To meet the growing demand for diagnosis and treatment of cardiovascular diseases, Eisenhower Health’s Cardiac Service Line is undergoing a $155 million expansion for the new Eisenhower Cardiovascular Institute — to integrate and streamline imaging, procedures, diagnosis, treatment and patient care; to expand procedural and surgical areas; and to create a new space for cardiac and pulmonary rehabilitation.
In this Physicians’ Roundtable, Eisenhower physicians discuss the importance of this much needed expansion of cardiac services, as well as cutting-edge treatments, new technologies and procedures. Our panel of experts includes Daniel Logsdon, MD, Cardiac/Thoracic Surgery; Joseph Wilson, MD, Board Certified in Cardiac/Thoracic Surgery; and Philip Patel, MD, Board Certified in Cardiovascular Disease, Echocardiography and Nuclear Cardiology, and President of Eisenhower Desert Cardiology Center. Justin Thomas, MD, Board Certified in Pulmonary Disease, Interventional Pulmonary Disease, Internal Medicine and Critical Care Medicine, moderated the discussion.
DR. THOMAS: What is the strategic plan for the future of the Eisenhower Health Cardiovascular Institute at Eisenhower?
DR. PATEL: As a result of our ongoing growth, we have had a continuous need to recruit additional high quality cardiologists to help service our growing patient population. As more patients are seen, the need for increased diagnostic testing space has become paramount. Because of this, we are in the process of developing a larger footprint to meet these increasing demands. This means consolidating diagnostic testing to a centralized area as well as bringing all facets of cardiovascular medicine, including cardiothoracic surgery and vascular surgery, under one roof.
DR. THOMAS: What types of diagnostics will be available?
DR. PATEL: In cardiology, diagnostic testing is essential to diagnose cardiovascular disease and then manage and monitor that disease progression. Imaging of the heart and the body’s vascular system is fundamental in the initial diagnosis of cardiac issues for all patients. Ultrasonography of the heart utilizes echocardiography. Ultrasonography of the vasculature utilizes vascular imaging. We use both of these modalities daily and we plan to expand their utilization even more in the future. Provocative testing is also key in the determination of the patient’s symptoms. In the evaluation of coronary artery disease, we search for ischemia, or decreased blood supply to the heart muscle by utilizing stress testing. Stress testing can be two types, either via exercise or via pharmacologic means. We often couple some type of imaging with the stress test to increase our sensitivity and specificity of picking up true disease. We currently utilize myocardial perfusion imaging with nuclear stress testing or we use echocardiography for stress echocardiograms. For monitoring, we have pacemakers, Holter monitoring, EKG and other technologies, but all of those require space and technicians. The more we grow, the more the demand for those services. The facility expansion will add more diagnostic testing equipment, allowing us to increase our diagnostic testing capability.
DR. THOMAS: Dr. Wilson and Dr. Logsdon, would you comment on the importance of teamwork, both from a physician standpoint, and from a patient perspective, as far as how the expansion will improve things moving forward?
DR. WILSON: The Cardiovascular Institute’s original idea was based on the fact that as technology improved and physicians currently perform the same procedures in two or three different places, we need our cutting-edge technology available for everyone to use in the same place. We have a beautiful hybrid operating room that we’ve been using for about five years which is bursting at the seams with regard to availability. One component of the expansion is building a hospital inside a hospital, so to speak, with seven operating rooms, three electrophysiology hybrid labs, a vascular lab and a cardiac or thoracic operating room.
As we surgeons and cardiologists — especially the structural and interventional cardiologists — have started working together more and more, the effects of the quality we can bring to the patients has really taken off. We have conferences for cardiac disease, coronary artery disease and valvular disease, where we meet together and discuss patient cases. The Cardiovascular Institute will strengthen this bond for improving the quality of patient care with physicians being in the same place as well as testing being done in the same place.
DR. LOGSDON: I would like to echo what Dr. Wilson said. The purpose of an institute is to bring together all of the clinicians who take care of a patient and to look at that patient across their lifespan. With the technologies that are advancing, it is no longer a conversation of how many valve replacements this patient may have, or who’s going to do them. The conversation now is when we will do them and how we plan for the next 30 or 40 years of that patient’s life.
The multidisciplinary meetings we have with our cardiology colleagues, with our nursing colleagues and with our interventional ICU colleagues have really allowed us to focus on the unique aspect of each patient and what benefits them across their lifespan. I think the purpose of an nstitute is to bring together the treatment group, the clinicians, for each patient. We can add research, advanced technology and clinical trials, all under one roof. DR. THOMAS: How might this expansion attract future staff?
DR. PATEL: Having a new, state-of-the-art facility with huge investments in technology, in addition to our current team of experts, should draw even more cardiac physicians to Eisenhower.
DR. WILSON: I agree. We have the technology and expertise for providing excellent care, and Eisenhower’s reputation echoes across the Pacific Northwest and Southern California, at the very least. Residents and fellows know about Eisenhower before they know there’s a job opportunity. Dr. Logsdon, being the newest member of our team, can talk about his impression of Eisenhower before he came here.
DR. LOGSDON: When you’re coming out of a good training program, like USC, from the cardiac and thoracic perspective, you’re looking for the group of people you’re going to be working with. When I came out here, I met with Dr. Wilson, saw the practice and met the cardiology group. And what I saw is very well-trained clinicians, all in one place. It’s difficult to find multiple specialties that have excellence in every field. I saw the potential for future growth and what is already happening in some of these programs, and I saw why this is a special place and why it will continue to attract well-trained clinicians.
DR. THOMAS: That’s a good segue into structural heart disease. We did a prior physicians’ roundtable discussing the MitraClip™ and transcatheter aortic valve replacement (TAVR). How many of these procedures have you now done?
DR. PATEL: We’ve performed well over 500 TAVRs, more than 100 MitraClip procedures and placed almost 500 WATCHMAN devices. We’ve also included patent foramen ovale (PFO) [hole in the heart] closure in our structural
heart program. Structural heart intervention is doing catheter-based therapeutic delivery of these techniques. There’s tremendous work on the treatment of atrial fibrillation with ablations, both endovascularly, as well as combination or hybrid procedures being done with the electrophysiologist and the cardiothoracic surgeon. The beauty of this field is that it’s really expanding.
DR. THOMAS: Describe TAVR for our readers. What is it used to treat?
DR. PATEL: TAVR — transcatheter aortic valve replacement — is used for diseases of the aortic valve, specifically aortic stenosis. Traditionally, that was done via open heart surgery. Initially TAVR was reserved only for the sickest people, the highest risk patients who were actually turned down for surgery — patients who had no other option. TAVR has worked really well worldwide. [Clinical trials] are now including an intermediate risk group, with the possibility of an even lower risk group.
Typically, we use the transcatheter approach via the femoral artery. However, if some patients have very poor lower extremity vasculature, we can deliver the valve using an alternative mode —going in from the carotid artery. We are one of the largest centers in the country doing TAVRs via the carotid approach.
DR. THOMAS: What are the symptoms of someone with aortic valve problems? What are the causes?
DR. LOGSDON: Aortic stenosis often has an insidious onset. It may happen over the course of a couple of years. Typically, we attribute it to aging; however, most people should still be fairly active in their 70s, even into their 80s. Patients may have symptoms of fatigue and shortness of breath. Usually by the time they start to show signs of heart failure — some swelling in the lower legs or continual shortness of breath that’s been there for weeks to months on end — they’ve probably already seen a physician.
Our goal with the TAVR program is to catch these patients before they start to develop those types of symptoms, to catch them as they’re starting to progress. If you look at the data with earlier intervention on these patients, they have better, longer-term outcomes. One of the things we’re working on is how to recognize these patients. How do we inform primary care physicians of these subtle symptoms, get them a referral and get them worked up with our team here at Eisenhower? We are a TAVR benchmark site for Edwards Lifesciences, which means we’re leaders in best practices in TAVR performance. If you look at our outcomes, we’re a leader across the board.
DR. THOMAS: That’s fantastic.
DR. LOGSDON: In the future, you’ll see other hospital groups coming to learn from us. Dr. Patel mentioned the transcarotid approach to TAVR. If a patient is unable to have the procedure done through their femoral arteries, which is our preferred route, we are a leading site and a training site for accessing the carotid arteries.
DR. THOMAS: At what point would you decide a patient may not be a TAVR candidate and instead need a traditional aortic valve replacement?
DR. LOGSDON: I think this comes back to the point of having a multidisciplinary team where we look at the unique patient, the lifespan of the valves in that patient, and our expectations. Our job as surgeons and cardiologists is to figure out the best way to keep this patient from progressing with aortic valve disease across their lifetime.
We consider younger patients (under the age of 70) for traditional valve replacement surgery because we know the lifespan of these valves is somewhere around 10 to 15 years. The data is still coming out. We consider patients who may not fit a TAVR valve, who may not have the ideal anatomy within their aorta. We also look at patients who have an aortic valve that’s too small for their body size. When we replace it, sometimes we’ll have to enlarge their aortic root to fit a larger valve. We don’t consider it to push the patient toward surgery, but to set them up with one surgery that allows them to prevent future surgical interventions as they age. If we’re able to do a surgery when they’re younger, they can typically avoid surgery later in life.
DR. THOMAS: Let’s talk about the WATCHMAN device. What is it?
DR. PATEL: The WATCHMAN device is a type of LAAO therapy— left atrial appendage occlusion therapy — and is a procedure used to close off the left atrial appendage in patients who have atrial fibrillation. The left atrial appendage is a little pocket in the left upper chamber of the heart. It usually doesn’t cause any problems unless you’ve developed atrial fibrillation. During atrial fibrillation, 90 to 95 percent of all blood clots form within the left atrial appendage and can dislodge from the appendage and travel to the brain causing a stroke. Therefore, patients with atrial fibrillation have an exceedingly higher risk of stroke, requiring lifelong therapy with an anticoagulant or “blood thinner.” However, there are many patients who cannot take blood thinners. In this subset of patients, LAAO therapy has been beneficial. The WATCHMAN device is a type of LAAO therapy in which a small filter basket is placed via catheter based approach from the right femoral vein, up the inferior vena cava into the left atrial appendage. This procedure mitigates the patient’s risk of stroke, and in all of the trials published worldwide, WATCHMAN device therapy has been shown to be equivalent to anticoagulation therapy. At Eisenhower, we have implanted almost 500 devices and we are currently the third largest WATCHMAN implanting center in Southern California.
DR. THOMAS: Dr. Logsdon, tell us about atrial fibrillation.
DR. LOGSDON: Atrial fibrillation is a rhythm disorder of the heart and there are many causes. They can be heart valve related. They can be idiopathic related, meaning it is caused by something that we haven’t detected. What we do know is that patients are often asymptomatic with atrial fibrillation. The reason for this concern is that atrial fibrillation allows the blood to move slowly through the heart, which can lead to clotting in the heart, which can lead to strokes.
So, it’s important to identify and treat it early.
The treatment options for atrial fibrillation have advanced over the last decade to where we’re aggressively attempting to rewire the heart through ablation procedures to try to return the patient to a normal sinus rhythm [cardiac rhythm]. One of the things surgically that we do along with the WATCHMAN device is place an atrial clip to the appendage. During our open surgical procedures, we’ve adopted the placement of an atrial clip on almost 100 percent of our patients.
We know the rate of atrial fibrillation after open heart surgery is not insignificant. And so we’ve begun placing atrial clips on those patients in the operating room prophylactically, and there’s new data coming out that it’s an appropriate treatment option and actually prevents future strokes.
Some patients may not be able to tolerate the anticoagulation and the antiplatelet medications required after placing the WATCHMAN device, or the anatomy is not appropriate with a WATCHMAN device such that it can’t be placed. In that case, we can do what we call an isolated appendage clip placement. We do that through a small procedure in the left chest that involves a camera and a couple of small incisions. We’re able to place the clip and usually discharge the patient home the next day after surgery. The clip provides them with the ability to prevent future strokes and possibly come off of future anticoagulation medication following a conversation with their cardiologist.
DR. PATEL: There are pros and cons for each procedure, and that’s where collaboration works really well. This is so important because atrial fibrillation is the most common arrhythmia affecting patients over the age of 65. According to American Heart Association data, just last year, two to two and a half million people per year were getting it. Currently, high blood pressure is the number one cause of stroke. Atrial fibrillation is the number two cause of stroke, and in our patient cohort here, they often have both. That’s why we have a tremendous expansion of atrial fibrillation therapies, not just the WATCHMAN, which prevents and mitigates stroke, but the ablation techniques and convergence procedures our electrophysiology doctors are doing.
DR. THOMAS: Is age the only risk factor for atrial fibrillation?
DR. PATEL: Age is a common risk factor but there are younger patients who get atrial fibrillation. There is a genetic predisposition. Some people have it in their families. And there are certain triggers —alcohol is a very big trigger. Excessive caffeine utilization is a big trigger, as are amphetamines taken for weight loss. Any type of physiologic stress is a trigger. One of the biggest physiologic stresses is where patients say they wake up in the morning with fast heart rates because in the night they have sleep apnea and develop periods of hypoxia which triggers the atrial fibrillation. Some people are just more predisposed than others.
DR. THOMAS: Let’s switch gears and talk about coronary artery disease. What is the indication for coronary stent placement? What determines whether you place a stent or a balloon?
DR. PATEL: The indication to do a percutaneous coronary intervention (PCI), either balloon or stent, is if the patient has symptoms from coronary disease. If a patient has ischemia [reduced or restricted blood fiow], we can also procced with PCI. We determine the patient’s ischemic burden by utilizing some form of provocative or stress testing as I mentioned earlier. If we have positive results from stress testing, we often proceed with PCI. Alternatively, if the patients continue to have a higher symptom burden, we will also consider PCI.
DR. THOMAS: With coronary disease, when do you involve a surgeon?
DR. PATEL: It depends upon where we find the disease. When I talk to patients, I tell them there are four possible outcomes of a coronary angiogram. The first is that we don’t find anything, which is wonderful. The second is that we find one single blocked vessel that we can open with either angioplasty or a stent. The third possibility is we find disease in critical areas that are best treated with bypass surgery. The fourth outcome is that we find disease everywhere, which we call diffuse disease. In that case, we only treat with medical therapy. So, it depends on what we see at the time of the coronary angiogram. If there is significant or critical disease in the left main coronary artery, those are primarily treated by surgical techniques.
DR. THOMAS: Dr. Wilson, what does a coronary bypass entail?
DR. WILSON: Coronary artery bypass graft surgery, or CABG [pronounced cabbage] as it’s usually called, is a procedure where conduits, which are harvested from different parts of the body, usually the veins in the leg, or a mammary artery on the inside of the breast bone, are used to provide blood fiow to one of the three major arteries— or possibly all three of the major arteries, to bring blood past the blocked area. That has not changed since it was first introduced, although techniques have improved. Advancements have been made in CABG, especially in patients who have left main coronary artery disease, patients who have three-vessel coronary disease, or in patients who don’t do well with stent placement, which typically are patients with diabetes.
There have been a lot of technological advancements in CABG, including better technique to harvest the conduit so that it lasts longer. We know that grafts can last much longer than 10 years.
DR. THOMAS: That’s great news. What are some of the advantages of these improved techniques?
DR. WILSON: First of all, it doesn’t mean that patients no longer have coronary artery disease after CABG. And it doesn’t mean they won’t need further treatment, but the bypass grafts tend to last longer. We have improved technology and decreased the risk for stroke, kidney failure and bleeding complications. There’s been a dramatic improvement over the last 10 years during surgical procedures to keep patients from having blood transfusions.