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Cardiac Care in Hampton Roads
Home Grown and World Class
By Bobbie Fisher
Heart disease is the leading cause of death for both men and women. And while that remains an established and undisputed fact, the numbers are still startling by any reckoning. Consider these statistics from the Centers for Disease Control and Prevention:
• About 600,000 people die of heart disease annually in the U.S. every year – one in every four deaths.
• More than 50 percent are men.
• More than 385,000 people die annually of coronary heart disease.
• Approximately 935,000 Americans have a heart attack every year.
• Of those, 610,000 are a first heart attack, and 325,000 a subsequent event.
According to the American Heart Association, in the next 20 years, more than 40 percent of the U.S. population is expected to have some form of heart disease; this will triple the total direct medical costs of caring for hypertension, coronary heart disease, heart failure, stroke, and other forms of cardiovascular disease – from the current $273 billion to more than $800 billion.
When the call went out for cardiologists to feature in this issue of Hampton Roads Physician, the publisher received numerous nominations, each worthy and each indicative of the high level of cardiac care available to the people of this geographically diverse community – and those who travel to Hampton Roads for care as well.
The physicians chosen for our cover story deal with very specific and complex disease processes, employing cutting-—edge technology with extraordinary professional knowledge, training and expertise.
Coronary Heart Disease
Also called coronary artery disease or arteriosclerotic heart disease, it’s the most common form of heart disease. Simply put, it is a narrowing of the small blood vessels that supply blood and oxygen to the heart, allowing plaque to build up inside the coronary arteries.
Dr. Leslie Webb, an interventional cardiologist with Cardiovascular Specialists who practices at Bon Secours Mary Immaculate Hospital in Newport News, describes the standard cardiac catheterization procedure, and the newer modality she now employs in appropriate patients: “When blockages in the arteries become significant enough to cause ischemia,” she says, “we go in with balloons and stents to open up the arteries to relieve those blockages and allow increased blood flow.”
Traditionally, cardiac catheterization is performed in the large femoral artery that begins at the inguinal ligament. Because it can be palpated through the skin, it’s a common point for catheter access. The downside, Dr. Webb explains, is that the procedure can be very difficult for some patients. “When we do a cath in the femoral artery, the patient has to lie flat for anywhere between two and eight hours, depending on whether we can put a closure device to seal the hole we’ve put in the artery, or whether they’ve had blood thinners or other conditions,” she says. “That can be torture for patients with back pain.”
During fellowship, Dr. Webb learned to do the procedure through the radial artery, which her patients much prefer for a number of reasons, not the least of which is there is less bleeding. And going in the radial artery can make a huge difference for patients’ comfort, because as soon as they get off the table, they can actually sit up in a chair – good news for older men with enlarged prostates, who have difficulty urinating lying down; they can get up and go right to the bathroom. Anyone with a good radial pulse, with no significant blockages in the artery from the arm, is a candidate for this procedure.
Recovery is much quicker: Dr. Webb’s femoral artery cath patients typically can’t work, drive or lift for three or more days. Going in through the wrist, however and she can tell her patients they can return to work in a day or two, minimizing wrist movements, but otherwise normally active.
Indications for cardiac cath usually involve specific symptoms: ongoing heart attack, chest pain, shortness of breath, dizziness – or in the absence of an ongoing heart attack, a positive functional study or positive stress test.
Dr. Webb also sees patients in the absence of a stress test, depending on presentation. “There are occasions where somebody has a non-ST elevation MI, which means that the blood work may be positive, the EKG may be positive, but it wasn’t an abrupt complete closure of the artery,” she says. In that case, she’d proceed straight to catheterization without waiting for a stress test. Likewise, a patient with unstable angina, having pain at rest, would be an indication for catheterization, based on history.
She also performs cardiac catheterization for structural or valvular heart disease, to assess for stenotic or regurginate valves, or on cardiomyopathy patients to assess how the heart is actually functioning.
Dr. Webb is looking forward to the availability of bioabsorbable stents. “Because there’s not stent material left after a certain period of time, they may actually be a better option long term,” she says.
Congestive Heart Failure
Coronary artery disease is the most common cause of congestive heart failure, which is responsible for 5 million deaths a year. Dr. H. Lee Kanter, an electrophysiologist with Cardiovascular Associates, an independent medical practice, established the electrophysiology department at Chesapeake Regional Medical Center (CRMC).
The term congestive heart failure is widely misunderstood. The ‘congested’ part is actually fluid in the lungs, caused when the main pumping chamber of the heart isn’t efficiently ejecting blood forward through the body. That leads to pressure increases in the lungs, which force fluid out into the lungs, making them congested and leading to poor, decreased exchange of air.
Untreated, worsening congestive heart failure can affect virtually every organ in the body. Dr. Kanter is quick to point out that many forms of heart failure can be controlled by treating the underlying causes, making lifestyle changes, and taking medication – information that he stresses to the Sentara Virginia Beach General patients who visit the CHF clinic at the Virginia Beach office of Cardiology Associates. The practice is getting ready to open a similar clinic in Chesapeake, where he will see CHF patients discharged from CRMC. “We’re setting up the clinic so we can see patients discharged with a diagnosis of CHF,” he says, “so we can communicate very closely with them about how to manage their weight, their sodium intake, and their medications. We partner with them, educate them and empower them to take responsibility for their care.”
One of the newer modalities for CHF patients is the biventricular pacemaker. Dr. Kanter was the first cardiologist to perform this procedure at CRMC. A normal pacemaker’s purpose is to keep the heart from beating too slowly and to provide synchrony between the top and the bottom chambers of the heart. The technology was specifically intended to provide an additional treatment for certain CHF patients, when the bottom pumping chamber of the heart – the walls of the heart – does not beat synchronously. These asynchronous or dyssynchronous contractions of the heart lead to a less – efficient pumping action. A biventricular pacemaker electrically stimulates the heart – the opposite walls of the heart at the same time – so those opposite walls then mechanically contract at the same time, therefore increasing the efficiency of the pumping action.
Dr. Kanter was involved early on in the research that led to the development of the biventricular pacemaker. That research – called the Miracle Study and reported in The New England Journal of Medicine, Cardiac Resynchronization in Chronic Heart Failure, June 2002 – led to FDA approval. He is currently involved in an international study investigating the application of biventricular pacing in extended indications, as a treatment of congestive heart failure.
An electrophysiologist is the electrician of the heart, says Dr. Ian Woollett , also with Cardiovascular Associates. His area of expertise is atrial fibrillation, or a-fib.
He likens a-fib to an electrical storm in the top chamber of the heart, using the analogy of a car with a spark plug malfunctioning: it still gets around, but inefficiently. Patients in a-fib feel tired and more fatigued because their hearts are beating too fast and irregularly.
A-fib can have a variety of causes, including conditions like high blood pressure and heart valve disease – but for many, “it just seems to be bad luck,” Dr. Woollett says. “When the heart was forming and the veins in the heart were connecting together, some of the cardiac cells remain in the pulmonary veins and can’t make up their mind if they’re part of the vein or part of the heart. Sometimes they start firing rapid electrical signals that drive the rest of the heart into a-fib.”
“Stroke is by far the biggest thing we’re worried about with a-fib,” Dr. Woollett says, noting that it is the most common arrhythmia in older patients in the United States, occasioning more hospitalizations than any other rhythm problem. It’s complicated by the fact that some people don’t feel it. Those patients can be treated with blood thinners to prevent stroke, but all of these have side effects and potential toxicities. “Historically, for the last 30 or 40 years, we’d treat with the anti-coagulant warfarin. It works most of the time, but can be very difficult to regulate.”
In the last few years, cardiologists have been excited about the new direct anti-thrombin inhibitors like Pradaxa (dabigatran etexilate) or Xarelto (rivaroxaban), which eliminate the need for monitoring and regulating. These drugs have been shown to be safer than warfarin, and more effective.
When medications fail, however, other modalities are available – in particular a procedure known as an atrial fibrillation ablation, which involves advancing catheters into the heart through the veins in the legs, mapping around to locate where the a-fib is coming from, and essentially disconnecting those areas by creating a line of scar tissue in very specific locations around that spot – thus keeping the a-fib from reaching the rest of the heart. The procedure is technically very difficult, with a long learning curve.
Dr. Woollett is optimistic about the HeartLight study, an FDA randomized pivotal trial for the CardioFocus endoscopic laser balloon for pulmonary vein isolation. “We’re able to take a little balloon and put it inside the heart, fill it with fluid, put a light down there with a fiberoptic camera, and actually see inside the heart with unprecedented precision.”
The first time he saw it, he was amazed. “We can take the laser and make a laser burn around each of the openings of the pulmonary veins. We can see exactly where it’s going; we can see that we’ve got good contact; we can make sure that there is a solid line rather then leaving gaps.” He cautions, “The hope in doing this is not that it’s going to be more successful the first time, but that there’s going to be a much lower risk of atrial fibrillation coming back.”
About 20 centers in the U.S., including Sentara’s Cardiovascular Research Institute, are involved in the HeartLight study. In addition, Dr. Woollett notes, Sentara’s Cardiovascular Research Institute is one of only a few centers in the country working on a study to help patients who go into a-fib and stay there (persistent a-fib). “These patients are very difficult to treat,” he says. “Neither drugs nor catheter ablations have had good long — term success. In the hybrid DEEP procedure, we’ve been trying to combine the best of catheter ablation and the best of a surgical ablation in a minimally invasive approach.”
“We’ve been seeing over 80 percent success rates here,” he says, noting that success from a catheter ablation alone over the long term are probably optimistically 30 percent in this difficult to treat population.
The work that these three physicians do on a daily basis involves so much more than what is outlined here. They are part of the community of dedicated cardiologists who make Hampton Roads a well-recognized and respected destination for exceptional cardiac care. Hampton Roads Physician is proud to feature these three exceptional practitioners who exemplify the practice of medicine at its best.