Tag Archives: cardiology

Saving the Brain: Proper Anticoagulation Therapy for Patients with Atrial Fibrillation

OAC Patient Target Mismatches

Number of eligible patients not taking oral anticoagulation (OAC). Image courtesy of Gerald Naccarelli, M.D.

As the population ages, increasing numbers of patients are presenting with atrial fibrillation, with the number projected to grow to more than 7.5 million in the U.S. by 2050.1 A strong correlation exists between atrial fibrillation and severe acute ischemic stroke.2 Citing large databases such as the PINNACLE-AF registry,3 Gerald Naccarelli M.D., Bernard Trabin Chair in Cardiology and chief, cardiology, Penn State Hershey Heart and Vascular Institute, says, “We have known since the late 1980s that warfarin was able to reduce the risk of stroke by two-thirds in high-risk patients with atrial fibrillation. However, close to half the patients who should be on anticoagulant therapy, according to guidelines, are not receiving it.” He cites multiple co-morbidities, shifting recommendations, and bleeding risk as possible causes, but emphasizes that maintaining brain function must be a key factor in treatment planning for even the  most medically complex patients. Continue reading

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Echocardiography Plays Vital Role in Planning, Execution and Follow-up of Transcatheter Aortic Valve Replacement

Current guidelines recommend a multidisciplinary approach as optimal for treating patients who qualify for transcatheter aortic valve replacement (TAVR).1 In addition to a care team of cardiac surgeons and interventional cardiologists, echocardiographers are involved in every phase of transcatheter valve replacement: from pre-implantation patient screening and selecting an appropriate valve size, to intraprocedural guidance of wire and valve position and post-implantation assessment.1

At Penn State Hershey Heart and Vascular Institute, patients first receive a transthoracic echocardiogram (TTE) to examine the aortic valve and quantify the degree of stenosis. Based on the combination of those results and other factors, high-risk patients who are not surgical candidates (due to multiple comorbidities) are referred for TAVR. “Further preparation involves several additional studies including a transesophageal echocardiogram (TEE) with three-dimensional (3D) imaging of the aortic root. This allows physicians to measure the aortic annulus and determine the appropriate size for the replacement valve,” says Michael Pfeiffer, M.D., Penn State Hershey Heart and Vascular Institute. TEE with 3D imaging also examines other aspects of the heart that may impact the TAVR procedure, such as the morphology of the left ventricular outflow track and aortic root, co-existing mitral valve disease and coronary artery position. Patients also receive multi-detector computed tomography (MDCT) evaluation as part of their pre-procedure assessment. Both imaging techniques are complementary pieces of the complete pre-implantation assessment. Continue reading

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First Implantable Wireless Hemodynamic Monitoring Device Shown to Reduce Hospitalizations

The CardioMEMS™ HF System is the first Food and Drug Administration (FDA)-approved heart failure (HF) monitor proven to significantly reduce HF hospital admissions and improve quality of life in NYHA class III patients.1 This implanted, wireless, battery-free device measures key vital signs, including pulmonary artery pressure in HF patients, and transmits this information remotely to the patient’s doctors for proactive management. The device was evaluated in 550 people in the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Patients) trial; Penn State Hershey Medical Center participated as an active enrolling center. During 15 months of follow-up, the treatment group had a 39 percent reduction in heart failure-related hospitalization compared with the control group.1

To participate, patients must have been hospitalized for HF in the 12 months prior. “That defines a relatively unstable population,” says John P. Boehmer, M.D., Penn State Hershey Heart and Vascular Institute. Once implanted, the CardioMEMS device requires patients to lie on a special mat every day. The mat includes an antenna that wirelessly connects and transmits data securely to a monitor that records 18 seconds of a pulmonary pressure tracing.

CardioMEMS Heart Failure Sensor

CardioMEMS Heart Failure Sensor. CardioMEMS and St. Jude Medical are trademarks of St. Jude Medical, Inc. or its related companies. Reprinted with permission of St. Jude Medical, ©2015. All rights reserved.

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Novel Surgical Approach Results in Significant Improvement of Symptoms for Often Misdiagnosed Thoracic Outlet Syndrome

Venous thoracic outlet case with effort thrombosis.

Venous thoracic outlet case with effort thrombosis. The patient has undergone first rib resection. Note area of residual venous stenosis which responded to venoplasty (middle image).

The upper extremity disorder thoracic outlet syndrome (TOS) is frequently misdiagnosed, as it appears in a younger patient population, typically between 20 and 50 years old, and is easily mistaken for a musculoskeletal disorder. Physical therapy (PT) is often the initial treatment for patients without blood clots; two-thirds with the neurogenic form of TOS can be treated with PT alone. However, a recent retrospective study of 538 patients during a 10-year period who underwent first rib resections (FRRs) for treatment of neurogenic, venous, and arterial TOS, showed that 93 to 96 percent experienced improved or fully resolved symptoms.1 Continue reading

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Novel Treatment Tested to Prevent Cardiac Remodeling and Congestive Heart Failure in Post-Acute Myocardial Infarction (AMI) Patients

Bellerophon Therapeutics Bioabsorbable Cardiac Matrix

Bellerophon Therapeutics Bioabsorbable Cardiac Matrix

A new device, bioabsorbable cardiac matrix (BCM), was just investigated in a randomized, double-blind, placebo-controlled trial to determine its safety and efficacy in preventing ventricular remodeling and congestive heart failure (CHF), when administered to subjects who had successful percutaneous coronary intervention (PCI) with stent placement after ST-elevation myocardial infarction (STEMI). Penn State Hershey Medical Center participated in this multi-center trial named PRESERVATION I.

BCM is an aqueous mixture of sodium alginate and calcium gluconate,1 which self-assembles in the body to form a gel-like “scaffold” for the heart in the presence of severely elevated calcium levels that occur as a result of cell death. This scaffold-like structure is designed to replace the damaged extracellular matrix that degraded during infarction, support the damaged myocardial tissue, decrease wall stress and prevent the heart from dilating.1 According to Ian Gilchrist, M.D., Penn State Hershey Heart and Vascular Institute, “It is thought that the heart dilates in the end-stage of congestive heart failure to compensate for areas of the muscle that are no longer viable; however, this causes the heart muscle to stretch and is the beginning of a downward spiral.” Continue reading

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Transcatheter Aortic Valve Replacement (TAVR) Expands Options for Inoperable Severe Aortic Stenosis Patients

Surgical aortic valve replacement is extremely low-risk for most patients. However, a significant number of patients are at high-risk for surgical valve replacement or are ineligible for surgery because of comorbidities. The less invasive TAVR procedure allows a new valve to be inserted within the native, diseased aortic valve, and can be performed utilizing multiple approaches (e.g., transfemoral, transapical, or transaortic).¹

Penn State Hershey Heart and Vascular Institute is unusual in its balanced case mix, according to chief of cardiac surgery, Walter E. Pae, Jr., M.D., “Our practice is fairly evenly divided among congenital pediatric heart defects, adult coronary disorders, and adult cardiac valve abnormalities. We perform up to 100 aortic valve replacements per year.” Interventional cardiologist Mark Kozak, M.D., concurs, noting that coronary disease is the focus of many institutions, due to its far greater frequency. Continue reading

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Grant Underscores Importance of Treating Peripheral Arterial Disease as a Chronic Condition

Lawrence Sinoway, M.D., director, Penn State Hershey Heart and Vascular Institute, has been the lead investigator on “Acute and Chronic Afferent Engagement: Sympathetic and End Organ Responses,” a National Institutes of Health-funded project that started in 2010 and examines four separate aspects of peripheral arterial disease (PAD).

Exercise Blood Pressure in Peripheral Arterial DiseaseLess than 50 percent of PAD patients report the classic symptom of claudication, making the condition difficult to diagnose and treat. However, PAD is an alarming prognostic sign and correlates with significantly increased risk of cardiovascular mortality.¹ Sinoway describes another common therapeutic conundrum: “On the one hand, we as physicians see a disease caused by an arterial blockage and believe that by removing the blockage, patients will improve. While this may be true acutely, it is crucial to note that PAD, and indeed all forms of atherosclerosis, are chronic conditions that will return if patients don’t make lifestyle changes to reduce their future risk.”

In his primary study, Sinoway demonstrates that when PAD patients perform exercise with the affected leg, their arterial blood pressure becomes elevated as a result of the exercise pressor reflex, a cardiovascular change caused by muscular contractions. (Figure)

This blood pressure increase, which is directly related to the severity of the arterial blockage, can be controlled with high doses of ascorbic acid administered intravenously. Continue reading

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