Heat and Cardiovascular news - Fall 2014

FALL 2014

HEART & CARDIOVASCULAR

A Biannual Publication of GRHealth

CHIEF’S NOTE

DEAR READERS,

A common theme runs throughout much of the con-tent in this edition of Heart & Cardiovascular: the importance of cardiac rehabilitation. Few areas of health are as dependent on lifestyle as heart health, and our second-to-none cardiac rehabilitation staff does an excellent job setting our patients on a path of active, healthy living. The super-vised and controlled exercise programs ensure a safe, supportive environment in which to optimize fitness. The benefits are innumerable and well-documented, as you’ll read in this edition of our newsletter. We hope you will find the evidence compelling enough to refer as many of your patients as possible for cardiac rehabilitation. Also in this edition of the newsletter, we introduce you to our pediatric heart surgeon, Dr. Anastasios Polimenakos, who comes to us from the Geisinger Health Center in Pennsylvania. His high-tech, high-touch approach to wellness inspires connections and relationships that last for years. We think you’ll agree he’s a magnificent addition to an exemplary group of health care professionals. We also hope you’ll enjoy the fresh new look of our newsletter. We seek to make this publication as appealing, relevant, helpful, and accessible as possible. We welcome your feedback in our quest for ongoing improvement. Here’s to your good health.

Best,

Dr. Vinayak KamathDirector, Heart & Cardiovascular ServicesChief, Cardiothoracic [email protected]

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IN THIS ISSUE

Heart & Cardiovascular is produced biannually by the Medical College of Georgia Department of Cardiology and the Georgia Regents University Office of Commu-nications and Marketing. Please direct comments or questions to Editor Christine Hurley Deriso at 706-721-2124 or [email protected].

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FALL 2014

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CARDIAC REHAb _________________4

YOUR 4-MINUTE MIlE _____________6

PERCUTANEOUS REPAIR OF A COMPlEx AORTIC COARCTATION ___7

FACUlTY SPOTlIGHT _____________8

2014-15 CARDIOlOGY FEllOwS ____9

CARDIAC CONFERENCE ___________10

THE TEAM _______________________11

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Medicare now covers cardiac rehabilitation for patients with stabilized heart failure and an ejection fraction of 35 percent or less. This decision was based on a review of much data, including two major studies. (See “Growing Data,” page 3.) So which of our patients are candidates for heart failure cardiac rehabilitation? Those who, in the months or years following their initial event, are diagnosed with reduced left ventricular function (an ejection fraction of 35 percent or less). Prior to enrollment, the patient must be on a good, stable heart failure medical regimen for approximately six weeks. This would include, when possible, advanced doses of ACEI or ARBs, as well as Beta blockers, with diuretics and possibly Spironolactone. If the physician predicts the patient will have a major cardiac procedure such as surgery or percutaneous intervention within six months, enrollment is generally postponed. Possible contraindications for cardiac rehab include severe valvular heart disease, very high resting heart rates, severely limiting neuromus-cular comorbidities, and/or other uncontrolled advanced medical issues. However, cardiac rehab staff members can evaluate every patient for possible inclusion. As always, patients with the standard criteria for cardiac rehab will still be enrolled for those reasons, regardless of the ejection fraction. The standard

criteria continue to be:n Recent myocardial infarc-tionn Coronary artery bypass graftn Percutaneous coronary interventionn Stable angina (without prior cardiac rehab)n Valve surgeryn Heart transplant An example of a heart failure candidate for cardiac rehab might be my patient who had a myocardial infarc-tion. Following coronary artery bypass grafting, good medical therapy, and standard cardiac rehab, he is doing well with an ejection fraction in the mid-30s. However, over the last several months, he has become more tired and subsequently more sedentary. No new medical issue has been diagnosed, and despite “optimizing” his meds, his condition remains the same. I believe that supervised, prescribed, monitored, and consistent exercise would do him a world of good. In the past, this patient would not fit neatly in the standard criteria, but with the new heart failure category, he is a prime candidate for cardiac rehab. Dr. David Whellan in a 2012 Journal of the American College of Cardiology editorial reminded us that Dr. William C. Roberts, a strong proponent of exercise, in 1984 called exercise training a “wonder drug.” Let us begin to employ this “drug” in our armamen-tarium for our heart failure patients as well!

MEDICARE COVERAGE

ExPANDS FOR CARDIAC REHAb

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By Dr. Preston D. Conger Jr.Director, Cardiac Rehabilitation ServicesAssistant Professor of Medicine

grhealth.org/cardio FALL 2014 HEART & CARDIOVASCULAR5

In my book, “Ready for a Change,” I discuss the benefits of exercise for those with depression and anxiety. Recovering from cardiac disease and adjusting to life changes can produce many psychosocial issues that may be unevaluated and consequently untreated. The monitored and supervised exercise provided during cardiac rehabili-tation can be very beneficial for patients with congestive heart failure, a recent myocardial infarction, acute coronary syndrome, or chronic stable angina. It is also helpful after coronary artery bypass surgery or percutaneous interven-tion. Cardiac rehab includes pre- and post-testing for anxiety and depression as well as intervention through a regular exercise program. Patients attend cardiac rehab two to three days a week for up to an hour for six to 12 weeks. For many patients, this could be either their first regular exercise program or the first time they have exercised in years. Potential benefits, most of which can reduce depression and anxiety, include the release of mood-enhancing endorphins; a sense of accomplishment, particularly for previously sedentary patients; weight loss and body fat reduction; an increased energy level; improved sleep; improved ejection fraction (a measure of heart health); and improved lipid levels. Cardiac rehab can also alleviate the social isolation common following myocardial infarction or surgery. The process surrounds patients with ongoing social support, education, and encouragement from registered nurses, exercise physiologists, and physicians. But most of the social support comes from other patients, fellow cardiac rehab participants who see each other frequently and share their experiences with each other. Patients exchange advice, provide encouragement, and develop relationships. Cardiac rehab also benefits family members, who are able to de-velop regular exercise programs with their loved one while receiving social support. Social support improves psychoso-cial factors tremendously. Yet very few eligible patients utilize the service, gen-erally because of lack of a physician referral. I hope the many well-documented benefits of this service will prompt physicians to refer their patients to cardiac rehab.

Growing Data

The two principle studies (in addition to adjunct data) that informed the decision to expand Medicare coverage of cardiac rehabilitation were:

HF-Action Study This involved 2,331 patients split evenly between ischemic and non-ischemic patients, with an average ejection fraction of 25 percent on good medical ther-apy. After 36 weeks of supervised exercise, patients were prescribed unsupervised exercise at home and followed for almost 30 months. The quality of life of those on the exercise program was significantly bet-ter than those in the control group, and the exercise group showed a modestly improved functional capac-ity. Though statistically insignificant, hospitalization and mortality rates were lower among the exercise group as well – 11 percent lower when factors of left ventricle ejection fraction, history of atrial fibrilla-tion, depression, and baseline exercise capacity were adjusted. Study weaknesses included a high dropout rate and non-supervision of the extended home exercise program.

10-Year Exercise Training in CHFThis study of 135 patients with an average ejection fraction of 37 percent was tightly designed with only a 12 percent dropout rate. Participants under-went supervised exercise three times a week for two months, then maintained with supervised exercise twice a week for 10 years. The exercise target was enhanced by using oxygen uptake measurements to ensure a target level of training. Participants had significantly improved quality of life measures within several weeks and showed a marked improvement in oxygen uptake (functional capacity) after a year. The one-year mark also showed a trend for improved survival rates (a 32 percent relative risk reduction) and a decreased hospitalization rate. Ejection fraction improved at five years. All early improvements were maintained throughout the 10 years of the study. As the authors of the study noted, this seems to bear out the general rule that one metabolic equivalent im-provement in exercise equals a 12.4 percent improve-ment in life expectancy and that stable heart failure does not prevent the body from responding positively to exercise.

CARDIAC REHAB IMPROVES PSYCHOSOCIAL FACTORS

By Crystal NealLead Exercise Physiologist, Cardiac Rehabilitation

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Before 1953, it was sincerely believed that running a mile in four minutes or less would kill you. Surely the body could not take such a pace for an entire mile, and besides, everyone knew that it was impossible to accomplish such a feat anyway – even in the best conditions. Yet in 1954, British run-ner Roger Bannister broke the four-minute barrier by six-tenths of a second. Even more remarkable were the conditions in which he did it. The track was slow, and the day was cold, windy, and damp. Even Roger

himself seriously considered skipping the race minutes before he was to report to the starting line. But in the end, he went – and the rest is history. Before breaking the four-minute mile, Bannister had to prepare. As a medical student, he studied the body’s response to exercise, and as an athlete, he

focused on the proper training needed for the event. He also had the patient assistance of his coach and the inspiration of his teammates. All this enabled him to safely achieve his feat. So what does Bannister’s four-minute mile have to do with cardiac rehabilitation? Well, when no one thought a runner could – or should – run a four-minute mile, it was also thought that no one with heart disease could – or should – get out of bed or an easy chair. However, researchers in the 1950s and 1960s challenged this notion and uncovered the physical and psychological con-sequences of this old approach to treatment. Since then, we have increasingly seen that ac-tive and involved patients feel better and do better. For many years, our Cardiac Rehabilitation Program has helped patients achieve or even surpass their previous level of cardiac fitness. Our patients (call them athletes) are assisted by the cardiac rehab staff (call them coaches) and are inspired by fellow patients (call them teammates). Sometimes, patients con-sider skipping cardiac rehab just as Bannister considered skipping his golden oppor-tunity. However, once they start and are focused, they become successful and go on to encourage their “teammates.” Our expert staff members are the most wonderful coaches and make exercise fun. They understand that each patient is different and adjust exercise and education to optimize the course for the patient.

Benefits of cardiac rehab include:n A 20 percent reduction in risk of dying in the first years after a cardiac eventn Improved exercise capacityn Early detection of problems following a cardiac issuen Improved measurements of potential risk factors (choles-terol, blood pressure, smoking, weight, etc.) But as important as these benefits are, one is even more important: knowing that upon graduation (call it “complet-ing the training”), you too can break your own “four-minute mile.” This will improve your outlook on life, which in turn actually improves your prog-nosis. Your family and friends (call them “fans”) will be ut-terly amazed. By the way, breaking the four-minute mile did not kill Bannister; he went on to be a well-respected physician. How-ever, he is most remembered for the challenge he almost walked away from – but didn’t. We can do it, too. See you at the starting line.

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By Dr. Preston D. Conger Jr.Director, Cardiac Rehabilitation ServicesAssistant Professor of Medicine

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Aortic coarctation, a congenital anomaly occurring in four in 10,000 live births, typically leads to refractory hyperten-sion, premature coronary artery disease, heart failure, and stroke when left untreated. Transcatheter techniques and novel devices enabling percu-taneous treatment are increas-ingly precluding surgery to repair the condition. Consider this case of complex aortic coarctation with a blind pouch and accessory right subclavian artery treated percutaneously via a transseptal approach: A 45-year-old woman with history of hypertension, tobacco use, chronic obstruc-tive pulmonary disease, chronic kidney disease, and alcoholic cirrhosis was hospitalized with worsening dyspnea. Initial CT angiography of the chest ruled out pulmonary embolism and incidentally revealed an aortic coarctation distal to the origin of the left brachioce-phalic artery. The patient was referred for possible surgical repair, deemed a poor surgical candidate, and recommended for percutaneous repair. The initial plan was to obtain femoral access and cross the coarctation via retrograde approach, avoiding the blind pouch noted on CT angiogra-phy. During the first procedure, the lesion could not be crossed, despite multiple attempts, as the wire persistently entered the blind pouch. Right radial access was obtained in an at-tempt to cross the lesion in an anterograde fashion, but the catheter could be advanced only through a vessel that was a collateral vessel between the right subclavian artery and the descending aorta. For the de-finitive procedure, right com-mon femoral venous access was

obtained. Transseptal puncture was performed, and a balloon wedge catheter was floated through the left atrium and left ventricle into the aorta. A wire was placed through this bal-loon, snared, and externalized via the contralateral femoral artery. Using a sizing balloon, the coarctation measured 7 to 8 mm in diameter. An ap-propriately sized stent was deployed with good results, and the hemodynamic gradi-ent improved significantly after implantation. The patient was discharged the following day without complications. Although percutaneous repair of coarctation is safe and effective, complex anatomy often impedes success. In many cases, the only feasible op-tion for patients with complex anatomy is surgical repair, sig-nificantly increasing the mor-bidity risk. With the progres-sive improvement in radial and brachial access, anterograde ap-proaches have been described via these access techniques. This optimizes success rates for endovascular repair when lesions are difficult to cross in a retrograde fashion. But cross-ing via upper-extremity access is not realistic for patients such as ours, with complex anatomy and extensive collateraliza-tion at the level of the aortic arch. In our case, we have demonstrated that trans-septal puncture is a safe and practi-cal method to cross a complex coarctation in anterograde fashion. We hope to expand such complex interventional techniques at Georgia Regents Medical Center to offer more convenient and less invasive treatment options.

PERCUTANEOUS REPAIR OF A COMPlEx AORTIC COARCTATION

By Drs. Jacob A. Misenheimer, Paul Poommipanit, and Zahid Amin

CT scan

Blind pouch

Glide wire

Final result

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Few health conditions have seen a larger pendulum swing in the past generation than congenital heart defects. “The outcome was very poor for children in the past,” said Dr. Anastasios Polimenakos, a pediatric heart surgeon who joined Georgia Regents Heart & Cardiovascular Services in July. “Most did not survive past age 1.” Today, not only do most of these children survive, they thrive – thanks to advances such as those that unfold daily at GRU’s Children’s Hospital of Georgia. “The vast majority of the corrective procedures available today enable patients to go on to lead normal lives,” said Polimenakos, who came to GRU from Geisinger Health Center in Pennsylvania. “It makes me so appreciative for their good health.” Good prenatal care, he stressed, is vital. “Most heart defects are diagnosed in utero,” he said. Upon diagnosis, a high-risk obstetrics team pairs with cardiologists to determine next steps. If the mother is already a GRHealth patient, the process is seamless. But many CHOG patients are referrals, and the team does everything possible to ensure the process goes just as smoothly for them.

The most common heart defects, such as hypoplastic left heart syndrome, generally require a single surgery for a veritable clean bill of health. Others, such as transposition of great arteries or extensive vessel abnormalities, can require more complex and potentially long-term treat-ment. But regardless of the complexity or severity, CHOG patients, their parents, and their referring physicians can rest assured that they are get-ting the best care possible. “Our specialized team of cardiologists, cardiac surgeons, and the primary care provider follows the child throughout childhood,” Polimenakos said, noting that the CHOG team is as committed as any he has ever worked with. “People here are very motivated and have significant expertise. There’s a lot of enthusiasm about the work we do.” The continuity of care creates bonds that often far outlive the patient’s medi-cal condition. “I often receive cards and updates from former patients and their families,” said Polimenakos, who has two young children himself. “The feedback is incredibly mean-ingful.”

PEDIATRIC HEART SURGEON ExTOlS

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“PEOPlE HERE ARE VERY MOTIVATED AND HAVE SIGNIFICANT ExPERTISE. THERE’S A lOT OF ENTHUSIASM AbOUT THE wORk wE DO.”– DR. ANASTASIOS POlIMENAkOS

Dr. Anastasios Polimenakos

FACULTY SPOTLIGHT

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Dr. Ismail Tabash

Medical School: Al-Quds UniversityResidency: University of Arizona

Dr. Ruchit Shah

Medical School: University of South AlabamaResidency: Yale Internal Medicine Residency

Dr. Supawat Ratanapo

Medical School: Phramong-kutklao Medical CollegeResidency: Bassett Medical Center (affiliate Columbia University Internal Medicine Training Program)

Dr. Lavinia Mitulescu

Medical School: University Carol DavilaResidency: Norwalk Hos-pital (affiliate Yale University Internal Medicine Training Program)

Dr. Aamisha Gupta

Medical school: St. George’s University (Grenada)Residency: New York Methodist Hospital

Dr. Mac Vining, who com-pleted his medical education, pediatrics residency, and pedi-atric cardiology at the Medical College of Georgia, has joined the faculty of his alma mater as MCG’s Outreach Pediatric Cardiologist for South Georgia (Albany, Thomasville, and Valdosta). Vining, who grew up in Douglas, Ga., developed a pas-sion for working with children as a guitar instructor in college. “After growing up in rural Georgia, I have always desired to return to south Georgia to areas underserved in pediatric cardiology,” he says.

His research and academic interests include medical edu-cation, specifically designing simulations to teach students and residents cardiac ausculta-tion techniques. Vining, who enjoys build-ing relationships with fami-lies, colleagues, and referring physicians, enjoys sports, hunting, and photography in his spare time. He and his wife of six years, college sweetheart Tiffinni, have two children: Jack, 3, and Julianna, 5 months.

MEET DR. MAC VINING, OUTREACH PEDIATRIC

CARDIOlOGIST

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2014-15 CARDIOlOGY FEllOwS

Dr. Mac Vining

FACULTY SPOTLIGHT

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“Fantastic,” “excellent,” “highly engaging,” and “superb” were among the superlatives offered up by attendees at the Georgia Regents University Cardiac Conference held May 29-31 in Savannah, Ga. Comments includ-ed: “one of the best meetings I’ve been to in a while”; “all interesting/applicable, and pertinent to perfusion practice”; and “I am thoroughly impressed and will try to make this my conference of choice in the future.” Next year’s conference will be held June 4-6.

CARDIAC CONFERENCE

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Director

M. Vinayak Kamath, MD

Chief, Cardiovascular Medicine

Neil L. Weintraub, MD

Chief, Pediatric Cardiology

Zahid Amin, MD

Chief, Pediatric & Congenital Cardiac Surgery

Anastasios Polimenakos, MD

Cardiovascular Electrophysiology

Adam Berman, MD

William Maddox, MD

Robert Sorrentino, MD

Cardiovascular Imaging (Echo, MRI, CT, and Nuclear Imaging)

Preston Conger, MD

Vincent Robinson, MBBS

Pascha Schafer, MD

Gyanendra Sharma, MD

Cardiothoracic Surgery

M. Vinayak Kamath MD

Vijay Patel, MD

HEART & CARDIOVASCUlAR TEAM Introducing a new physician referral tool

making it simple for you and your patients–

grhealth.org/referral

No-hassle referralsYour time is valuable. To make an appointment for your patient, please call:

Cardiology 706-721-BEATCardiac Surgery 706-721-3226Pediatric Surgery 706-721-8522Pediatric Cardiac Surgery 706-721-5621

Convenient LocationsPediatric

AuGuSTACHOG 706-721-8522

THOMASViLLEArchbold Hospital 229-228-8006

VALDOSTAChildren’s Medical ServicesSouth Georgia Medical Center 229-245-4310ALBANYPhoebe Putney Memorial HospitalPediatric Specialty Clinic 229-312-5480

AdultAuGuSTAGRMC 706-721-CARE

Trinity HospitalSummerville Bldg. 706-481-7070

WASHiNGTONWills Memorial 706-678-9334

GREENSBOROLake Oconee 706-453-9803

General Cardiology

Preston Conger, MD

Chris Pallas, MD

Mahendra Mandawat, MD

Vincent Robinson, MBBS

Pascha Schafer, MD

Gyanendra Sharma, MD

John Thornton, MD

Neil L. Weintraub, MD

Interventional Cardiology (Coronary and Vascular)

Vishal Arora, MD

Deepak Kapoor, M.D., MBBS

Paul Poommipanit, MD

Pediatric Cardiology

Zahid Amin, MD

William Lutin, MD

Kenneth Murdison, MD

William Strong, MD

Mac Vining, MD

Henry Wiles, MD

Pediatric Cardiothoracic Surgery

Anastasios Polimenakos, MD

Rehabilitation and Prevention

Preston Conger, MD

Vascular Surgery

Gautam Agarwal, MD, RPVi

Communications and Marketing1120 15th Street, TR-101Augusta, Georgia 30912

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PAIDAugusta, GA

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wrong address?Need to update your information?Tell us by email at [email protected] online to gru.edu/updateinfoOr call us at 706-721-4001

Oct. 25-26

The course “Update in Cardiovascular Disease Management for Primary Care Providers” will be held at the Marriott Hotel and Suites in downtown Augusta. The course will feature a care-based approach to managing common cardiovascular disorders, includ-ing atrial fibrillation, chest pain management, hypertension, and lipid disorders.

COURSE SCHEDULE

For more information or to register, visitgru.edu/ce/medicalce/2014/cardiovascular2014.php.