A
S U P P L E M E n t
to
W E s t c h E s t E R
h E a lt h
&
l I F E
M AG A Z i n E
advaNces iN
cardiovascular CARE westchester medical ceNter
‘i dodGEd A BULLEt!’ UGLY VEinS, BEGonE! ‘VAPoRiZinG’ BLoCKAGES GUARdinG tHE AoRtA’S WALLS fiX foR A toddLER’S RACinG HEARt
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coNteNts
HEART & VASCULAR
4 9 6 caRdIology
New wiNdsor divisioN 845.561.2773
hawthorNe divisioN 914.909.6900 imaging 914.909.6925
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noninvasive cardiology
advaNces iN
cardiovascular care 3
6 9
i N N ovat i o N s
in the cath lab
Electrophysiology/devices
a pass i o N
largest artery
Martin Cohen, M.d. Paul Eugenio, M.d. Andrea Cronin, R.n., fnP-C Carmela Musial, PA-C
‘i d o d g e d
heart Failure/vad/transplant
p r ot e c t i N g t h e
a bullet!’
10
Alan L. Gass, M.d. Gregg Lanier, M.d. Elizabeth Stevens, R.n., CCRn, MSn, fnP-BC Kathy Brown, R.n., B.S., M.S., A-nP, CCRn
BaNishiNg
ugly veins
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l e t yo u r
914.762.5810
blood flow
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Invasive–Interventional cardiology Hasan Ahmad, M.d. Martin Cohen, M.d. Linda Cuomo, M.d. William Gotsis, M.d. Gary Silverman, M.d. Robert timmermans, M.d.
for pictures
4
William frishman, M.d. John McClung, M.d. Joshua Melcer, M.d. tanya dutta, M.d. Joseph Harburger, M.d. nyree Sencion-Akhtar, R.n., fnP-C Vicki Klein, P.A.-C
a l i t t l e B oy s u rv i v e s
a big heart problem Advances in Cardiovascular Care is published by Wainscot Media, Montvale, n.J. © 2011. All rights reserved. the information in this publication is written by professional journalists and/or physicians. However, no publication can replace the direct care or advice of medical professionals.
clinical & nonInvasive cardiology John tighe, M.d. Stephen Lazar, M.d. Joseph George, M.d.
Invasive–Interventional cardiology Ahmad A. Hadid, M.d. Ahmad B. Hadid, M.d. Gladys Pacenza, R.n., fnP Patricia Rainaldi, R.n., fnP
sURgERy valhalla divisioN 914.493.8793 cardiothoracic surgery Steven Lansman, M.d., Ph.d. david Spielvogel, M.d. Rocco Lafaro, M.d. Ramin Malekan, M.d. Masashi Kai, M.d. Cindy Yu, R.n., n.P.
hawthorNe divisioN 914.593.1200 vascular surgery Sateesh Babu, M.d. Pravin Shah, M.d. Arun Goyal, M.d. Romeo Mateo, M.d. igor Laskowski, M.d. francis Carroll, M.d.
clinical & nonInvasive cardiology
lasER vEIn cEntERs
Arthur fass, M.d. franklin Zimmerman, M.d. dina Katz, M.d. deborah okoniewski, R.n., fnP Holly Mcnamara, R.n., AnP
Hawthorne 914.593.1200 Mount Kisco 914.241.3204 new Windsor 845.561.2773 White Plains 914.593.1234 Carmel 845.278.9670
go to WEstchEstERhEaRtandvascUlaR.com foR CoMPLEtE AddRESS LiStinGS And to SCHEdULE 2
advances in cardiovascular
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westchesterheartaNdvascular.com An APPointMEnt onLinE.
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a passion foR PiCtURES
This specialist knows how imaging technologies can help treat heart disease—and prevent it t h e y s ay a p i c t u r e i s w o r t h a thousand words, and Westchester
valves and other structures; • a 256-slice ct scanner, which
there are areas of scarring in the heart,” says Dr. Dutta, who trains Westchester
Heart & Vascular cardiologist Tanya
produces detailed images of the heart
Heart & Vascular’s cardiac fellows in
Dutta, M.D., agrees. She interprets
and its blood vessels in less than two
imaging technologies. “These tests also
nuclear stress tests, echocardiograms,
beats of a patient’s heart—so speedy that
help us evaluate treatment that has
cardiac CT (computed tomography)
it uses 80 percent less radiation than a
already begun.”
scans, and cardiac MrI (magnetic
standard scanner; and
resonance imaging) scans. These tools
• a 3 tesla mRI imaging system that
Dr. Dutta believes heart disease, America’s number-one killer, can someday
help her accurately assess patients’
is twice as strong as conventional MrI
be tamed. “With better early
hearts to assure definitive diagnoses—
machines and produces high-resolution
detection, medications and
and also provide assessments to help
images that do not require radiation.
lifestyle modification,” she
“Three-D echocardiography is par-
others stay healthy. “Today we have many options to treat heart disease that can be used before we
says, “we can make great
ticularly helpful for evaluating the heart’s
progress in preventing heart
muscles and valves and determining if
disease in those at risk.”
have to refer a patient for an angioplasty or surgery,” says Dr. Dutta. “Cardiac imaging studies can help us detect heart disease at an earlier, more treatable stage than other tests. With them, we can often step back from recommending an invasive procedure and better guide treatment with medications and lifestyle changes.” For patients who require surgery, she adds, cardiac imaging studies can fine-tune the treatment needed and help surgeons plan their procedures. A nuclear stress test or cardiac CT can replace an invasive angiogram for patients who cannot tolerate those tests. ways to view the heart Westchester Medical Center’s cardiac imaging technology, unequaled in the lower Hudson Valley, includes: • 3-d echocardiography, which can be used alone or
a WoUld-BE JoURnalIst gEts to thE
hEaRt oF thE mattER
tanya dutta, m.d.
tanya dutta, m.d., might have been an ace reporter. at first inclined toward a career in journalism, she edited harvard college’s daily newspaper, The Harvard Crimson, before switching to biology and earning her B.a./m.a. degree magna cum laude. “i realized halfway through college that i wanted to do more than interview patients—i wanted to treat them,” says the native chicagoan. while at cornell medical college in New york city, she fell in love with fellow student Neville Bamji—and with cardiology. “there are many fewer women cardiologists than men, yet almost as many american women as men with heart disease,” she says. “i thought i could offer my women patients a fresh perspective.” cardiology, she says, also promised her the ability to practice medicine based on an abundance of clinical research and evidencebased outcomes data. after completing an internal medicine residency at New york presbyterian hospital-cornell and a cardiology fellowship at montefiore medical center in the Bronx, she studied under the “guru of cardiac imaging,” Nathaniel reichek, m.d., at st. Francis hospital in roslyn, N.y. she completed a fellowship there in cardiac mr and cardiac ct and did research in cardiac imaging. she and Neville have two children, daughter tara, 2, and baby son Jayden, born June 14.
with cardiac MrI to assess heart
to find A
physician WMC_Cardio_1011Final_REV1.indd 3
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Innovations in the cath lab
a New
collaBoRatIvE spacE Now in late-stage planning, westchester medical center’s “hybrid” operating room will enable cardiovascular surgeons and cardiologists to work collaboratively with vascular surgeons and neurosurgeons on advanced interventions for patients. “heart and vascular problems often go hand in hand, so we must work together in performing both percutaneous and surgical procedures,” says interventional cardiologist hasan ahmad, m.d. Besides performing cardiac interventions, dr. ahmad also treats peripheral vascular disease, carotid artery disease and other circulatory problems.
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advances in cardiovascular
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At the region’s largest cardiovascular center, cardiologists and surgeons make heart-disease treatment more effective patieNts are the wiNNers
of clinical medicine at New York Medical
when different kinds of doctors work
College. “The heart does not beat exclusive
together—and that’s what’s happening
of the circulatory system; neither can we
now in the cardiac catheterization (or
afford to work without close collaboration
“cath”) laboratory, once the exclusive
with our vascular-surgeon colleagues.”
bastion of interventional cardiologists.
Since the 1970s, the Medical
Today it has opened its doors to cardiac
Center’s five cardiac catheterization
and vascular surgeons, signaling a more
labs have bustled with interventional
collaborative approach to treating people
cardiologists performing diagnostic
with cardiovascular disease.
angiograms, which let doctors watch
“research today proves that integrating the skills and knowledge of all members of the cardiovascular team
how blood flows through the heart and coronary arteries. While the patient is sedated with a
results in better outcomes for our patients,
local anesthetic, the cardiologist threads
and that is validated at Westchester
a thin tube, called a catheter, into the
Medical Center daily,” says interventional
femoral or radial artery and up to the
cardiologist and electrophysiologist Martin
heart. Contrast material is injected into
Cohen, M.D., Acting Director of Cardiac
the blood vessels to produce a real-time
Catheterization and an associate professor
X-ray image of the heart and its coronary
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arteries, which the cardiologist views on a monitor. Angiograms can show whether a coronary artery is blocked, help assess blood pressure in the heart’s
martin cohen, m.d.
chambers and reveal the volume of
linda cuomo, m.d.
gary silverman, m.d.
william gotsis, m.d.
blood pumped out of the left ventricle during each heartbeat. M.D., Director of Westchester Medical
M.D., Co-Director of Interventional
have also used cardiac catheterization to
Center’s Coronary Care Unit. “But
Cardiology, were colleagues at Montefiore
perform minimally invasive procedures
with exciting advances in nonsurgical
Medical Center in New York City. “We
called percutaneous (through-the-
percutaneous procedures coming down the
are thrilled to be working again with
skin) coronary interventions (PCIs) to
pipeline and the hybrid room that is being
one of our mentors, Chair of Medicine
treat blocked coronary arteries. One of
built here, we’ll all be working together.”
Dr. William Frishman, with whom we
Since the late 1980s, cardiologists
these, angioplasty—which uses a small
Among these advances is
inflated balloon atop a catheter to open
transcatheter aortic-valve
a blocked artery—revolutionized the
implantation (tavI), a new
nonsurgical treatment of coronary artery
treatment for patients with
disease. By the mid-1990s, tiny metal
aortic stenosis—a life-
scaffolds called stents were added to
threatening narrowing
angioplasty to help prevent restenosis
of the aortic valve—who
(re-blockage), a common complication.
cannot undergo valve
In 2003, stents began to be coated with
replacement because
medications to make restenosis even
of age or other medical
less likely.
conditions.
Also in the cath lab, interventional
In TAVI, an interventional
cardiologists and electrophysiologists
cardiologist and a cardiac surgeon
(cardiologists who treat heart-rhythm
replace a patient’s damaged aortic
abnormalities) perform:
valve with a bioprosthetic one. They
• laser procedures to vaporize
enter through a small skin puncture in the femoral artery instead of making
blockages; • coronary thrombectomies using
the large traditional neck-to-navel
vacuum aspiration with a catheter to
incision standard in open surgery. Once
remove a blood clot from a coronary artery;
the bioprosthetic valve is implanted, it
• heart biopsies;
handles the function of allowing oxygen-
• implantations of pacemakers and
rich blood to flow from the ventricle to
implantable cardioverter-defibrillators
the aorta and then out to the rest
(ICDs) to correct irregular heartbeats;
of the body.
• transesophageal echocardiograms
“We want to bring TAVI to our
(in which an ultrasound tool is guided down
patients in the lower Hudson Valley,”
the patient’s throat on a scope) to diagnose
says Gary Silverman, M.D., Co-Director of
structural problems of the heart, and
Interventional Cardiology at Westchester
• radiofrequency and cryo-energy
Medical Center and an associate clinical
ablations, which use heat and freezing
professor of medicine at New York
techniques, respectively, to vaporize tissue
Medical College. “Here at Westchester
that causes heart-rhythm disturbances.
Medical Center, we are putting the pieces in place, both diagnostic and therapeutic,
what teamworK caN do
to perform the TAVI procedure and other
“Historically, interventionalists and cardiac
percutaneous treatments that will save
surgeons competed for patients,” says
countless lives.”
interventional cardiologist linda Cuomo,
to find A
physician WMC_Cardio_1011Final_REV1.indd 5
conducted research at Montefiore,” says Dr. Gotsis, who now directs Westchester Medical Center’s interventional cardiology fellowship program.
USING A BETTEr
EntRy poInt
the newest twist on cardiac catheterization is to thread the catheters and other instruments “transradially”—up to the heart through the radial artery in the patient’s wrist instead of the femoral artery in the groin. interventional cardiologist robert J. timmermans, m.d., made the switch to the transradial approach several years ago and strives to use the technique almost exclusively. “the transradial approach results in a 50-percent lower risk of major bleeding complications at the wrist than in the groin—and less pain too,” says dr. timmermans. “patients can sit up immediately following the catheterization and can usually go home sooner than patients who must remain lying down flat for several hours after the femoral approach. “we’re working to minimize delays and return patients home as safely and expeditiously as possible,” adds the doctor.
Dr. Silverman and William Gotsis,
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protectiNg THE
largest artery
A vigilant program at Westchester Medical Center helps save the lives of patients with thoracic aortic aneurysms
6
advances in cardiovascular
WMC_Cardio_1011Final_REV1.indd 6
care
the aorta, shaped liKe a caNdy cane, is the body’s largest blood vessel. It carries oxygenated blood and nutrients from the heart to the rest of the system. Originating in the heart’s left ventricle, the aorta rises and then arches backward over the left lung, descends throughout the chest into the abdomen, and then ends by dividing into the iliac arteries in the pelvis. In the average adult, the aorta’s strong and fibrous walls
westchesterheartaNdvascular.com
11/23/11 11:38 AM
must withstand the pressure of 10 pints
Heart & Vascular
of blood gushing through at all times.
colleagues,
An aortic aneurysm occurs when
cardiothoracic
the walls of the aorta weaken or balloon
surgeons Steven l.
out. Aortic aneurysms are called
lansman, M.D., Ph.D.,
thoracic if they occur in the chest above
and ramin Malekan,
the diaphragm and abdominal if they
M.D., consider
appear below.
each patient’s stature, family history
david spielvogel, m.d.
and other medical conditions as well preveNtiNg disaster
as the aneurysm’s rate of growth and
Thoracic aortic aneurysms can develop
its diameter.
slowly or quickly. Two famous TV
Thoracic aortic aneurysms usually
comedians lost their lives to problems
do not make their presence known until
in the thoracic aorta: lucille Ball
disaster is imminent. But sometimes the
from a ruptured aorta following heart
condition is uncovered during a CT scan
surgery, and John ritter from an aortic
or other radiologic study for another
dissection.
medical issue.
At Westchester Medical
If an aortic aneurysm is found and
Center, Westchester Heart &
is within a safe size, the patient is placed
Vascular’s internationally recognized
on an individualized care schedule of
cardiothoracic surgeons have
ongoing exams and imaging studies.
implemented a comprehensive Aortic
If a patient has experienced an aortic
Aneurysm Program to prevent such
dissection and has had surgery to repair
tragedies by carefully screening all
it, he or she is immediately enrolled in
patients diagnosed with thoracic
the database because the patient is at
aortic aneurysms and managing their
risk to develop an aortic aneurysm.
care. The surgeons work closely with
ContinUEd on PAGE 8
ramin malekan, m.d.
steven l. lansman, m.d., ph.d.
“
Obviously we prefer to treat a thoracic aortic aneurysm safely and effectively before it reaches a dangerous stage.
”
patients’ primary care physicians, cardiologists and vascular surgeons to track any changes in these aneurysms
WHEn An
anEURysm BURsts
through regular checkups, computed tomography (CT) scans and/or magnetic resonance imaging (MrI) studies. “Obviously we prefer to treat a thoracic aortic aneurysm safely and electively before it reaches a dangerous stage,” says cardiothoracic surgeon David Spielvogel, M.D., Director of the Medical Center’s Aortic Aneurysm Program. moNitoriNg aortic aNeurysms For many years, a thoracic aortic aneurysm was considered safe until it reached 5 centimeters in size. Today, however, doctors at Westchester Medical Center look beyond this simple cutoff. To determine when to intervene,
an aortic aneurysm that bursts is a medical emergency, requiring immediate attention. call 9-1-1 if you experience: • sudden, intense, persistent abdominal, chest or back pain • pain that radiates to your back or legs • sweatiness • clammy skin • dizziness • loss of consciousness • shortness of breath • signs of stroke: weakness on one side of the body, difficulty speaking, blurry vision
Dr. Spielvogel and his Westchester
to find A
physician WMC_Cardio_1011Final_REV1.indd 7
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ContinUEd fRoM PAGE 7
protectiNg THE
largest artery
“Since 2006, when we began this program at Westchester Medical Center,
Cardiovascular Surgery at Westchester
—developed by Dr. Spielvogel—is fast
Medical Center.
becoming the standard at heart centers
we have perfected our surveillance and
around the world.
our surgical techniques so that we have
wheN surgery is Necessary
achieved very successful outcomes
“We look for subtle changes to time
replaces the aortic arch with a Dacron
and very low mortality rates,” says Dr.
elective surgery, rather than risk having
graft. A separate graft containing three
Spielvogel, who is also a professor of
to repair the aorta in an emergency,” says
“limbs” is substituted for the area where
cardiothoracic surgery at New York
Dr. lansman, Chief of Cardiothoracic
three arteries branch off the arch.
Medical College, Director of Heart
Surgery at Westchester Medical Center
Transplantation, and Associate Chief of
and a professor of cardiothoracic surgery
in the descending aorta and the patient’s
at New York Medical College.
medical condition permits, the surgeon
The type of surgery used to
Sometimes when aneurysms are
may use an endovascular stent-graft
treat a thoracic aortic aneurysm
procedure, avoiding “open” surgery to
depends on the site of the weakness.
treat the aneurysm. Because there is no
The “gold standard” of surgery to
large chest incision, both pain and the
treat an aneurysm in the aortic root
risk of complications are reduced, and
and ascending aorta is the Bentall
there is a quicker recovery.
procedure, named for the English surgeon who created it in the 1960s. During a Bentall, the surgeon
KnoW YoUR
In this procedure, the surgeon
The Westchester Heart & Vascular cardiovascular surgery team also performs complex surgical procedures
removes the area of the aorta containing
through incisions in the chest and
the aneurysm, replaces the aortic valve
abdomen to treat thoraco-abdominal
with a mechanical or bioprosthetic
aneurysms, which lie in both the chest
one, and then re-implants the coronary
and abdomen. Few heart centers have
arteries into a Dacron polyester tube
experience with such extensive aortic
graft that replaces the section of
reconstructions.
anEURysm RIsK
ascending aorta that has been removed.
you’re at higher-than-average risk of aortic aneurysm if you: • are age 60 or older • use tobacco • have high blood pressure • have atherosclerosis (buildup of plaque in your arteries) • are male (but women are at higher risk for rupture) • have a family history of the condition • suffer chest trauma • have a bicuspid aortic valve • have marfan’s syndrome or ehlers-danlos syndrome
Malekan use a technique called valve-
Preventing a stroke during aortic surgery
sparing aortic-root reconstruction for
is a challenge, as a stroke can occur
patients whose aortic valves are healthy.
as the result of tiny particles of debris,
Drs. Spielvogel, lansman and
“This saves a patient from a lifetime of taking anticoagulant medications, which are necessary to prevent blood
guardiNg BraiN aNd spiNal cord
called emboli, traveling to the brain and blocking blood flow there. At Westchester Medical Center,
clots from forming around a mechanical
special protocols protect the brain during
valve and putting the patient at risk for a
surgery. Methods include connecting the
stroke,” says Dr. Malekan.
heart-lung bypass machine to the axillary artery, keeping blood flowing to the brain
advaNced procedures
while the heart is stopped, and cooling
If a patient requires repair of the aortic
the patient’s body temperature to slow
arch, a procedure called a trifurcated
the metabolism while stopping blood
graft technique will be used. This surgery
flow to vital areas. .
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advances in cardiovascular
WMC_Cardio_1011Final_REV1.indd 8
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11/23/11 11:38 AM
Center’s Emergency Department
removed when his heart is
on September 6, he was chronically
fully recovered.
short of breath and his heart was
“I’m looking forward
racing at an alarmingly fast rate. An
to driving again and
electrocardiogram was abnormal, and
returning to work,” says
he was promptly admitted.
Aruilio, who is grateful for
Aruilio was hooked up to an
alan l. gass, m.d.
the treatment he received.
extracorporeal membrane
“I placed my trust in Dr. Gass,” he
oxygenation (ECMO)
adds, “and had complete confidence in
machine to help
his ability to save my heart.”
his lungs while a percutaneous
HELPinG PAtiEntS WitH
(through-theskin) CentriMag
®
ventricular assist device (VAD) was implanted through the groin into his heart to take over its function temporarily and pump oxygenated blood through the body. Together the two technologies gave Aruilio’s endangered heart the chance it needed to recuperate. This combination, pioneered by Alan l. Gass, M.D., Director, Heart Transplantation
Today’s heart-failure treatments save lives that would have been lost a few years ago
and Mechanical Circulatory Support, and his team at Westchester Medical Center, can be initiated within 15 minutes in an operating room or a cardiac catheterization lab. And it’s helping to change heart-failure treatment today. At an international conference in Pennsylvania in June 2011, Dr. Gass
Joseph aruilio shudders wheN
presented data from almost 100
he recalls how close he came to dying.
ECMO procedures he and the team
“My doctor says I dodged a big bullet,”
at Westchester Heart & Vascular
says Aruilio, 52, a Carmel resident
have performed over four years. “We
who works as a service manager for a
rescued many of these patients from
medical equipment firm.
certain death, so that we could initiate
What almost killed Aruilio was heart failure, caused by a virus that enlarged his heart and compromised
further treatment and save their lives,” says Dr. Gass. Aruilio was slowly weaned off
its ability to pump blood. When he
the ECMO machine and discharged
was brought to Westchester Medical
September 26. The device will be
to find A
physician WMC_Cardio_1011Final_REV1.indd 9
hEaRt FaIlURE despite its name, heart failure doesn’t mean the heart stops completely. it’s a chronic condition in which the heart can’t do its usual stellar job of pumping 2,000 gallons of blood daily. and the american heart association says it affects 5 million people in the u.s. many heart-failure patients are helped by lifestyle modifications, including smoking cessation, weight loss, exercise, proper sleep and a low-salt diet, and by medications that remove remove fluid from the body, dilate blood vessels and calm the heart muscle. others require more aggressive treatments such as these, which are provided in westchester medical center’s comprehensive heart Failure program: • Electrophysiology treatments, which utilize a pacemaker to synchronize the beating of the heart’s two ventricles; • percutaneous coronary interventions (including angioplasty and stenting), which open up blocked or narrowed coronary arteries; • latest-generation mechanical assist devices, which perform the pumping action of the heart and serve as bridges to transplant or as a longterm destination therapy; and • cardiac surgery, including heart transplantation, coronary artery bypass, valve repair or replacement and aortic surgery.
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BAniSHinG
ugly
i F va r i co s e v e i N s h av e K e p t you from revealing your legs, stand up and take notice. A minimally invasive
An outpatient procedure has made the treatment of varicose veins simpler and more effective
treatment can get you back into your shorts and dresses without sidelining you for days. “I was surprised by how easy and painless it was,” reports luAnne Izzo of Katonah, 48, who is proud of her legs once again after years of hiding them. Vascular surgeons at Westchester Heart & Vascular are using the outpatient VNUS Closure™ procedure to treat varicose veins with little discomfort. Patients often experience immediate relief from burning or throbbing in the legs and can usually go back to work and resume their normal activities the following day. Healthy leg veins contain one-way valves that open and close to assist the return of blood to the upper part of our body. When these valves become damaged or diseased, blood can pool in the veins, causing a condition called venous reflux or venous insufficiency in which leg veins may become swollen, discolored and knotted. Symptoms— including pain, throbbing, burning, muscle cramps and leg fatigue—often follow. This condition, commonly known as varicose veins, can progress to leg ulcers and dangerous blood clots. It’s been estimated that nearly 60 percent of all American women and
10
advances in cardiovascular
WMC_Cardio_1011Final_REV1.indd 10
care
westchesterheartaNdvascular.com
11/23/11 11:38 AM
G
Who’s at RIsK? you may be at risk for varicose or spider veins if you: • are a woman • have been pregnant more than once • have a family history of the condition • work at a job that requires long periods of standing • do a lot of heavy lifting • are overweight
the most severe cases. Endovascular procedures are
Closure™ procedure takes about an hour, and patients
performed without an incision instead of
go home one to two hours
with “open” surgical cuts. radiofrequency
later. If an ultrasound test
ablation involves using heat energy to
performed prior to the
remove diseased tissue, in this case the
procedure has shown
varicose veins.
venous reflux disease in
arun goyal, m.d.
veins other than the saphenous, they can the power oF heat Dr. Goyal performs VNUS Closure™ in
be treated at the same time. “research studies have shown that
the Atrium laser Vein Center, using
the Closure™ procedure is about 97
42 percent of men have varicose veins.
local anesthesia. A Closure™ catheter
percent effective,” says Dr. Goyal. “And
And though the problem sometimes
is inserted into the patient’s saphenous
most patients require just one treatment.”
affects younger adults, its incidence
vein percutaneously at the knee through
increases with age.
a small needle prick. Using ultrasound
the next day. Postoperative care involves
imaging to guide him, Dr. Goyal delivers
wearing compression stockings for one to
few conditions that affect clinical health,
quick bursts of radiofrequency energy
two weeks and walking at least one mile a
aesthetics and quality of life,” says
within the catheter to sections of the
day. Any bruising or scarring is minimal.
surgeon Arun Goyal, M.D., Director of
vein’s wall. The heat shrinks the wall,
Vascular Imaging and the Atrium laser
causing it to collapse and seal up. Healthy
satisfied patient Izzo. “If I had known how
Vein Center and an assistant professor
veins take over the job of taking blood
uncomplicated it was going to be, I would
of surgery at New York Medical College.
from the legs back to the heart. The
have done it a lot sooner.”
“Varicose veins are one of only a
“By the time patients come to me, many have suffered for years and greatly curtailed their activities.” closiNg oFF diseased veiNs Until about 10 years ago, doctors treated varicose veins with an invasive procedure called vein stripping, which Izzo recalls her mother undergoing. The patient was placed under general anesthesia while a vascular surgeon made several incisions near the knee and groin and then inserted a medical tool into the great saphenous vein, the major vein in the leg from which smaller veins branch off. The saphenous vein was tied off and then pulled from the leg. Because smaller veins broke during this process, blood frequently leaked into surrounding tissues; patients had postoperative pain, soreness and bruising, and recovery took up to four weeks. In the early 2000s, the surgeons at Westchester Medical Center began performing a procedure called radiofrequency endovascular ablation to treat varicose veins. As embodied in a system known as VNUS Closure™, it has
“
Patients usually go back to work
“There was no down time,” says
If I had known how uncomplicated it was, I would have done it a lot sooner. along camE ‘spIdERs’
”
spider veins are varicose veins’ annoying but harmless cousins: tangled groups of tiny blood vessels that turn blue or red from mild venous reflux, located near the surface of the skin. people at risk for varicose veins are also at risk for spider veins. spider veins can be caused by ultraviolet rays of the sun, certain medications or an injury to the skin surface. generally, spider veins are treated with one of two noninvasive or minimally invasive methods: • sclerotherapy, the injection of an irritant solution into the spider veins, which causes them to seal shut. the veins are absorbed by the patient’s body. • laser treatment, during which a device is used to deliver heat to the surface of the skin to destroy the veins. Because these treatments are considered cosmetic procedures, they are not covered by health insurance. patients usually require four treatments over a period of six months. although general practitioners, dermatologists and other healthcare professionals offer spider-vein treatments, dr. goyal recommends consulting a boardcertified vascular surgeon. “we have extensive knowledge about the complex functioning and malfunctioning of the entire circulatory system, so that if there are other medical issues affecting this system we can address them too,” he says.
since replaced vein stripping in all but
to find A
physician WMC_Cardio_1011Final_REV1.indd 11
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d i d yo u K N ow yo u r B lo o d travels through roughly 60,000 miles of arteries, veins, capillaries, organs and cells of your body every day? When it circulates normally, this blood (about 10 pints in the average adult) distributes oxygen and nutrients, then picks up waste matter and carbon dioxide from organ and tissue cells. When something impedes blood flow—either by blocking or weakening blood vessels or by damaging valves inside veins—a person is said to have vascular disease. Fortunately, today’s endovascular (inside blood vessels) treatments can in many cases restore good health to people with vascular disease without long hospitalizations. At Westchester Heart & Vascular,
let your
six board-certified vascular surgeons specialize in diagnosing and treating conditions of the circulatory system. They work closely with a team of cardiologists and cardiothoracic
blood flow Endovascular procedures often can restore healthy circulation without a long hospital stay
surgeons to provide comprehensive care of the entire cardiovascular system. Our vascular surgeons are also an integral part of Westchester Medical Center’s level I Trauma Center team, which treats patients who often require immediate emergency care. Vascular disease can be caused by: • atherosclerosis, a slow, progressive disease marked by a buildup of plaque (fat, cholesterol, calcium) in an artery; • inflammation in a blood vessel that leads to narrowing or blockage; • blockage by an embolus (tiny mass of debris) or thrombus (blood clot); or • injury or trauma to blood vessels. miNimally iNvasive procedures “By far the most exciting advances in the treatment of vascular disease involve minimally invasive endovascular procedures,” says Sateesh Babu, M.D., Chief of Vascular and Endovascular Surgery at Westchester Medical Center and professor of clinical surgery at
12
advances in cardiovascular
WMC_Cardio_1011Final_REV1.indd 12
care
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New York Medical College. “These can
anatomy is different,” says Dr. Babu,
often spare a patient major surgery
“a vascular surgeon’s decision to use
to prevent or stop a life-threatening
an endovascular procedure (in about
vascular condition.” With Pravin Shah,
75 percent of cases) or an “open”
M.D., Dr. Babu cofounded the Medical
repair (25 percent) must take into
Çenter’s oldest vascular surgery
consideration the location of the
practice in 1980; it has since joined
aneurysm, any twists and turns of the
Westchester Heart & Vascular.
aorta and any blockages in arteries on
sateesh Babu, m.d.
pravin shah, m.d.
the way from the femoral artery up to preveNtiNg “triple a” disasters
the AAA.”
In the past decade, the endovascular treatment of a common yet potentially
carotid artery disease
deadly condition called abdominal aortic
A major risk factor for stroke, carotid
aneurysm (AAA or “triple A”) has spared
artery disease occurs when plaque
many patients complex abdominal
builds up in one or both carotid arteries
surgery that would have required a
located in the neck, which carry blood
hospital stay.
to the brain and supply blood to your
An AAA is a ballooning of the aorta
face, scalp and neck. A stroke can
in the abdominal area, most often below
occur if plaque narrows the artery
the kidneys. If it ruptures, this can cause
or if a blood clot sitting atop plaque
death in up to 50 percent of patients
breaks off and then blocks blood flow
before they reach the hospital. By far
to the brain.
the greatest risk factor is cigarette
Dr. Babu and his colleagues took
smoking. (See “When an Aneurysm
part in a major National Institutes
Bursts,” on page 7.)
of Health clinical trial investigating
Insidious by nature, AAAs do not
two treatments for carotid artery
usually cause any symptoms. Often
disease. The Carotid revascularization
they are discovered during a physical
Endarterectomy versus Stenting Trial
exam or an imaging test for another
(CrEST) demonstrated that carotid
medical condition.
endarterectomy, a traditional surgical
“Once we know a patient has an
procedure to clear a blockage, and
AAA, we develop a surveillance plan of
the minimally invasive endovascular
checkups and ultrasounds to keep an
angioplasty/stenting used to open
eye on it,” says Dr. Babu. “In men, we
up a carotid artery had similar out-
may recommend treatment if it grows
comes (though there is a slightly higher
above 5.5 centimeters, in women above
stroke risk with stenting in patients
5 centimeters, and in both if the AAA is
over age 80).
growing rapidly. There is also a familial
Open surgery entails removing
risk, so we recommend ultrasound
plaque and diseased portions of the
screening for family members.”
artery through a small neck incision.
During endovascular AAA repair, a
“
By far the most exciting advances in the treatment of vascular disease involve minimally invasive endovascular procedures.
”
The stenting procedure involves
stent graft is threaded up to the site
threading a balloon-tipped catheter,
of the aneurysm from the femoral
metal stent and a tiny umbrella-like
Dr. Babu. “Once the blockage goes
artery. The stent graft acts as a bridge
“embolic protection device” (to guard
over 75 percent, the stroke risk leaps
between the healthy parts of the aorta,
against the formation of embolisms)
to 7 to 10 percent per year. Surgical
reinforcing the weakened section and
up from an artery in the groin to the
endarterectomy and stenting have
allowing blood to flow through the
carotid artery in the neck.
similar success rates, so the choice of
graft and avoid the aneurysm, which eventually shrinks. “Because every patient’s
to find A
physician WMC_Cardio_1011Final_REV1.indd 13
“A carotid artery that is less than
treatment is based on each patient’s
75 percent blocked carries only a 1
individual anatomy, medical condition,
to 1.5 percent risk of stroke,” explains
age and overall health.”
WESTCHESTEr MEDICAl CENTEr 1.877.wmc.docs (1.877.962.3627) | westchesterheartaNdvascular.com
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A little boy survives a
big heart problem How an electrophysiology procedure cured a rapid heart rate i n s e p t e m e r 2 0 1 0 , s h a nn o n
pediatric cardiology team. By this
Holmes of Millbrook, N.Y., thought her
time, Hunter’s heart rate was up to 225
three-year-old son, Hunter, was coming
beats. An electrocardiogram revealed
down with a bug. Even the excitement of
supraventricular tachycardia (SVT),
his cousin’s birthday party didn’t get him
a disturbance of the heart’s electrical
up and running.
system that starts in the upper chambers.
On September 28, a call from Hunter Holmes, 4, above and with friends Noah Mead, 4 (left), and Isabella Marie Tibodeau, 2, at a summer carnival
“Children,” says pediatric electrophysiologist Irfan Warsy, M.D., “may not know how to convey that they are experiencing heart palpitations. They may describe their heart as ‘beeping’ or say they are ‘having chest pains.’” If your child does so, go first to your regular pediatrician, who may recommend a pediatric cardiologist; 16 of them are on the faculty of the Maria Fareri Children’s Hospital at Westchester Medical Center.
14
advances in cardiovascular
WMC_Cardio_1011Final_REV1.indd 14
rest in between beats and its chambers
sent Shannon into a whirlwind of activity,
cannot fill with blood properly to create
ending in Hunter’s being diagnosed in
the force for normal blood flow.
the Pediatric Emergency Department
Is my child having palpitations?
“Our first step was to use maximum
(ED) of Maria Fareri Children’s Hospital
dosages of an intravenous medication
at Westchester Medical Center with a
to try to break the SVT, but his heart
dangerous abnormal heartbeat, known as
continued to beat too fast,” says Irfan
an arrhythmia.
Warsy, M.D., who was called in to
Upon the recommendation of
supervise Hunter’s treatment. Director
Hunter’s pediatrician—who measured
of Pediatric Electrophysiology at Maria
the boy’s heart rate at 194 beats per
Fareri Children’s Hospital and an assistant
minute instead of the normal 90 to
professor of pediatrics at New York
110—Shannon and her husband, Mark,
Medical College, Dr. Warsy specializes in
made the one-hour drive to Maria Fareri
heart arrhythmias in children. “When a second medication also
Children’s Hospital. As they reached the Emergency
care
When a heart beats that fast, it cannot
Hunter’s child care provider, also a nurse,
failed, we had to consider: Was Hunter’s
Department (ED), the family was
enlarged heart a result of the SVT or was
immediately met by the hospital’s
it, perhaps, a reaction to something viral?”
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11/23/11 11:39 AM
recalls Dr. Warsy. “We formulated a plan
the 60 or so children each year that
to treat him in the hospital’s Arlene and
Dr. Warsy treats and cures with this
Arnold Goldstein Pediatric Intensive Care
procedure. After an overnight stay, he
Unit with another potent medication and, if
returned home with no evidence of
necessary, to use a ventilator to breathe for
the SVT. He underwent imaging tests
him so his heart could rest.”
every couple of months until Dr. Warsy
Fortunately, a third medication broke
discharged him from his care eight
the SVT overnight, and a ventilator was
months later, noting that his heart
not needed. Hunter’s heart returned to a
function had normalized. There are no
normal rhythm after about four days of an incessant rapid heartbeat.
restrictions on Hunter’s future activities. Irfan Warsy, M.D.
“We were allowed to stay all seven
“I finally exhaled when Dr. Warsy said he was cured,” says Shannon with a laugh.
days that Hunter was in the hospital,” says
disturbances in children to discover
Shannon. “By the fourth day, he started to
if a true arrhythmia exists. “Inducing an
of SVT can be a burden for children,
look like himself and wanted to play again.”
arrhythmia is not dangerous in children,”
notes Dr. Warsy: “They often become
the doctor says. “Within the carefully
withdrawn and anxious and live in fear of
that Hunter had a rare form of SVT called
controlled environment of the EP lab, we
recurrences that can bring an ambulance
permanent junctional reciprocating
can provoke the heart into an arrhythmia,
to their school. This procedure, which
tachycardia. The culprit was not a virus,
study the characteristics of the substrate
carries just a minimal one to three per-
but a group of cells called a substrate.
and then pace the heart back to normal.
Further tests revealed to Dr. Warsy
“A substrate is present from birth and
In the majority of children on whom we
acts as a kind of short circuit,” explains Dr.
perform this test, if we can’t induce a
Warsy. “It is patient and waits in a child
disturbance, there is no arrhythmia.”
until there’s a perfect environment of
A “roving” catheter moved
heart maturity, neurological growth and
by the electrophysiologist can
hormones, then it acts up.”
pinpoint a substrate, such as Hunter’s, within millimeters. “The
diagnosing arrythmias
key is to avoid the atrioventricular
Dr. Warsy oversees the only pediatric
(AV) node, electrically the ‘holiest’
electrophysiology (EP) service in the
spot in the heart,” says Dr. Warsy.
region. This subspecialty of cardiology
Because the medication Hunter
involves the diagnosis and treatment of
was taking to control his SVT can
arrhythmias, disturbances in the heart’s
cause significant side effects, Dr. Warsy
intricate electrical conduction system.
recommended a minimally invasive
Electrophysiologists divide arrhythmias
radiofrequency ablation procedure to put
into tachycardias, in which the heart rate
an end to the arrhythmia permanently.
is faster than normal; and bradycardias, in
While Hunter was placed under
which it is slower. Noninvasive cardiac tests
general anesthesia, Dr. Warsy employed
used to diagnose arrhythmias include:
catheters placed in stable predetermined
• electrocardiograms (EKGs);
positions to provoke Hunter’s SVT with
• short- and long-term home EKG
electrical currents. Using 3-D imaging, he determined the pathway of the SVT
Holter monitoring; • event monitors and loop recordings (which detect palpitations); and • exercise stress tests (which
and guided a roving catheter to locate the offending substrate tissue. Within millimeters of the substrate he used
evaluate the heart’s ability to respond
radiofrequency energy heated to 60º
appropriately to exercise and assess
Celsius (140º Fahrenheit) to destroy the
medications’ effectiveness).
substrate, monitoring the temperature with
Dr. Warsy and his EP team also use invasive tests to provoke rhythm
to find A
physician WMC_Cardio_1011Final_REV1.indd 15
special technology within the catheter.
Living with recurrent episodes
cent risk, can turn a child’s life around.”
Ventricular arrhythmia, in which the heart’s lower pumping chambers beat faster than normal, can result from a structural abnormality of the heart muscles, a problem with the coronary arteries or a channelopathy, a genetic aberration of the heart’s electrical conduction system. If not treated promptly, it may cause sudden cardiac arrest. If such an arrest in a child is successfully relieved, a small device called an implantable cardioverter-defibrillator (ICD) can be used to maintain a regular heartbeat. “The advanced ICDs we now use can differentiate between pathologic tachycardia and a normal fast heart rate during a child’s everyday activities,” says Dr. Warsy. “Once the ICD determines via complex algorithms that the rapid heart rate is truly an abnormal arrhythmia, it can simply pace the heart out of the arrhythmia or send a small electrical current to shock it into a normal rhythm, saving the child’s life.”
Happily, Hunter became one of
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11/23/11 11:39 AM
Westchester Medical Center. One of America’s 100 Best Hospitals for Cardiac Surgery.
Since 1977, our team of world-class physicians has dedicated as much effort to advancing cardiac treatment methods as it has to perfecting them. That’s why, with nearly 6,000 hospitals in the United States, HealthGrades®, the most trusted, independent source of physician information and hospital quality ratings, has placed us in the top 100 for Cardiac Surgery.
877•WMC•DOCS westchestermedicalcenter.com Maria Fareri Children’s Hospital • Westchester Heart & Vascular • Cancer Center • Transplant Center Neuroscience Center • Joel A. Halpern Regional Trauma Center • Burn Center Behavioral Health Center • Advanced Imaging Center • Advanced OB/GYN Associates
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