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
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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. 4
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. 5
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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. 8
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