Lower Mortality and Readmission Rates Reflect Medical, Mechanical Support and Transplant Innovations

Photo of care provider assisting a women seated in a wheelchair.One of the most compelling untold stories in medicine has been the dramatic reduction in mortality among heart failure patients over the past 30 years, and Penn State Health Milton S. Hershey Medical Center has been at the forefront of this effort.

Hershey Medical Center is certified by the United Network of Organ Sharing (UNOS) and has been offering heart transplant surgery since 1984. John Boehmer, MD, heart failure program director, says, “In the 1980s, heart failure was associated with an extraordinarily high mortality rate, and between the use of medical therapy, mechanical devices such as implantable defibrillators, pacemakers and left or right ventricular assist devices (LVADs, RVADs), as well as transplantation, that mortality has been reduced by nearly 80 percent. This improvement has come in incremental steps that have often gone unnoticed.” Continue reading

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Groundbreaking Subcutaneous Implantable Defibrillator Expands Options, Improves Quality of Care for Pediatric Patients

Cardiac electrophysiologists have been placing implantable cardioverter defibrillators (ICDs) for many years, with the standard system using a transvenous device. Although small, the device required physicians to implant directly into the heart and used leads with limited durability. Several years ago, subcutaneous implantable cardioverter defibrillators (S-ICDs) were introduced, but the first generation S-ICD was largely restricted to adult patients, due to its size and the lack of remote monitoring capability. A newer, smaller model of the device was released in summer 2015, allowing pediatric electrophysiologists at Penn State Children’s Hospital to implant this device in children.

Image of male chest with EMBLEM (TM) S-ICD device implanted.

EMBLEM TM S-ICD device.

This second-generation device is smaller and thinner, projected to last 40 percent longer than the previous version and is enabled for remote patient monitoring. It eliminates many of the potential complications associated with transvenous leads and has demonstrated excellent real-world results, including low complication rates and high conversion efficacy.1,2 “The smaller size and remote monitoring capability of the second-generation S-ICD have made it more compatible for our patient population, and we do not have to implant anything directly into the heart,” says Jason R. Imundo, MD, pediatric cardiologist and electrophysiologist, Penn State Children’s Heart Group. Instead, the device is implanted just under the skin near the ribs. Continue reading

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Innovative Solution to Treat Portal Vein Hypertension

The Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure has long been used to treat portal vein hypertension in patients with cirrhosis and other conditions, prior to liver transplant surgery, however, it could not be used in those with a complete portal vein occlusion. 1 The transsplenic approach allows interventional radiologists (IRs) to bypass the liver.1 Penn State Health Milton S. Hershey Medical Center is one of a few teaching hospitals in Pennsylvania to offer this innovative approach.

In the transsplenic approach, clinicians use a splenic sheath and lasso snare, transverse the spleen and continue the procedure using X-ray, achieving end-to-end anastomosis, which allows for balloon angioplasty in the blocked vein and facilitates completion of the TIPS. Portal veins are patent and anatomically normal nearly 80 percent of the time when imaged months later. 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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