JAN/FEB/MAR 2009 CLINICAL LETTER - Pocono Medical Center · ESSA HEART AND VASCULAR INSTITUTE FIRST EDITION- JAN/FEB/MAR 2009 POCONO MEDICAL CENTER PAGE 1 Who We Are Since the program

ESSA HEART AND VASCULAR INSTITUTE FIRST EDITION- JAN/FEB/MAR 2009

POCONO MEDICAL CENTER PAGE 1

Who We AreSince the program

opened in 2007 we have performed over 450 cardiac surgeries, 2000 diagnostic cardiac caths and over 500 cardiac interventions,including angioplasty and stents. We offer the following services:

*Diagnostic cardiac and peripheral angiograms

*Interventional cardiac and peripheral procedures such as balloons and stents

*24 hour cath lab support for all cardiac emergencies

*CABG- on pump and off pump

*Valve replacements and repair

*High risk patients *Ventricular

reconstruction surgeries*Minimally invasive

atrial fibrillation surgeries *Full range of thoracic

surgeries

CLINICAL LETTERI am delighted to welcome you to this f i r s t i s sue o f the Card io va scu la r Newsletter. It is hard to believe that about two years ago the new ESSA Heart & Vascular Institute was born. From its very humble beginnings to where we are today, our mission has been unchanged – to provide world class cardiovascular care second to none. This successful journey has in many ways been a testimonial to your support and encoura gement, coupled with a belief in a team approach which is crucial in providing excellent cardiovascular medical care. The superb team of competent and qua l i f ied cardiologists and cardiac surgeons now pro v ide a broad spect r um of cardiovascular services to the people of Monroe County and beyond. Also of significance has been the fact that the clinical outcomes for this program have been excellent and are comparable to many o f the h igh l y re spected cardiovascular programs in the United States.

We ha ve seen our busy ca rd iac catheterization laboratory, with its highly engaged and competent staff, maintain an average door to balloon time of under 65 minutes, which is significantly superior to the national average of 106 minutes. Additionally our laboratories provide complex peripheral vascular diagnostics and interventions.

Our surgical outcomes demonstrate extremely low mortality and morbidity rates which in many instances exceed regional and national standards. We now of fe r a compendium of surg ica l procedures such as coronary artery revascularization, valve replacement, valve reconstruction and valve addition. We also offer the Maze operation for atrial fibrillation, surgical ventricular reconstruction and surgery for Idiopathic Hypertrophic Sub-aortic Stenosis (IHSS), to name a few. All this really translates to better care for the ones we serve, our PATIENTS. But we are not about to rest

on our laurels. We are challenged to grow, expand and improve.

Treatment of cardiovascular disease is a dynamic and evolutionary field. We must strive to remain at the cutting edge of diagnostic and therapeutic options for the various problems in cardiovascular medicine. The addition of the 64-slice CT scanner last year was pivotal as this will continue to enhance our diagnostic capabilities. The Electrophysiology Laboratory will soon be fully operational. This facility will tremendously enhance our e f for t s to t reat a myr iad o f challenging arrhythmia problems from which so many of our patients suffer.It is our profound belief that the future success of this program is predicated on the continuing support of individuals like yourself, and a team approach by all clinicians who are functioning as a unit.

Finally, we recognize that continuing education must play a pivotal role for this program to continue to provide quality cardiovascular care. To meet this need our quarterly publication will feature exciting clinical articles on pertinent cardiovascular problems as well as personal interest articles about some of our patients. We welcome questions, comments and essential feedback or suggestions from you. Our goal is to make each and every publication relevant, informative and enriching.

This first edition features an article that discusses the surgical treatment of cardiac valve disease. This issue also contains a poignant story about a patient who survived a cardiac arrest in the community and underwent successful urgent coronary revascularization by Dr. Gordon Fried.

Please enjoy and have a Happy New Year!

Nche Zama, MD, PhD Director of Cardiovascular and Thoracic Surgery, ESSA Heart and Vascular InstituteAssociate Clinical Professor, University of Pennsylvania



44-year old George Ketz was feeling so good on Wednesday, October 15 2008, he found himself te"ing people exactly how good he felt.

The next evening, the athletic, non-smoker took his regular place as referee for the seventh and eighth grade girls’ basketba" team at Monsignor McHugh School, in Cresco. At the half-time buzzer, Ketz approached his fe"ow refereeing partner, Vince, and casua"y spoke of some discomfort he was having and asked Vince if he had ever experienced acid reflux. Stating that he persona"y hadn’t, Vince reassured Ketz that his wife did indeed suffer 'om acid reflux and that the symptoms were a match. Confident that the radiating pains and burning in his chest were simply some form of indigestion, Ketz returned to his station on the court. Approximately three minutes into the third quarter, Ketz reca"s, “feeling a little dizzy.” The next thing Ketz remembers is lying on the floor of the gymnasium with a large crowd gathered around him. What Ketz did not realize at that point was that he had suffered a major coronary episode which stopped his heart, and it took two shocks 'om the AED and several minutes of CPR to bring him back.

“I didn’t think that the discomfort I was experiencing was anything serious; and I didn’t want or feel like going home,” Ketz says. “I’m active – I work out four times a week, I don’t drink or smoke, I eat reasonably well. I mean, I build houses for a living so I’m always

moving. I considered myself to be in great health. I never expected that night that I would be lying dead on the floor.”

Ketz was extremely lucky, and now thankful, that there were individuals in the stands that night who knew CPR and how to properly operate the defibrillator. Three registered nurses came to Ketz’s rescue: Trudie Lemon who got the AED; Nira Estoniza who performed CPR; and Chris Craig, who operated the AED. Spiritual support was also given by the members of the two teams, who retreated immediately to the locker room to pray for Ketz and his family. When the paramedics arrived, they saw the immediate severity of the situation and called ahead to Pocono Medical Center to prepare the cardiac catheterization lab. Within 30 minutes. Ketz was in the cath lab, under the expertise of Dr. Gordon Fried, who had found that Ketz’s left coronary had completely shut down. As Dr. Fried observed, “he probably would have died – plain and simple. The left coronary artery feeds the anterior portion of the heart. He risked irreparably damaging a large portion of his heart, and therefore, depriving critical organs of oxygen carried in the blood.”Ketz is expected to make a full recovery, but will need to keep a close watch on his cholesterol.

“His LDL, or bad cholesterol, was at 260. This high number had absolutely nothing to do with his lifestyle, it had to do with genetics. This is why it is so very important to know your risk factors and talk about these factors with your doctors on a regular basis,” says Fried. The Ketz family will be forever grateful to those individuals who saved his life that day on the basketball court. Ketz also acknowledges the doctors and staff at PMC for their outstanding service, quality of care and compassion during this difficult time.

“Three years ago, someone in a similar situation as George Ketz would have had to be transported to another facility as PMC did not have the resources to care for this level of heart attack. This is an example of how important the “chain of survival” is to emergency care;. community placement of the AED, the EMS response to PMC’s Emergency Department, and the rapid door to balloon time from PMC’s Physicians and staff” said Robyn Stein, Executive Director of the ESSA Heart and Vascular Institute.

AED IS THE MVP AT LOCAL BASKETBALL GAME



UPDATE ON SURGICAL MANAGEMENT OF CARDIAC VALVE DISEASE - NCHE ZAMA MD, PH.D.We have come a long way since September 1952 when

Hufnagel performed the first prosthetic implant in a patient with severe aortic valve insufficiency. That landmark operation was performed without cardiopulmonary bypass as Dr. Hufnagel inserted the prosthetic valve into the descending aorta. The introduction of the heart lung machine in 1954 ushered in a new and exciting era in cardiac valve surgery thereby making these complex valve operations much more feasible. Over the past fifty years, technological advancements in cardiac surgical care, coupled with many advances in anesthesia and critical care management have combined to improve outcomes in cardiac valve surgery.

Despite all the significant strides that have been made in this area, sadly, many patients still continue to receive medical management for structural heart valve disease and are only referred for surgical intervention after they have developed significant or serious symptomatology. Expectedly, surgical outcomes for many of these patients are suboptimal because of either the chronicity of their cardiac dysfunction or a combination of other secondary or associated pathologies.

Recognizing the importance and benefits of earlier and timely referral for surgical interventions in cardiac valvulopathies, the American Heart Association recently published guidelines for the management and treatment of these patients. (Please refer to enclosed brochure)

Additionally, it must be recognized that cardiac valve problems are oftentimes “mechanical problems necessitating mechanical solutions.” Without timely surgical intervention, valvular problems do progress inevitably to heart failure and possibly death.

This article presents a brief review of common valvular pathophysiologies and surgical treatment options. It is by no means intended to be an exhaustive treatise on surgical management of valve disease, but can be a helpful guide to any practitioner encountering a symptomatic patient or one with an asymptomatic murmur.

Valvular PathophysiologyA normal human heart has four valves which essentially

are “one-way gates” allowing unidirectional blood flow either from an upper cardiac chamber to a lower chamber, or from the heart to a great vessel. The atrio-ventricular (AV) valves – tricuspid and mitral are located between the right atrium and right ventricle, and the left atrium and left ventricle respectively. The aortic valve allows blood flow from the left ventricle to the aorta during systole. The pulmonary valve allows flow from the right ventricle to the pulmonary artery. Normal cardiac physiology requires not

A few specific etiologies of cardiac valve problems include:1. bacterial endocarditis2. myocardial infarction (mitral and tricuspid)3. rheumatic disease4. senile degeneration5. congenital changes (congenital bicuspid aortic valve)6. benign and malignant tumors7. anoretic drugs8. aortic dissection (aortic valve)9. myxomatous degeneration10. Marfan’s Syndrome (aortic valve)

Generally, valve problems can either be due to STENOSIS or INSUFFICIENCY. Rheumatic fever is the most important associated factor worldwide in cardiac valve disease. The incidence of rheumatic valve disease however has been decreasing significantly in America because of the availability of antibiotics. It generally affects the aortic, mitral and tricuspid valves, causing stenosis principally, and some insufficiency. Often times when it affects the mitral complex, it causes mitral leaflet scarring and thickening, choral thickening and shortening, commissural fusion, and at times, papillary muscle scarring.

Rheumatic valve disease is progressive and may lead to annular calcification. No known medical therapy can reverse, arrest or cure it. Surgical intervention is the best option in these patients. Prolonged life expectancy in the USA has been associated with the increasing incidence of senile degenerative valve disease.

Because many elderly patients develop other significant medical problems such as diabetes, hypertension, renal insufficiency and infections, all of which can adversely impact surgical outcomes, early diagnosis and treatment of cardiac valvulopathies in this population is of the essence. (continued p4)

only a unidirectional flow pattern through heart valves, but also smooth, “silky”, compliant and unobstructive opening and closing of these valves. Infectious, inflammatory, degenerative, ischemic, congenital, and oncologic changes can directly affect valvular structures and impede their normal function.



UPDATE ON SURGICAL MANAGEMENT OF CARDIAC VALVE DISEASE- CONTINUED FROM P3

The mitral valve (mitral insufficiency) is most commonly the culprit in severe myocardial infarction. It has been shown that early mitral valve surgery (reconstruction), usually in conjunction with coronary revascularization is associated with improved long term survival in these patients. Bacteria endocarditis usually affects the aortic, mitral and tricuspid valves, although tricuspid endocarditis more commonly is seen and associated with intravenous drug users in larger metropolitan areas. Appropriate, aggressive systemic antibiotic therapy can completely eliminate valvular vegetation in a certain number of patients, however for those who are demonstrating hemodynamic instability, persistent sepsis after several days of intensive antibiotic infusion, evidence of septic embolization, vulnerable lesion or candida endocarditis, early surgical intervention can be life saving.

Patients with congenital bicuspid aortic valve (the

most common congenital heart problem in humans) generally develop aortic valve stenosis between forty and sixty years of age. Aortic valve replacement, properly timed, can be maximally beneficial in these patients.

In most adult medical practices, clinically important tricuspid and pulmonary valve problems are encountered rarely. Oftentimes, tricuspid insufficiency presents as a “functional” problem secondary to left sided heart problems such as mitral insufficiency, mitral stenosis or left heart failure. It is also seen in cor pulmonale and right heart failure with pulmonary hypertension.

Presentation and DiagnosisEarly valve disease may be totally asymptomatic. As

valve dysfunction progresses, patients may present with effort dyspnea, dyspnea at rest, orthopnea, angina, syncope, palpitations, persistent cough, hemoptysis (mitral), or sepsis. Oftentimes, patients with advanced valvulopathies would minimize their symptoms. Cardiac auscultation is the most widely used method to screen for

heart valve disease, although a murmur may have no pathological significance. This is especially true of systolic murmurs. On the contrary, diastolic and continuous murmurs virtually always represent pathological conditions and mandate further cardiac evaluation by echocardiography.

In general, documentation of a significant murmur on physical examination even in an asymptomatic patient should be followed by a diagnostic workup because such a finding may be associated with a potentially serious valvulopathy.

It must be noted that ischemic heart disease can also present in the setting of a valvular abnormality. Such a patient might need to undergo stress testing or maybe cardiac catheterization. Most surgical services often encounter patients who had been treated variously for asthma, bronchitis or other presumed pulmonary problems only to find out that the actual problem was ischemic cardiac or valvular and not pulmonary.

Once a diagnosis of valve disease has been made, a timely surgical opinion can be beneficial in determining the best algorithm for managing the patients’ pathology, while keeping in mind that most valve problems are progressive and that earlier intervention can produce better outcomes.

Surgical ConsiderationsDefective heart valves are either replaced or repaired.

For selected patients the entire native valve can be retained and a new prosthetic valve “added.”

Patients over 40 years of age, or younger patients with significant risk factors for coronary artery disease should undergo a cardiac catheterization to determine the need for coronary bypass (CABG) surgery during valve surgery.

Tricuspid and mitral insufficiency can generally be treated by reconstruction. It has been shown that preserving the valvular apparatus can lead to better ventricular function and improved survival.However, under circumstances where reconstruction may not be optimal, a prosthetic valve can be “added” to the native valve position while preserving the anatomic state of the native valve and consequently preserving ventricular function. This is a more technically challenging operation which we have successfully applied on our service. Few specific aortic valve problems can be addressed by performing a valve repair. However, the indications for this must be clear and appropriate.Balloon valvuloplasty (aortic and mitral) is rarely performed these days because of very few indications and suboptimal outcomes.



UPDATE ON SURGICAL MANAGEMENT OF CARDIAC VALVE DISEASE- CONTINUED FROM P4

Selection of Valve ProsthesisThe current options for valve replacement include- mechanical valves- xenograft tissue (bovine pericardium or porcine valve)- autograft valve (patient’s own pulmonar y valve

transposed to aortic position in Ross operations)- allograft valve

There is no ideal valve for all patients. In selecting a heart valve, several considerations must be in order. The most important of these is patient lifestyle (anticoagulation) and life expectancy. Mechanical valves are the most durable (they generally will outlast the patient). However, these patients must be on lifelong anticoagulation.Biological valves are not as durable as mechanical ones. However they generally do not require anticoagulation. There has been a lot of innovation in biological valve engineering such as improvements in tissue preservation and anticalcification technology. These improvements have reduced the incidence of str uctura l va lve degeneration in some biological valves to less than 10% in fifteen to twenty years.

In choosing a valve for a particular patient the decision must be individualized. The younger the patient, the more difficult the choice. Younger patients can either outlive or outgrow their prosthesis. They have a higher metabolic rate and tend to destroy their biological valves faster. Anticoagulation in an active young patient with a mechanical valve can pose problems.

An active adult, forties and up, may select to receive a biological valve in order to avoid anticoagulation and its potential complication of bleeding, and accept the possibility of a repeat valve replacement in 10 to 20 years. Other important factors that affect the choice of a valve include renal failure, old age, concurrent coronary artery disease and severe left ventricular dysfunction. All of these factors are associated with a decrease in survival after valve replacement.

In some patients with atrial fibrillation, history of cerebrovascular disease or cardiomyopathy, a mechanical valve may be preferred when valve replacement is

indicated because these patients need anticoagulation for these cardiac problems. Medically non-compliant patients may be better off with a biological valve. Whatever prosthesis is used, it must be recognized that CHOICE OF PROSTHESIS DOES NOT INFLUENCE PATIENT SURVIVAL. The most important factor affecting survival is relief of the offending valvular pathology. Additionally, patient-related determinants of long term survival include age, the presence of coronary disease and left ventricular function. Surgical ApproachAll valve operations can be approached and reliably performed via a median sternotomy (longitudinally splitting the sternum). Isolated mitral and tricuspid operations can be performed via the minimally invasive approach of a mini right thoracotomy. A minimally invasive approach though an upper sternotomy, transverse sternotomy or right anterior, second intercostal minithoracotomy affords excellent visualization for aortic valve surgery.Minimally invasive approaches for isolated valve operations are not only cosmetically pleasing, they have been shown to result in shorter hospital stays, less cost and fewer post-operative complications.Most recently there have been several cases of successful deployment of prosthetic aortic valve via a percutaneous approach. This method will certainly feature prominently in the near future given the evolution of catheter-based interventions for cardiovascular problems. ConclusionCardiac valve disease can now be treated successfully using many currently available surgical options. Operative mortality for isolated valve surgery in the average patient is less than 3%. Surgery increases life expectancy of patients with significant valvular disease. Survival is not related to choice of prosthesis. 80% OF MEDICALLY MANAGED PATIENTS WITH AORTIC VALVE DISEASE DIE WITHIN TWO YEARS OF DIAGNOSIS. Valvular heart disease is generally progressive. For better outcomes and improved survival early referral for surgery is important.

There are new American Heart Association guidelines for referring patients to surgery for valve disease.

When we realize that the human heart beats about one hundred twenty thousand times a day, not only does the cardiovascular impact of an abnormally functioning heart valve become obvious, the importance of early surgical intervention to avert any untoward cardiovascular outcome becomes pertinent.



In 1979 Pocono Hospital established a hospital-based Cardiac Rehabilitation program as an expansion of a program conducted at East Stroudsburg State College. It was determined at that time that a team approach and the hospital setting would better serve the patient’s needs. The program expanded from a mainly maintenance exercise format to one of inpatient education and exercise, outpatient monitored exercise and education as well as outpatient supervised exercise.As the names changed to Pocono Medical Center and East Stroudsburg University, the Cardiac Rehabilitation program also evolved. Risk factor assessment and education, secondary prevention guidance along with earlier and more aggressive exercise training shaped the program. As physicians witnessed the benefits of the program for their patients, referrals increased. Patients themselves began to spread the news of this great service offered at a local hospital. Today the Cardiac Rehabilitation is an integral part of PMC’s heart program.On February 23, 2009 the Cardiac Rehab team will celebrate the 30th anniversary of the program. Past and current cardiac rehab patients, their families and friends will be invited to join the festivities to be held at the Medical Center. One highlight of the day will be a tour of the newly renovated Cardiac Rehab exercise lab.For more information and to refer patients to the program you may contact the Pocono Medical Center Cardiac Rehab staff at 570-476-3606. Georgeann Golias DiGiovanni MS RN Manager Cardiac Services

CARDIAC REHAB CELEBRATES 30TH ANNIVERSARY

COMING SOON-CME Grand Rounds at PMC:*February 6th at noon in Stroud/Brodhead rooms- Dr. Nche Zama, “Surgical Management of Heart Failure” February 19, noon to 1:30 PM at Sycamore Grille, Delaware Water Gap- Physician Lecture and Lunch- Dr. Charles Herman, Board Certified Plastic Surgeon, “Look as Young as You Feel”

PMC’s new Outpatient Coagulation Clinic, under the direction of Dr. Kaoutar Tlemcani, MD opening in the Spring of 2009

Save The Date- April 25, 2009 7AM to 1PM- Cardiology Updates for the Primary Care Physician-to be held at Pocono Medical Center



ESSA HEART AND VASCULAR INSTITUTE FIRST EDITION - JAN/FEB 2009

COMING IN THE NEXT ISSUE: ARRHYTHMIA CONTROL @PMCOur new Heart Rhythm Center at Pocono Medical Center’s Heart and Vascular

Institute, including the latest atrial fibrillation treatment and management.

Dr. Anne T Cahill MDDept. of Cardiothoracic Surgery

Dr. Praveer Jain MDDept. of Electrophysiology

“Clinical Letter”- a publication of ESSA Heart and Vascular Institute at PMC

Editor - R. Eileen Butz RN, CCRN Questions/Comments? 570.420.5332

JAN/FEB/MAR 2009 CLINICAL LETTER - Pocono Medical Center · ESSA HEART AND VASCULAR INSTITUTE FIRST EDITION- JAN/FEB/MAR 2009 POCONO MEDICAL CENTER PAGE 1 Who We Are Since the program

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