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Low LDL & Normal Blood Pressure Slows Arterial Plaque Growth p4

CardiacConsult

The Young Helpingthe Old? p3

Indicationsfor Ventricular Assist Devices Expanded p6

Remote Moni-toring in Heart Failure p16

Genetic Cause of Deadly Irregular Heart Beat Discovered p17

Inside This Issue

Heart and Vascular News from Cleveland Clinic | Summer 2009 | Vol. XVIV No. 2

Featured Article

Minimally Invasive Cardiac Surgery Comes of Age- p8

Flashback:

Dear Colleagues,

Minimally invasive surgery is no longer exotic. Thirteen years ago, Delos M.

Cosgrove, MD, performed the fi rst minimally invasive aortic valve surgery.

In 2008, we performed 462 minimally invasive aortic and mitral valve

procedures, with 0 percent hospital mortality. Cleveland Clinic surgeons

now consider a minimally invasive option fi rst for nearly every patient.

This issue of Cardiac Consult offers a brisk review of Cleveland Clinic’s minimally

invasive thoracic and cardiovascular surgery program. You’ll fi nd mention of the

highly successful valve procedures, along with our robotic surgery program,

video-assisted lobectomies, and new percutaneous techniques.

Medical technology is racing to keep ahead of demand for minimally invasive

alternatives. The appeal is obvious: less pain, fewer complications, shorter hospital

stays. Minimally invasive cardiac surgery is bound to be a hot topic at the big

The Treatment of Cardiovascular Disease: Legacy & Innovation symposium, being

held here in June. We invite you to join us for this one-time “state of the heart”

global overview of the very latest in cardiac surgery, vascular surgery, cardio-

vascular medicine, and their related disciplines.

The other articles in this issue of Cardiac Consult refl ect the breadth and variety

of our fi eld: new views on ventricular assist devices, lung transplant donation,

remote monitoring in heart failure and more.

We continue to be inspired by the way new technologies advance medicine

and transform lives. As minimally invasive techniques become commonplace,

you’ll fi nd us at the frontier of the next big advance, whatever it may be.

Sincerely,

Christopher Bajzer, MD Sean Lyden, MDAssociate Director, Peripheral Intervention Staff Surgeon, Interventional Cardiology Vascular Surgery

A. Marc Gillinov, MDThe Judith Dion Pyle Chair in Heart Valve ResearchThoracic and Cardiovascular Surgery

| Cardiac Consult | Summer 09 | Cleveland Clinic’s toll-free physician referral number is 800.553.5056

Cardiac Consult offers updates on state-of-the-art diagnostic and management techniques from Cleveland Clinic heart and vascular specialists. Please direct correspondence to:

Medical Editors

Christopher Bajzer, MDA. Marc Gillinov, MDSean Lyden, [email protected]@[email protected]

Managing Editor

Ann Bungo

Marketing Manager

Megan Frankel

Art Director

Michael Viars

Photographers

Tom MerceSteve TravarcaDon GerdaRussell Lee

clevelandclinic.org/heart offers informa-tion on new procedures and services, clini-cal trials, and upcoming CME symposia, as well as recent issues of Cardiac Consult.

The Sydell and Arnold Miller Family Heart & Vascular Institute, ranked No. 1 in the nation for cardiac care by U.S.News & World Report every year since 1995, accommodates nearly 300,000 patient visits each year in world-class facilities. Staff are committed to researching and applying state-of-the-art diagnostic and management techniques. Cleveland Clinic is a not-for-profi t, multispecialty academic medical center.

Cardiac Consult is written for physicians and should be relied upon for medical education purposes only. It does not provide a complete overview of the topics covered, and should not replace the inde-pendent judgment of a physician about the appropriateness or risks of a procedure for a given patient.

© The Cleveland Clinic Foundation 2009

Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 |

The Young Helping the Old?

Can younger or newer stem cells give a regenerative boost to

donors could help older patients who are recovering from heart attacks or aortic stenosis.

Marc Penn, MD, PhD, Cleveland Clinic Stem Cell Biology and Regenera-

tive Medicine and Department of Cardiovascular Medicine, investigates

how hearts damaged by heart attacks attract adult stem cells by sending

out “homing” signals. Stem cells found in the bone marrow respond to this

signal and migrate to the damaged area to become new heart tissue cells.

Dr. Penn’s research has expanded to also focus on how aging might affect

the homing process and the stem cells’ ability to specialize, or differenti-

Dr. Penn induced aortic stenosis in mice. Stem cells from the bone marrow of

an older generation of the mice were transplanted into younger mice with the

condition. The younger mice didn’t respond well and the condition worsened.

However, stem cells from the younger mice’s bone marrow were trans-

planted into the older generation — with noticeable improvement to the

older mice’s cardiac health.

“It would appear that stem cells may tire out over time. There’s evidence

that aging does play a role on stem cell function. Now we’re trying to

determine if it’s the heart not sending out the message to stem cells, or the

stem cells not responding to the signal,” Dr. Penn says. “The heart needs

to grow new vessels to nourish the new cells. But if the stem cells aren’t

getting to the heart, the heart dilates and the patient develops heart failure

in response to aortic stenosis.

“We hope that by deciphering the signaling process we will be able to

develop new therapies for patients with aortic stenosis and weak hearts.”

To coordinate the range of stem cell and regenerative medicine research

projects focused on cardiovascular diseases, Dr. Penn organized the

Center for Cardiovascular Cell Therapy. The center currently has six

clinical trials involving laboratories at Lerner Research Institute and

Cleveland Clinic, as well as being a founding partner in the National

Institutes of Health’s Cardiovascular Cell Therapy Research Network.

Additionally, Dr. Penn directs the Skirball Laboratory for Cardiovascular

Cellular Therapeutics and is Director of Cleveland Clinic’s Earl and Doris

Bakken Heart-Brain Institute.

“The new center and our role in the NIH’s consortium are working to

actually bring what we’re learning about cardiovascular cell therapies

to patients,” he says.

Marc Penn, MD, PhD


Cleveland Clinic Researchers: Low LDL and Normal Blood Pressure Slows Arterial Plaque Growth

Low levels of LDL cholesterol coupled with normal blood pressure can significantly slow the progression of coronary artery disease, according to a study by Cleveland Clinic researchers.

The study, which was published in the March 31 issue of the Journal of the

American College of Cardiology, is the first to show that aggressive treatment to

lower both cholesterol and blood pressure can slow plaque build-up in patients

with a history of coronary artery disease.

“The take-home message here is that heart disease is caused by many factors

and it’s likely that aggressive management of just one risk factor alone is

not the answer,” said Cleveland Clinic cardiologist Stephen J. Nicholls,

MD, PhD, a co-author of the paper. “In this study, we looked at aggres-

sively controlling multiple risk factors to see if it would have an impact.

And it did.”

The study examined 3,437 patients with coronary artery disease,

using intravascular ultrasound (IVUS) to track the formation of

plaque in their arteries. The researchers found that very low

levels of LDL (70 mg/dl or less), in combination with normal

systolic blood pressure (120 or less), significantly slowed

arterial plaque formation.

“What this study shows is that when it comes to blood

pressure and cholesterol ‘good’ control isn’t enough,” said

lead author Adnan K. Chhatriwalla, MD, an intervention-

al cardiology fellow at Cleveland Clinic. “Optimal con-

trol should be the goal of treatment because it is shown

to have a greater effect on slowing the progression of

atherosclerotic plaque.”

The authors suggest that a randomized controlled

trial to directly test the clinical benefit of aggres-

sively treating multiple risk factors would

provide further support for this concept.

Researchers from Cleveland Clinic’s depart-

ments of Cardiovascular Medicine, Cell

Biology, and Radiology participated in the

study, along with the Cleveland Clinic

Center for Cardiovascular Diagnostics

and Prevention.

| Cardiac Consult | Summer 09 | Visit clevelandclinic.org/heart

Case Study: Cervical Carotid Aneurysm

REFERENCES

(1) Painter T, Hertzer N, Beven E, O’Hara P. Ex-tracranial carotid aneurysms: report of six cases and review of the literature. J Vasc Surg 1985;2:312-8.

(2) Moreau P, Albot B, Thevenet A. Surgical treatment of extracranial internal carotid artery aneurysms. Ann Vasc Surg 1994;8:404-16.

(3) Knight GC, Hallman GL, Reul GJ, Ott DA, Cooley DA. Surgical Management of ExtracranialCarotid Artery Aneurysms:Report of 17 Cases. Texas Heart Inst J 1988;15:91-7.

(4) McCollum CH, Wheeler WG, Noon GP, DeBakey ME. Aneurysms of the Extracranial carotid artery. Twenty one years’ experience. Am Jour Surg 2005; 196-200.

(5) Davidovic L, Dusan K, Maksimovic Z, Markovic D, Dragan VM, Duvnjak S. Carotid artery aneurysms. Vascular 2004;12:166-70.

(6) Kaupp H HSJMBJTO. Aneurysms of the ex-tracranial carotid artery. Surgery 1972;72:946-52.

(7) Zwolak R, Whitehouse WJ, Knake J, Bernfeld B, Zelenock G, Cronenwett J. Atherosclerotic extracranial carotid artery aneurysms. Jour Vasc Surg 1984;1:415-22.

(8) May J, White GH, Waugh R, Brennan J. Endoluminal repair of internal carotid artery aneurysm: a feasible but hazardous procedure. Jour Vasc Surg. 1997;26:1055-60.

(9) Szopinski P, Ciostek P, Kielar P, Myrcha P, Pleban E, Noszczyk W. A series of 15 patients with extracranial carotid artery aneurysms:Surgical and Endovascular treatment. Eur Jour Endovasc Surg2005;29:256-61.

(10) Miksic K, Flis V, Kosir G, Pavlovic M, Tetickovic E. Fusiform and saccular extracra-nial carotid artery aneurysms. Cardiovasc Surg 1997;5(2):190-5.

(11) Radak D, Davidovic L, Vukobratov V, Il-lijevski N, Kostic D, Maksimovic S. Carotid Artery Aneurysms: Serbian Multicentric Study. Ann Vasc Surg 2007;21(1):23-9.

(12) Attigah N, Kulkens S, Hansmann J, Ringleb P, Hakimi M, Eckstein H, et al. Sugical Therapy of Extracranial Carotid Artery Aneurysms:Long term results over a 24 year period. Eur Jour Endovasc Surg 2008;37:127-33.

Presentation

artery aneurysm found on an incidental CT scan of her sinuses for deviated septum and upper respiratory tract infections. She denies any recent or past trauma and has no history of peripheral aneurysms.

Examination and Diagnosis

CT scans of the aortic arch to the Circle of Willis and cerebral angiography were performed, resulting in the following images (See Fig 1 and 2.)

Due to the proximal extent of the internal carotid artery aneurysm in the neck, an ENT consult also was obtained for potential mandibular manipulation to allow access to the vessels.

Treatment

The patient underwent resection of the aneurysm with end-to-end anastomosis due to redundancy of the vessels and their large caliber. Surgical pathology was consistent with atherosclerotic aneurysm.

Discussion

Cervical carotid aneurysms are rare and represent less than 1 percent of all carotid pathologies treated surgically. In the past, mycotic aneurysms were more prevalent and now atherosclerotic aneurysms are more commonly diagnosed. Patients can present with symptoms such as dysphagia, neck swelling, hoarseness and less commonly with bleeding or rupture. The prognosis with nonoperative management is poor with the seqeulae of neurologic symptoms such as stroke or TIA with either embolization of aneurysm contents or thrombosis of the aneurysm.

aneurysms with carotid ligation in London in 1808 and the patient did well. Today, standard surgical therapy consists of aneurysmorraphy with patch or interposition bypass with an autologous conduit. This patient had a very redundant internal carotid, so primary resection with end-to-end repair was possible. Results with open surgery are superior to nonoperative

similarly low. Endovascular options also are available, but have not been evaluated for long-term durability and success.

Contact Dr. Sunita Srivastava at 216.445.6939 or [email protected].

Figure (1)

Figure (2)

Sunita Srivastava, MDVascular Surgery

Indications for VADs Expanded

“Most individuals with medically refractory heart failure may potentially qualify for VAD therapy,” says Cleveland Clinic heart transplant surgeon Gonzalo Gonzalez-Stawinski, MD.

Building a better VAD

Early VADs were large and cumbersome. Ongoing innovations in technology eventually produced smaller, more powerful devices. By 2000, VADs were more successful than medical therapy for patients with end-stage heart failure, but morbidity remained high. Subsequent advances in design and biocompatibility have resulted in improved safety.

Two years ago, changes in Northern Ohio’s organ allocation system reduced the number of donor organs available in the region. Simultaneously, the number of baby boomers with advanced heart failure exploded. Circumstances were ideal for testing a new generation of VADs, and with 30 years’ experience, Cleveland Clinic was poised to meet the need.

“The newer pumps are sturdier, longer-lasting and less prone to infection. We had become good at predicting complications associated with VADs and were having fewer failures. There have been few complications,” says Dr. Gonzalez.

With a low overall mortality rate of 9.7 percent for VAD patients, Cleveland Clinic was approved by the Centers for Medicare and Medicaid Services and Food and Drug Administration (FDA) to offer this life-saving therapy as a treatment for heart failure.

VADs remain a valuable resource for patients awaiting transplantation. Yet a newer, larger group of benefi ciaries are patients with heart failure who are deterred by the potential complications of lifetime immunosuppression, but desire a better quality of life.

Cleveland Clinic also utilizes VADs as a bridge to medical decision in selected patents, primarily those with acute processes that stun the heart, such as myocarditis. In these patients, a VAD may support the heart during recovery and enable appropriate treatment to be initiated later.

Cleveland Clinic has one of the oldest and largest ventricular assist device (VAD) programs in the United States. In the 1970s, Cleveland Clinic surgeons pioneered

and technology have given newer models a wider application. Of the record 49 VADs implanted at Cleveland Clinic in 2008, nine were used as destination therapy, nine as a bridge to decision and 31 as a bridge to transplantation.


Gonzalo Gonzalez-Stawinski, MD

“The newer pumps are sturdier, longer-lasting and less prone to infection.

We had become good at predicting complications associated with VADs

and were having fewer failures. There have been few complications.”


A design for every need

Cleveland Clinic is one of few institutions worldwide with access to multiple FDA- approved VADs from a variety of leading manufacturers.

“This allows us to choose the device that will best suit each patient’s clinical needs,” says Dr. Gonzalez.

VADs with pulsatile turbines readily adjust to the body’s metabolic demands, enabling the patient to participate in physical activity. Such VADs are designed to provide circulatory support for one to three years, depending on the model.

Second-generation VADs are non-pulsatile, continuous fl ow pumps. These small, powerful machines are totally implantable. Biocompatible design and materials reduce thromboembolism and require minimum anticoagula-tion. Cleveland Clinic now uses Thoratec’s HeartMate II as bridge to transplantation, and is using the device in a clinical trial of destination therapy in patients who are not considered candidates for transplantation.

Although a series of HeartMate II devices built prior to June 2006 was recalled in December 2008 due to cracks in the driveline, Cleveland Clinic never en-countered one of the faulty devices, says Dr. Gonzalez. Thoratec has since changed the design and eliminated the problem that led to the recall.

Miniaturized third-generation VADs have a single mov-ing part, are highly biocompatible and are resistant to wear and corrosion, making them ideal for per-manent use. Cleveland Clinic is studying several HeartWare (Thoratec) models with extended-life batteries. These models may be recharged using a household current.

The surgeons also are studying the total artifi cial heart (TAH) as a bridge to transplantation. The safety arm of this study has been completed, and they are now evaluating a portable power source that would enable patients with the device to leave the hospital.

For more information

To discuss the potential for VAD therapy in a patient with advanced heart failure, please call 877.8-HEART-1 (877.843.2781).

More patients with medically refractory heart failure now qualify for VAD therapy


Cardiac Surgery Comes of Age

A new chapter has been

opened in the history of

cardiac surgery. Minimally

invasive surgery is now

the standard treatment for

an increasing number of

cardiovascular procedures.

As techniques improve,

more and more minimally

invasive procedures are able

to duplicate the outcomes of

conventional surgery, with

fewer complications, and

more rapid recovery time.


The goal of minimally invasive surgery (MIS) is

to complete the surgical task with the minimum

of insult to the patient’s body. MIS techniques are

usually accomplished without sternotomy, and

may not involve stoppage of the heart, or extracorporeal

circulation. Smaller incisions offer less opportunity for

post-surgical wound infection, and speed recovery times.

They are the clear preference of most patients.

Surgeons in the Department of Thoracic and Cardiovas-

cular Surgery at Cleveland Clinic have been pioneers

in evaluating and adopting minimally invasive surgical

techniques. Delos M. Cosgrove, MD, performed the

international broadcast from Cleveland Clinic in 1996.

Cleveland Clinic cardiovascular surgeons, cardiologists

and cardiovascular imaging specialists work as a team

to prepare for and execute an increasing variety of

minimally invasive techniques.

This special section of Cardiac Consult offers an overview

of Cleveland Clinic’s minimally invasive interventions.

We invite you to refer patients for evaluation for minimally

invasive cardiac surgery at Cleveland Clinic by calling

216.444.3500 or 877.8HEART1.


Mitral Valve Replacement and Repair

Mitral valve repair is the most frequently

performed minimally invasive cardiac

surgery. A. Marc Gillinov, MD, and

Tomislav Mihaljevic, MD, who share a

great deal of experience in all minimally

invasive cardiac procedures (including

robotically assisted), indicate that it

is possible to both repair and replace

valves minimally invasively. However,

they believe that long-term outcomes

are superior with repair, and recommend

repairs in most cases. More minimally

invasive mitral valve repairs have been

performed at Cleveland Clinic than at

any other medical center.

Robotically assisted mitral valve repair

is the least invasive approach to mitral

valve repair. Robotically assisted pro-

cedures are performed endoscopically,

through small ports (rather than formal

incisions) in the right side of the chest.

A Minimally Invasive Approach

Minimally invasive mitral valve repair

can be performed through a 2 to 4-inch

incision, either a right mini-thoracotomy

or partial upper sternotomy. The surgical

approach or technique for each patient

is based on age, condition, co-morbidi-

ties and anatomical considerations.

The right mini-thoracotomy is performed

with a 2- to 3-inch skin incision created in

a skin fold on the right chest, providing an

excellent cosmetic result. The heart is ap-

proached between the ribs, providing the

surgeon access to the mitral valve. There

is no sternal incision or spreading of the

ribs required for this surgical technique.

Using special instruments, the surgeon

and place an annuloplasty ring, just as

in conventional surgery. A partial upper

sternotomy includes a 2- to 3-inch skin

incision and division of the upper portion

of the sternum, as opposed to the 8- to

10-inch incision of a full sternotomy. The

partial upper sternotomy offers the sur-

geon an excellent view of the mitral valve

and may be an appropriate approach for

patients who require combined mitral

valve and aortic valve procedures.

These minimally invasive approaches

also can be used when mitral valve

repair is combined with ablation for

has been instrumental in developing

Robotically Assisted Mitral Valve Surgery

Robotically assisted mitral valve surgery

is a type of minimally invasive surgery

in which the surgeon uses a specially-

designed computer console to control

surgical instruments on thin robotic arms.

The robotic arms are introduced through

1- to 2-cm incisions in the right side of the

chest. The surgeon’s hands control the

movement and placement of the endo-

scopic instruments to open the pericar-

dium and to perform the procedure.

Robotically assisted mitral valve surgery

provides the surgeon with an undistort-

ed, three-dimensional view of the mitral

with the use of a special camera. This

approach enables surgeons to perform

complex repairs without the need for


division of the sternum or spreading of

the ribs, in most cases.

At the current stage, all patients who have

leaky mitral valves and or tricuspid valves

can be evaluated as a potential patient

for minimally invasive robotic surgery. It

is even an option for selected patients

who have already had conventional heart

surgery – even after previously failed at-

tempts at repairing the mitral valve.

Robotic surgery requires specially trained

surgeons and a specially trained operat-

ing room team. In the rare event that the

robotic approach needs to be switched

to conventional surgery (fewer than 2

percent of all cases) the team needs to

be able to make that switch quickly and

built robotic surgical suite, this can be

accomplished in less than two minutes.

Cleveland Clinic has excellent results

with minimally invasive mitral valve

surgery. In 2008, 53 percent of all

isolated mitral valve procedures done

at Cleveland Clinic were performed

robotically, with 0 percent mortality.

Coronary Artery Bypass Graft Surgery

The traditional coronary artery bypass

graft (CABG) surgery, which was pio-

neered at Cleveland Clinic in 1967, is

performed every day at academic medical

centers and community hospitals alike.

But recently, surgeons have been success-

fully performing this operation through

a smaller incision and – in some cases –

without the use of a heart-lung machine.

Joseph F. Sabik, MD, Chairman of

Thoracic and Cardiovascular Surgery is

now performing a “mini” coronary artery

bypass through 3- to 4-inch incisions.

The traditional method, by comparison,

requires a patient’s sternum to be split.

“The mini-procedure offers less pain and

a hospital stay that’s shorter by about

two days,” says Dr. Sabik. In addition,

the surgery is most often done without

a blood transfusion.

As with the traditional CABG, the mini-

procedure uses a healthy artery or vein

from the patient’s chest, leg or arm to

bypass the clogged artery.

Decisions are made on a case-by-case

basis, weighing a patient’s size, coronary

artery quality and the number of grafts

needed. “Many people can take advantage

of this new procedure,” Dr. Sabik says.

“For an average person who needs two or

three grafts, we can perform the mini-

CABG procedure instead.”

Percutaneous Procedures

Some cardiac procedures that are usually

done through full exposure or minimally

invasively, can now also be performed

percutaneously. Some of these techniques

are experimental. Others are part of every-

day clinical practice. For instance, many

patients currently receive percutaneous

valvotomy for stenosis of the mitral, aortic

or pulmonic valve. In this procedure, ex-

plains interventional cardiologist Samir K.

Kapadia, MD, a balloon-tipped catheter is

inserted into the femoral artery and guided

to the site of the valve. The balloon is


leaving nothing but a valve that is more

“There are a lot of patients, especially old-

open heart surgery for various reasons,”

says surgeon Lars Svensson, MD, PhD,

of Thoracic and Cardiovascular Surgery.

“We’ve been able to develop techniques

that we can approach these valves with-

out having to open the patient’s chest.”

Other percutaneous valve procedures

are still in the experimental stage.

to study percutaneous aortic valve

replacement using a new compressed-

tissue heart valve. The valve is placed

on a balloon-mounted catheter and

positioned directly over the diseased

aortic valve. “When we know we are

in the right position, we get the heart

to race faster so it’s not pumping as

much,” says Dr. Svensson. “Then we in-

balloon is withdrawn. Cleveland Clinic

is participating in a U.S. Food and Drug

Administration study to determine the

feasibility of this treatment.

“What surprised many of us in the surgical

profession is that this has worked out very

well,” says Dr. Svensson. “Obviously there

are higher risks than a routine open heart

operation, but it is an option for older or

high-risk patients.”

Another experimental technique is being

tested at Cleveland Clinic for the treatment

of mitral valve regurgitation. A very small,

specially made metal clip device is deliv-

ered via catheter to the mitral valve. The

center of the valve, allowing the blood to

clip is adjusted until optimal improvement

valve are observed. When the catheter is

in position, which limits the leakage.

The mitral valve itself is untouched in

another experimental percutaneous treat-

ment for mitral valve regurgitation. In

this novel approach, a small metal bar is

guided by catheter into the coronary sinus

to a position just alongside the annulus

of the mitral valve, and left there. The

slight rigidity of the bar exerts pressure on

the dilated annulus, pushing it and its at-

Cleveland Clinic surgeons and cardiologists

percutaneous valve placement to remedy

the impact of tricuspid regurgitation on

the body using a special device developed

at Cleveland Clinic. This may eventually

provide a means of treating valve disease

caused by radiation treatments to the

chest, which sometimes render the patient

unsuitable for open surgery.

In considering all these techniques, it

should be kept in mind that mortality

for conventional valve replacement and


lower than the national averages (0.3

percent for primary isolated mitral valve

repair in 2008). This means that experi-

mental minimally invasive alternatives

are most frequently recommended for

patients who are too frail or elderly for

conventional surgery.

Video-assisted Thorascopic Lobectomy

Patients with small, early stage, primary

lobectomy, which removes the tumor along

with the lobe of the lung were it resides. A

conventional lobectomy is performed dur-

ing a thoracotomy. Cleveland Clinic is now

one of the few centers in the nation that

-

mally invasive alternative to this approach.

Video-assisted thoracoscopic surgery

lobectomy (VATS lobectomy) is performed

through three 1-inch incisions and one

3- to 4-inch incision in the chest. A

thorascope and specially adapted surgical

instruments are inserted into the incisions.

Guided by the images from the thorascope,

the thoracic surgeon cuts and removes the

tumor and other affected tissue. If an early-

stage cancer tumor is being removed, the

lymph nodes in the mid-chest area also

may be removed or biopsied to ensure that

the cancer has not spread.

“Small lung cancers and lung cancers

that tend to be more toward the surface

of the lung are the best candidates for

VATS however most lung cancers can be

removed by VATS, says David Mason, MD

of the Department of Thoracic and Cardio-

vascular Surgery. “The CT scan should be

able to identify the location of the tumor

and the likelihood of removal with VATS.”

The outcomes for VATS lobectomy are

comparable to those for conventional

surgery. Traditional thoracotomy may

be more appropriate for some patients

with large tumors, involved lymph

nodes, or prior chest surgery. VATS

techniques are also applied to other

procedures, including wedge resection,

lung biopsy, drainage of pleural effu-

sions, and mediastinal, pericardial and

thymus thoracoscopic procedures.

“Minimally invasive lung surgery is clearly

-

racic diseases that require surgery,” says

Dr. Mason. “However, few surgeons are

trained in these techniques and only a

minority of thoracic surgery procedures are

performed minimally invasively around the

country. At Cleveland Clinic, all thoracic

surgery patients are considered for mini-

in these techniques exists. In our experi-

ence, outcomes for cancer cure is identical

to more traumatic techniques and clearly

this is not a compromise procedure.”

Minimally Invasive Vein Harvesting

Cleveland Clinic cardiac surgeons

established the superiority of the internal

thoracic artery as a conduit for coronary

artery bypass. Prior to that, the saphen-

ous vein was the preferred conduit for

this procedure. Today, the saphenous

vein continues to be used where the

internal thoracic artery is inappropriate

or unusable, and for bypass procedures

in the legs for peripheral artery disease.

The radial artery in the arm may also be

harvested and used as a conduit.

The saphenous vein and radial artery are

traditionally harvested through a long in-

cision that is often uncomfortable for the

patient. More and more, however, these

conduits are being harvested minimally

invasively, using an endoscope. Cleve-

land Clinic surgeons have considerable

experience in performing endoscopic

saphenous vein harvesting and have

expanded its use for lower extremity

bypass. To harvest the saphenous vein,

the surgeon makes a small incision in

the groin and one or two 1-inch inci-

sions in the leg, near the knee. Special

instruments are slid down the inside leg,

alongside the vein. A miniature camera

allows the surgeon to view the vein,

and measure off the length that will be

needed. That length is cut and the vein

is removed through the incision.

In 2005, Cleveland Clinic surgeons

expanded the minimally invasive

approach to include harvesting of radial

arteries. In this procedure, the surgeon

makes a small incision near the wrist

and one near the forearm.

“Applying endoscopic vein harvesting

for lower extremity bypass is a bit more

challenging than for coronary bypass

for a variety of reasons,” says Cleveland

Clinic vascular surgeon Vikram Kashyap,

reduced pain, morbidity and hospital

length of stay can be accomplished for

these patients.”

“Minimally invasive lung surgery is clearly beneficial to patients for almost

all thoracic diseases that require surgery. However, few surgeons are trained

in these techniques and only a minority of thoracic surgery procedures are

performed minimally invasively around the country.” - Dr. David Mason


Important Genetic Findings

There were two major genetic discoveries from Qing Wang,

PhD, Department of Molecular Cardiology and Director of

the Center for Cardiovascular Genetics:

A year ago, researchers found that a cluster of genetic variants

artery disease (CAD) in white people in northern Europe and

North America. People who have that genetic quirk are more

susceptible to developing CAD or having a heart attack. Dr.

Wang and his team have shown the same genetic material also

is associated with coronary artery diseases in the South Korean

identify people at risk of arterial diseases or heart attacks.

lead to new diagnostic tests and treatment options for cardiac

patients. Qing K. Wang, PhD found the new gene – NUP155

– by analyzing the genetics of a family with severe, early-onset

tailored treatment strategies to prevent and/or treat the common

Using Drugs to Facilitate PCI for Myocardial Infarction

The results of an international clinical trial led by Cleveland

Clinic Cardiologist Stephen A. Ellis, MD, should have high im-

pact on the treatment of patients presenting with heart attacks

caused by blocked coronary arteries. Before the study, it was

given certain blood-thinning agents, either singularly or in

combination, before being taken to a catheterization lab to get

an angioplasty, or other percutaneous intervention (PCI). But

Dr. Ellis’s study showed that administering the drugs before

may actually cause harm by promoting bleeding.

New Findings in Vascular Surgery

Cleveland Clinic Vascular Surgeon Vikram S. Kashyap, MD,

-

fectiveness of using the anticoagulant bivalirudin in patients

undergoing lower extremity bypass. This small study suggests

anticoagulant in lower extremity bypass.

Blockage of the large blood vessels in the pelvis (aorta and

iliac arteries) can starve the lower extremities of blood and

lead to the need for amputation. Traditionally, this condition

is treated with major surgery: the grafting of a y-shaped syn-

thetic tube to bypass the blockage. Less invasive alternatives

are available, but it has not been known for certain how well

they compare to the bypass graft. Now, in a retrospective

review of cases performed at Cleveland Clinic, Dr. Kashyap

has shown that outcomes from percutaneous angioplasty and

stenting for this condition compare favorably to bypass graft-

ing – a step forward for patients who hope to avoid major

surgery for pelvic blockages.

Research RoundupHighlights of Recent Heart and Vascular Research from Cleveland Clinic


Critical Care Transport

Staff

Our team is made up of Cleveland Clinic physicians and pediatric intensivists, nurse practitioners, critical care nurses, paramedics and allied health professionals. Each medical team is customized to meet the needs of the patient and is ready at a moment’s notice for regular patient transfers, as well as transfers of highly acute patients with ST-elevation acute MI (STEMI) and acute aortic syndrome.

Services Offered

24/7 Adult critical care transport by ground or air by a team experienced in critical care and/or emergency services and trained in transport environment care, 24/7 pediatric critical care transport by ground or air by a team specially trained in neonatal and pediatric intensive care, emergency and transport medicine and flight physiology.

More Beds

To make sure your patients get the specialized care he or she needs, we now have 24 dedicated Cardiovascular ICU beds with adjacent imaging and cath labs, and a cardiology fellow in attendance, 24/7. In addition, we have a dedicated heart failure ICU and two surgical ICUs (totaling more than 100 Cardiovascular ICU beds).

Our Fleet

Patients can be transferred to Cleveland Clinic by fully staffed Mobile Intensive Care Units. Our air transport capabilities include a Sikorsky S-76 A++ for our immediate 250-mile radius, and a Beechjet 400A and Hawker 800 for longer distances – both staffed and equipped as “flying ICUs.”

For more information, visit clevelandclinic.org/cct.

In the Spotlight

Instructions for TransportNEW! Acute transfers (acute stroke, STEMI, ICH and acute

aortic syndrome conditons), call 877.379.CODE (2633).

with no delay-causing dispatch protocols.

Routine transfers, call 216.444.8302 or 800.533.5056

Have the following information ready

Patient name

Date of birth

Cleveland Clinic medical record number

Insurance information

Diagnosis and location of patient

Need for telemetry

If the patient has invasive lines, assistive devices or drip;

if the patient is hemodynamically stable

Cleveland Clinic’s Critical Care Transport team is ready to respond 24/7 to just about any 9-1-1 call, anywhere in the world. Our transport team can start tertiary care during transfer to one of our many facilities, thus improving the outcomes for many serious and complex conditions.


Remote Monitoring in Heart Failure

a new era of remote monitoring. These devices provide a steady stream of data that can be remotely monitored to assess and manage patients with heart failure. For cardiologists, the immediate challenge is to access these data in a timely fashion

“With the broad application of im-

planted device therapies, we now

have the unprecedented access

to physiologic data,” says W. H.

Wilson Tang, MD, a cardiologist

and Research Director of the Sec-

tion of Heart Failure and Cardiac

Transplantation at the Sydell and

Arnold Miller Family Heart & Vas-

cular Institute at Cleveland Clinic.

“This data includes measurements that were originally devised

to monitor device integrity. Now we can take advantage of them

to provide insight into the clinical stability of patients with heart

failure, particularly in between their clinic visits.”

Of particular interest is the ability of devices to measure

changes in impedance in the thoracic cavity. Impedance is

the body’s resistance against an electrical current. “Impedance

was originally a self-check measurement to assess the status of

recognized that impedance technology also can indirectly assess

cardiac hemodynamics. Physiological changes may correlate

the thorax. This detectable change in impedance may occur

weeks before the actual event of hospitalization. The hypothesis

that is currently being tested is whether this early warning can

provide opportunities for early intervention, whether it is by

changing drugs or by intensifying counseling.”

Such measurements have been widely available as part of

complementary data on some CRT-Ds and ICDs, but not for

indications for treatment or alerts. “In fact, when we review

such data in front of our patients, we can even go back and

uncover unreported events,” says Dr. Tang. “It’s a powerful tool

if used appropriately. We have incorporated such information at

the time of clinic visit, as well as systematically reviewed them

when downloaded at the time of remote device interrogation

as part of our heart failure disease management program.”

There are some limitations as data from these remote devices

can be variable. “Some patients have big changes and some

patients have small changes,” says Dr. Tang. “Like any diagnos-

tic test, individual measurements need to be interpreted in

the context of the patient’s clinical status. We also don’t know

how frequent we should monitor these data, nor do we have a

universally agreed upon strategy to approach these patients. If

in doubt, we contact the patient to clarify or ask them to come

and see us for follow-up.” The value of this approach has been

supported by the availability of CPT codes for this purpose.

“For now, observing changes in device data can raise suspicion

regarding a patient’s clinical instability,” says Dr. Tang.

The next step is to perform large studies to establish the safety

Bruce Wilkoff, MD, Randall Starling, MD, MPH, and several

members of the Center for Electrical Therapies of Heart Failure

at the Miller Family Heart & Vascular Institute are actively

participating in the design and conduct of prospective clinical

trials to determine the value of these measurements in differ-

of heart failure.

“We have the challenge of establishing what is the most ap-

propriate response to these diagnostics,” says Dr. Tang, who is

leading several of these studies. “Up until now, the treatment

of heart failure has been reactive, based on a patient feeling

worse. In this generation, we would like to be proactive, using

drugs, counseling, following up closely, and calling the patient.

The advent of broad implantation of these devices in this popu-

lation allows us to test usefulness of this data in a management

strategy. It’s a tremendous opportunity to advance the treat-

ment of heart failure, perhaps way before patients demanded

the need for hospital admissions.”

W.H. Wilson Tang, MD


Genetic Cause of Deadly Irregular Heart Beat Discovered

Qing K. Wang, PhD, Cleveland Clinic Lerner Research Insti-tute’s Department of Molecular Cardiology and Director of the Center for Cardiovascular Genetics, and his colleagues found the mutation of the gene NUP155 by analyzing the genetics of a family with severe, early-onset AF and sudden cardiac death.

AF is the most common rhythm disturbance of the heart found in the clinical setting. It affects 3 million people in the United States alone. AF accounts for nearly 15 percent of all strokes and is also associated with worsening heart failure and increased mortality. Despite signifi cant advances in AF management, available treatment options remain far from optimal.

“The new finding may provide a new molecular target to develop patient-tailored treatment strategies to prevent and/or treat the common form of atrial fi brillation,” says Dr. Wang.

Each cell in your body contains instructions encoded in your DNA that are parceled into 23 pairs of chromosomes. Approxi-mately 39,000 genes, which are the instruction booklets con-taining the DNA, are found dotted along all the chromosomes. Differences in people come from slight variations in these genes, which determine everything from hair and eye color to whether or not a person is more or less susceptible to certain diseases.

The DNA in genes is translated or decoded into another ge-netic material called RNA in the nucleus of a cell. Then, the RNA is transported from the nucleus to the liquid inside the cell called cytosol by a special apparatus called the nuclear pore complex (NPC). In turn, RNA in the cytosol produces proteins that are the basic building blocks and workers of each cell in the body. This conversion – DNA to RNA to protein – is a tightly regulated process.

NUP155 makes a protein that is a critical component of the NPC. The NPC acts as a gateway to control the exchange of ma-terials like RNA and proteins between the cell’s nucleus and the cytosol that surrounds the nucleus. This exchange of RNAs and proteins through a nucleus membrane is essential to numerous functions of the cell.

could lead to new diagnostic tests and treatment options for cardiac patients.

Dr. Wang’s studies revealed that mutant NUP155 causes atrial fi brillation by altering how RNAs are exported out of the nucle-us and how proteins are imported into the nucleus. Specifi cally, NUP155 affects the gene/protein called Hsp70, a protein that can be induced by stress, exercise, surgery, heat shock, and decreased blood supply to heart tissues.

Hsp70 plays a role in maintaining the proper balance of cardiac calcium and protecting the structure of heart tissue cells, both of which are cellular processes important to the maintenance of heart rhythm. If the level of Hsp70 is low, the heart is not protected from development of abnormal heart rhythms.

“Identifying a gene linked to AF could lead to new ways to genetically screen people. For example, individuals in families with a history of AF could be screened to see if they carry the mutated NUP155 gene and, therefore, have a greater likeli-hood of developing AF,” Dr. Wang says. “It also explains a molecular process or pathway that we might be able to control with new therapies. These therapies could stop AF from devel-oping in the fi rst place, or treat it after it has been diagnosed.”

Dr. Wang’s research team included Xianqin Zhang, PhD, Shenghan Chen, PhD, Shin Yoo, Susmita Chakrabarti, Teng Zhang, PhD, Tie Ke, Carlos Oberti, Sandro L. Yong, Fang Fang, Lin Li, Lejin Wang, and Qiuyun Chen, all of Molecular Cardiology, and R. de la Fuente, PhD, Department of Cardiol-ogy, Ospedale Italiano Umberto I, in Uruguay.

The research was published recently in Cell ( www.cell.com/ 2008; 135(6) pp. 1017-1027). This study was supported by the American Heart Association, the State of Ohio Wright Center of Innovation grant and Biomedical Research and Technology Transfer Partnership Award (BRTT, Ohio’s Third Frontier Proj-ect), and the National Basic Research Program of China.


First Implant of Heartware Ventricular Assist System at Cleveland Clinic

In March 2009, Nicholas Smedira, MD, a cardiac surgeon with the

of the Heartware® Ventricular Assist System, developed by Heartware International, at Cleveland Clinic.

Only a handful of the miniaturized circulatory assist devices have been implanted in the United States to date. The HeartWare® Ventricular Assist System features the HVAD™ pump, the only full-output pump designed to be implanted next to the heart, avoiding the abdominal surgery generally required to implant competing devices.

HeartWare has completed an international clinical trial for the device involving five investigational centres in Europe and Australia. The device is currently the subject of a 150-patient clinical trial in the United States for a Bridge-to-Transplant indication.

A Comprehensive International SymposiumThe Treatment of Cardiovascular Disease: Legacy & InnovationJune 3-5 InterContinental Hotel & Bank of America Conference Center Cleveland, Ohio

Diabetes and the Heart August 6-7 Intercontinental Hotel & Bank of America Conference Center Cleveland, Ohio

A Primer in Vascular DiseaseSeptember 25-26InterContinental Hotel & Bank of America Conference CenterCleveland, Ohio

Congenital Heart Disease in the Adult: The Second Annual Ronald and Helen Ross SymposiumOctober 9 InterContinental Hotel & Bank of America Conference CenterCleveland, Ohio

2009 Heart-Brain SummitOctober 15-16Sheraton Chicago Hotel & Towers Chicago

For more information about the above events, call the Cleveland Clinic De-partment of Continuing Education at 216.444.5696 or 800.762.8173,or visit clevelandclinicmeded.com.

CME Calendar

Visit clevelandclinic.org/heart | Cardiac Consult | Summer 09 |

DrConnect Make Your Next Report Electronic

DrConnect is an Internet-based service developed to provide our community physician colleagues real-time electronic medical record information about the treatment their patients receive at Cleveland Clinic.

After establishing a DrConnect account with a secure log-in

personnel to receive security rights, allowing DrConnect patient updates to be immediately integrated into a busy medical

Web address (URL) gives you one-click access to all newly released patient-related information, which is presented in easy-to-navigate “What’s New” screens for quick access and effective case and time management.

Establishing your own DrConnect account is easy. 1) Log onto drconnect.clevelandclinic.org. 2) Click on the OnLine Signup button. 3)including choosing a secure password, and submit.

Special Assistance for Out-of-State PatientsThe Cleveland Clinic’s Medical Concierge program is

a complimentary service for patients who travel to

Cleveland Clinic from outside Ohio. Our patient care

representatives facilitate and coordinate the schedul-

ing of multiple medical appointments; provide access

to discounts on airline tickets and hotels, when avail-

able; make reservations for hotel or housing accom-

modations; and arrange leisure activities.

For more information: call 800.223.2273, ext.

55580, visit clevelandclinic.org/services, or email

[email protected].

HVI ReferralsTo refer cardiology patients, please call 216.444.6697 or 800.553.5056.

To refer surgical patients, call 877.843.2781.

New patients, in most cases, can be seen by a cardiologist within one week of calling for an appointment. Most patients requiring surgery also can be accommodated within one week.

Same-day Visits Now AvailableThe Miller Family Heart & Vascular Institute has begun offering same-day appointments

for new patients and follow-up visits. Patients who want or need to be seen immediately

will be scheduled with a HVI Cardiovascular Medicine staff member.

same-day visit, call 216.444.6697 or 800.659.7822.

C L E V E L A N D C L I N I C A C C E S S G U I D E

The Cleveland Clinic Foundation9500 Euclid Avenue/AC311Cleveland, OH 44195

A Primer in

Vascular Disease

Save the DateSeptember 25-26, 2009InterContinental Hotel & Bank of America Conference CenterCleveland, Ohio

www.ccfcme.org/Vascular09This activity has been approved for AMA PRA Category 1 Credit™.

CardiacConsult