Tag Archives: Penn State Hershey Heart and Vascular Institute

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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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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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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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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Technological Advances Lead to Improved Survival with Permanent Left Ventricular Assist Devices

HEART AND VASCULAR INSTITUTE CARDIOLOGISTS USE LATEST TOOLS TO EXPAND PATIENT OPTIONS

LVAD Case StudySince 1976, when surgeons at Penn State Hershey Medical Center implanted the first Pierce-Donachy left ventricular assist device (LVAD) in the country, the technology has helped thousands of patients with severe heart failure survive until a donor heart is available for transplant. Today, however, Penn State Hershey Heart and Vascular Institute uses LVAD therapy not only as a bridge-to-transplant (BTT), but also as long-term destination therapy (DT). In fact, half of the LVAD placements now performed at Penn State Hershey are for DT usage.

Although heart transplantation remains the gold standard for advanced heart failure, LVAD can provide a viable option for many. Patients must have three main qualifications to be considered for LVAD therapy: 1) must be in advanced heart failure, but contraindicated for a heart transplant, or too sick to wait for a transplant, 2) must have reached the limits of medical therapy, and 3) must have a life expectancy of more than two years. 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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Novel Techniques for Removal of Embedded Inferior Vena Cava (IVC) Filters Reduce Risk of Long-Term Complications

Technique for Removal of Embedded Inferior Vena Cava (IVC)

With the loop snare forcefully closed around the filter legs, the metal guide is pulled back with the filter into the sheath. The captured filter legs fold in half and the filter apex begins to invert (arrow).

Retrievable IVC filters are used to treat patients temporarily for pulmonary embolism (PE) prophylaxis, including those facing prolonged bedrest following lower-limb surgery. The devices may be removed to prevent the risk of long-term complications once there is no immediate risk of thromboembolism, with medical management superseding cardiovascular interventions.¹ Complications can include filter fracture, embolization, caval penetration, and, ironically, an increased incidence of recurrent deep vein thrombosis after filter placement.¹ Regular patient follow-up is critical for optimal outcomes, along with periodic chart reviews and multiple attempts to contact patients.¹ Inferior vena cava filters, particularly those in place for many months or years, can embed themselves in surrounding tissue, but novel techniques can often succeed in even the most complicated IVC filter removal cases. Continue reading

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