Advances in Cardiac: December 2011
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Transcript of Advances in Cardiac: December 2011
A S U P P L E M E n t t o W E s t c h E s t E R h E a l t h & l I F E M A G A Z i n E
cardiovascularadvaNces iN
westchester medical ceNter CAREcardiovascularcardiovascular
CAREcardiovascular
CAREcardiovascular
‘i dodGEd A BULLEt!’
UGLY VEinS,BEGonE!
‘VAPoRiZinG’BLoCKAGES
GUARdinG tHEAoRtA’S WALLS
fiX foR AtoddLER’SRACinG HEARt
WMC_Cardio_1011Final_REV1.indd 1 11/23/11 11:37 AM
cardiovascular careadvances in2 westchesterheartaNdvascular.com
9
3 a passioN
for pictures
4 iNNovatioNs
in the cath lab
6 protectiNg the
largest artery
9 ‘ i dodged
a bullet!’
10 BaNishiNg
ugly veins
12 let your
blood fl ow
14 a little Boy survives
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.
HEART & VASCULAR
coNteNts
6
12
caRdIology
hawthorNe divisioN914.909.6900imaging 914.909.6925
noninvasive cardiologyWilliam 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
Invasive–Interventional cardiologyHasan Ahmad, M.d.
Martin Cohen, M.d.
Linda Cuomo, M.d.
William Gotsis, M.d.
Gary Silverman, M.d.
Robert timmermans, M.d.
Electrophysiology/devicesMartin Cohen, M.d.
Paul Eugenio, M.d.
Andrea Cronin, R.n., fnP-C
Carmela Musial, PA-C
heart Failure/vad/transplantAlan 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
North state divisioN914.762.5810
clinical & nonInvasivecardiologyArthur fass, M.d.
franklin Zimmerman, M.d.
dina Katz, M.d.
deborah okoniewski, R.n., fnP
Holly Mcnamara, R.n., AnP
New wiNdsor divisioN845.561.2773
clinical & nonInvasivecardiologyJohn tighe, M.d.Stephen Lazar, M.d.Joseph George, M.d.
Invasive–Interventional cardiologyAhmad A. Hadid, M.d.Ahmad B. Hadid, M.d.Gladys Pacenza, R.n., fnPPatricia Rainaldi, R.n., fnP
sURgERy
valhalla divisioN914.493.8793
cardiothoracic surgerySteven 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 divisioN914.593.1200
vascular surgerySateesh Babu, M.d.Pravin Shah, M.d.Arun Goyal, M.d.Romeo Mateo, M.d.igor Laskowski, M.d.francis Carroll, M.d.
lasER vEIn cEntERs
Hawthorne 914.593.1200Mount Kisco 914.241.3204new Windsor 845.561.2773White Plains 914.593.1234Carmel 845.278.9670
cardiovascularadvaNces iN
care
go to WEstchEstERhEaRtandvascUlaR.com
foR CoMPLEtE AddRESS LiStinGS And to SCHEdULE
An APPointMEnt onLinE.
4
WMC_Cardio_1011Final_REV1.indd 2 11/23/11 11:37 AM
This specialist knows how imaging technologies
can help treat heart disease—and prevent it
a passionthey say a p icture is worth
a thousand words, and Westchester
Heart & Vascular cardiologist Tanya
Dutta, M.D., agrees. She interprets
nuclear stress tests, echocardiograms,
cardiac CT (computed tomography)
scans, and cardiac MrI (magnetic
resonance imaging) scans. These tools
help her accurately assess patients’
hearts to assure defi nitive diagnoses—
and also provide assessments to help
others stay healthy.
“Today we have many options to treat
heart disease that can be used before we
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 fi ne-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
with cardiac MrI to assess heart
valves and other structures;
• a 256-slice ct scanner, which
produces detailed images of the heart
and its blood vessels in less than two
beats of a patient’s heart—so speedy that
it uses 80 percent less radiation than a
standard scanner; and
• a 3 tesla mRI imaging system that
is twice as strong as conventional MrI
machines and produces high-resolution
images that do not require radiation.
“Three-D echocardiography is par-
ticularly helpful for evaluating the heart’s
muscles and valves and determining if
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tanya dutta, m.d., might have been an ace reporter. at fi rst 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 evidence-
based outcomes data.
after completing an internal medicine residency at New
york presbyterian hospital-cornell and a cardiology fellowship at
montefi ore 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.
a WoUld-BE JoURnalIst gEts to thEhEaRt oF thE mattER tanya dutta, m.d.
foR PiCtURES
there are areas of scarring in the heart,”
says Dr. Dutta, who trains Westchester
Heart & Vascular’s cardiac fellows in
imaging technologies. “These tests also
help us evaluate treatment that has
already begun.”
Dr. Dutta believes heart disease,
America’s number-one killer, can someday
be tamed. “With better early
detection, medications and
lifestyle modifi cation,” she
says, “we can make great
progress in preventing heart
disease in those at risk.”
yet almost as many american women as men with heart disease,” she
WMC_Cardio_1011Final_REV1.indd 3 11/23/11 11:37 AM
cardiovascular careadvances in4 westchesterheartaNdvascular.com
in the cath labin the
InnovationsAt the region’s largest cardiovascular
center, cardiologists and surgeons make
heart-disease treatment more effective
of clinical medicine at New York Medical
College. “The heart does not beat exclusive
of the circulatory system; neither can we
afford to work without close collaboration
with our vascular-surgeon colleagues.”
Since the 1970s, the Medical
Center’s fi ve cardiac catheterization
labs have bustled with interventional
cardiologists performing diagnostic
angiograms, which let doctors watch
how blood fl ows through the heart and
coronary arteries.
While the patient is sedated with a
local anesthetic, the cardiologist threads
a thin tube, called a catheter, into the
femoral or radial artery and up to the
heart. Contrast material is injected into
the blood vessels to produce a real-time
X-ray image of the heart and its coronary
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.
a New collaBoRatIvE spacE
patieNts are the wiNNers
when different kinds of doctors work
together—and that’s what’s happening
now in the cardiac catheterization (or
“cath”) laboratory, once the exclusive
bastion of interventional cardiologists.
Today it has opened its doors to cardiac
and vascular surgeons, signaling a more
collaborative approach to treating people
with cardiovascular disease.
“research today proves that
integrating the skills and knowledge of
all members of the cardiovascular team
results in better outcomes for our patients,
and that is validated at Westchester
Medical Center daily,” says interventional
cardiologist and electrophysiologist Martin
Cohen, M.D., Acting Director of Cardiac
Catheterization and an associate professor
WMC_Cardio_1011Final_REV1.indd 4 11/23/11 11:37 AM
william gotsis, m.d.
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
chambers and reveal the volume of
blood pumped out of the left ventricle
during each heartbeat.
Since the late 1980s, cardiologists
have also used cardiac catheterization to
perform minimally invasive procedures
called percutaneous (through-the-
skin) coronary interventions (PCIs) to
treat blocked coronary arteries. One of
these, angioplasty—which uses a small
infl ated balloon atop a catheter to open
a blocked artery—revolutionized the
nonsurgical treatment of coronary artery
disease. By the mid-1990s, tiny metal
scaffolds called stents were added to
angioplasty to help prevent restenosis
(re-blockage), a common complication.
In 2003, stents began to be coated with
medications to make restenosis even
less likely.
Also in the cath lab, interventional
cardiologists and electrophysiologists
(cardiologists who treat heart-rhythm
abnormalities) perform:
• laser procedures to vaporize
blockages;
• coronary thrombectomies using
vacuum aspiration with a catheter to
remove a blood clot from a coronary artery;
• heart biopsies;
• implantations of pacemakers and
implantable cardioverter-defi brillators
(ICDs) to correct irregular heartbeats;
• transesophageal echocardiograms
(in which an ultrasound tool is guided down
the patient’s throat on a scope) to diagnose
structural problems of the heart, and
• radiofrequency and cryo-energy
ablations, which use heat and freezing
techniques, respectively, to vaporize tissue
that causes heart-rhythm disturbances.
what teamworK caN do
“Historically, interventionalists and cardiac
surgeons competed for patients,” says
interventional cardiologist linda Cuomo,
M.D., Director of Westchester Medical
Center’s Coronary Care Unit. “But
with exciting advances in nonsurgical
percutaneous procedures coming down the
pipeline and the hybrid room that is being
built here, we’ll all be working together.”
Among these advances is
transcatheter aortic-valve
implantation (tavI), a new
treatment for patients with
aortic stenosis—a life-
threatening narrowing
of the aortic valve—who
cannot undergo valve
replacement because
of age or other medical
conditions.
In TAVI, an interventional
cardiologist and a cardiac surgeon
replace a patient’s damaged aortic
valve with a bioprosthetic one. They
enter through a small skin puncture in
the femoral artery instead of making
the large traditional neck-to-navel
incision standard in open surgery. Once
the bioprosthetic valve is implanted, it
handles the function of allowing oxygen-
rich blood to fl ow from the ventricle to
the aorta and then out to the rest
of the body.
“We want to bring TAVI to our
patients in the lower Hudson Valley,”
says Gary Silverman, M.D., Co-Director of
Interventional Cardiology at Westchester
Medical Center and an associate clinical
professor of medicine at New York
Medical College. “Here at Westchester
Medical Center, we are putting the pieces
in place, both diagnostic and therapeutic,
to perform the TAVI procedure and other
percutaneous treatments that will save
countless lives.”
Dr. Silverman and William Gotsis,
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 fl at 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.
USING A BETTErEntRy poInt
M.D., Co-Director of Interventional
Cardiology, were colleagues at Montefi ore
Medical Center in New York City. “We
are thrilled to be working again with
one of our mentors, Chair of Medicine
Dr. William Frishman, with whom we
conducted research at Montefi ore,” says
Dr. Gotsis, who now directs
Westchester Medical
Center’s interventional
cardiology fellowship
program.
gary silverman, m.d.linda cuomo, m.d.martin cohen, m.d.
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cardiovascular careadvances in6 westchesterheartaNdvascular.com
largest 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 fi brous walls
THEprotectiNg
arterylargest 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.
aorta’s strong and fi brous walls
protectiNg
arterylargestarterylargestA vigilant program at Westchester
Medical Center helps save the lives of
patients with thoracic aortic aneurysms
WMC_Cardio_1011Final_REV1.indd 6 11/23/11 11:38 AM
must withstand the pressure of 10 pints
of blood gushing through at all times.
An aortic aneurysm occurs when
the walls of the aorta weaken or balloon
out. Aortic aneurysms are called
thoracic if they occur in the chest above
the diaphragm and abdominal if they
appear below.
preveNtiNg disaster
Thoracic aortic aneurysms can develop
slowly or quickly. Two famous TV
comedians lost their lives to problems
in the thoracic aorta: lucille Ball
from a ruptured aorta following heart
surgery, and John ritter from an aortic
dissection.
At Westchester Medical
Center, Westchester Heart &
Vascular’s internationally recognized
cardiothoracic surgeons have
implemented a comprehensive Aortic
Aneurysm Program to prevent such
tragedies by carefully screening all
patients diagnosed with thoracic
aortic aneurysms and managing their
care. The surgeons work closely with
patients’ primary care physicians,
cardiologists and vascular surgeons to
track any changes in these aneurysms
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,
Dr. Spielvogel and his Westchester
Heart & Vascular
colleagues,
cardiothoracic
surgeons Steven l.
lansman, M.D., Ph.D.,
and ramin Malekan,
M.D., consider
each patient’s stature, family history
and other medical conditions as well
as the aneurysm’s rate of growth and
its diameter.
Thoracic aortic aneurysms usually
do not make their presence known until
disaster is imminent. But sometimes the
condition is uncovered during a CT scan
or other radiologic study for another
medical issue.
If an aortic aneurysm is found and
is within a safe size, the patient is placed
on an individualized care schedule of
ongoing exams and imaging studies.
If a patient has experienced an aortic
dissection and has had surgery to repair
it, he or she is immediately enrolled in
the database because the patient is at
risk to develop an aortic aneurysm.
steven l. lansman, m.d., ph.d.
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, diffi culty
speaking, blurry vision
ramin malekan, m.d.david spielvogel, m.d.
ContinUEd on PAGE 8
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WHEn AnanEURysm BURsts
“Obviously we prefer to treat a thoracic aortic aneurysm safely and effectively before it reaches a dangerous stage.”
WMC_Cardio_1011Final_REV1.indd 7 11/23/11 11:38 AM
cardiovascular careadvances in8 westchesterheartaNdvascular.com
“Since 2006, when we began this
program at Westchester Medical Center,
we have perfected our surveillance and
our surgical techniques so that we have
achieved very successful outcomes
and very low mortality rates,” says Dr.
Spielvogel, who is also a professor of
cardiothoracic surgery at New York
Medical College, Director of Heart
Transplantation, and Associate Chief of
Cardiovascular Surgery at Westchester
Medical Center.
wheN surgery is Necessary
“We look for subtle changes to time
elective surgery, rather than risk having
to repair the aorta in an emergency,” says
Dr. lansman, Chief of Cardiothoracic
Surgery at Westchester Medical Center
and a professor of cardiothoracic surgery
at New York Medical College.
The type of surgery used to
treat a thoracic aortic aneurysm
depends on the site of the weakness.
The “gold standard” of surgery to
treat an aneurysm in the aortic root
and ascending aorta is the Bentall
procedure, named for the English
surgeon who created it in the 1960s.
During a Bentall, the surgeon
removes the area of the aorta containing
the aneurysm, replaces the aortic valve
with a mechanical or bioprosthetic
one, and then re-implants the coronary
arteries into a Dacron polyester tube
graft that replaces the section of
ascending aorta that has been removed.
Drs. Spielvogel, lansman and
Malekan use a technique called valve-
sparing aortic-root reconstruction for
patients whose aortic valves are healthy.
“This saves a patient from a lifetime
of taking anticoagulant medications,
which are necessary to prevent blood
clots from forming around a mechanical
valve and putting the patient at risk for a
stroke,” says Dr. Malekan.
advaNced procedures
If a patient requires repair of the aortic
arch, a procedure called a trifurcated
graft technique will be used. This surgery
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
KnoW YoURanEURysm RIsK
—developed by Dr. Spielvogel—is fast
becoming the standard at heart centers
around the world.
In this procedure, the surgeon
replaces the aortic arch with a Dacron
graft. A separate graft containing three
“limbs” is substituted for the area where
three arteries branch off the arch.
Sometimes when aneurysms are
in the descending aorta and the patient’s
medical condition permits, the surgeon
may use an endovascular stent-graft
procedure, avoiding “open” surgery to
treat the aneurysm. Because there is no
large chest incision, both pain and the
risk of complications are reduced, and
there is a quicker recovery.
The Westchester Heart & Vascular
cardiovascular surgery team also
performs complex surgical procedures
through incisions in the chest and
abdomen to treat thoraco-abdominal
aneurysms, which lie in both the chest
and abdomen. Few heart centers have
experience with such extensive aortic
reconstructions.
guardiNg BraiN aNd spiNal cord
Preventing a stroke during aortic surgery
is a challenge, as a stroke can occur
as the result of tiny particles of debris,
called emboli, traveling to the brain and
blocking blood fl ow there.
At Westchester Medical Center,
special protocols protect the brain during
surgery. Methods include connecting the
heart-lung bypass machine to the axillary
artery, keeping blood fl owing to the brain
while the heart is stopped, and cooling
the patient’s body temperature to slow
the metabolism while stopping blood
fl ow to vital areas.
.
protectiNg THE
largest arteryprotectiNg
largest artery
ContinUEd fRoM PAGE 7
WMC_Cardio_1011Final_REV1.indd 8 11/23/11 11:38 AM
Joseph aruilio shudders wheN
he recalls how close he came to dying.
“My doctor says I dodged a big bullet,”
says Aruilio, 52, a Carmel resident
who works as a service manager for a
medical equipment fi rm.
What almost killed Aruilio was
heart failure, caused by a virus that
enlarged his heart and compromised
its ability to pump blood. When he
was brought to Westchester Medical
alan l. gass, m.d.
Today’s heart-failure
treatments save lives
that would have been
lost a few years ago
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removed when his heart is
fully recovered.
“I’m looking forward
to driving again and
returning to work,” says
Aruilio, who is grateful for
the treatment he received.
“I placed my trust in Dr. Gass,” he
adds, “and had complete confi dence in
his ability to save my heart.”
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 fl uid 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 long-
term destination therapy; and
• cardiac surgery, including heart
transplantation, coronary artery
bypass, valve repair or replacement
and aortic surgery.
HELPinG PAtiEntS WitHhEaRt FaIlURE
Today’s heart-failure
Center’s Emergency Department
on September 6, he was chronically
short of breath and his heart was
racing at an alarmingly fast rate. An
electrocardiogram was abnormal, and
he was promptly admitted.
Aruilio was hooked up to an
extracorporeal membrane
oxygenation (ECMO)
machine to help
his lungs while
a percutaneous
(through-the-
skin) 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
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
presented data from almost 100
ECMO procedures he and the team
at Westchester Heart & Vascular
have performed over four years. “We
rescued many of these patients from
certain death, so that we could initiate
further treatment and save their lives,”
says Dr. Gass.
Aruilio was slowly weaned off
the ECMO machine and discharged
September 26. The device will be
WMC_Cardio_1011Final_REV1.indd 9 11/23/11 11:38 AM
cardiovascular careadvances in10 westchesterheartaNdvascular.com
iF varicose veiNs have Kept
you from revealing your legs, stand up
and take notice. A minimally invasive
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 refl ux or venous insuffi ciency 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
An
outpatient
procedure
has made the
treatment
of varicose
veins simpler
and more
effective
ugly BAniSHinG
WMC_Cardio_1011Final_REV1.indd 10 11/23/11 11:38 AM
42 percent of men have varicose veins.
And though the problem sometimes
affects younger adults, its incidence
increases with age.
“Varicose veins are one of only a
few conditions that affect clinical health,
aesthetics and quality of life,” says
surgeon Arun Goyal, M.D., Director of
Vascular Imaging and the Atrium laser
Vein Center and an assistant professor
of surgery at New York Medical College.
“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 radio-
frequency endovascular ablation to
treat varicose veins. As embodied in a
system known as VNUS Closure™, it has
since replaced vein stripping in all but
arun goyal, m.d.
the most severe cases.
Endovascular procedures are
performed without an incision instead of
with “open” surgical cuts. radiofrequency
ablation involves using heat energy to
remove diseased tissue, in this case the
varicose veins.
the power oF heat
Dr. Goyal performs VNUS Closure™ in
the Atrium laser Vein Center, using
local anesthesia. A Closure™ catheter
is inserted into the patient’s saphenous
vein percutaneously at the knee through
a small needle prick. Using ultrasound
imaging to guide him, Dr. Goyal delivers
quick bursts of radiofrequency energy
within the catheter to sections of the
vein’s wall. The heat shrinks the wall,
causing it to collapse and seal up. Healthy
veins take over the job of taking blood
from the legs back to the heart. The
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 refl ux, 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 board-
certifi ed 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.
ugly BAniSHinG
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
Closure™ procedure takes
about an hour, and patients
go home one to two hours
later. If an ultrasound test
performed prior to the
procedure has shown
venous refl ux disease in
veins other than the saphenous, they can
be treated at the same time.
“research studies have shown that
the Closure™ procedure is about 97
percent effective,” says Dr. Goyal. “And
most patients require just one treatment.”
Patients usually go back to work
the next day. Postoperative care involves
wearing compression stockings for one to
two weeks and walking at least one mile a
day. Any bruising or scarring is minimal.
“There was no down time,” says
satisfi ed patient Izzo. “If I had known how
uncomplicated it was going to be, I would
have done it a lot sooner.”
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“If I had known how uncomplicatedit was, I would have done it a lot sooner.”
WMC_Cardio_1011Final_REV1.indd 11 11/23/11 11:38 AM
cardiovascular careadvances in12 westchesterheartaNdvascular.com
Endovascular procedures
often can restore healthy
circulation without a
long hospital stay
let your
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 fl ow—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,
six board-certifi ed vascular surgeons
specialize in diagnosing and treating
conditions of the circulatory system.
They work closely with a team of
cardiologists and cardiothoracic
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;
• infl ammation 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
flowblood
WMC_Cardio_1011Final_REV1.indd 12 11/23/11 11:39 AM
New York Medical College. “These can
often spare a patient major surgery
to prevent or stop a life-threatening
vascular condition.” With Pravin Shah,
M.D., Dr. Babu cofounded the Medical
Çenter’s oldest vascular surgery
practice in 1980; it has since joined
Westchester Heart & Vascular.
preveNtiNg “triple a” disasters
In the past decade, the endovascular
treatment of a common yet potentially
deadly condition called abdominal aortic
aneurysm (AAA or “triple A”) has spared
many patients complex abdominal
surgery that would have required a
hospital stay.
An AAA is a ballooning of the aorta
in the abdominal area, most often below
the kidneys. If it ruptures, this can cause
death in up to 50 percent of patients
before they reach the hospital. By far
the greatest risk factor is cigarette
smoking. (See “When an Aneurysm
Bursts,” on page 7.)
Insidious by nature, AAAs do not
usually cause any symptoms. Often
they are discovered during a physical
exam or an imaging test for another
medical condition.
“Once we know a patient has an
AAA, we develop a surveillance plan of
checkups and ultrasounds to keep an
eye on it,” says Dr. Babu. “In men, we
may recommend treatment if it grows
above 5.5 centimeters, in women above
5 centimeters, and in both if the AAA is
growing rapidly. There is also a familial
risk, so we recommend ultrasound
screening for family members.”
During endovascular AAA repair, a
stent graft is threaded up to the site
of the aneurysm from the femoral
artery. The stent graft acts as a bridge
between the healthy parts of the aorta,
reinforcing the weakened section and
allowing blood to fl ow through the
graft and avoid the aneurysm, which
eventually shrinks.
“Because every patient’s
anatomy is different,” says Dr. Babu,
“a vascular surgeon’s decision to use
an endovascular procedure (in about
75 percent of cases) or an “open”
repair (25 percent) must take into
consideration the location of the
aneurysm, any twists and turns of the
aorta and any blockages in arteries on
the way from the femoral artery up to
the AAA.”
carotid artery disease
A major risk factor for stroke, carotid
artery disease occurs when plaque
builds up in one or both carotid arteries
located in the neck, which carry blood
to the brain and supply blood to your
face, scalp and neck. A stroke can
occur if plaque narrows the artery
or if a blood clot sitting atop plaque
breaks off and then blocks blood fl ow
to the brain.
Dr. Babu and his colleagues took
part in a major National Institutes
of Health clinical trial investigating
two treatments for carotid artery
disease. The Carotid revascularization
Endarterectomy versus Stenting Trial
(CrEST) demonstrated that carotid
endarterectomy, a traditional surgical
procedure to clear a blockage, and
the minimally invasive endovascular
angioplasty/stenting used to open
up a carotid artery had similar out-
comes (though there is a slightly higher
stroke risk with stenting in patients
over age 80).
Open surgery entails removing
plaque and diseased portions of the
artery through a small neck incision.
The stenting procedure involves
threading a balloon-tipped catheter,
metal stent and a tiny umbrella-like
“embolic protection device” (to guard
against the formation of embolisms)
up from an artery in the groin to the
carotid artery in the neck.
“A carotid artery that is less than
75 percent blocked carries only a 1
to 1.5 percent risk of stroke,” explains
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Dr. Babu. “Once the blockage goes
over 75 percent, the stroke risk leaps
to 7 to 10 percent per year. Surgical
endarterectomy and stenting have
similar success rates, so the choice of
treatment is based on each patient’s
individual anatomy, medical condition,
age and overall health.”
pravin shah, m.d.sateesh Babu, m.d.
“By far the most exciting advances in the treatment of vascular disease involve minimally invasive endovascular procedures.”
WMC_Cardio_1011Final_REV1.indd 13 11/23/11 11:39 AM
cardiovascular careadvances in14 westchesterheartaNdvascular.com
iN septemer 2010, shaNNoN
Holmes of Millbrook, N.Y., thought her
three-year-old son, Hunter, was coming
down with a bug. Even the excitement of
his cousin’s birthday party didn’t get him
up and running.
On September 28, a call from
Hunter’s child care provider, also a nurse,
sent Shannon into a whirlwind of activity,
ending in Hunter’s being diagnosed in
the Pediatric Emergency Department
(ED) of Maria Fareri Children’s Hospital
at Westchester Medical Center with a
dangerous abnormal heartbeat, known as
an arrhythmia.
Upon the recommendation of
Hunter’s pediatrician—who measured
the boy’s heart rate at 194 beats per
minute instead of the normal 90 to
110—Shannon and her husband, Mark,
made the one-hour drive to Maria Fareri
Children’s Hospital.
As they reached the Emergency
Department (ED), the family was
immediately met by the hospital’s
pediatric cardiology team. By this
time, Hunter’s heart rate was up to 225
beats. An electrocardiogram revealed
supraventricular tachycardia (SVT),
a disturbance of the heart’s electrical
system that starts in the upper chambers.
When a heart beats that fast, it cannot
rest in between beats and its chambers
cannot fill with blood properly to create
the force for normal blood flow.
“Our first step was to use maximum
dosages of an intravenous medication
to try to break the SVT, but his heart
continued to beat too fast,” says Irfan
Warsy, M.D., who was called in to
supervise Hunter’s treatment. Director
of Pediatric Electrophysiology at Maria
Fareri Children’s Hospital and an assistant
professor of pediatrics at New York
Medical College, Dr. Warsy specializes in
heart arrhythmias in children.
“When a second medication also
failed, we had to consider: Was Hunter’s
enlarged heart a result of the SVT or was
it, perhaps, a reaction to something viral?”
A lITTlE BOY survives A
big heart problem
How an electrophysiology procedure
cured a rapid heart rate
hunter holmes, 4, above and with friends Noah mead, 4 (left), and isabella marie tibodeau, 2, at a summer carnival
Is my chIld havIng palpItatIons?“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.
WMC_Cardio_1011Final_REV1.indd 14 11/23/11 11:39 AM
recalls Dr. Warsy. “We formulated a plan
to treat him in the hospital’s Arlene and
Arnold Goldstein Pediatric Intensive Care
Unit with another potent medication and, if
necessary, to use a ventilator to breathe for
him so his heart could rest.”
Fortunately, a third medication broke
the SVT overnight, and a ventilator was
not needed. Hunter’s heart returned to a
normal rhythm after about four days of an
incessant rapid heartbeat.
“We were allowed to stay all seven
days that Hunter was in the hospital,” says
Shannon. “By the fourth day, he started to
look like himself and wanted to play again.”
Further tests revealed to Dr. Warsy
that Hunter had a rare form of SVT called
permanent junctional reciprocating
tachycardia. The culprit was not a virus,
but a group of cells called a substrate.
“A substrate is present from birth and
acts as a kind of short circuit,” explains Dr.
Warsy. “It is patient and waits in a child
until there’s a perfect environment of
heart maturity, neurological growth and
hormones, then it acts up.”
diagNosiNg arrythmias
Dr. Warsy oversees the only pediatric
electrophysiology (EP) service in the
region. This subspecialty of cardiology
involves the diagnosis and treatment of
arrhythmias, disturbances in the heart’s
intricate electrical conduction system.
Electrophysiologists divide arrhythmias
into tachycardias, in which the heart rate
is faster than normal; and bradycardias, in
which it is slower. Noninvasive cardiac tests
used to diagnose arrhythmias include:
• electrocardiograms (EKGs);
• short- and long-term home EKG
Holter monitoring;
• event monitors and loop recordings
(which detect palpitations); and
• exercise stress tests (which
evaluate the heart’s ability to respond
appropriately to exercise and assess
medications’ effectiveness).
Dr. Warsy and his EP team also
use invasive tests to provoke rhythm
disturbances in children to discover
if a true arrhythmia exists. “Inducing an
arrhythmia is not dangerous in children,”
the doctor says. “Within the carefully
controlled environment of the EP lab, we
can provoke the heart into an arrhythmia,
study the characteristics of the substrate
and then pace the heart back to normal.
In the majority of children on whom we
perform this test, if we can’t induce a
disturbance, there is no arrhythmia.”
A “roving” catheter moved
by the electrophysiologist can
pinpoint a substrate, such as
Hunter’s, within millimeters. “The
key is to avoid the atrioventricular
(AV) node, electrically the ‘holiest’
spot in the heart,” says Dr. Warsy.
Because the medication Hunter
was taking to control his SVT can
cause significant side effects, Dr. Warsy
recommended a minimally invasive
radiofrequency ablation procedure to put
an end to the arrhythmia permanently.
While Hunter was placed under
general anesthesia, Dr. Warsy employed
catheters placed in stable predetermined
positions to provoke Hunter’s SVT with
electrical currents. Using 3-D imaging,
he determined the pathway of the SVT
and guided a roving catheter to locate
the offending substrate tissue. Within
millimeters of the substrate he used
radiofrequency energy heated to 60º
Celsius (140º Fahrenheit) to destroy the
substrate, monitoring the temperature with
special technology within the catheter.
Happily, Hunter became one of
ventricular
arrhythmia, in
which the heart’s
lower pumping
chambers beat
faster than normal,
can result from a struc-
tural abnormality of the
heart muscles, a problem
with the coronary arteries or a channelo-
pathy, 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 implant-
able cardioverter-defibrillator (icd) can be
used to maintain a regular heartbeat.
“the advanced icds we now use can
differentiate between pathologic tachycar-
dia 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.”
the 60 or so children each year that
Dr. Warsy treats and cures with this
procedure. After an overnight stay, he
returned home with no evidence of
the SVT. He underwent imaging tests
every couple of months until Dr. Warsy
discharged him from his care eight
months later, noting that his heart
function had normalized. There are no
restrictions on Hunter’s future activities.
“I finally exhaled when Dr. Warsy said
he was cured,” says Shannon with a laugh.
living with recurrent episodes
of SVT can be a burden for children,
notes Dr. Warsy: “They often become
withdrawn and anxious and live in fear of
recurrences that can bring an ambulance
to their school. This procedure, which
carries just a minimal one to three per-
cent risk, can turn a
child’s life around.”
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irfan warsy, m.d.
WMC_Cardio_1011Final_REV1.indd 15 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.
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