Reprinted from MD NEWS, Central New Jersey Edition, Vol.5, No.2, February 2008
The 21st century patient has an unprecedented opportunity to participate in a healthcare system that has enjoyed a dramatic evolution, not only in its technology but in the diversity of specialized expertise offered by its physicians. Most of us, especially as we age, currently receive care from a variety of healthcare providers, specializing in a particular branch of medicine that addresses each of our health issues. Even better, sub-specialization within these areas allows for precision of care and treatment that significantly surpasses what was available just a few short decades ago. Almost without exception, every field of medicine has benefited from these developments.
Continuing with this trend, in its ongoing effort to provide the most specialized and sophisticated cardiac care services, the Saint Barnabas Health Care System has put into place two new and innovative programs designed to build upon the already renowned and extremely high-volume cardiac programs offered at the Saint Barnabas Heart Centers. Located at both Newark Beth Israel Medical Center and Saint Barnabas Medical Center in Livingston, the Atrial Fibrillation Center and the Valve Center have been created to provide a multi-disciplinary, comprehensive and collaborative approach to the treatment of atrial fibrillation (AF) and valvular disease. This is quite timely since both of these conditions have seen significant growth with respect to the number of cases presenting. As we continue to live longer, more of us are affected with these problems because they are age-related to a greater extent. There has also been an increase in the availability of new treatment options in these areas, as well as more accurate diagnostic capabilities with sophisticated advances in cardiac imaging, such as 3D echocardiography, transesophageal echocardiography, coronary angiography, cardiac MRI and 64-slide coronary CT scanning.
Gary J. Rogal, M.D., Chief of Cardiology for the Saint Barnabas Health Care System, explains the rationale behind formulating multi-disciplinary centers, “Tremendous benefits result from a collaborative team effort in devising a treatment plan for patients on a case-by-case basis. Skilled surgeons and cardiologists who employ advanced imaging techniques to fully and completely understand each patient’s complete cardiac profile, sit down together on a regular basis to discuss the most appropriate treatment options,” explains Dr. Rogal.
Patients who are referred either to the Atrial Fibrillation Center or the Valve Center are evaluated by a team of sub-specialists, which can include cardiologists, cardiothoracic surgeons, electrophysiologists and interventional cardiologists, who consult with the referring physician to review imaging and other pertinent information. Using the referring physician’s workup, the expertise of each member of the team contributes to the formulation of a thorough assessment of every patient’s cardiac situation and the most appropriate treatment plan. For those patients ho require intervention, great emphasis is placed on utilizing procedures that are minimally invasive, whenever possible.
Additionally, through customized databases, information about patients who are treated at the Valve and Atrial Fibrillation Centers will be painstakingly evaluated and updated as they are continually monitored and tracked over time to ascertain which treatment options prove to be the most successful. Although the advantages of treating patients in this manner and following their outcomes over time seem obvious, as of now, the Saint Barnabas Heart Centers in Newark and Livingston are the only facilities in the New Jersey and perhaps, the region, to offer referring physicians the opportunity to obtain this multi-disciplinary and collaborative approach and the benefits of reliable clinical data for their patients.
The high volume of patients referred to the Saint Barnabas Heart Centers for the treatment of cardiac conditions such as AF and valve disease, permits its highly skilled team to perform procedures with extraordinary expertise – ultimately improving the rate of successful outcomes. With the addition of the Atrial Fibrillation Center and the Valve Center, referring physicians have the enhanced benefit of consulting on their patients with the multi-disciplinary team of experts which review imaging studies and case histories of each patient, as well as relevant literature, to determine the appropriate intervention. This is especially important because during this extensive evaluation, there are times when patients who are referred with one diagnosis are found to have additional cardiac problems. Not surprisingly, for example, patients who are being evaluated primarily for a valvular disorder may be found to have an arrhythmia. Paul Burns, M.D., who is the Director of Cardiac Surgery at Saint Barnabas Medical Center, elaborates. “Patients often present with multiple problems. They need an entire cardiac evaluation to define the exact pathology. As the new technologies improve, this multi-disciplinary team of sub-specialized cardiologists and surgeons sit down together to plan a treatment recommendation for a patient, that we think is going to have the best long-term result,” explains Dr. Burns.
Ablation, a modality being utilized both in the catheterization lab and the operating room for converting patients in AF back to a normal rhythm, continues to evolve. Today, approximately 1 out of every 100 individuals over the age of 65 is diagnosed with atrial fibrillation. In AF, the electrical impulses that are normally generated by the sinoatrial node are replaced by disorganized activity in the atria, leading to irregular conduction of impulses to the ventricles that generate the heartbeat. This results in an irregular heartbeat which may be a continuous (permanent AF) or alternating between periods of a normal heart rhythm (paroxysmal AF). People in AF have twice the mortality rate of those who are in normal rhythm. Primarily, this is due to the fact that atrial fibrillation causes blood clots to form in the chamber of the heart that is fibrillating. Their potential for embolic stroke is increased. It has also been found that there are long-term detrimental effects to heart function from prolonged irregular heart rhythm.
Research has shown that most atrial fibrillation signals come from the pulmonary veins. Catheter-based ablation is a percutaneous intervention, in which the pulmonary veins are isolated, usually by burning with radio frequency current, to create a circumferential set of point lesions around the vein. Known as circumferential pulmonary vein isolation, the procedure blocks any signals from firing from within the pulmonary veins, thereby disconnecting the pathway of the abnormal rhythm. Electrophysiologists at the Saint Barnabas Heart Centers employ a highly sophisticated mapping system, a 3-D model of the heart generated from 64-slide CT scanning and intracardiac ultrasound to ensure the most precise delivery of the ablation. Unfortunately, electrical gaps can occur over time, allowing signals to escape and causing the recurrence of an abnormal rhythm. This can create the need for an additional procedure.
Marc Roelke, M.D., Director of Electrophysiology at Newark Beth Israel Medical Center and Saint Barnabas Medical Center stresses the tremendous value in having cardiologists, surgeons and electrophysiologists on the center’s AF Management Board to discussing the options for each patient, particularly for patient show require additional interventions. Dr. Roelke, says, “Due to the limitations of even the most advanced techniques, a percentage of patients will need two procedures. At the AF Management Board meeting we talk about all the options and determine the best possible treatment for each patient.”
Dr. Roelke explains further, that when contemplating whether to do another catheter ablation or perhaps a more aggressive surgical intervention, the experts at the meeting have a chance to review the patient’s clinical presentation, prior ablation procedures, and 3-D image reconstruction of the left atrium and the pulmonary veins. If it is found, for example, that one of the veins was not well isolated or there was not enough signal to burn in one area, a surgical approach might be suggested. Also, if the left atrial appendage is found to be narrow and therefore more prone to clotting, it may be decided that it would be more amenable to a surgical procedure which would also allow amputation of the appendage. If, however, the team recommends another catheter ablation, segmental pulmonary vein isolation would most likely be performed. During this procedure, the electrophysiologist only burns where there are signals present and not continuously around each vein, in order to seal gaps which remain or have developed since their performance of the first procedure.
Surgical ablation can now be done with minimally invasive, video-assisted thoracic surgery (VATS). This is accomplished using a few small incisions. A thoracoscope (small video camera) is inserted through one of these incisions and transmits images of the operative area onto a computer monitor. Surgeons use microwave energy sources to create lesions and ultimately scar tissue that block the abnormal electrical impulses or signals from being conducted through the heart. Dr. Burns related that these procedures have about a 75 percent success rate in promoting the normal conduction of impulses the result in restoration of normal rhythm.
Whichever procedure(s) a patient who is treated at the Atrial Fibrillation Center undergoes, he or her clinical status will be followed indefinitely. The extended tracking is done, of course, to ascertain whether or not a normal rhythm is being sustained over time and for the physicians to gather information they can use to determine which approaches have the best long-term outcome. Dr. Roelke explains, “If we look out a year and determine that one procedure has a 70 percent success rate and one has a 90 percent, that will greatly impact our future treatment decisions,” he says.
Marc Cohen, M.D., Chief of the Division of Cardiology at Newark Beth Israel Medical Center, reports that more and more patients are coming to Saint Barnabas Heart Centers for second and third opinions for complex cardiac disease. He talks about the timely creation of the Valve Center. “It is now becoming apparent that many older patients have age-related, degenerative aortic and mitral valve disease,” relates Dr. Cohen. “We are in a unique position of offering quality cardiology, quality interventional cardiology and quality cardiac surgery.” Certainly over the last few years, with the more sophisticated imaging and enhanced surgical techniques, valve surgery has become an increasingly important option in the treatment of valve disease. Along with his colleagues, Dr. Cohen stresses the importance of the collaborative team approach offered at the Valve Center and emphasizes that the Saint Barnabas Heart Centers are among only a few prestigious programs that offer this level of cardiac care.
Aortic stenosis refers to obstruction of flow at the level of the aortic valve. In the aging population, calcific aortic stenosis accounts for the vast majority of aortic valve disease. Late life, degenerative aortic stenosis progresses slowly and patients often present between the ages of 70 and 90 years. Patients who are referred to the Valve Center are evaluated by the multi-disciplinary team. Traditionally, many facilities have shied away from operating on patients in their eighties or nineties but the experienced surgeons on staff at the Saint Barnabas Heart Centers have developed protocols for performing aortic valve surgery with minimized risks to elderly patients.
Diseases of the mitral valve, which are more common as we age, are on the rise, as well. Mitral regurgitation is leaking of blood from the left ventricle into the left atrium during systole. Mitral regurgitation imposes an extra load of the heart because the left ventricle pumps more blood per beat in order to maintain its normal output. Mitral valve prolapse is the systolic billowing of one or both mitral leaflets into the left atrium during systole. It is an important cause of mitral regurgitation and is the most common valvular disorder in the United States.
“The clinical value of performing a mitral valve repair instead of a mitral valve replacement cannot be overstated,” says Craig Saunders, M.D., Chairman of Cardiothoracic Surgery for the Saint Barnabas Health Care System, “Mitral valve repair involves lower risk to the patient, requires no anticoagulation and studies confirm that it improves outcomes and survival rates,” he explains. Dr. Rogal also emphasizes the benefits of mitral valve repair. “With mitral valve repair, we can address problems earlier and save patients the morbidity and complications of a prosthetic replacement,” he says.
Cardiothoracic surgeons at the Valve Center have been at the forefront of the development of minimally invasive surgical approaches to valve repairs and replacements. It has been well established that minimally invasive surgery allows for faster recovery times, less pain and trauma, decreased blood loss, shorter hospital stays and involves a much lower risk of complications. Minimally invasive valve surgery usually involves 2- or 3-inch incisions on the side of the chest. This approach may be further enhanced by the use of a surgical robot. The surgeons at the Saint Barnabas Heart Center at Newark Beth Israel Medical Center were the first in New Jersey to utilize the robot for minimally invasive valve surgery.
Dr. Saunders reports that the Saint Barnabas Heart Centers conduct more valve procedures with better outcomes than most facilities in the nation. Its survival rates for high risk procedures for heart valve repair is more than 99 percent and for valve replacement is only slightly less than 99 percent. He attributes the outstanding success rate to a new paradigm in mitral and aortic valve surgery in which the team has streamlined the procedures to create a reproducible and effective operation with an extraordinarily high rate of success and full recovery. Currently, the team performs two-to-three mitral or aortic valve repairs or replacements a week and more than 40 staff members are involved with the care of a patient once a referral is made.
On the horizon for patients who may not be candidates for open surgery, percutaneous valve implantation is being investigated by cardiologists around the world. Physicians at the Valve Center are already planning to be at the forefront of these revolutionary advancements with potential for eliminating the need for cardiopulmonary bypass, speeding the recovery process and offering a lower risk of complications. Percutaneous valve implantation may be available to patients within the next decade.
When planning for the treatment of patients with valve disease, the benefits of having a multi-disciplinary team of cardiac sub-specialists collaborate to precisely identify the pathology cannot be overemphasized. Knowing what to expect before a surgical procedure is undertaken dramatically improves success rates and can actually shorten operative times, reducing the incidence of complications, especially for patients who are placed on cardiopulmonary bypass during surgery.
Additionally, the accumulation of data and its evaluation by the Valve Center team over time allows for an unbiased interpretation that can be used to educate physicians and continuously improve the level of care provided to patients with valvular diseases. Dr. Rogal describes the basic principle upon which the Valve Center was created. When discussing how to maximize what can be offered to patients, he says with great certainty, “You have to be able to draw upon the wisdom of the collaborative team.”
Saint Barnabas Health Care System (SBHCS) provides a comprehensive range of integrated cardiac services in its six Heart Centers throughout the state. In addition to those at Newark Beth Israel and Saint Barnabas Medical Centers, where the Atrial Fibrillation Center and the Valve Center are now in operation, Saint Barnabas Heart Centers are located at each of the SBHCS hospitals. Monmouth Medical Center in Long Branch, Community Medical Center in Toms River, Kimball Medical Center in Lakewood and Clara Maass Medical Center in Belleville all provide the highest level of cardiac care. As a result, the Saint Barnabas Heart Centers have developed a strong relationship with referring physicians across all of New Jersey. Physicians who refer patients for treatment to the Valve Center or to the Atrial Fibrillation Center can be assured that they will be included in the multi-disciplinary, decision-making process and that their patients will benefit from the Heart Centers’ experience and skill that is among the finest in our region. With the creation of the Atrial Fibrillation Center and Valve Center, the Saint Barnabas Health Care System has taken its Heart Centers to a new and exciting level.
:
call 866-549-AFIB.
:
call 888-NJVALV1.
Date: February 2008
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