemodynamic pertubations to name a few.

A relatively safe, although invasive, monitor called “TEE” trumps other monitoring devices such as electrocardiography (ECG) and pulmonary artery catheters by rapidly providing important qualitative and quantitative information on valvular and ventricular functions not possible otherwise. In 1993, the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists established a Task Force on Practice Parameters for Transesophageal Echocardiography to develop evidence-based guidelines on the proper indications for performing TEE in the operative setting labeling it as a class I indication for all valve repairs, repair of HOCM, congenital heart surgery, pericardial widows and endocarditis, among others. At Augusta University Heart and Cardiovascular Services, we use TEE in every cardiac procedure as well as some thoracic and major vascular procedures.

Introduction of real-time 3D imaging has been another important milestone in the evolution of TEE in the operating rooms. 3D TEE offers much better spatial and temporal resolutions enabling more intelligent intraoperative surgical valve repair and replacement decisions. With the help of our 3D-enabled state-of-the art TEE machines, we were also able to do the following: • Play a vital role in minimally invasive and percutaneous interventions helping in last-minute evaluation of suitability for an intervention.

• Provide guidance during the intervention to detect complications.

• Comment on the success of the procedure.

The Section of Cardiac Anesthesia has recently expanded with the addition of four cardiac anesthesiologists. Our highly skilled and dedicated group of anesthesiologists continue to provide anesthesia, sedation ICU care and perioperative TEE services for all cardiac, thoracic, major vascular surgeries and out-of-OR procedures in the electrophysiology, cardiac catheterization and echocardiography labs.

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CLINICAL RESEARCH

Complex transradial coronary intervention:

Jacob Misenheimer, MD Interventional Cardiologist Assistant Professor, Medicine

Adapting transradial techniques to more complex lesions and higher-risk patients In recent years, transradial cardiac catheterization and intervention has been growing in prevalence and popularity due to lower bleeding risk, to early patient mobilization, and even to cost savings. Many operators, however, are reluctant to adopt transradial interventional techniques out of concerns regarding the steep learning curve to develop the necessary technical skills.

This is especially true in regards to patients with complex anatomy, such as calcified or bifurcation lesions, and in high-risk patients, including patients suffering from acute ST segment elevation myocardial infarction.

A recent meta-analysis published in the Journal of the American College of Cardiology: Cardiovascular Interventions

by Ferrante and colleagues has demonstrated that transradial coronary intervention is associated not only with reduced risks of bleeding and vascular access site complications but also with lower mortality as compared to transfemoral intervention. These benefits were found to be consistent across all patient subsets, including stable patients and patients presenting with acute coronary syndromes. Most interestingly, subgroup analysis revealed the mortality benefit to be the greatest in patients presenting with acute ST segment elevation myocardial infarction, and these benefits all came without increased risk of postprocedural myocardial infarction or stroke.

Although these findings are striking, it is notable that all of the studies analyzed were performed in high-volume transradial centers by operators skilled in transradial coronary interventions. For this reason, the Society for Cardiovascular Angiography and Interventions (SCAI) recommends a stepwise approach for developing transradial skills. Operators and labs should first develop competence performing simple diagnostic and interventional procedures on patients with favorable upper limb and

Figure 1: Rotational atherectomy of the right coronary artery via transradial approach using a sheathless guide catheter and transvenous pacemaker placed via right brachial vein access.

coronary anatomy and then become proficient performing elective and urgent interventions on patients with more challenging anatomy, including subclavian loops, radial loops and complex coronary anatomy. Finally, after attaining competence in these types of cases, operators can move on to performing multivessel interventions, chronic total occlusion interventions and interventions, during acute myocardial infarction via the transradial approach.

At Augusta University, our lab is well-experienced in transradial coronary interventions, allowing our patients to benefit from the advantages of the approach, even if they present with acute myocardial infarction or have complex coronary anatomy. Utilizing state-of-the-art, sheathless guide catheters, both traditional rotational atherectomy devices, and newer, smaller-bore, orbital atherectomy devices, even calcified lesions (Figure 1) and high-risk bifurcation lesions, including left main lesions (Figure 2), can be intervened upon safely with a transradial approach.

Most importantly, patients who present with acute ST segment elevation myocardial infarction, who derive the greatest benefit from a transradial approach, can be intervened upon safely and expediently with excellent results (Figure 3).

Figure 2: Left main percutaneous coronary intervention performed via transradial approach.

Figure 3: Percutaneous coronary intervention to the right coronary artery during acute, inferior ST segment elevation myocardial infarction via transradial approach.

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Figure 1

Figure 2

Augusta University Heart and Cardiovascular Grand Round Series DATE

2016-2017 Academic Year Surgical Amphitheater BI 4081 Fridays 7:10 – 8 a.m.

SPEAKER

TITLE

EMAIL

12/02/16

Jason Reingold, MD

Advocacy: Shaping the Future of Cardiology

jreingold@gmail.com

12/09/16

Stuart Cavaleri, MD

Revascularization vs. Medical Therapy in Stable Ischemic Heart Disease – The ISCHEMIA Trial

Stuart.cavaleri@va.gov

12/16/16

Arun Nagabandi, MD

How much “Metal” is too much?

anagabandi@augusta.edu

12/23/16

NO GRAND ROUNDS

12/30/16

NO GRAND ROUNDS

1/6/17

David Haburchak, MD

1/13/17

Ismail Tabash, MD

1/20/17

Ruchit Shah, MD

Current Understanding of Cardiorenal Syndrome: Pathophysiology and Treatment

rushah@augusta.edu

1/27/17

Manni Vannan, MD

Cardiovascular Imaging 2017: Progress, Promise and Challenges

Mani.vannan@piedmont.org

2/03/17

Abhishek Garg, MD

2/10/17

Michael Ibe, MD

2/17/17

dhaburchak@augusta.edu itabash@augusta.edu

agarg@augusta.edu Pulmonary HTN

mibe@augusta.edu

PCI vs Surgical Revascularization in Multivessel Coronary Artery Disease

2/24/17

Haitham Hreibe, MD

3/03/17

Thomas Deering, MD

3/10/17

Lavinia Mitulescu, MD

3/17/17

hhreibe@augusta.edu Incorporating Stroke and Bleeding Risk Stratification Tools in Atrial Fibrillation Management – Making Sense of the Alphabet Soup Algorithms

Thomas.deering@piedmont.org lmitulescu@augusta.edu

NO GRAND ROUNDS

3/24/17

Jacob Misenheimer, MD

3/31/17

Gurpreet Johal, MD

4/07/17 4/14/17

Infective Endocarditis for Cardiologists-2017

gjohal@augusta.edu NO GRAND ROUNDS

Vinod Thourani, MD

What?? You Want Your Valve Surgery Performed without an Incision?? An Update on Transcatheter Aortic and Mitral Valve Surgery.

vthoura@emory.edu

4/21/17 4/28/17

Christina Dookhan, MD

cdookhan@augusta.edu

5/05/17

Abdullah Omar, MD

aomar@augusta.edu

5/12/17

Jilang Zhou, MD

5/19/17

Tarun Sharma, MD

Critical Role of the Transcription Factor TEAD1 in Cardiovascular Development and Vascular Diseases

tsharma@augusta.edu

15 112472 - HEART AND CARDIO FALL 2016.indd 15

jizhou@augusta.edu

augustahealth.org/cardio

FALL 2016 HEART & CARDIOVASCULAR

12/6/16 3:48 PM

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SAVE THE DATE March 18, 2017

MCG ACC.17 Cardiology Alumni Reception 6:30 p.m. – Marriott Marquis, Washington, D.C.

August 19-20, 2017

Kimmerling MCG Faculty and Graduate Cardiovascular Showcase 2017 J. Harold Harrison, M.D. Education Commons $99 for physicians, NPs, PAs 15 hours CME Credit

112472 - HEART AND CARDIO FALL 2016.indd 16

12/6/16 3:48 PM