News

Emory Cardiologist Elected President of American Society for Preventive Cardiology

Emory Heart & Vascular CenterEmory Heart & Vascular cardiologist, Laurence S. Sperling, MD, was recently named the president-elect of the American Society for Preventive Cardiology (ASPC). Dr. Sperling’s two-year-term will begin in 2014.

The ASPC was founded in 1975 and represents the increasingly multidisciplinary group of healthcare providers (including nurses, nurse practitioners, dieticians and other healthcare specialists in addition to physicians) along with researchers and industry representatives who share an interest in and passion for preventive cardiology.

Dr. Sperling is the medical director of the Emory’s Heart Disease Prevention Center and also serves as medical director for a number of unique programs at Emory including the HeartWise Risk Reduction Program and Optimal Living. In 2004, Dr. Sperling founded and currently directs the first and only LDL apheresis program in the state of Georgia. He has also been instrumental in the development of the Emory Women’s Heart Center which will be opening up two new locations, Emory University Hospital Midtown and Emory Johns Creek Hospital, in September 2014.

Sperling has been an investigator in a number of important clinical trials and has authored more than 150 manuscripts, abstracts and book chapters. He is co-editor of the American College of Cardiology’s Diabetes Self Assessment Program and has served as special consultant to the Centers for Disease Control and Prevention. Since 2011, Sperling has served annually on the U.S. News & World Report’s panel of 22 national dietary experts evaluating the country’s most popular diets for the publication’s “Best Diets” rankings.

Congratulations Dr. Sperling! We are happy to have you on the Emory team.

About Dr. Laurence Sperling

Dr. Laurence Sperling

Dr. Sperling specializes in internal medicine and cardiology—his areas of clinical interest are cardiac catheterization, cardiac rehabilitation, general cardiology, echocardiogram, lipid metabolism, and electron beam computed tomography. Dr. Sperling has received various awards from the American College of Cardiology, the American Heart Association Council, and Emory University Hospital and has been a special consultant to the Centers for Disease Control. Dr. Sperling received his undergraduate degree from Emory College and graduated with his medical degree from Emory University School of Medicine in 1989. He subsequently completed eight additional years of training at Emory, including a residency in internal medicine, chief resident year at Emory University Hospital, a National Institutes of Health-supported research fellowship in molecular and vascular medicine and a clinical fellowship in cardiovascular diseases.

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Dr. Samady talks George W. Bush, Cardiac Angioplasty with Associated Press

Many of the Associated Press new stories on former United States President George W. Bush’s recent surgery to unblock an artery in his heart feature discussion from Emory Heart & Vascular Center’s Director of Interventional Cardiology, Habib Samady, MD, who was interviewed to discuss details of the former President’s cardiac angioplasty and how arteries in the heart become blocked.

During a routine physical, doctors found a blockage in Bush’s artery. In order to open up the artery blockage, cardiologists at a Texas hospital performed a cardiac angioplasty procedure.

Dr. Samady says it takes 20 to 30 years for cholesterol to build up in the arteries. When the narrowing of the blood vessel gets to 80– 90 % then the blockage will limit blood flow. When this occurs patients may experience symptoms of heart disease such as:

• Chest pain
• Pressure in chest
• Shortness of breath
• Fatigue

Learn more about cardiac angioplasties and the former President’s heart surgery in this AP video featuring Dr. Samady!

Cardiac angioplasties are fairly common procedures and many times the patients go home the same day or the next day. They can be performed for outpatients with symptoms of angina or evidence of low blood flow on a stress test or for inpatients with heart attacks or “near heart attacks”. Emory cardiologists were pioneers in developing the angioplasty procedure in the 1980’s. Former Emory cardiologist Andreas Gruentzig performed the first balloon angioplasty in 1977 in Zurich, Switzerland before immigrating to the United States and coming to Emory from where the procedure was taught and disseminated through out the world. In 1987, Emory interventional cardiologists were the first to deploy coronary stents in the United States and currently are national leaders in determining which patient needs to have a blockage unblocked by measuring blood flow in each artery as well as in the use of miniaturized ultrasound and infrared cameras for the optimal deployment of coronary stents.

Dr. Habib SamadyAbout Habib Samady, MD
Dr. Samady is the Director of Interventional Cardiology at Emory Hospitals as well as an Associate Professor of Medicine at Emory University School of Medicine. He has been practicing medicine for over 20 years and has been on faculty at Emory since 1998. Dr. Samady has been instrumental in the development of the interventional cardiology program at Emory. He specializes in cardiac cauterization, interventional cardiology, nuclear cardiology and valve disease. He is a published author and has published several articles in peer reviewed publications.

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Christine Nell – Dybdahl Awarded 2013 Life Changer Award

HeartWise events AtlantaEmory Heart & Vascular Center, Nurse Practitioner, Christine Nell – Dybdahl, MSN, MPH was recently awarded the 2013 Life Changer Award by the Health Monitor Magazine, in conjunction with the American Association of Nurse Practitioners (AANP).

Christine was nominated by two of her patients in her preventive cardiovascular clinic who nominated her because of her great compassion and concern for all of her patients. One patient noted, that “Christine has so much humanity that she brings to the office”. The award recognizes and honors outstanding service to patients and community care by nurse practitioners.

Christine has been a nurse practitioner at Emory for 14 years and is currently the Clinical Nurse Director within the Emory Center for Heart Disease Prevention. She also is very active in the Women’s Heart program at Emory. She is adjunct faculty with the Emory School of Nursing. We are very proud to have Christine as a part of the Emory Heart & Vascular Center team!

Learn more about this honor and about Christine in this short video

New Treatments for High Risk Complex Abdominal Aortic Aneurysms Patients

Aortic Aneurysm TreatmentIn recent years, endovascular techniques have greatly improved the safety of surgical treatment for patients with abdominal aortic aneurysms (AAAs) who had concomitant health conditions that affect cardio-pulmonary and renal function. Because many patients with AAAs do not qualify for endo-vascular repair, newer procedures called “fenestrated and branched endografts” were designed as an alternative for these patients. Until recently, fenestrated endografts were not commercially available and surgeons had to modify grafts themselves to repair the AAAs. In November of 2012, Emory vascular surgeons Yazan Duwayri, MD, and Ravi Veeraswamy, MD, performed Georgia’s first implantation of an U.S. Food and Drug Administration (FDA) approved fenestrated graft. The new device can be used to repair aneurysms in patients who are not candidates for other traditional repair options.

Treatment Options for Abdominal Aortic Aneurysms

Emory offers the full range of treatment options for abdominal aortic aneurysms, including open and endovascular repair techniques. For patients who are not candidates for the newer FDA-approved devices, Emory surgeons still offer open surgical and endovascular repair using the chimney and snorkel techniques. We tailor AAA treatment, selecting the treatment option that is most appropriate for each patient. Learn more about our

There are many benefits to fenestrated endovascular repair including:

  • Shorter days in ICU
  • Less blood loss
  • Fewer mortalities
  • Fewer complications post surgery
  • Shorter average number of days to resume normal diet
  • Fewer days spent in the hospital

Fenestrated Graft Procedure Video



Learn more about fenestrated and branched endografts >>


Dr. Ravi VeeraswamyAbout Ravi Veeraswamy, MD

Dr. Veeraswamy specializes in vascular surgery, and has been practicing with Emory since 2006. Some of his areas of clinical interest include aortic aneurysm repair, carotid endarterectomy and stenting, peripheral arterial and vascular disease, and vascular surgery. Recently, Dr. Veeraswamy has published articles in the Washington University Manual of Surgery, Vascular and Endovascular Challenges, and the Annals of Vascular Surgery.

 

Yazan Duwayri, M.D.About Yazan Duwayri, MD

Dr. Duwayri specializes in endoluminal and endovascular surgery. His areas of clinical interest include treatment of carotid stenosis, abdominal and thoracic aortic aneurysms, aortoiliac occlusive disease, renal arterial stenosis, thoracic outlet syndrome, dialysis access, peripheral arterial disease, and venous disease. He has published articles in several journals including the Journal of Vascular Surgery and Annals of Vascular Surgery, in addition to several textbook chapters.

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Emory Honored with International Heart Failure Research Grant!

Emory is one of 17 collaborating centers from 10 countries participating in a new international consortium project aimed at earlier detection and prevention of heart failure.

The European Commission has awarded a grant of almost $16 million (EUR 12 million) to the Heart Omics in Ageing (HOMAGE) project, with a goal of better identifying more specific biomarkers for heart failure and then developing methods for earlier detection of risk in the elderly population.

A biomarker, or biological marker, is a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention. It serves as a guide for health and physiology related assessments.

The prevalence of heart failure is increasing worldwide because of the aging population and a rising trend of risk factors for heart disease — such as diabetes, obesity and hypertension. Heart failure is a major cause of death and disability in the world and remains the most frequent cause of hospitalization for patients over 65 years old. An essential step in preventing heart failure is to first accurately identify individuals at high-risk.

Traditional risk factors such as high blood pressure still remain important clinical guides but we are now seeing more cases of heart failure develop in individuals who do not have any specific high risk diseases. Therefore, this research will try to determine more accurate methods of detecting heart failure risk using biomarkers leveraging the latest technology.

This project will evaluate data from 30,000 patients from 10 countries. Emory investigators will work with the National Institutes of Aging-funded Health Aging and Body Composition Study, to assess the value of this approach among 3,000 elderly individuals in the U.S.

HOMAGE will also lead a clinical trial to look for novel treatments of heart failure that can be targeted specifically to those patients at risk.

This research has the potential to benefit thousands of individuals in the U.S. and researchers at Emory are very excited to work with colleagues across Europe in this trans-Atlantic collaboration.

About Dr. Javed Butler
Professor of Medicine, Emory University School of Medicine
Director of Heart Failure Research at Emory

After completing medical school from Aga Khan University in Karachi, Pakistan, Dr. Butler did his residency and chief residency at Yale University, Masters in Public Health from Harvard University, and cardiology fellowship including transplant training at Vanderbilt University. Before moving to Emory University, he was the director for the Heart and Heart-Lung Transplant programs at Vanderbilt University. He also has done special cardiac imaging training at the Massachusetts General Hospital. He is on the Editorial Board for the Journal of the American College of Cardiology, Journal of Cardiac Failure, American Heart Journal and Congestive Heart Failure. He served on the American College of Cardiology Committee on Heart Failure and Transplantation. He is board certified in Cardiology, Internal Medicine, and Nuclear Cardiology. Currently he serves as the Deputy Chief Science Advisor for the American Heart Association. While also heavily involved in research and clinical care at Emory. Dr. Butler’s research focuses primarily on the disease progression, outcomes, and prognosis determination in patients with heart failure, with special emphasis on patients undergoing cardiac transplantation and left ventricular assist device placement. He has published many original research articles in multiple peer reviewed journals. He serves on the national board, events committee, and steering committees of several multicenter clinical trials. Dr. Butler is involved in the evaluation and management of all aspects of patients with heart failure including cardiac transplantation and left ventricular assist devices. He is also involved in the cardiac CT program at Emory University.

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Two Emory Physicians Honored with National Red Dress Award!

Dr. Leslee ShawDr. Sanjay GuptaWoman’s Day magazine is honoring Leslee Shaw, PhD, and Sanjay Gupta, MD, with two of its four Red Dress Awards for 2013. The award honors those who have made significant contributions in the fight against heart disease among women.

Dr. Shaw and Dr. Gupta join the ranks of other distinguished Red Dress award recipients including United States Surgeon General Regina M. Benjamin, renowned journalist Barbara Walters and Elizabeth Nabel, MD, former head of the National Heart, Lung and Blood Institute.

Dr. Shaw is a professor of medicine at Emory School of Medicine and co-directs the Emory Clinical Cardiovascular Research Institute. She currently serves on the Cardiovascular Imaging Committee for the American Heart Association and is on the Board of Directors for the Society of Cardiovascular Computed Tomography. She is a past-president of the American Society of Nuclear Cardiology.

Dr. Shaw Red Dress AwardHer areas of interest and expertise include test accuracy, risk assessment, prognosis and cost efficiency—with a particular emphasis on the role of how diagnostic tests work differently to assess heart disease risk in various ethnic groups and in women versus men.

Dr. Gupta is CNN’s chief medical correspondent and is an assistant professor of neurosurgery at Emory School of Medicine and associate chief of neurosurgery at Grady Memorial Hospital. He is a practicing neurosurgeon at Emory University and Grady hospitals.

Gupta’s medical training and public health policy experience distinguish his reporting on a range of medical and scientific topics including brain injury, disaster recovery, health care reform, fitness, military medicine, HIV/AIDS and other areas.

The prestigious award will be presented on February 12 at Lincoln Center in New York City. To learn more about this award visit Red Dress Awards 2013 – Woman’s Day.

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And the 2013 Best Diet Winner according to U.S. New & World Report is…

Diet weight loss rankingsFor a meaningful start to a healthy new year, today U.S. News & World Report released its Best Diets of 2013 rankings, featuring a variety of weight loss programs and options.

The 2013 list of best diets provides a look at 29 diets, ranging from the Traditional Asian Diet to Weight Watchers. Diets were ranked based on ratings from an independent panel of 20 experts. The experts rated each diet in categories such as ease of compliance, diabetes control and management, heart health, weight loss, safety, and nutritional completeness.

“Many Americans struggle with maintaining a healthy diet, and especially around the first of the year tend to become interested in trying a new one,” said Brian Kelly, Editor and Chief Content Officer of U.S. News. “Diets are serious business, so we’ve assembled the experts to provide the best and most current information for consumers.” Emory Heart & Vascular Center physician Laurence Sperling, MD was one of the 16 nationally recognized experts who judged the diets.

The 2013 best diet rankings also include expanded coverage over previous years, including rankings of new plant-based diets. Increasingly popular in health and wellness circles, plant-based diets have gained attention as a potential antidote to the obesity epidemic in this country. In addition to weight loss, research suggests these diets help protect against diabetes, heart disease, and other health conditions. U.S. News evaluated 11 plant-based diets, including the Anti-Inflammatory Diet, Engine 2 Diet, and Flexitarian Diet.

Check the winners of the 2013 Best Diet rankings below and visit the U.S. News Website in the Related Resources area for details.

Best Diet Overall
The DASH Diet ranked No. 1 overall. The TLC Diet came in at a close second, while the Mediterranean Diet, Mayo Clinic Diet, and Weight Watchers tied for third place.

Best Weight-Loss Diet
Weight Watchers ranked first place in weight loss. Tied for second place were Jenny Craig, the Biggest Loser Diet, and the raw food diet.

Best Diabetes Diet
The DASH Diet tied with the Biggest Loser Diet for the top diet for preventing or managing diabetes. Close behind it was a five-way tie among the Mayo Clinic Diet, the Ornish Diet, the vegan diet, Engine 2 Diet, and Flexitarian Diet.

Best Plant-Based Diets
The Mediterranean Diet took first place in the survey’s newest category. It was followed closely by Dawn Jackson Blatner’s Flexitarian Diet, a flexible approach to vegetarianism, and then Dean Ornish’s Diet, a low-fat, heart-healthy eating regimen bolstered by exercise, social support and stress management techniques.

Bonus Recipe: Mediterranean Salmon Recipe from Emory’s Dr. Cutchins

Best Heart-Healthy Diets
The Ornish Diet ranked No. 1 for heart health. The TLC Diet, a government-designed eating plan that stands for Therapeutic Lifestyle Changes, took second place. Another government-developed diet, DASH (Dietary Approaches to Stop Hypertension), came in third.

Best Commercial Diet Plans
Some dieters may seek the structure and social support provided by many brand-name programs, so U.S. News also examined 12 commercial diet plans, from Dukan to Slim-Fast. Weight Watchers ranked No. 1, followed by Jenny Craig at No. 2, and the Biggest Loser Diet in third place.

Best Diet for Healthy Eating
Considered the gold standard by our panelists, the DASH diet claimed first place for healthfulness. Scoring second place was the TLC Diet, with the Mediterranean diet placing third.

Easiest Diet to Follow
With its extensive guidance and support, Weight Watchers ranked No. 1 among the easiest diets to follow. Jenny Craig followed close behind in second place. A tie for third went to the Mediterranean Diet and Flexitarian Diet.

Among other things, an in-depth profile for each diet explains how the diet works, evaluates its claims, and reveals what it’s like to live on the diet. For more information, please visit www.usnews.com/bestdiets2013.

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Emory Vascular Surgeons Implant 1st FDA-approved Fenestrated Stent Graft in Georgia

Emory Heart & VascularContinuing its prominent regional and national role as a top-tier center for the treatment of arterial and venous disease, the division of vascular surgery and endovascular therapy of the Emory University School of Medicine now provides implantation of the FDA-approved Zenith® Fenestrated Endovascular Graft. Emory vascular surgeons Yazan Duwayri, MD, and Ravi Veeraswamy, MD, recently performed Georgia’s first implantation of the stent graft, which has been approved as a minimally invasive treatment option for patients with abdominal aortic aneurysms (AAA) that possess an aneurysm anatomy that is incompatible with currently available devices.

“In recent years, endovascular techniques have greatly improved the safety of surgical treatment of AAA, but there are high risk patients whose aneurysms are too close to the arteries that feed the kidneys to qualify for these methods,” says Dr. Veeraswamy. “If placed, the endovascular graft itself would block blood flow. And unfortunately, traditional, open techniques of repair have significantly high morbidity and mortality rates.”

Designed as an endovascular alternative for such patients, the fenestrated system is associated with faster recovery and decreased risk of complications. The most unique factor of the graft—essentially a tube of fabric and metal that functions as a sleeve inside the aorta that excludes the aneurysm from blood flow—is that it can be customized to accommodate the anatomical specifications of each individual patient. “We use specialized software to design the fenestrations or scallops of the Zenith device so that they line up with the patient’s renal and mesenteric arteries,” says Dr. Duwayri. “Through these holes, we can place additional stents into the branch arteries to repair the aneurysm.”

The graft is inserted through small punctures in the groin and femoral arteries and guided into place using x-ray images. Wires, catheters, and stents can be placed inside the artery without the external aorta ever being touched.

By offering this new, FDA-approved technology and other devices in the clinical trial phase, Emory vascular surgeons are advancing the delivery of care to patients with these complex aneurysms.

About Ravi Veeraswamy, MD
Dr. Veeraswamy specializes in surgery and vascular surgery, and has been practicing with Emory since 2006. Some of his areas of clinical interest include aortic aneurysm, carotid endarterectomy, peripheral arterial and vascular disease, and vascular surgery. Recently, Dr. Veeraswamy has published articles in the Washington University Manual of Surgery, Vascular and Endovascular Challenges, and the Annals of Vascular Surgery.

About Yazan Duwayri, MD
Dr. Duwayri specializes in endoluminal and open vascular surgery. His areas of clinical interest include treatment of carotid stenosis, abdominal and thoracic aortic aneurysms, aortoiliac occlusive disease, renal arterial stenosis, thoracic outlet syndrome, dialysis access, peripheral arterial disease, and venous disease.


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Dr. Lundberg Shares Her Heart Healthy Holiday Gift Ideas

Emory Healthcare and Saint Joseph’s physician Gina Lundberg, MD provides gift suggestions to help the people you love stay healthy this holiday season. She strongly advocates giving gifts that promote healthy activity to your children to start them off with healthy habits at a young age.

View the full CNN Health Minute and get more tips about good healthy gift options for your family and friends!

About Gina Lundberg, MD

Gina Price Lundberg, MD FACC is the Director of the Heart Center for Women. She founded and directed The Women’s Heart Center, the first women’s cardiac prevention program in the state of Georgia in 1998.

She was named by Governor Sonny Perdue to the Advisory Board for Women’s Health, Georgia Department of Women’s Health, Department of Community Health for 2007-2008. She is a Clinical Associate Professor of Medicine at Emory University and teaches cardiology fellows at Grady Hospital. She also teaches medical students from the Medical College of Georgia in preventive cardiology. She is a member of the American College of Cardiologist’s Prevention of Cardiovascular Disease Committee.

Dr. Gina Lundberg

She has been a Board Member of the American Heart Association for Atlanta since 2001. She has been involved with the Go Red for Women campaign since it launched in 2004. She has been on the Southeast Affiliate for the AHA’s Strategic Initiative Committee representing Go Red for Women. She is national speaker for the American Heart Association. She has also been working with the national organization, Sister to Sister Foundation from 2004 till the present with their Atlanta program.

She has been interviewed on the subject of Heart Disease in Women in Glamour Magazine, MD News, the Journal of the Medical Association of Georgia, the Atlanta Business Chronicle, the Atlanta Journal Constitution and other magazines. She has been interviewed on numerous local news shows and many radio programs over the years. Dr. Lundberg has published articles in several medical journals and contributed to several text books.

Dr. Lundberg has lived most of her life in Atlanta,GA. She attended the Medical College of Georgia and trained in Internal Medicine at Atlanta Medical Center (Georgia Baptist). Her cardiology fellowship was at Rush University in Chicago. She has been in private practice in Atlanta since 1994. She is Board Certified in Cardiology and Internal Medicine and re-certified in both in 2002. She has two children and considers motherhood her first and foremost career.

True Coordination of Care: Our New Advanced Heart Failure Program

Advanced Heart Failure ProgramWe’ve experienced quite a bit of growth and expansion over the last few years here at Emory Healthcare, and with that growth, our patients are continually afforded a more collaborative and integrated total care experience. When Saint Joseph’s Hospital became part of the Emory Healthcare family earlier this year, for example, two of the state’s leading heart and vascular care providers became one, making comprehensive cardiac care a seamless process for our patients.

Every day we take steps to make receiving care at any one of our Emory Healthcare facilities more convenient and our latest effort has resulted in one of the most comprehensive heart failure treatment programs in the country. The new Advanced Heart Failure Program, is a cardiac network that includes the expert care from subspecialists at Emory University Hospital (EUH), Emory University Hospital Midtown (EUHM) and Saint Joseph’s Hospital of Atlanta.

For over 20 years Emory Healthcare and Saint Joseph’s Hospital have had the largest advanced heart failure programs in Georgia and the new collaboration will focus on meeting the needs of patients and referring physicians across the Southeast. EUH, EUHM and Saint Joseph’s have established cultures of excellent multidisciplinary care with emphasis on the lives of patients and families dealing with heart failure. We are excited to expand the bond of physicians, nurses, dietitians, social workers, and others in improving outcomes for those we serve.

The surgical heart transplant services at Saint Joseph’s Hospital will be the only component of its current heart failure program to move to a new campus—transplants now will be performed by Emory Transplant Center surgeons only at Emory University Hospital. Heart failure patients will receive pre- and post-operative care from their physician of choice at Saint Joseph’s, EUH and EUHM. Patients in need of advanced heart failure management, medical and surgical management of all heart conditions and related therapies may access treatment at any of the three facilities. Saint Joseph’s patients on the heart transplant wait list are in the process of being transferred to transplant centers of their choice, including Emory. Their status and place on the wait list will not be impacted since it is regulated by UNOS.

The program’s services also will include the surgical implantation of ventricular assist devices (VADs) at Emory University Hospital and Saint Joseph’s—a growing enterprise because of improved technology—and the medical management of VADs at all three hospitals.

The goal of the program is for all of our heart failure and transplant patients to experience enhanced coordination of their overall care and increased communication between their medical and surgical specialists.

The program currently has five cardiologists who are certified in advanced heart failure and transplantation and a number of other cardiologists pursuing certification who will be available to see patients. The Emory School of Medicine has an accredited advanced heart failure and transplantation fellowship training program for cardiologists. In addition, Emory is one of only nine centers in the country that is a member of the Heart Failure Clinical Research Network (HFCRN), sponsored by the National Heart, Lung and Blood Institute. Earlier this year, Emory received a seven-year, $2.7 million grant to develop heart failure clinical trials, with additional funding down the road to carry them out. Dr. Javed Butler, professor of cardiology, is principal investigator. As part of our new merger, Saint Joseph’s will participate in upcoming HFCRN trials, too.

 

About Andy Smith, MD, Director of Heart Failure and Transplantation, Bahgat/Smith Endowed Chair in Heart Failure Therapy and chief of cardiology at EUH

Dr. Andrew Lee Smith, Emory HealthcareAndrew Lee Smith, MD joined Emory University’s faculty in 1992 and established the Center for Heart Failure Therapy and Transplantation, a specialty practice for treatment of patients with heart failure in all stages (early to end stage) of the disease. Under his leadership, heart failure outpatient visits have surpassed 5000 annually, over 500 heart transplant procedures have been performed since the program began, and the Ventricular Assist Device program is strong and growing. Dr. Smith is recognized as an innovative leader in the treatment of heart failure and most notably for his work in collaboration with electrophysiologists on cardiac resynchronization therapy which lead to FDA approval for these devices. To learn more about Andrew Lee Smith, MD, check out Dr. Smith’s physician profile.