Better tools and improved computer mapping technology allow for more surgical precision
Last year, Russell Vestuto told his cardiologists that he’d rather die than continue to live with a blocked coronary artery.
“The pain was so bad that I didn’t want to live with it anymore,” recalls the 69-year-old Plainfield resident.
Vestuto had developed a chronic total occlusion (CTO) of his right coronary artery, one of two that provide oxygen-enriched blood to the heart muscle. Though he’d undergone bypass surgery in 2002, it didn’t replace the amount of oxygen that the artery used to deliver to his heart. By early 2014, the pain that erupted every time he moved had forced him to quit his job at a garden center and live as an invalid, unable to perform even light household chores without provoking angina attacks.
For years doctors had told Vestuto that his blockage was impossible to remove because the coronary arteries are narrow and run along the outside of the heart, making surgery too risky and difficult to attempt. But a new procedure using state-of-the-art equipment has restored near-normal heart function to many CTO patients and is giving hope to many more.
“We have options for patients now that we didn’t used to have a year ago,” asserts Dr. Mark Goodwin, medical director of the cardiac catheterization lab at Edward Hospital. “It’s really dramatic how much their lives improve after their coronary arteries are unblocked.”
Goodwin cleared Vestuto’s artery by inserting two catheters — one in the left femoral vein and one in the right femoral vein — and guiding one of them to the front of the blockage and the other through the heart to the back of the blockage. “These catheters have been developed to go through the tiniest branch arteries,” explains Goodwin. “That enables us to reach both sides of the blockage and push through it. It’s almost like running dental floss through the heart.”
Vestuto woke from the surgery a changed man. “Believe me, the difference was night and day,” he says. “One minute you’re in bad shape, the next, it’s over and done with. The chest pain was totally gone. It’s unbelievable.”
Surgeons can tip the catheters with tiny lasers or diamond drills to remove plaque from the blockage, making it easier to push through, Goodwin notes. Once the artery is cleared, the surgeon inserts a medicine-coated stent to hold it open so that it doesn’t collapse or collect more plaque.
Only about 80 interventional cardiologists in the U.S. are qualified to use these new CTO-clearing procedures, says Dr. Parag Doshi, medical director of cardiology at West Suburban Medical Center in Oak Park and founding director of the Chicago Cardiology Institute. “This is the last frontier of interventional cardiology,” he says. “We are able to help a lot more people for whom nothing could be done before, but there are risks. Using lasers to clear a blockage presents difficult challenges. Without training and experience, the cardiologist can tear the coronary artery, which requires stopping the procedure and performing an emergency bypass. Patients who are considering this procedure should look for a board-certified interventional cardiologist who performs at least 75 PCI (percutaneous coronary intervention) procedures a year.” Both Doshi and Goodwin teach the new techniques to other cardiologists, both at their respective hospitals and at conferences around the country and abroad.
“We are working to spread these skills because all patients should have access to these procedures,” Doshi asserts.
New atrial fibrillation patients also have new hope for a cure — or, at worst, escaping the cost and disappointment of failed procedures when a cure is still out of reach. Several new imaging technologies and surgical tools are taking much of the guesswork out of the treatment process, doctors agree.
“We’ve developed a novel way to view atrial fibrillation,” explains Dr. Smit Vasaiwala of Loyola University Medical Center in Maywood. “For the first time we can see the mechanics of a-fib as it happens.”
A normal heart draws blood from the pulmonary arteries into the right atrium, which pumps it down into the right ventricle. From there, the ventricle sends it through the lungs to pick up oxygen. The oxygenated blood then returns to the heart through the left atrium, which pumps it into the left ventricle, which empties it into the aorta to circulate through the body.
Atrial fibrillation, one of the most common heart rhythm abnormalities, happens when heart cells spontaneously generate electrical signals that interfere with the network of signals that coordinates the heart’s pumping action. When the signal disruption is strong enough, the two atrial chambers of the heart stop beating properly, which slows the passage of blood from the atria to the ventricles. Consequently, the lungs have a harder time transferring oxygen to the blood cells, and the heart struggles to send blood throughout the circulatory system. The end result is that the patient suffers from constant low-level oxygen debt, limiting his ability to perform physically energetic tasks.
“We don’t know yet why some heart cells decide that they want to be electrical cells and start sending rogue signals, but at least we can now see which ones are doing it,” says Dr. Andrew Rauh, a cardiologist with DuPage Medical Group and Elmhurst Memorial Hospital. “Then we can target these cells, called rotors, and block the signals that are causing the problem.”
Surgeons block rogue electrical signals with ablation, which involves surrounding the rotor cell clusters with tiny rings of scar tissue that prevent the signals from reaching other parts of the heart. Unfortunately, patients whose atrial fibrillation wasn’t caught early usually redevelop the condition even after undergoing the ablation procedure. Loyola University Medical Center is pioneering the use of delayed enhancement MRI technology to gauge patients’ chances of maintaining a normal heart rhythm after ablation surgery.
“Prolonged a-fib creates scarring in the wall of the left atrium. The more scarring a patient has, the less effective ablation will be,” Vasaiwala explains. “DE-MRI can show us how much atrial fibrosis (scar tissue) a patient has, which gives us an indication of whether the patient will benefit from ablation.”
For years, surgeons performing ablation procedures simply targeted those parts of the heart known to be prone to developing rotor cells because they had no way of pinpointing where in each patient’s heart the rotors actually were. Now a new 64-electrode sensor called the Topera mapping system can display a near-real-time map of all the electrical activity going on in the heart, including the location of all rotor cells. Just before ablation begins, doctors insert the sensor through a catheter and guide it to the affected atrium. The sensor then opens into a basket that cradles the atrium, while the electrodes transmit information about the electrical signals to a computer that translates them into a three-dimensional map of the heart’s electrical network.
“You can see the a-fib currents spinning around on the screen. That’s why we call them rotors,” Vasaiwala notes. “Now we’re able to terminate the actual sources of the bad signals in half the time and with less tissue damage than just ablating every possible source.”
Another “best guess” aspect of traditional ablation surgery is how much scar tissue the ablation technique — usually a radio frequency pulse — is creating. “We want the lesions (scar tissue rings) to be deep enough to block the electrical signals, but not so deep that they damage the heart wall,” explains Dr. Andrew Lawrence, a cardiac electrophysiologist at Adventist Hinsdale Hospital. “With a standard RF ablation catheter, we can make a lesion, but we have no idea if it will be effective because we don’t know how much pressure we’re applying to the heart tissue. Sometimes we would burn for a long duration and not get good results because we were too far from the tissue to make the lesion deep enough.”
Last November, Lawrence and Dr. Francisco Aguilar performed the first ablation surgery in the Chicago area using the TactiCath Quartz ablation catheter, which the Food and Drug Administration approved in October. The catheter transmits information to the surgeons about its angle relative to the heart wall and the amount of pressure it’s exerting on the tissue.
“Using the feedback from the catheter, we can change the angle and the pressure to make the lesions exactly the right depth,” Lawrence asserts. “The patient benefits because we’re not pushing too hard and risking puncturing the heart wall, which is a major complication; because we can make fewer, more effective lesions that reduce the chances that the a-fib will recur; and because we can shorten the procedure and keep the patient under anesthesia for less time.”
Even patients whose atrial fibrillation is too chronic to respond to ablation can benefit from a new treatment designed to prevent a-fib related strokes. Chronic a-fib sufferers must take blood thinners, such as Coumadin, Pradaxa and aspirin, because the weakness of their atrial pumping action lets blood pool in a small pouch called the left atrial appendage. The stagnant blood clots, putting patients at risk of stroke if the clots escape the appendage and enter the bloodstream. The downside is that blood thinners increase the patient’s risk of internal hemorrhage after an injury, as well as causing chronic fatigue, bruising and other side effects. Adding insult to injury, patients on Coumadin — the most commonly prescribed blood thinner — must have their blood drawn weekly or monthly to have their clotting factors tested and their dosages adjusted.
Last year, Loyola cardiologists introduced the Lariat procedure in which surgeons use catheters to tie off the opening to the left atrial appendage so that less blood can get in and no clots can escape. The patient can then discontinue using blood thinners. “It doesn’t cure the a-fib, but it reduces bleeding risks and improves patients’ quality of life,” Rauh states.
Another advance that’s improving patients’ quality of life is the CardioMEMS implantable blood pressure monitor. Anchored in the pulmonary artery of a patient with chronic heart failure, it relays that patient’s pulmonary artery pressure wirelessly to the patient’s cardiologist. Changes in pulmonary artery pressure often signal heart failure complications that can require long hospital stays to treat if not caught early, says Dr. Maria Costanzo of Edward Hospital.
“When a patient’s condition changes and his medications are no longer at the appropriate dosage, the blood pressure in the pulmonary artery rises well before the patient experiences symptoms,” Costanzo explains. “At that point, we can’t avoid hospitalizing the patient, but if we begin to treat the problem when the pressure starts to rise, we can resolve it quickly without hospitalization.”
The tiny CardioMEMS monitor stores pressure readings until the patient “downloads” them by lying on a pillow that contains a receiver/transmitter. After receiving the data from the monitor, the device transmits it to the cardiologist’s office, where staff can read it and alert the doctor to any changes, Costanzo says.
Clinical trials last year showed that using the CardioMEMs monitor reduced patients’ overall hospital admission rates by 37 percent and their 30-day re-admission rates by 20 to 30 percent, says Costanzo. The FDA approved the devices last fall.
“There’s a close relationship between reduced heart failure episodes and reduced mortality rates,” notes Costanzo. “By catching changes in patients’ conditions
as early as possible, we’re helping them extend their lives as well as live them outside of a hospital.”
Newer implanted devices help restore quality of life
When left ventricular assist devices (LVADs) first hit the headlines in 1988, they were billed as a last-ditch effort to keep end-stage heart disease patients alive while they waited for heart transplants. Now the new, third-generation LVADs are starting to replace heart transplants, as new technologies make them less intrusive and more effective.
“Heart transplants are not the answer because there just aren’t enough donor hearts to go around,” asserts Dr. Andrew Rauh of DuPage Medical Group. “An LVAD won’t help a heart failure patient as much as a completely new heart will, but they are getting more patients back to a more normal life.”
With 670,000 new heart failure cases diagnosed each year, 300,000 end-stage patients who urgently need heart transplants, and only about 2,300 donor hearts available each year, living long enough to get a new heart is less likely than winning the lottery, agrees Dr. Edwin McGee of Loyola University Medical Center. “As people live longer with heart failure, LVADs have gone from being primarily a bridge to transplant therapy to a destination therapy,” he remarks. “They don’t cure heart failure, but they do slow the disease’s progress and they can prolong a patient’s active life.”
An LVAD consists of a small electrical pump that attaches to the left ventricle and to the aorta. When the ventricle contracts, it pushes blood into the LVAD, which re-pumps it at a higher pressure into the aorta. Powered by a battery pack worn by the patient, the LVAD increases blood flow throughout the body, oxygenating organs and muscles so that they can function properly.
The first LVAD versions imposed significant restrictions on their users. Doctors had to make a pocket in the abdominal wall to hold the pump that sometimes became infected, requiring extra surgeries to treat. The power cord, which leads from the pump through the chest wall to the battery pack, was short and thick, and the battery pack itself was bulky and heavy. The device effectively confined most patients to their beds even after their circulations improved.
Over the last decade, LVADs have become lighter, sleeker and more manageable. “When I trained in LVAD implantation 12 years ago, the power wire was as thick as my thumb,” McGee recalls. “Five years ago, it was as thick as my little finger. Now it’s about as thick as a [computer] mouse cable. That really makes a big difference to patients.”
The battery pack has shrunk to a 10-lb box about the size and shape of a cassette tape, so patients can comfortably carry it with them in a fanny pack. “You can play sports, run, walk or do anything else with it except swim,” says McGee. “Some of my younger patients have gone back to work after getting their LVADs. Usually patients can lower or discontinue their medications with the LVADs, which makes them feel much better because they no longer have side effects like low blood pressure and chronic fatigue.”
Researchers are working on an LVAD version that incorporates the battery into the pump, eliminating the power cord sticking out of the body and the need to carry a separate battery pack, McGee notes. But he warns heart failure patients not to hold their breaths waiting for it.
“The fully implantable LVADs have some significant issues to be overcome, like needing surgery to replace the batteries,” says McGee. “I think it will take years to bring them to market.”
While not a replacement for hands-on resuscitation efforts, new machines can be a life-saving supplement
Cardiopulmonary resuscitation has saved the lives of many heart attack victims waiting for the ambulance to arrive. It has also caused many broken ribs and other internal damage — and sometimes it fails because the person administering it is either untrained, out of practice or just wears out after long minutes of pushing down someone’s chest over and over again.
So when the Lucas 2 artificial CPR machine became available in 2011, doctors and paramedics cheered it — even if it took a while for them to convince hospital managers to buy the $15,000 device.
“We use it and we love it,” says Dr. Mark Goodwin of Edward Hospital in Naperville, which owns one of the few Lucas 2 machines in the western suburbs. “It’s a lot more prevalent in Europe, but it’s slowly getting adopted in this country.”
The Lucas 2 works by encircling the victim’s torso and using a motor to propel a suction cup-tipped plunger to compress the chest, Goodwin explains. Once the machine senses how far the plunger is from the chest wall, it calculates how much force it needs to compress the victim’s chest the optimal 1 ½ inches to maintain adequate blood flow. Then it delivers that amount of compression with every stroke, without the inconsistencies that creep into human-powered CPR.
“When people performing CPR get tired, they get less compression depth because they’re not pushing as hard,” notes Goodwin. “Worse, sometimes they push too hard in an effort to compensate [for their fatigue], which can damage the ribs and chest. The Lucas 2 eliminates those problems.”
The suction cup makes CPR more effective because it mimics the chest’s natural rise and fall. “A lot of blood pressure is generated by the negative force of the chest expanding, not the positive force of compression,” says Goodwin. “We can’t pull someone’s chest up by hand when we’re doing CPR, but the Lucas 2’s suction cup can.”
Another advantage is that the Lucas 2 transitions seamlessly from the ambulance to the catheter lab, Goodwin states. “There’s no metal in it, so we can do angiograms and even angioplasties while it’s still on the patient, working,” he explains. “In a typical ambulance staffed by two paramedics, one can be driving to the ER while the other can put the device on the patient, then do other things to help the patient instead of just performing CPR the whole trip. Then in the ER and the catheter lab, we don’t have staff tied up performing CPR on the patient. Everyone in the room is available to help treat the patient instead of just keeping him alive long enough to treat.”
Goodwin says he hopes to see more area hospitals and fire departments make room in their budgets for artificial CPR machines. “It’s already saved lives here,” he says. “We had one patient who arrived clinically dead, with no pulse and no blood pressure. We put the machine on, worked for an hour, and the patient revived and went home.”
Having a CPR machine available in their communities should not discourage west suburban residents from learning to perform CPR, cautions Goodwin. “The most important thing is for everyone to take a CPR course,” he says, “because you never know when someone around you is going to need it.”Edit Module