Healing Hearts in the Hills
Oct 29, 2016 11:25AM ● Published by MED Magazine
Gallery: Healing Hearts in the Hills [4 Images] Click any image to expand.
By Alex Strauss
Right Place, Right Time
When cardiologist Bhaskar Purushottam, MD, was completing his fellowship training in Endovascular & Structural Interventional Cardiology at Mount Sinai Medical Center in New York in 2015, he never imagined that, less than a year later, he would be the first to bring an important new cardiac advance to the state of South Dakota.
But this spring, Dr. Purushottam, who had joined Regional Heart Doctors just eight months earlier, became the first physician in the Dakotas to implant the world’s smallest heart pump, Abiomed’s Impella RP, into the right ventricle of a Rapid City patient. Even the Mayo Clinic had not yet offered this procedure when Dr. Purushottam performed it at RCRH in May.
“The patient came in with a blocked artery and in a critical state. He was sent for an emergency bypass but in the meantime went into cardiac arrest and had to be resuscitated,” recalls Dr. Purushottam. “After the bypass, he wasn’t doing well. He was on vasopressors to get his blood pressure up, but the right side of the heart was just so inflated that it wasn’t working.”
Right heart failure typically carries a mortality rate of 60 to 70 percent and the situation had, indeed, begun to look grim for Dr. Purushottam’s patient. Jaundice had set in as his liver and kidneys shut down from lack of adequate blood supply. The damaged right ventricle was not healing on its own and the team was running out of options and time.
Fortunately for the patient, during his cardiology fellowship at Einstein Medical Center in Philadelphia, Dr. Purushottam had been trained in the use of an advanced new device designed to take the burden off a damaged right ventricle for up to 14 days to facilitate healing. The Impella RP catheter device sits across the right ventricle and delivers blood from an inlet in the inferior vena cava to an opening near the tip of the catheter in the pulmonary artery. The pump, which was granted a Humanitarian Device Exemption by the FDA in 2015, can be deployed through a standard catheterization procedure through the femoral vein without the need for an incision.
Dr. Purushottam was convinced that the procedure was his patient’s best hope and Regional’s administration quickly agreed. The final hurdle was to convince Abiomed.
“The device is still in its baby stages, so if there are too many negative outcomes, it might jeopardize its chances for approval,” says Dr. Purushottam. “I called the company and told them that I had a patient that I thought could truly benefit and was not improving with medication, that I had had experience with the device, and that I would appreciate it if they would let me do this. This was a huge decision but, thankfully, it was approved very quickly, which made all the difference.”
The device was shipped to RCRH overnight and, in 24 hours, Dr. Purushottam was taking his patient into the cath lab with an Abiomed representative at his side. Within three days, it was clear that it had been the right call.
“This was enough time for the heart to shrink in size and let the healing happen,” says Dr. Purushottam. “We were able to take him off the blood pressure medicine and he is doing phenomenally well. I have trained in big centers like Mount Sinai and this patient’s story is miraculous. To put it in layman’s terms, he kissed death and came back.”
Although there are other pumping options for right heart failure, the Impella RP’s tiny size means that it can be inserted without incision, minimizing the risk of complications and setting a new standard for minimally invasive heart care.
“For patients on whom we had nearly given up, this tool gives us a new hope,” says Dr. Purushottam.
Pacemaking Without Leads
Just three months after Dr. Purushottam implanted the region’s first Impella RP in his patient’s right ventricle, his colleague, cardiologist/electrophysiologist Kelly Airey, MD, who joined the practice in April of 2014, performed a first of her own. On August 23rd, Dr. Airey became the first in the Dakota’s to implant the world’s smallest minimally invasive pacemaker, the Micra Transcatheter Pacing System from Medtronic, which was FDA-approved last April.
At less than two grams, the system is a tenth of the size of a conventional pacemaker - about the size of a large vitamin tablet - making it easier and quicker to implant than a traditional system. The entire 1-inch-long system is completely self-contained within the heart, including the battery, and attaches to the heart wall with small tines. But Dr. Airey says what may be even more important about the Micra is the fact that it uses no leads.
“The problem with leads is that they can wear over time because of constant stress,” says Dr. Airey, who did fellowship training in Cardiovascular Diseases at the University of Nebraska Medical Center and in Clinical Cardiac Electrophysiology at the University of Utah. “They can wear down in ten to 15 years. It is possible to extract them, but that is risky. The more leads a patient has, the more likely they are to develop an infection. And, because these are foreign bodies they can become encapsulated by scar tissue and even occlude blood vessels.”
In the case of the region’s first Micra Pacemaker recipient, the leads were indeed the problem. The 94-year-old patient’s leads had failed. Dr. Airey had tried to place a new lead from the chest a year earlier but could not get a lead across the patient’s artificial tricuspid valve from that angle.
“The only other option was to put the lead on top of his heart and tunnel it through his chest wall up to the pacemaker in his shoulder,” says Dr. Airey. “That was the best option I had until the Micra came along and I was able to put it in through the femoral vein in about 30 minutes.”
Without the need to create a pocket to hold the pacemaker, the procedure is faster and easier on both doctor and patient. And because there is no incision to heal, the Micra reduces the need for restricted activity after implantation. It also reduces the risk of inadvertently collapsing a lung while attempting to run leads across the lung to the heart from the shoulder area. The device self-adjusts to match heart rate with activity level.
According to Medtronic, the Micra Pacemaker is indicated for patients with symptomatic paroxysmal or permanent high grade AV block in the presence of atrial fibrillation, or in the absence of AF as an alternative to dual chamber pacing when atrial lead placement is considered difficult, risky or unnecessary. Patients with symptomatic bradycardia-tachycardia syndrome or sinus node dysfunction may also be candidates. The initial trial of about 700 patients who received Micra Pacemakers demonstrated a 48 percent reduction in complications compared to a similar transvenous pacemaker with leads.
Dr. Airey, who estimates that she sees one or two patients a month in her practice who could benefit from the Micra, worked closely with Medtronic to help bring the procedure to RCRH. “Another great thing about this procedure is that patients can go home the same day,” she says. “With a standard pacemaker, we typically keep them overnight.”
Dr. Airey says miniaturization is likely to be the future of pacemaking technology. The Micra is one result of Medtronic’s decade-long commitment to what it calls “deep miniaturization”, an effort to reduce medical device sizes by up to 90 percent. The company is currently developing technology similar to the Micra for the atrium.
A New Direction for Heart Surgery
Cardiothoracic surgeon Zahir Rashid, MD, has been a part of Regional Heart Doctors for just seven months but, already, he has introduced several new approaches to the surgical treatment of heart patients at RCRH.
One of the most notable is the ability to perform mitral valve and aortic valve replacements through small incisions between the ribs, eliminating the need for sternotomy in certain patients and dramatically reducing risk, pain, and recovery time.
“Mitral valve operations have been done with small incisions in the right chest for years,” says Dr. Rashid, who was fellowship trained in Thoracic & Cardiovascular Surgery at the Medical College of Wisconsin in Milwaukee. “The difference now is that the incision is even smaller. The technology is better and we have improved the technique. Now, anything on the right side of the heart like a tricuspid valve or the removal of a tumor from the right or left atrium, we can do without a sternotomy.”
Dr. Rashid was the first to perform a minimally invasive procedure to replace a patient’s diseased aortic valve through the right chest at RCRH and says this surgical technique may be particularly appealing to women and younger patients since the tiny scar can easily be hidden under the bra line. For patients suffering from atrial fibrillation, Dr. Rashid offers the Maze ablation procedure through a small incision on the right side.
New technology has also made the left side of the heart more accessible. Another first for Dr. Rashid at RCRH is minimally invasive coronary artery bypass from the left side of the chest, a procedure that may be recommended when there are blockages in one or two coronary arteries, usually in the front of the heart.
For certain heart patients, the availability of minimally invasive cardiac surgery locally is about more than faster recovery and smaller scars. “The biggest benefit is for people at highest risk such as those with multiple comorbidities, people who have had a previous sternotomy, or elderly people with a condition like COPD or emphysema,” says Dr. Rashid. “With a minimally invasive approach, we don’t compromise lung function with a big incision.”
National figures show sternotomy patients spend 5 to 10 days in the hospital and do not return to work for two or three months. In contrast, patients who undergo minimally invasive cardiac surgery stay in the hospital only three to five days and can usually resume normal activities in four to six weeks. Recently, an 83-year-old female patient of Dr. Rashid went home just three days after undergoing minimally invasive bypass surgery.
“Hospital stays for me and my partner are down. We are trying to change the culture and show that people can go home earlier,” he says.
Although minimally invasive cardiac techniques present more challenges for the surgeon than sternotomy, it seems apparent that the region was ready for the new surgical options RHD is offering, RCRH’s volume of heart cases climbed by 40 percent over the previous year during the first quarter after he joined the practice.
“I think we are making good progress,” he says. “Everyone has a role to play in making it happen.”
In addition to the team of board certified physicians, Regional Heart Doctors includes Certified Nurse Practitioners, a Certified Physician Assistant, and an extensive support staff. Many team members are involved in cardiovascular research and the group works closely with a nationally accredited laboratory which is also located on site.