Innovative Procedures

Coronary Artery Disease Treatment – A Patient Story

Michael Halkos, MDMichael Armstrong joined the gym to get some aerobic exercise and lose some weight. One day, he was walking on a treadmill when he noticed pain in his chest as well as pain that went up into his throat. The pain then began radiating down his left arm.

Michael has worked in the health care industry for many years, so he quickly realized what he was experiencing could be signs of a heart attack, and he consulted his primary care physician. Michael told his physician about the symptoms and the physician quickly referred him to me at Emory University Hospital Midtown for an innovative procedure called hybrid coronary revascularization.

As I mentioned in my previous blog post about hybrid coronary revascularization, this procedure is typically performed on a patient who has blockage in the artery in the front of the heart and one other blood vessel with disease in it. This unique approach is a best of both world’s strategy where we combine durability of surgery with the minimally invasive nature of a procedure called stenting. Optimal therapy with this minimally invasive approach translates into shorter recovery time, potentially fewer complications and a quicker return to work. Emory is one of only a few centers in the nation offering this procedure.

Michael Armstrong sums up his experience:

“I didn’t know what to expect, this was my first hospitalization in my life but I was comfortable getting my heart care at Emory University Hospital Midtown. Dr. Halkos had done more than 100 robotic surgeries so I was very impressed with that. Dr. Halkos knows the road you are about to take together is treacherous and comes across as very knowledgeable while still friendly and empathetic.  Now shortly after the surgery, I am back to full exercise, I walk around the neighborhood with my wife, and even last weekend I walked to the top of Stone Mountain with a friend. That made me feel good. I know Emory talks about quality patient and family centered care, but actually experiencing it was pretty wonderful.”

Watch Michael’s story in this video.

Do you have questions or feedback? If so, please leave them in the comments section below.

About Michael Halkos, MD
Dr. Halkos is a cardiothoracic surgeon at the Emory Heart & Vascular Center. He specializes in minimally invasive adult cardiac surgery. He is leading the innovative Emory work with the hybrid coronary revascularization procedure being performed at Emory University Hospital Midtown. He finished his Medical School, Residency and Fellowship at Emory University School of Medicine and is a member of the American Medical Association.

Innovative New Intravascular Imaging System Now Available at Emory

image from St. Jude Medical

We’re pleased to announce that Emory Healthcare is the first in Georgia to receive the new, FDA-approved C7-XR OCT Intravascular Imaging System. Optical Coherence Tomography (OCT) is a high-resolution cross-sectional modality that is used to visualize and quantify clinically important coronary artery microstructures. In essence, it images plaques that cause heart attack and stroke.

This technology allow us to see more clearly what is occurring in the coronary artery wall in patients who have developed—or who are at risk for developing heart attacks. Additionally, we’ll be collaborating with St. Jude Medical, the maker of the OCT system, as well as with Medtronic Vascular, and conducting a clinical trial that will examine the ability of OCT to guide the duration of anti-platelet therapy following drug eluting stent placement.

Ultimately, the research will establish OCT as a surrogate measure for determining optimal anti-platelet therapy following stent implantation.

All interventional cardiologists at Emory will be able to perform this procedure. If you’re interested in hearing more about the OCT Intravascular Imaging System, please feel free to leave me a response in the comments section, or contact me at 404.686.2508.

About Aloke Finn, MD:

Dr. Finn specializes in Internal Medicine and Cardiology, and has been practicing at Emory since 2007. His areas of clinical interest include cardiac catheterization, interventional cardiology, and cardiovascular disease. Dr. Finn holds an organizational leadership membership at the American Heart Association.

Minimally Invasive Treatment for Peripheral Artery Disease: Dave Kirschner’s Story

In 2008, Dave Kirschner chose to retire from a successful 50-year career in the radio business. For years, CNN Radio listeners listened to him as he brought them up to speed on current events. Now, Kirschner spends his time working around the house, staying in touch with industry friends, and working out on the treadmill several times a week. However, when he began to notice a recurring pain shooting down the back of his right leg during exercise, he was concerned.

At first, Kirschner thought that he might have a pulled muscle, so he attempted to ease the pain with stretching, massage, and over-the-counter remedies. When nothing worked, he realized that he may have a deeper problem, and he called his internal medicine doctor.

His doctor conducted a test called an Ankle Brachial Pressure Index, or ABI—which revealed that Kirschner was suffering from peripheral artery disease (PAD).  As we’ve described in previous blog posts, PAD develops when arteries become clogged with plaque and fatty deposits that limit the flow of blood to extremities, especially the legs.

The major symptom that Kirschner was experiencing is called intermittent claudication—a pain that occurs during periods of exercise, such as walking or climbing the stairs. When we exercise our muscles require more blood flow—if there is blockage in the blood vessels, the muscles don’t receive enough blood, which causes intermittent claudication.

The first Atlanta cardiology group that Kirschner visited recommended that he have a stent inserted into his leg to unblock the artery. However, this option wasn’t appealing to him—he’d had cardiac bypass surgery in the past and wanted to avoid invasive surgery if at all possible.

Kirschner proceeded to search for other alternatives for PAD treatment—he researched the Internet and asked several of his trusted friends for advice. He even considered traveling out-of-state to find a facility that would offer what he was looking for. Finally, he spoke with a podiatrist friend, who recommended that he contact me at Emory.

After examining Mr. Kirschner, we reviewed his options and decided that a minimally invasive outpatient procedure would be the best way to treat his condition. We used a recently developed device to shave away the plaque in his arteries—the device deploys a tiny rotating blade on the tip of a catheter to remove plaque from the arterial wall. This procedure has been extremely successful in helping patients to prevent blood flow problems that could potentially result in something as serious as amputation.

The device doesn’t stretch the blood vessel wall, unlike the use of stents. It is used to treat calcified and non-calcified lesions of any length. Further, it is minimally invasive and doesn’t require that we open up the leg.

Kirschner’s procedure took less than two hours. When he asked me how long I thought it would be before he could go back to working out, he was shocked when I replied, “How about tomorrow?” He left our office the same day that he went in, with only a tiny incision at the top of his leg, covered by a band-aid.

Today, Kirschner can hit the gym and exercise with no pain. His workout regimen consists of hour-long walks, which he enjoys without any problems. We’re thrilled that we were able to treat his condition with our innovative technology, and we look forward to achieving the same results with future patients suffering from PAD.

About Gregory Robertson, MD:

Dr. Robertson specializes in Cardiology and Internal Medicine, and is an Assistant Professor of Medicine at Emory. Some of his areas of clinical interest include atherosclerosis, cardiac catheterization, cardiovascular disease, valve disease, and peripheral artery disease. Dr. Robertson holds an organizational leadership membership at The American College of Cardiology, and has contributed to multiple publications in his field.

Emory Heart Valve Study Featured on Fox 5 News

As we’ve pointed out in past blog posts, aortic stenosis refers to the narrowing of the aortic valve. This is most commonly caused by the simple wear and tear of aging. As people age, calcium builds up in the valve, causing it to narrow and restrict blood flow from the heart to the body. Recently, Fox 5 News featured Emory on a news piece describing our work with a new, minimally invasive procedure that is showing great promise in the treatment of this condition.

For more details, you can view the news clip here:

About Vasilis Babaliaros, MD:

Dr. Babaliaros specializes in Internal Medicine and Cardiology, and his areas of clinical interest are cardiology-interventional, valve disease, and valve repair/replacement. He received his Biomedical Engineering degree at Duke University (1992), his MD degree at Emory University (1996), and completed his training in Internal Medicine and Cardiology at Emory (2003). In 2004, he completed fellowship training in Interventional Cardiology at Emory University and then continued sub-specialty training in Valvular Interventional Cardiology under Alain Cribier MD at the University of Rouen, France (2005). He joined the faculty working with Peter Block MD as the Associate Director of the Emory Center for Valvular Intervention and Structural Heart Disease Treatment in 2006.

Managing Patients with Fontan Circulation

Dr. Francois Fontan first performed the Fontan procedure in 1971 on children with tricuspid atresia, or lack of a tricuspid valve. Fontan redirects venous blood from the right atrium to the pulmonary arteries, without pumping it from the lungs to the heart.

The Fontan Procedure is a palliative surgery; in other words, it doesn’t focus on curing the disease, rather, it reduces the symptoms and severity of it, resulting in an improved quality of life for the patient. It’s generally performed on children with complex congenital heart defects. Specifically, it’s used when a child only has one effective ventricle.

The Fontan is typically done as a two-stage repair. The first stage is referred to as a Bidirectional Glen procedure, or Hemi-Fontan. In this stage, oxygen-poor blood is redirected from the upper part of the body to the lungs. The pulmonary arteries are disconnected from their blood supply and the superior vena cava is removed from the heart and directed into the pulmonary arteries. The inferior vena cava transports blood from the lower body and remains connected to the heart. This redirection allows the single ventricle of the heart to do much less work. The second stage is known as Fontan completion, and it also redirects blood from the inferior vena cava to the lungs.

Although there are many different types of Fontan operations, they all serve a common purpose: to cause one effective ventricle to pump oxygen-rich blood to the aorta and into the body.

Patients who undergo Fontan surgery require life-long management to address any problems that may occur, such as heart rhythm issues, a weakened ventricle, or blockages and/or narrowing in the Fontan circulation. In many cases, children who undergo these procedures will require some form of Fontan revision surgery later in life.

It’s difficult to predict exact outcomes for Fontan children—in some cases patients will be able to participate in sports and vigorous activity; however, others may be severely limited in terms of exercise. Because this procedure is still relatively new, there are still many questions as to how well single ventricle heart/Fontan patients will fare as they enter their 30s and 40s, which is why ongoing monitoring is so crucial.

Please feel free to post any questions or comments you may have regarding this or other congenital heart defect procedures in the comments section.

About Michael McConnell, M.D.:

Dr. McConnell specializes in Pediatric Cardiology and general Pediatrics. His area of clinical interest is in cyanotic congenital heart disease management, syncope, and single ventricle patient management. Dr. McConnell completed his residency at the Children’s Hospital of Alabama, and his fellowship was held at the Children’s Hospital Medical Center in Cincinnati, OH. He’s been practicing at Emory since 2000.

Revealing Results from Heart Valve Study at Emory

Glenrose Gay of Vidalia: first Emory heart patient to receive new transcatheter aortic valve procedure. Pictured here with Dr. Peter Block (left) and Dr. Vasilis Babaliaros.

As we’ve mentioned in previous posts, Emory University Hospital has been engaged in a clinical trial for patients suffering from severe aortic stenosis since October of 2007. To review: in aortic stenosis, the aortic valve narrows, restricting blood flow from the heart to the body.

Emory is the first hospital in the Southeast to study the non-surgical treatment known as transcatheter aortic valve implantation (TAVI). This procedure involves the replacement of the narrowed valve with a better-functioning synthetic valve from outside the body. We place a small incision into the groin or chest wall, and then feed a wire mesh valve through a catheter, or tube, placing it where the new valve is needed. The technique is ideal for those who are too ill or too frail to endure open-heart surgery.

Emory is one of approximately 20 nationwide hospitals participating in this study; Phase II of the trial compares TAVI to traditional, open-heart surgery or medication therapy in high-risk patients with aortic stenosis.

Last Wednesday, the initial findings of the study were published in The New England Journal of Medicine (NEJM). Specifically, the trial followed 358 patients who received either catheter-delivered valves or standard non-surgical treatment. The results reflected that patients who had replacement heart valves via catheter were more likely to survive a year following surgery than patients who were treated without the replacement of their original valves. The authors of the study went as far to say that catheter-delivered valves “should be the new standard of care” for patients who are unable to undergo surgery.

Although TAVI has yet to be approved by the FDA, we anticipate that the catheter-implanted valves will receive FDA approval by late 2011.

These results are particularly groundbreaking, as the number of people with failing valves is expected to greatly increase as baby boomers continue to age. Overall, this is a giant step forward in our battle against this common disease.

Do you have questions about the heart valve study, or about aortic valve stenosis? If so, be sure to let me know in the comments section.

Pulmonary Valve Replacement

Over the past few decades, we’ve made great strides in congenital heart surgery, which has increased survivorship among long-term sufferers of congenital heart disease. While many options for congenital heart disease and defect repairs are available, patients may require future additional surgeries.

Tetrology of Fallot is one of the most common types of congenital heart defects, and is a prime example of a condition that could require pulmonary valve replacement. Tetraology of Fallot (TOF) actually refers to four heart defects present from the time of birth: a ventricular septal defect (hole between the ventricular chambers which allows blue and red blood to mix), pulmonary stenosis (narrowing that makes it difficult for blue blood to reach the lungs), right ventricular hypertrophy (thickening of the heart muscle from pumping blood past the narrowing) and an overriding aorta. These defects often cause an infant to have cyanosis, or blue-tinged color of the skin, resulting from lack of oxygen-rich blood.

Fortunately, the prognosis for children with this condition has greatly improved over the last several decades (assuming proper diagnosis and treatment is administered). During surgical repair of TOF, the hole is closed with a patch, and the narrowing from the diseases pulmonary valve is removed, which can leave patients with a ‘leaky’ pulmonary valve. Although some patients may do well for a decade or more with the leaky valve, the pulmonary valve will eventually need to be replaced in most children born with TOF. Perhaps the most challenging aspect of treatment for patients suffering from this condition is exactly when to time treatment.

Other repairs may be associated with the need for pulmonary valve replacement in the future, including repair for pulmonary atresia with ventricular septal defect (VSD), truncus arteriosus, the Ross procedure for aortic valve disease, and double outlet right ventricle and d-transposition of the great arteries with VSD.

Surgical replacement of the pulmonary valve is the standard treatment for pulmonary valve disease.  Valve replacement surgery involves the replacement of one (or more) of the valves of the heart, typically with an artificial heart valve or a bioprosthesis (a prosthesis consisting of an animal part or animal tissue).

Pulmonary valve replacement is the most common operation performed in the adult congenital heart disease population. This surgery can be performed with extremely low morbidity and mortality. Patients are typically out of the hospital within the first week, and able to perform their normal daily routine. They’re fully recovered within 4 weeks. A surgically placed pulmonary valve is expected to last 10-15 years, or longer.

For very select patients who have already had conduit replacement of the pulmonary valve, transcatheter pulmonary valve replacement may be an option. While this option has a shorter recovery time, the longevity of the valve remains unknown. Early findings show that transcatheter PVR could be used as an alternative to traditional surgical methods in appropriate patients. The percutaneous PVR approach involves the placement of a bovine valve inside a balloon stent.

As physicians, we’re encouraged by the great strides we’re making from both surgical and technological standpoints with pulmonary valve replacement and congenital heart disease in general.

Do you have questions regarding any of these medical advances? If so, please be sure to let me know in the comments section.

About Brian E. Kogon, MD:

Dr. Kogon is an assistant professor of surgery and director of the congenital cardiac surgery fellowship at Emory. Additionally, he’s the surgical director of adult congenital cardiac surgery at Emory University Hospital. His clinical interests include pediatric cardiac surgery, cardiac transplantation, and adult congenital heart surgery. Dr. Kogon has been with Emory as a faculty member since 2004.

Case Study: A Catheter Ablation Approach to Atrial Fibrillation

In recent posts, we’ve presented various case studies and examples of patients suffering from atrial fibrillation (A-fib). We’ve seen how debilitating this condition can be, and how severely it can affect a patient’s quality of life.

In this post, we’ll take a glimpse into the life of a Georgia 55-year-old school administrator who developed A-fib over a two-year period, causing him to suffer from fatigue, shortness of breath, and a decreased ability to exercise.

His local physicians made every effort to restore the rhythm of his heart through the use of anti-arrhythmic drugs—unfortunately; the medication generated side effects that necessitated the placement of a pacemaker implant.

When the patients’ A-fib continued to reoccur, the physicians realized that the drug therapy was failing and decided to pursue a course of rate control and anticoagulation therapy. This attempt failed to alleviate the symptoms as well, which prompted his local cardiologist to refer him to Emory University Hospital Midtown to be evaluated for catheter ablation.

Catheter ablation is a minimally invasive procedure that doesn’t involve open-heart surgery, making it a viable option for patients suffering from A-fib. In our patient’s case, it was the ideal solution for his condition—which is why in February of 2010 he underwent the procedure for treatment of his arrhythmia.

Catheter ablation involves threading catheters through the blood vessels towards the heart, which destroys (or ablates) the abnormal heart tissue that causes the condition. We performed the ablation on our patient using conscious sedation, and achieved femoral vein access with catheterization into the patient’s left atrium. Electro-anatomic mapping guided the irrigated-catheter ablation system.

The procedure was completed in less than three hours, and our patient was discharged the following morning. He was able to return to normal activity two days later. After the ablation, we continued to keep him on anti-arrhythmic medication for a month.

At his 3-month and 6-month follow-up visits, he showed no signs of A-fib, and we were able to discontinue the use of the anti-arrhythmic drugs. Today, our patient says that he feels “great”, and he continues to be completely free of atrial arrhythmia and its symptoms.

When anti-arrhythmic drugs fail to alleviate the symptoms of A-fib, catheter ablation is an advantageous alternative. While the procedure works best for patients with recurring A-fib, it can also make sense for A-fib cases without the presence of significant heart disease. Further, recent pilot studies have revealed that catheter ablation is superior to medication as the primary form of therapy for A-fib.

Do you have questions about this procedure, or about A-fib in general? If so, please let me know in the comments section.

About Angel Leon, MD:

Dr. Leon is a Professor of Medicine and the Chief of Cardiology at Emory University Midtown. His specialties include electrophysiology, cardiology, and internal medicine, and his areas of clinical interest include arrhythmia ablation, electrophysiology lab, and pacemaker. Dr. Leon holds organizational leadership memberships with the American College of Cardiology and the American Heart Association, and he’s been practicing with Emory since 1991.

A Look at Transapical Aortic Valve Implantation

Transapical aortic valve implantation (AVI) is a minimally invasive technique that replaces the aortic valve through the placement of a small incision under the left breast—directly below the heart—without using cardiopulmonary bypass. It’s designed for patients who do not have appropriate sized femoral vessels in the groin for the treatment of aortic stenosis.

Transapical AVI is actually a type of transcatheter valve implantation. There are two ways to go about this sort of implantation: through transapical or transfemoral routes (a transfemoral procedure involves an incision in the groin area).

Transapical AVI is often referred to as an “off-pump” procedure, as routine surgical aortic valve replacement (AVR) requires that the breastbone be opened, and patients must be placed on a heart lung machine. Conversely, transapical AVI doesn’t involve opening the breastbone, nor does the procedure require utilization of the heart lung machine; hence the term “off-pump.”

So, why would a surgeon opt for transapical AVI, as opposed to transfemoral AVI? If a patient has too much calcium in their arteries or groin, this prevents us from being able to insert catheters in these areas, creating a case for transapical AVI.

Some of the typical candidates for this procedure include patients with severe aortic stenosis, or those who have blockage of the aortic valve. However, some patients do not qualify for this procedure, particularly for the purposes of the trial that Dr. Block mentioned in his last post. These include patients who are on dialysis, or who have had previous valve surgery. That said—we do anticipate that these parameters may change, potentially in late 2011.

Emory is truly a “one-stop-shop” in that we offer a multitude of services for the treatment of aortic stenosis: minimally invasive AVR, transcatheter AVI (transfemoral or transapical), off-pump left ventricle to descending aorta bypass, or balloon aortic valvuloplasty.  We are truly fortunate to be able to provide all of these services for our patients.

If you have any questions about transapical AVI or any of the numerous procedures we offer at Emory Heart & Vascular, please feel free to let me know in the comments section, or call me at 404-686-2513.

About Vinod H. Thourani, MD:

Dr. Thourani specializes in minimally invasive valve surgery (including mitral valve repair and replacement and aortic valve surgery) and transcatheter valve surgery (transfemoral and transapical aortic valve implantation).  He also performs other facets of adult cardiac surgery including on and off-pump coronary artery revascularization and atrial fibrillation surgery. He completed his general surgery residency, cardiothoracic residency, and cardiothoracic surgical research and clinical fellowships at Emory University.  Dr. Thourani joined Emory as a faculty member in 2005.

Robotic-Assisted, Minimally Invasive Bypass Surgery at Emory

At Emory, we are constantly pushing the boundaries of modern medicine in an effort to discover safer, more effective ways of healing patients. At Emory Heart & Vascular, we’ve made remarkable strides in minimally invasive coronary artery bypass surgery (CABG) through the use of robotic technology.

Our minimally invasive CABG procedure utilizes a robotically assisted endoscopic technique, allowing the procedure to be performed with small incisions between the ribs, as opposed to opening the chest through splitting the breastbone (median sternotomy).

One of the many advantages of robotic-assisted CABG is that it doesn’t require the use of a heart-lung machine, or cardiopulmonary bypass, and can be performed without dividing the ribs or sternum. Therefore, the recovery from the procedure can be considerably shorter, and may be associated with a lower risk of some complications. Most patients are able to leave the hospital in as few as three days, and may return to normal activities in two-three weeks, as opposed to two-three months—the recovery time period generally associated with traditional CABG surgery.

Robotic-assisted CABG is most often performed on patients with single-vessel coronary artery disease. However, the procedure can be part of a hybrid approach for patients with multi-vessel disease. With a hybrid revascularization approach, surgeons work together with interventional cardiologists to combine the benefits of surgery with the benefits of stenting. Typically, the surgeon will perform a single-vessel robotic-assisted CABG for a blocked artery on the front of the heart, and cardiologists can perform a stenting procedure to the other blocked vessels.

Emory has been performing minimally invasive CABG since 2003, and is one of only a few medical facilities in the country offering the procedure.

Do you have questions about this or any other procedure at Emory Heart & Vascular? If so, please feel free to let me know here in the comments section.

About Michael E. Halkos, MD:

Joining the faculty in July 2009, Dr. Halkos received his MD and did his general and cardiothoracic surgical training as well as a two year research fellowship at Emory. He is currently Editor of the Resident Section of CTSNet and serves on the Executive Committee of the Thoracic Surgeons Residents Association. His clinical specialties include off-pump coronary artery bypass surgery, valve repair/replacement surgery, and minimally-invasive valve and coronary surgery, and his research interests are stroke after cardiac surgery and surgical outcomes.