VOLUME 1, ISSUE 4 Update C A R D I O V A S C U L A R Winter 2006 The best in Complex 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 KDMC introduces t is well documented that higher volumes mean 64-slice CT imaging 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, 1-866-HEART-KY Cardiac surgery innovations (432-7859). INSIDE 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 | kdmc.com 2201 Lexington Ave., Ashland, KY 41101 2 CARDIOVASCULAR UPDATE KING’S DAUGHTERS HEART AND VASCULAR CENTER LEADERSHIP TEAM 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. firstname.lastname@example.org 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 arranged. 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 kdmc.com 4 CARDIOVASCULAR UPDATE KING’S DAUGHTERS HEART AND VASCULAR CENTER 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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