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Advances in Medicine – Cardiology
By Kevin Brown

Our "Advances in Medicine" feature looks at some of the latest advances in heart care in western Pennsylvania. We spoke with doctors at Allegheny Health Network (AHN) and UPMC to find out what is being done locally to help those with serious heart conditions. Both institutions are leading the way in providing innovative technologies to improve the treatment of heart disease.

Treating Aortic Stenosis

For patients with severe aortic stenosis, a procedure called Transcatheter Aortic Valve Replacement (TAVR) is an important alternative to open heart surgery. Aortic stenosis is a stiffening and narrowing of the aortic valve which makes the heart work harder to pump blood through the damaged valve. If untreated, it can lead to progressive deterioration of heart function and eventually lead to death.

During a TAVR procedure, cardiac surgeons and interventional cardiologists work together to implant a special valve folded onto a catheter through a blood vessel in the left leg or the shoulder. This avoids opening a patient's chest or placing the patient on the heart-lung bypass machine and allows for quicker recovery. Patients can be up and around within a day. Prior to the TAVR procedure, a patient's only option was open-heart surgery, which for many elderly patients could be too risky.

Doctors at both Allegheny General Hospital (AGH) and UPMC perform the TAVR procedure with Transcatheter Heart Valves (THV), including a new generation THV called the Sapien 3.

"TAVR really revolutionizes the way we're treating heart valve disease for a number of patients," said Stephen Bailey, M.D., director of Cardiac Surgery at AGH. "This new transcatheter valve (Sapien 3) provides a wonderful alternative for patients whose medical comorbidities put them at high risk for open heart surgery."

According to Joon Sup Lee, M.D., co-director of the UPMC Heart and Vascular Institute, and chief, Division of Cardiology at the University of Pittsburgh School of Medicine, "(The availability of the TAVR procedure) has increased the options and made the treatment overall safer for patients with aortic stenosis. For some with a high risk for surgery, TAVR allows a safer method of treatment."

Last year, the Food and Drug Administration (FDA) also approved TAVR as an alternative treatment option for intermediate-risk patients. AGH is now part of a national trial to see if TAVR is as effective as surgery for low-risk patients as well.

Improving Life for Heart Failure Patients

Heart failure is a serious condition that affects six million Americans and is one of the most common reasons for hospitalizations among those 65 and older, according to the American Heart Association. It is a progressive condition and there is no cure, other than a heart transplant. However, new treatments are available. Left ventricular assist devices (LVADs) can be surgically implanted to take over the pumping action of a weakened heart.

Doctors at AGH and UPMC have been implanting ventricular assist devices since the 1980s.

The latest generation LVAD is the HeartMate 3, which has been the focus of a clinical trial, Momentum 3, for the past year.  The results were recently presented at the American Heart Association (AHA) Scientific Sessions and published in the New England Journal of Medicine.

According to Srinivas Murali, M.D., a heart failure specialist and director of the AHN Cardiovascular Institute, patients in the randomized trial received either the Heartmate 3 pump or the older version called the Heartmate II.

"The trial was positive in the treatment of advanced heart failure," he said. "There were less incidents of pump malfunction and less incidents of clot formation in the pump. The new pump was superior."

Jeffrey Teuteberg, M.D., medical director of the Artificial Heart Program at UPMC, and assistant professor of medicine in the Department of Cardiology at the University of Pittsburgh School of Medicine, agrees with the results.

"Preliminary results demonstrate the HeartMate 3 has excellent outcomes, but has a much lower rate of clot forming in the pump than the prior generation of devices," he said.

A minimally invasive device to treat heart failure is also in clinical trial and doctors at AGH and UPMC have been using it as an alternative to the LVAD or heart transplant. The Parachute Ventricular Partitioning Device is the first minimally invasive, catheter-based implant device to isolate coronary muscle damaged by a heart attack.

Implanted into the left ventricle of the heart via catheter, the Parachute is made for patients who have had a heart attack of the anterior wall of the heart. A permanent device, the Parachute reduces the volume of the ventricle, allowing the heart to pump more efficiently.

"The Parachute device may offer yet another option to control symptoms, improve exercise tolerance, and reduce the risk of hospitalization and death for heart failure patients," said Dr. Murali.

Helping Those with AFib

Atrial fibrillation (AFib) is one of the most common heart rhythm disorders. According to the Centers for Disease Control (CDC), between 2.7 and 6.1 million Americans have AFib. Left untreated, it can lead to stroke. AFib is usually treated with medications, however, the blood thinners normally prescribed for AFib can cause bleeding complications.

Doctors at UPMC began using the new Watchman implantable device in 2016 and AGH doctors started offering the device this year. The device, implanted into the heart via catheter, closes the area of the heart where most clots form, thus reducing the risk of stroke.

"Patients who are at high risk of stroke and bleeding can now be protected by the Watchman device against strokes and other thromboembolic events without having to be committed to taking blood thinners in the long term," said Samir Saba, M.D., associate chief of Cardiology at the UPMC Heart and Vascular Institute, and associate professor of medicine in the Division of Cardiology at the University of Pittsburgh.

Fighting Coronary Artery Disease

Coronary artery disease (CAD) is the most common type of heart disease in the United States according to the CDC. CAD is caused by the buildup of plaque deposits inside the walls of the arteries that supply blood to the heart. Over time, the plaque deposits cause the arteries to narrow, reducing the flow of blood. CAD can cause chest pain, or angina, and can lead to heart attack and heart failure.

The non-surgical placement of stents inside the arterial walls has been a common treatment for a number of years. However, the metal stents restrict vessel movement and limit future treatment options. Furthermore, late re-narrowing of the artery can occur in the segment caged by the metaling implant.

Doctors at AGH and UPMC are using a new implantable stent called the Absorb GT1 Biodegradable Vascular Scaffold System (BVS), a first-of-its-kind device recently approved by the FDA.

The Absorb GT1 BVS is made of naturally resorbable material that disappears in about three years, leaving behind a restored vessel, free of a permanent implant. The BVS is coated with a drug that prevents the re-narrowing of the vessel over time.

"The most effective and safe means of restoring natural blood vessel function in the setting of coronary disease is ultimately a treatment that leaves nothing behind in the vessel," said David Lasorda, D.O., director of Interventional Cardiology at AGH. "There has always been a desire to find a better way to accomplish the pivotal short-term function of stents, without the possible long-term complications of permanent stents. The Absorb stent moves us toward that goal."

Catalin Toma, M.D., director of Interventional Cardiology at the UPMC Heart and Vascular Institute and assistant professor of medicine at the University of Pittsburgh School of Medicine, said "The results obtained with the Absorb BVS are excellent and comparable to the current generation drug-eluting stents platforms with proper implantation technique. Current metallic stents, although performing exceedingly well, result in a permanent solution which has been linked in some cases to late events and re-narrowing of the vessel in the stented area."

Enhancing Care for Patients

Several new developments at AGH are also enabling enhanced treatment of heart disease and care of heart patients.

Last January, AGH unveiled a new 48-bed Critical Care/Telemetry Unit for the care of cardiovascular patients, including 24 critical care beds and a 24-bed monitored step-down unit.

"The new 48-bed unit has been a great investment in the care of cardiovascular patients," said Dr. Murali. "It brings new technology to the bedside, allowing us to practice multidisciplinary team care and minimize the risk of moving patients to other parts of the hospital for testing."

AGH also opened a new electrophysiology lab for the treatment of heart arrhythmias featuring a low-radiation, three-dimensional navigation system called MediGuide. The lab also features the use of ultrasound to reduce the exposure to radiation during lengthy procedures.

"MediGuide is like the GPS system in a car that enables navigation of devices on a pre-recorded X-ray image helping to identify and place catheters at the precise location of the heart rhythm irregularity," said Dr. Murali. "Using this advanced technology we have limited radiation exposure and achieved cure rates approaching 70 per cent for patients with atrial fibrillation."

With the most advanced heart care available at institutions such as AGH and UPMC, western Pennsylvania residents can count on access to the latest technology in the treatment of heart conditions.

"This is an exciting time to be in the medical field when we have these new technologies to help improve the quality of life for people with serious heart conditions," said Dr. Bailey.

For more information about these advanced medical technologies, visit www.ahn.org and www.upmc.com.

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