Heart & Cardiovascular - Spring 2016

A Semiannual Publication of Augusta University Heart and Cardiovascular Services

Heart & Cardiovascular

SPRING 2016

SPRING 2016 HEART & CARDIOVASCULAR

In This Issue SPRING 2016

INTRODUCTION_______________________ 3-5

Heart & Cardiovascular is produced semiannually

by Augusta University Heart and Cardiovascular

CATHETER-DIRECTED THERAPY IN ACUTE PULMONARY EMBOLISM_________ 6

Services and the Augusta University Division of Communications

and

Marketing.

Please

direct

BRACHYTHERAPY_____________________ 7

comments or questions to 706-721-4997.

CARDIOVASCULAR DISEASE TRAINING PROGRAM___________________________ 9-10 NEWEST FREESTANDING CENTER_______ 10 A HOME AWAY FROM HOME____________ 11

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MESSAGE FROM CARDIOTHORACIC SURGERY

Dear Readers, This publication serves to keep all friends and stakeholders abreast regarding what’s new at Augusta University’s health system in the area of heart and cardiovascular health.

We have had a very successful year in clinical cardiovascular care and cardiothoracic surgery. We appreciate your continued support, and some of the more important occurrences over the year are listed below: 2015 was a banner year for the section of cardiothoracic surgery: n Surgical volumes are at an all-time high. n Outreach and collaborative efforts have extended our network across the Southeast. n Complex robotic-assisted thoracic cases are now routine. n Pediatric cardiac services crossed the 500 mark for interventions and 100 cases for congenital heart surgery in 2015. n We are now the only area program offering complex thoracic aortic M. Vinayak Kamath, MD

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

interventions. The anticipated opening of a hybrid OR suite later this year will add to our capabilities in this field. n We have established programs for hybrid management of atrial fibrillation, angio-dynamics/thrombus evacuation and other interventions such as diaphragmatic pacing for ALS. n Discussions for restarting of the CTS training program are ongoing.

kamath@augusta.edu

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MESSAGE FROM ADULT CARDIOLOGY

Neal L. Weintraub, MD

Interim Chief, Division of Cardiology;

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

Dear Readers, As Interim Division Chief, I am pleased to update you on the activities of the Division of Cardiology at the Medical College of Georgia at Augusta University and Augusta University Health.

As indicated by the name change, this is truly an exciting time for our entire health system. Over this past academic year, the Cardiology Division has continued to evolve, and our faculty and fellows have soared to even greater heights of achievement. Here are some of the recent developments and areas of interest in our division.

We have instituted two new interventional programs.

revascularization program continues to grow, with

The first is an acute clot-directed therapy program

referrals coming in from all around the region for this

for patients suffering from massive pulmonary and/or

complex interventional procedure. Under Dr. Kapoor’s

venous thromboembolic disease, which encompasses

leadership, we also serve as a national training site for

traditional and catheter-based thrombolytic and

CTO revascularization procedures.

mechanical treatment strategies. Our multi-disciplinary

We are proud to welcome a new faculty member to

team of experts, led by Dr. Arora, has achieved

our team. Dr. Sean Javaheri (interventional cardiologist)

remarkable success in improving patient outcomes

has joined us following a highly decorated career

and reducing disease morbidity. Second, we have

as a military cardiologist/educator. He has previous

established a brachytherapy program with our

appointments at both the Dwight D. Eisenhower Army

colleagues in Radiation Oncology. The purpose is to

Medical Center in Augusta and the Madigan Army

deliver intracoronary radiation to patients with recurring

Medical Center in Tacoma, Washington. He is currently

restenosis despite drug-eluting stent placement, thus

serving as the Associate Program Director of the

circumventing the need for more invasive procedures

Cardiology Fellowship and has truly invigorated the

such as bypass surgery. We have joined a select group

didactic training program. Speaking of our fellowship

of centers in the Eastern United States offering this

program, it continues to flourish, with a 100 percent

type of therapy and expect to be the second largest

pass rate on the Cardiovascular Board Exam and our

brachytherapy program in the Southeast. Meanwhile,

graduates securing outstanding positions in academics,

the chronic total occlusion (CTO) percutaneous

practice and advanced training programs.

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MESSAGE FROM PEDIATRIC CARDIOLOGY

Zahid Amin, MD, FSCAI, William B. Strong Endowed Chair,

Our EP program has established itself as an elite regional

Professor and Chief, Division of

leader and will continue to do so, given our expertise

Pediatric Cardiology, Children’s

in complex ablation techniques. Patients are routinely

Hospital of Georgia

referred from around the region (and beyond) on account of our program’s superb outcomes, even in the most

State of Congenital and Structural Interventions

technically difficult and refractory cases. Moreover, our faculty have travelled worldwide to train other operators in the use of the robotic techniques for catheter ablation.

This last year has proven to be successful for our growing

The last year has been very busy in our interventional

cardiovascular research and academic programs. We

cardiac hybrid suite. Almost 35 percent of patients

have greatly expanded our clinical trials activities and

were adults, and the remainder were less than

continue to pursue cutting-edge research projects, such as

18 years old. Procedures including ventricular

intracardiac stem cell therapy for patients with advanced

septal defects, atrial septal defects, patent ductus

heart failure. As a collective faculty, we published 27

arteriosus, mitral valvuloplasty, aortic and pulmonary

manuscripts last year ranging from case reports to basic

valvuloplasties were performed successfully.

science investigations. We are actively engaged across

Transcatheter stent placement in the branch

campus, collaborating closely with many departments and

pulmonary arteries, coarctation of aorta was also

centers, including the Vascular Biology Center and the

performed.

Georgia Prevention Institute.

We are an active hybrid program and have placed

Finally, a special faculty member was recognized at our

hybrid valves and closed atrial septal defects in small

most recent Faculty Senate Award Ceremony. Dr. Deepak

and complicated subsets of our patients, using small

Kapoor, Director of the Cardiac Catheterization Lab,

incisions and avoiding cardiopulmonary bypass. These

received the distinguished faculty award for patient care.

procedures were performed in collaboration with our

He is truly a remarkable physician who is always eager

cardiothoracic surgeon Dr. Anastasios Polimenakos.

to help and makes the most difficult problems look easy.

Not only is Dr. Kapoor widely known in the region for his

Our program for Melody transcatheter valve

brilliance in the cardiac catheterization lab, but he is also

placement in the right ventricular outflow tract is

absolutely adored by his patients and deeply admired by

approved. We also use Edwards transcatheter valve

colleagues and staff.

for pulmonary position and are approved for its use in aortic position. Hence, all interventions that are

The success of our programs at Augusta University is

available in the United States are available for our

undeniable. We are truly “on the move” and excited

patient population at Augusta University.

about taking on future challenges and reaching our goals to excel in patient care, education and research. Our success depends on you, and we truly appreciate your strong support.

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CLINICAL RESEARCH

Vishal Arora, MD, Interventional Cardiology

Catheter-Directed Therapy in Acute Pulmonary Embolism Acute pulmonary embolism (PE) is a leading cause of cardiovascular mortality, accounting for 5-10 percent of in-hospital deaths in the Western world.

Most patients with PE have a low risk for mortality and are treated with anticoagulation only. Nearly half of the patients with PE fall into the intermediate- to high-risk category, with a mortality rate ranging from 21 percent to 58 percent in three months. Patients surviving acute PE remain at risk for recurrent emboli and chronic pulmonary thromboembolism, ultimately resulting in a poor quality of life.

Current guidelines recommend treatment with

absolute contraindication for the use of thrombolytics,

systemic thrombolysis in cases of acute massive PE for

catheter-based mechanical thrombus removal

improved hemodynamics and survival. Despite careful

techniques are often the only alternative.

screening for contraindications for thrombolysis, there is a 22 percent risk for major bleeding complications,

In our center, we have been successfully performing

including 3 percent risk of intracranial hemorrhage.

rheolytic thrombectomy using an AngioJet device and

Furthermore, only one-third of patients with acute

manual suction thrombectomy in patients with acute

massive PE in clinical practice actually receive the

massive PE with contraindication to thrombolytics.

lifesaving thrombolysis. In patients with submassive

Ultrasound-assisted, catheter-directed thrombolysis

PE, systemic thrombolysis is not routinely used, as the

(USAT) is the newest tool in the armamentarium for

risk of bleeding complications outweighs the modest

the treatment of acute PE, which has enabled us to

mortality benefit.

further reduce the treatment dose of the thrombolytic used in catheter-directed interventions. This new

Recent developments in catheter-based intervention

technology utilizes ultrasound waves that are delivered

have enabled us to treat massive and submassive

to the thrombus via ultrasonic core wire that help in

PEs with pharmacological, mechanical and

“loosening� the thrombus, thus aiding in better lytic

pharmacomechanical techniques. These new

penetration.

techniques have significantly decreased bleeding

The ULTIMA study has demonstrated better right

complications, compared to systemic thrombolysis, and

ventricular function at 24 hours and six months post

the overall survival rate is comparable. In patients with

procedure in patients with submassive PE who are

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treated with USAT along with heparin, compared to heparin alone. We have successfully used this technique in the treatment of both deep venous thrombosis (DVT) and acute submassive pulmonary embolus.

The case below illustrates a common scenario where we use ultrasound-guided, catheter-based thrombolysis. A 59-year-old male presented to the emergency department (ED) with dizziness followed by syncope. He was normotensive. His troponin was mildly elevated in the ED. On subsequent work up, he was noted to have a saddle

Fluoroscopic image of the chest shows the placement of

PE on CT chest and right ventricular dilatation on echo. His

two 12-centimeter EkoSonic devices with radio-opaque

vitals remained stable.

CLINICAL RESEARCH

treatment zone markers and ultrasound elements.

Paul Poommipanit, MD, Interventional Cardiologist

Brachytherapy The concept of coronary brachytherapy dates back to the 1990s, when restenosis of bare metal stents occurred.

Coronary brachytherapy, which is the delivery of ionizing radiation to the coronary artery, provided more durable results than other percutaneous revascularization techniques at that time.

In more recent years, this has been supplanted by drug-

who develop restenosis of these newer stents. Additionally,

eluting stents. Second-generation drug-eluting stents

there is some debate about the best therapy for these

perform extremely well and have a restenosis rate of less

patients. The current consensus opinion suggests that

than 5 percent.

repeat drug-eluting stenting is the most beneficial. Other institutions perform repeated balloon angioplasty within

Despite our best efforts in the cardiac catheterization lab,

these stents, noting that increasing layers of stent in the

there is still an unmet need in a subset of our population

coronary artery “shrinks the room� available for blood 7

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flow. At Augusta University Heart and Cardiovascular

procedure and the multiple specialties involved. Our

services, like most other programs around the country,

first session was in June 2015, in which we performed

we have patients who continue to present with in-stent

coronary brachytherapy successfully on four of our

restenosis, despite multiple drug-eluting stents and

most refractory patients.

angioplasties, and, thus, another, more durable solution is needed. Coronary brachytherapy provides us with

Coronary brachytherapy can potentially help these

that possible solution.

patients to obtain a more durable and long-lasting outcome, resulting in an improved quality of life.

To this end, we have restarted the coronary

A collaborative, multidisciplinary effort at Augusta

brachytherapy program at Augusta University in

University, involving interventional cardiologists,

order to better serve our patients and community.

radiation oncologists, radiation safety and medical

We are currently the only center in Georgia and one

physicists, has resulted in the ability to successfully

of two centers in the entire Southeast with coronary

perform this procedure, to the benefit of our patients

brachytherapy available. Part of the reluctance of many

and the state of Georgia.

centers to do this is the labor-intensive nature of the

A patient presented with symptomatic coronary artery occlusion with a drug-eluting stent in stent restenosis.

The length of the lesion, as

The Beta-Cath(TM)

depicted by the black arrows.

coronary brachytherapy system in place.

Appropriate dosing was calculated by the radiation oncologist present during the procedure, and the duration of dwell time was ensured by the medical physicist who was present during the procedure.

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The final result, with the lesion depicted by the black arrows.

TRAINING PROGRAM

Vincent Robinson, MD, FACC FRCP(C), Co-Director of Nuclear Cardiology and Director of Cardiology Fellowship

The Cardiovascular Disease Training Program At Augusta University’s health system, we have a cardiovascular disease training program, which started at the onset of specialty training in cardiology in the early 1960s.

As the curriculum expanded, training increased from one up to three years at the present time. Currently, there are more than 200 graduates from the cardiovascular disease training program who practice mainly in the Southeast but can be found throughout the entire country.

It is an understatement to say that the cardiovascular

Fat Meal Induces Oxidative Stress and Inflammatory

disease training program continues to be the “crown

Remodeling in Erythrocytes.” In November 2015, Dr.

jewel” of our academic practice in cardiology. Having

Michael Ibe, first-year cardiology fellow, followed up with

talented and motivated young minds working with us as

first prize for his project titled “Using Thrombolytic Agents

we treat complex clinical cases is the best way to bring

to Improve Specificity of the d-Dimer Test for Detection

the added value of an academic practice in cardiology to

of Intravascular Clots in Patients Suspected of Pulmonary

our patients. It also provides a boost for research within

Embolism.”

our division. I will outline some of the achievements over the past two years, which continue to propel our academic

The cardiology fellows have continued to be exceptional

practice to greater heights.

performers academically. In 2012, the graduating fellows were 100 points above the national average for their

In the area of research, the cardiology fellows were authors

scores in the ACC In- Training Examination. In 2013, our

and co-authors on 16 publications over the last two years.

first-year fellows were 100 points above the national

They have presented at national meetings seven times

average in the score for the same examination. In the last

within the past two years. This has interfaced smoothly

national ACC in-training examinations of October 2015,

with increasing publications and funded trials managed by

the third-year graduating class of four fellows’ average

our faculty. At the last faculty awards ceremony, Division

score was 133 points above the national average score for

of Cardiology faculty garnered the distinguished faculty

third-year fellows. Two graduating fellows were above the

award for both basic and clinical research. In the last two

98th percentile nationally for their scores on the in-training

years, our cardiology fellows have garnered first prize at

exam. Our cardiology program has gone seven years

the annual scientific session of the ACC Georgia Chapter

continuously with a 100 percent pass rate in the ABIM

at Lake Oconee. In November 2014, our chief fellow Dr.

certifying examination in cardiovascular disease.

Lauren Holliday won first prize for her project titled “High

continued

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We recently obtained the services of Dr. Sean Javaheri, former cardiology program coordinator in the Internal Medicine Residency Program at Dwight D. Eisenhower Army Medical Center and Madigan Army Medical Center from 2009 to 2015.

Javaheri, who is a board-certified interventional cardiologist, has been very effective in reinvigorating our didactic training program in general cardiovascular disease. We hope to offer interventional cardiology subspecialty training within the next two years. This would be in addition to our established electrophysiology training program.

We ask for your support of our fellows as they present at the National ACC in Chicago, Illinois, April 1-3, 2016. Dr. Amudhan

Our Newest Freestanding Cardiovascular Center Augusta University Heart and Cardiovascular Services opened a new center on campus June 19, 2015. The 15th Street Cardiovascular Center is located at 937 15th Street in Augusta, Georgia. The center houses general cardiology, interventional cardiology, cardiac rehabilitation and an outpatient echocardiography lab. It offers state-of-the-art cardiac rehabilitation monitoring equipment, on-site cardiology diagnostic testing, a walking track, a conference room and caregiver tables and chairs.

There is ample convenient parking and close proximity to hospital-based services.

Cardiac rehabilitation was the first service to join the Cardiovascular Center 15th Street after sharing space and equipment with the Wellness Center on Augusta University’s Health Sciences Campus since August 2007. The new location not only gives the program its own space, but it also resides in the same building as the clinic. This allows patients to schedule upcoming clinic appointments and cardiac rehabilitation sessions during a single visit. The importance of emotional and social support in the rehabilitation process inspired the setup. For instance, the exercise machines encircle the monitoring station from which all patients can be observed, receive education as a group and interact with one another.

Jyothidasan, third-year cardiology

2015 Graduates & Affiliation

fellow is also participating as a member of the Georgia team in the

Michele Murphy, MD Clinical Cardiac Electrophysiology Fellow, University of Virginia, Charlottesville

FIT Jeopardy competition. Thank you for your support of cardiovascular disease training at Augusta University.

2016 Graduates & Affiliation Rebecca Napier, MD (Chief Fellow) Advanced Heart Failure/Cardiac Transplantation Fellowship, Mayo Clinic, Rochester, Minnesota

Loren Garrison Morgan, MD Interventional Fellowship Program, Miami Heart Institute, Mount Sinai Medical Center, Miami Beach, Florida

Amudhan Jyothidasan, MD Interventional Cardiology Fellowship, University of Texas Medical Branch, Galveston, Texas

Pratik Choksy, MD Interventional Cardiology Fellowship, University of Oklahoma, Oklahoma City, Oklahoma

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NOT PICTURED Lauren Holliday, MD (Chief Fellow) Staff Cardiologist, Carlisle Heart Center in Columbia, South Carolina Jacob Misenheimer, MD Interventional Cardiology Fellow, University of North Carolina, Chapel Hill Simi Kumar, MD Private Practice, Jacksonville, Florida

Stefani Samples, MD Pediatric Cardiology Fellow

EDITORIAL

Betts Murdison, President & CEO, Ronald McDonald House Charities of Augusta

A Home Away From H me A diagnosis of congenital heart disease can be a scary thing for any parent to hear.

If that family lives far away from the critical medical care their child needs, it is exponentially scarier. That’s where Ronald McDonald House Charities of Augusta steps in.

We are a “home away from home” for families of all

and friendship are provided by the council. They also are

pediatric patients who come to Augusta for medical

constant participants at our annual Plane Pull and even

treatment. In 2014, nearly 10 percent of our families were

won the coveted trophy last year! Go Little Brave Hearts!

identified as pediatric heart program patients. This does not include the newborn babies in the NICU who are often

Families can stay at the house and not worry about

seen by a pediatric cardiologist during their stay.

everyday details, like what’s for dinner or where to sleep.

We take care of the little things so they can focus on what’s

We enable the physicians to complete their mission of

really important: the health of their child. Our house has

caring for the children of Georgia in their outreach clinics

23 bedrooms, each with a private bathroom, full kitchen,

in other parts of our state. When a child is seen in Albany,

dining room, play rooms, and lots of fun distractions

Valdosta or Thomasville and needs further treatment, the

offered daily. We provide all meals, which are lovingly

family can come to Augusta knowing that they have a safe,

prepared daily by volunteers, and hugs are given away

caring and fun home to stay in that is steps away from the

freely. Families are asked for a donation to stay with us, but

hospital. If a mom has a prenatal cardiology diagnosis, she,

no family is ever turned away for an inability to pay.

too, can come and stay at the house prior to her expected delivery date. When the child is born, he or she can be

Our partnership with the Children’s Hospital of Georgia

transported from the delivery room to the NICU or over to

is strong. We are proud to be here for pediatric heart

the OR, all under the same roof. This is safe for the mom,

patients and their families. Our pediatric heart patients

safe for the child and comforting for the rest of the family.

deserve the best care possible, and, in Augusta, they receive it within the hospital and at the Ronald McDonald

In 2014, we served families from 98 counties throughout

House. Thank you to the physicians, nurses and all the staff

Georgia, and 75 percent of our families live south of

at Children’s Hospital of Georgia for allowing us to help

Macon.

you take care of our littlest hearts.

The house has also partnered with the pediatric program’s

Note: Mrs. Murdison is married to pediatric cardiologist Dr. Kenneth Murdison and happy to be his partner in helping his patients!

parent volunteer group, the Children’s Heart Program Volunteer Council, to ensure that all Heart Kids get everything they need when they stay with us. Meals, toys 11

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SAVE THE DATE

September 3-4, 2016

“Kimmerling MCG Faculty and Graduate Cardiovascular Showcase 2016” J. Harold Harrison, M.D. Education Commons

November 5-6, 2016

“Update in Cardiovascular Disease Management for Primary Care Providers” J. Harold Harrison, M.D. Education Commons