Non-Sternotomy Valve Surgery Eases Cardiac Recovery for Patients

MORE PATIENTS NOW CANDIDATES FOR VALVE REPAIR AND REPLACEMENT

Open sternotomy has long been considered the standard of care in cardiac valve surgery, affording the surgeon an unobstructed field in which to operate. Non-sternotomy procedures, however, are gaining in popularity as the advantages become clearer. However, due to the steep learning curve involved in this less invasive approach, a paradigm shift still needs to occur before it becomes as commonplace as open sternotomy is currently. Given the proliferation of hybrid surgical approaches and the increasing usage of non-sternotomy cardiac valve surgeries, Walter Pae, M.D., chief, cardiac surgery, Penn State Hershey Heart and Vascular Institute, hopes that paradigm shift is beginning. “Ultimately, our goal is to eradicate the sternotomy altogether.”

Single-institution experiences, compared to national results in the absence of randomized trials, have demonstrated that both mortality rates and the rate of dysrhythmias, such as supraventricular arrhythmias, are the same with non-sternotomy cardiac procedures and open sternotomy procedures. Length of hospital stay is reduced more than 20 percent, and one study showed 100 percent five-year survival using the non-sternotomy surgery versus 85 percent using the open sternotomy technique.¹ Continue reading

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Cross-disciplinary Collaboration, Around-the-Clock Nurse Practitioners Provide Consistent Care in ICU

As the population ages, the number of ICU beds and demand for intensivists is increasing, but these specially-trained physicians are in dramatically short supply.1 Over the last decade, the 30-bed Heart and Vascular Critical Care Unit (CCU) at Penn State Health Milton S. Hershey Medical Center has addressed this challenge with intensivist-led care teams that increasingly rely on nurse practitioners (NPs), while continuing to meet the complex needs of critically ill patients. Research suggests the model may confer a slight boost in ICU survival rates.2

The Heart and Vascular Institute plans to add one intensivist and five NPs to its current team of three intensivists and 11 NPs, according to Christoph Brehm, MD, and Angela Manoskey, CRNP. Continue reading

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Chemoembolization and Radioembolization for Difficult Liver Tumors; Choice May Depend on Blood Flow

Two-thirds of primary liver cancer patients and 90 percent of secondary liver cancer patients have inoperable tumors that are unresponsive to systemic chemotherapy and may benefit from transarterial chemoembolization or radioembolization with yttrium-90 (Y-90), both minimally-invasive, palliative procedures. Although research shows transarterial chemoembolization and Y-90 are usually equivalent treatments for most intermediate-stage hepatocellular carcinomas (HCCs)1, Heart and Vascular Institute considers tumor blood supply when deciding which therapy would be most beneficial for a specific patient.

Image on the left: Pre-chemoembolization axial, contrast-enhanced CT scan at the level of the liver. Image on the right: Post-chemoembolization axial, contrast-enhanced CT scan at the same level as the previous image.

Image on the left: Pre-chemoembolization axial, contrast-enhanced CT scan at the level of the liver. White arrow shows a hypervascular lesion (33.8 mm x 31.6 mm) in segment 7 of the liver consistent with hepatocellular carcinoma.
Image on the right: Post-chemoembolization axial, contrast-enhanced CT scan at the same level as the previous image. White arrows show the treated lesion (22.4 mm x 24.0 mm) in segment 7. The lesion is no longer enhancing and has decreased in size.

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Case Study: Chemoembolization for Transplant-Eligible Patient with HCC

A 41-year-old African male with a history of hepatitis B whose disease has progressed to Childs A cirrhosis, making him at increased risk for HCC. In April 2014, ultrasound describes two masses in the liver as worrisome for hepatocellular carcinoma. Additional imaging is recommended for further evaluation of the masses. The patient’s Alpha-fetoprotein (AFP) was 13.9 at this time. CT imaging demonstrated a hypervascular mass without washout in segment 7 of the liver. The other mass seen on ultrasound was not visualized on CT. The worrisome lesion was designated LIRADs 4B because of hypervascularity, lack of washout and size greater than 2.0 cm. The percutaneous biopsy performed for further evaluation was negative for malignancy. Subsequent imaging demonstrates continued lesion growth. That, combined with the elevated AFP, suggests that the lesion is HCC despite the biopsy results. The patient was evaluated for liver transplant and subsequently placed on the transplant list. In order to maintain the patient’s eligibility for transplantation, the decision was made to have the patient undergo chemoembolization. The patient underwent a single drug eluting bead chemoembolization approximately 20 months after the initial diagnosis of the mass lesion by US. The patient’s AFP decreased from a peak of 69.9 to 5.1 (normal is less than 7.5) post treatment. He will undergo routine follow-up until transplantation. If recurrent or new lesions are found, repeat chemoembolization can be considered.

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WATCHMAN™ Device: Innovative Therapy for Stroke Prevention in Growing Atrial Fibrillation (AF) Population

By the year 2050, it is estimated that nearly 16 million people could suffer from atrial fibrillation (AF), but not all will tolerate long-term anticoagulant therapy.1 The WATCHMAN™ Left Atrial Appendage Closure (LAAC) device, the latest minimally invasive option at the Heart and Vascular Institute, can help bridge this clinical gap. In March, Penn State Health Milton S. Hershey Medical Center became the first in the region to implant the WATCHMAN device in non-valvular AF patients at increased risk for stroke and systemic embolism seeking an alternative to long-term warfarin therapy.

WATCHMAN<sup>TM</sup> device

WATCHMAN™ is delivered via a transfemoral approach and is designed to close the left atrial appendage (LAA) to prevent migration of blood clots, thus reducing the risk of stroke and systemic embolism. Images provided courtesy of Boston Scientific.© 2016 Boston Scientific Corporation or its affiliates. All rights reserved.

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Total Artificial Heart: More Options for Those in Need of Smaller Heart, Destination Therapy

Penn State Health Milton S. Hershey Medical Center has joined two multicenter trials that evaluate a total artificial heart (TAH) and may save the lives of even more patients with irreversible biventricular heart failure (BVHF). The focus of the observational studies is the SynCardia® TAH, which was first approved by the FDA as a bridge to transplant in a 70cc size, based on a study of 81 patients, 79 percent of whom survived to receive a transplant.1

Image of SynCardia® TAHThe first study examines the safety of the 70cc device for use as destination therapy in patients with life-threatening BVHF who are ineligible for cardiac transplant. To date, 12 centers, including Milton S. Hershey Medical Center, are set to enroll patients and follow them for six months to confirm the device’s benefits. Researchers define success as survival to six months without permanent deficits from stroke. Patients may also participate in a secondary arm of the trial to determine whether a broader patient population would also benefit from the device.2 Continue reading

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Team-based Approach to Targeted Temperature Management (TTM) Optimizes Recovery Post-Cardiac Arrest

Penn State Hershey Medical Center Life LionFor patients in cardiac arrest, every second counts, and targeted temperature management (TTM), or therapeutic hypothermia (TH), can prevent further damage. At Penn State Hershey, TTM protocol begins in the field, as the mobile intensive care unit, Life Lion, is empowered to initiate this neuroprotective therapy to unresponsive patients with vital signs. Upon arrival at the Medical Center, cooling to a targeted temperature of 32 to 36 degrees Celsius is continued via leg and torso wraps that are connected to a core cooling/warming pump device that travels with the patient to the cardiac catheterization lab and to the cardiac critical care unit. This temperature range is new, and recently has changed based on the most current research. TTM has been shown to improve neurological outcomes in patients following sudden cardiac arrest with return of spontaneous circulation (SCA-ROSC).1 A cerebral performance category (CPC) scale is used to measure cognitive recovery. Continue reading

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New Subspecialty of Adult Congenital Heart Disease Now Available to Address Unique Cardiac Needs

Due to advances in treatment and technology, more patients than ever before who are born with congenital heart disease (CHD) are living into adulthood. For the first time, there are more adult than pediatric CHD patients, with the number of adult cases in the U.S. estimated at 1.3 million.1 The management of these patients is so complex that a new subspecialty of adult congenital heart disease (ACHD) is now available for certification by the American Board of Medical Specialties. Penn State Hershey Heart and Vascular Institute has long recognized the complex needs of this growing population, and started a program for adult congenital heart disease (PACHD) in 1991, which is directed by William Davidson, Jr., M.D.

Color Doppler image of severe pulmonic insufficiency

Color Doppler image of severe pulmonic insufficiency, commonly found in Tetralogy of
Fallot patients.

Currently, the PACHD has three ACHD providers, all of whom are board certified, having sat for the first-ever ACHD subspecialty boards in October 2015. These specialized clinicians provide 24/7 coverage to all ACHD inpatients, and provide personalized, consistent care to complex patients, most of whom have six to 10 active medical conditions. Problems associated with congenital heart disease include valve disease, heart failure, arrhythmias, aortic and other vascular diseases; pulmonary, renal and liver disease; and a history of multiple surgeries. For example, one of the fastest growing ACHD patient populations have tetralogy of Fallot (ToF).2 This condition requires complex intracardiac “corrective” surgery. A common late consequence is pulmonary valve insufficiency (PI), which can lead to right ventricular dysfunction and sudden death.2 PI is a common lesion in this population that is often missed with conventional testing, according to Dr. Davidson. All ACHD patients require lifelong follow-up and regular visits to an ACHD specialist. Continue reading

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