Thebest in cardiac surgery by yte37472


									 VOLUME 1, ISSUE 4
                          C A R D I O V A S C U L A R

                                                                                                                                            Winter 2006

                                   The best in
CV surgery
case study
                                  cardiac surgery
  Page 2
                                   a t K i n g ’s D a u g h t e r s M e d i c a l C e n t e r
introduces                t is well documented that higher volumes mean
64-slice CT
   Page 3            I    superior outcomes. The Cardiothoracic Surgery
                          program at King’s Daughters ranks among the
                          region’s top programs for volumes and reports
                     significantly lower mortality, morbidity and complication
                     rates than the national average (KDMC overall mortality
  IV pumps           = 1.9 percent; Society of Thoracic Surgery overall
 donated to          mortality = 2.6 percent). Our program has a reputation
area medics          for early adoption of new and innovative techniques that
    Page 3           improve patient outcomes, even as we perform the most
                     complex procedures on the highest
                     risk patients. And while high
CDC says                                                       I For a consult
                     volumes are good for outcomes,
 diabetes                                                      or to refer a
                     we also maintain a patient-centered
on the rise                                                    patient to one of
                     focus. Each patient is carefully
  Page 4                                                       our cardiothoracic
                     evaluated and treated according
                                                               surgeons, please
                     to an individualized plan.
                                                               call toll free,
                     Cardiac surgery innovations               (432-7859).

                     at King’s Daughters include:

                     Off-pump or “beating heart” bypass surgery
                        This type of coronary artery bypass surgery
                     (CABG) is especially beneficial for patients who
                     are at increased risk for stroke and other
                     complications from clamping the aorta.
                     Performing CABG surgery without the bypass
                     pump has been associated with improved survival, and           KDMC cardiothoracic surgeons, from left, Robert Fried, M.D.;
                                                                                    Marcos Nores, M.D.; and Richard Heuer, M.D.
                     lower rates of strokes and blood transfusions, without a
                     decrease in the number of grafts. In 2005 we performed
                                                                                    annuloplasty ring, are utilized when appropriate. The
                     about 25 percent of isolated CABG cases without the
                                                                                    most common valve procedures at King’s Daughters
                     bypass pump. The Society of Thoracic Surgeons reports
                                                                                    involve the mitral and aortic valves, and we have the
                     a national off-pump CABG rate of 18 percent.
                                                                                    expertise to repair the tricuspid and pulmonary valves,
                                                                                    as well. Valve repair or replacement often is indicated
                     Valve surgery
                                                                                    in patients who experience:
                        Surgeons now are treating valve disorders earlier,
                                                                                    • Fatigue, especially during times of increased activity
                     reducing mortality and morbidity rates. Repair is
                                                                                    • Shortness of breath, especially with exertion or when
                     preferable to replacement whenever possible, leading
                                                                                      lying down
                     to long-lasting results without anticoagulation therapy.
                     The latest proven innovations, such as the GeoForm                            See cardiac surgery, page 2

 1-866-HEART-KY |                                                                                 2201 Lexington Ave., Ashland, KY 41101
2     CARDIOVASCULAR UPDATE                                              KING’S DAUGHTERS HEART AND VASCULAR CENTER

        Richard Paulus, M.D.
           medical director
   of the Heart and Vascular Center
                                             cardiac surgery                                            continued from front page

           (606) 324-4745
                                             • Swollen feet or ankles                                 CASE STUDY
      Kristie Estep, R.N., MSN               • Heart palpitations
         vice president of the               • Frequent respiratory infections, such as
      Heart and Vascular Center                                                                       Problem patient
            (606) 327-4691                     bronchitis
                                                                                                         A 63-year-old female presented to the
                                             • Heavy coughing, sometimes with blood-tinged
                                                                                                      Emergency Department with chest pain and
         Richard Heuer, M.D.                   sputum
          medical director of                                                                         shortness of breath. She admits to shortness
                                             • Rarely, chest discomfort or chest pain
        Cardiothoracic Surgery                                                                        of breath with minimal exertion, including
           (606) 326-9847                                                                             being awakened at night with breathlessness.
                                             Atrial fibrillation surgery
                                                                                                      Cardiac risk factors include hypertension,
          Zane Darnell, M.D.                    The cardiothoracic surgeons at King’s
            medical director                                                                          hyperlipidemia, diabetes, and obesity. She had
                                             Daughters are experienced with microwave,
         of the Chest Pain Unit                                                                       undergone angioplasty with placement of
             (606) 324-4745                  radiofrequency or cryoblation energy for
                                                                                                      two stents several years previously. She said
                                             treatment of atrial fibrillation. Patients with atrial
                                                                                                      she has had intermittent atrial fibrillation
      John Van Deren III, M.D.               fibrillation who have advanced coronary artery
 medical director of Electrophysiology                                                                since the age of 27. She underwent a stress
                                             disease, mitral or aortic valve disease and need
            (606) 324-4745                                                                            test which showed anterior wall ischemia and
                                             surgery can also receive accompanying “maze”
                                                                                                      an ejection fraction of 57 percent. Carotid
       Heart Transfer Number                 procedures to redirect electrical impulses through
                                                                                                      duplex was negative. A cardiac
  1-866-HEART KY (1-866-432-7859)            the heart. Patients with severe coronary artery
                                                                                                      catheterization performed by cardiologist
                                             disease, mitral stenosis and/or regurgitation,
Physician Courtesy Number to access                                                                   Richard Paulus, M.D., revealed 85 percent
   KDMC operator (606) 327-7100              aortic stenosis or regurgitation who have atrial
                                                                                                      stenosis in the left anterior descending artery,
                                             fibrillation are candidates to have a maze
                                                                                                      and 75 percent lesions in the diagonal. The
    KDMC Emergency Department                procedure while the open-heart surgery is
         (606) 327-4565                                                                               patient also was found to have moderate
                                             performed. Also, stand-alone surgery for atrial
                                                                                                      aortic stenosis, aortic insufficiency and mitral
  Newsletter Questions/Comments              fibrillation can be performed through very small
                                                                                                      regurgitation. Cardiothoracic surgeon Robert
    Julie Marsh (606) 327-4436               incisions on the chest without the use of the
                                                                                                      Fried, M.D., was consulted.                   heart-lung machine or dividing the sternum.
   Newsletter                                                                                         Physician action plan
      Editor                                 Thoracic aortic aneurysm surgery
                                                                                                         Dr. Fried offered multiple procedures
Chris Epling, D.O.                              Surgeons at King’s Daughters routinely
                                                                                                      to treat the patient, including an aortic
 (606) 327-4745                              perform aortic aneurysm surgery for dissecting or
                                                                                                      valve replacement, mitral valve repair, two
                                             atherosclerotic aneurysms, and repair aneurysms
                                                                                                      vessel coronary artery bypass grafting, and
                                             that affect the function of the aortic valve.
                                                                                                      a possible microwave maze procedure to
                                                                                                      treat her atrial fibrillation. The patient
                                             Other cardiothoracic surgeries
    Heart and Vascular Outreach                                                                       agreed to the treatment plan.
                                                Our surgeons also perform uncommon and
    Coordinator Jamie Mills can
provide your office with additional
                                             complex surgeries such as minimally invasive             Outcome
information about our services and           lobectomies for lung cancer; “elephant trunk”
                                                                                                         The patient underwent two vessel
   can arrange meetings with our             aortic arch repair utilizing tubular aortic graft
 physicians. She can be reached at                                                                    bypass, receiving a left internal mammary
                                             prosthesis to repair the ascending aorta and aortic
          (606) 922-3818.                                                                             artery graft to the left anterior descending
                                             arch; esophageal repair; and tracheal resections.
                                                                                                      and a vein graft to the marginal.
                                                                                                      Endoscopic vein harvesting was used.
                                             External heart assist device
                                                                                                      A #21 pericardial aortic valve was
                                                King’s Daughters recently purchased the
                                                                                                      replaced, and the mitral valve underwent
                                             AbioMed AB5000 ventricle pump and console.
                                                                                                      a 28 Cosgrove ring repair. A maze
                                             This system is used to keep a patient’s blood
                                                                                                      procedure with microwave energy was
                                             flowing and help the heart rest and recover, in
                                                                                                      performed. The patient recovered well
                                             a process called “unloading,” following a heart
        2201 Lexington Ave.                                                                           from surgery, but experienced persistent
         Ashland, KY 41101                   attack and cardiogenic shock. Once hooked up
                                                                                                      junctional bradycardia in the 30s with
                                             to the device, the patient’s heart still beats, but
                                                                                                      QRS complex. Electrophysiologist Terence
                                             the muscle doesn’t have to pump the three to
                                                                                                      Ross, M.D., implanted a pacemaker four
                                             six liters of blood per minute that it normally
                                                                                                      days post operatively. The patient was
                                             would. The system can sustain a patient for
                                                                                                      discharged in good condition about two
                                             several months until the heart recovers, or
                                                                                                      weeks following the surgery.
                                             can bridge the time until a transplant can be

                                         KDMC was recently named among the nation’s 100 Top Hospitals® by Solucient
CARDIOVASCULAR UPDATE                                        KING’S DAUGHTERS HEART AND VASCULAR CENTER                                         3
                                                                                                     Alex Hou opens new vascular practice
   Heart and Vascular Center Roundup                                                                    Vascular/endovascular
                                                                                                     surgeon Alex Hou,
Quick Facts about the KDMC Heart                                                                     M.D., has opened a new
                                                    have typical symptoms (especially chest
and Vascular Center                                                                                  private practice in
                                                    pain, shortness of breath, or fatigue
                                                                                                     Ashland, located at
    King’s Daughters Medical Center now             during heavy physical activity).
                                                                                                     Medical Plaza A, Suite
ranks fourth in the state of Kentucky in          • Unusual symptoms for coronary artery
                                                                                                     445, 617 23rd St.,
terms of admissions, and experienced                disease (chest pain unrelated to physical
                                                                                                     Ashland. He will be      Alex Hou, M.D.
another record year in 2005. Our heart              exertion), but low to intermediate risk
                                                                                                     joined by general
and vascular services performed 11,000              profiles for coronary artery disease.
                                                                                                     surgeon William
catheterization procedures in the past year,      • Unclear or inconclusive stress-test
                                                                                                     Dunlop, M.D., whose
including:                                          (treadmill test) results.
                                                                                                     office was previously
• 5,600 heart caths                                  The patient’s initial consultation with
                                                                                                     located in the Medical
• 2,000 angioplasty/stent procedures              their primary physician is key for patients
                                                                                                     Arts Building. Their
• 1,300 diagnostic and non-invasive               seeking to determine the appropriateness
                                                                                                     office can be reached by
   procedures                                     of coronary CTA. For more details about
                                                                                                     calling (606) 327-5628.
• 1,300 peripheral vascular catheterizations      Coronary CTA, call the King’s Daughters                                       William Dunlop, M.D.
   and interventions                              Radiology Dept. at (606) 327-4724.
     Our team also performed 850 open-
heart surgeries in the past year.                                                                    KDMC donates IV Pumps to
                                                  KDMC one of top 50 enrollers in
    To receive a 2006 physician directory                                                            medics in eastern Kentucky
listing the more than 230 medical specalists
                                                  international ACUITY trial                            In a program called “Hearts in
                                                        Patient enrollment in the 13,800 patient
at King’s Daughters, please call                                                                     Action,” King’s Daughters Medical
                                                    global Phase III ACUITY trial (Acute
1-888-377-KDMC (5362).                                                                               Center has partnered with Paul B. Hall
                                                    Catheterization and Urgent
                                                                                                     Regional Medical Center in Paintsville,
                                                    Revascularization Triage Strategy) was
KDMC now performing 64-slice                                                                         and medical transportation/EMS
                                                    completed in December, and King’s
                                                                                                     companies in the eastern Kentucky region
CT imaging                                          Daughters was ranked among the top 50
                                                                                                     in an effort to improve the care of
    King’s Daughters Medical Center now is enrollers. This randomized clinical trial,
                                                                                                     patients. In late 2005, Paul B. Hall hosted
performing 64-slice CT imaging, with the            which enrolled patients over a two-year
                                                                                                     an educational program where nurses
ability to perform cardiac CT, including            period, is evaluating the direct thrombin
                                                                                                     from King’s Daughters and other experts
coronary CT angiography                             inhibitor Angiomax® (bivalirudin) replacing
                                                                                                     trained about 45 EMTs and paramedics
(CTA). CT angiograms help                                  heparins in patients with acute
                                                                                                     on the topic of optimal protocols for
determine, with up to 90                                    coronary syndromes presenting to
                                                                                                     treating and transporting chest pain
percent accuracy, whether                                     the emergency department.
                                                                                                     patients. King’s Daughters then presented
obstructions have built                                          ACUITY is being conducted at
                                                                                                     participating companies with four
up in the coronary                                               450 clinical trail sites in 17
                                                                                                     intravenous infusion (IV) pumps, for a
arteries.                                                        countries worldwide.
                                                                                                     total of 20, to place in their ambulances
    Coronary catheter-                                             ACUITY is evaluating the use
                                                                                                     for administering intravenous
ization remains the                                              of Angiomax, starting in the
                                                                                                     medications. The training and equipment
“gold standard” for                                              emergency department and
                                                                                                     were provided at no charge by King’s
detecting coronary                                               continued through the cardiac
                                                                                                     Daughters. The 20 pumps, valued at
artery stenosis.                                                catheterization laboratory.
                                                                                                     about $40,000, were chosen for their
However, this new CT                                           Investigators are anticipating that
                                                                                                     durability, reliability and special features.
technology has                                               the trial will support the use of
                                                                                                     The pumps are essential for delivering the
consistently shown the                                      Angiomax in acute coronary
                                                                                                     proper dose of medications during the
ability to rule out significant                           syndrome patients, whether or not
                                                                                                     transport of patients from a community
narrowing of the major          A 64-slice CT image    patients undergo angioplasty, and will
                                                                                                     hospital to a regional referral center for
coronary arteries and can       of the heart.          provide patients with a safe and effective
                                                                                                     more advanced care.
non-invasively detect soft                             treatment option to unfractionated
                                                                                                        The EMS and medical transportation
plaque or fatty matter that has not yet             heparin or enoxaparin.
                                                                                                     companies included in this initiative are
hardened but may lead to future problems                Editor’s Comment: Several cardiologists
                                                                                                     Paintsville Fire and Rescue, DHP, Net
without lifestyle changes or medical                at King’s Daughters participated in
                                                                                                     Care, Stat Ambulance and Trans Star.
treatment.                                          enrolling appropriate patients in the study.
                                                                                                     These companies serve the southeast
    Editor’s Comment: King’s Daughters              The first announcement of ACUITY results
                                                                                                     region and have a high volume of patient
currently supports the selective use of             is expected at the American College of
                                                                                                     transports from the Johnson and Floyd
Coronary CTA for patients who have:                 Cardiology Annual Scientific Session in
                                                                                                     county area to larger hospitals
• Intermediate to high-risk profiles for            March, and to be published in leading
                                                                                                     throughout the state.
   coronary artery disease, but who do not          peer-reviewed journals.

                              To request a free 2006 Physician Directory, call 1-888-377-KDMC or visit

                                                                                                Cardiology, an Italian study showed that
                                                                                                contrary to current guidelines, aggressive
                                                                                                efforts to detect coronary artery disease
                                                                                                are worthwhile in asymptomatic patients
                                                                                                with type 2 diabetes.
                                                                                                   Current coronary artery disease
                                                                                                screening guidelines from the American
 New recommendations for use of                                                                 Diabetes Association recommend stress
                                               have questions regarding nesiritide, do not
 heart failure drug Nesiritide                                                                  testing asymptomatic patients with
                                               hesitate to contact one of KDMC’s
                                                                                                diabetes if they have two or more
    Nesiritide (Natrecor®) is a                cardiologists or Jen Van Cura, Pharmacy
                                                                                                additional risk factors. In an attempt to
 recombinant form of human-type                director, at (606) 327-4485.
                                                                                                “verify the effectiveness” of these
 natriuretic peptide (hBNP) that occurs
                                                                                                guidelines, the researchers studied 1,899
 naturally in the ventricles of the heart.     Diabetes on the rise, says CDC                   asymptomatic type 2 diabetic patients 60
 Approved only for the treatment of acute
                                                   New figures from the Centers for             years old or younger. The patients were
 decompensated heart failure (ADHF) in
                                               Disease Control and Prevention (CDC)             divided into two groups: group A
 patients with dyspnea at rest, it has
                                               reveal that 20.8 million Americans are           included 1,121 patients with two or more
 previously been used in patients with
                                               now living with diabetes, a 14 percent           CAD risk factors, and group B included
 varying degrees of heart failure including
                                               increase from the 18.2 million the CDC           778 patients with no or only one risk
 those seeking treatment in outpatient
                                               reported in 2003. Another 41 million             factor. All the subjects underwent cardiac
 clinics. Nesiritide causes a rapid decrease
                                               have pre-diabetes, a condition that              stress tests, and those with abnormal
 in ventricular filling pressure, thus
                                               indicates an increased risk for developing       results underwent angiography. According
 reversing the dyspnea that heart failure
                                               type 2 diabetes. It is estimated that two        to the researchers, the prevalence of
 patients experience.
                                               out of three people with diabetes die from       abnormal stress test findings were similar
    Two meta-analyses recently conducted
                                               heart disease and stroke.                        between group A and group B, as was the
 led to the concern that nesiritide may
                                                   Make the Link! Diabetes, Heart               prevalence of significant CAD found
 cause renal dysfunction as well as increase
                                               Disease and Stroke is an initiative of the       during angiography. This suggests that a
 mortality. In response to this information
                                               American Diabetes Association and the            substantial number of asymptomatic
 Scios (manufacturer of nesiritide) hired a
                                               American College of Cardiology aimed at          diabetic patients with few risk factors
 panel of experts to review all data
                                               increasing awareness of the link between         might have occult coronary artery disease
 available on the medication.
                                               diabetes and heart disease. Make the Link!       that may be missed on the basis of current
    There were several final
                                               stresses that diabetes management is more        ADA guidelines.
 recommendations made by the panel:
                                               than control of blood glucose. People with
    1. Nesiritide should be restricted to
                                               diabetes need to know their ABC targets:         New study finds PCI cuts AMI death
 patients with Class IV heart failure –
                                               • A – A1C test, which should be done at          risk in half
 patients with dyspnea at rest.
                                                  least twice a year. The results should be
    2. Nesiritide should NOT be used to                                                            A study published recently in the New
                                                  seven percent or below.
 replace diuretics, nor should the                                                              England Journal of Medicine found that
                                               • B – Blood pressure. This should be
 medication be used for intermittent                                                            when clot-busting drugs fail to stop a
                                                  120/80 and checked frequently.
 outpatient infusions, for scheduled                                                            heart attack, angioplasty, or PCI, is the
                                               • C – Cholesterol (LDL) should be below
 repetitive use, to improve renal function                                                      most effective treatment. The study also
                                                  100, and needs to be checked at least
 or to enhance diuresis.                                                                        found that patients benefited even when
                                                  once a year.
    3. The drug manufacturer should                                                             they had to be transferred to another
 immediately begin educating physicians                                                         facility to undergo angioplasty. Study
 about instances where nesiritide should       Type 2 diabetics should have                     results also showed that PCI reduces by
 not be used and all future marketing          cardiac stress test                              half the risk of stroke, heart failure or
 activities should be consistent with this                                                      later heart attack. Giving more clot-
                                                  In an article in the Jan. 3 issue of the
 new information. The educational effort                                                        busting drugs when the first round did
                                               Journal of the American College of
 by Scios is currently underway. If you                                                         not work offered virtually no benefit.

Our Mission: To Care. To Serve. To Heal                                                       Our Vision: World-Class Care in Our Communities

                                                                                                                         Ashland, KY 41101
                                                                                                                         2201 Lexington Ave.

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