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Welcome. I n This I ssue Welcome. Dear Colleague,. Balloon Aortic Valvuloplasty. Welcome to the first letter of the New Year from the Heart and Car d iovasc u lar Service Line.

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  1. Welcome • InThisIssue • Welcome DearColleague, • BalloonAorticValvuloplasty WelcometothefirstletteroftheNewYearfrom the Heart andCardiovascularServiceLine. TheMedicalCollegeofGeorgiahasa50-yeartraditionoftakingcareofchildrenwithheartproblems.Therefore,itshouldnotcomeasasurprisetoanyonethatthesechildren,nowproductiveyoungadults, looktousforcontinuity oftheircare.Thecardiovascularservice linehasahighlyspecializedteamconsistingofadedicatedcadreofphysicians,nurses,perfusionistsandaparents'grouptotakecareofthesecomplexpatients.SheldonLitwin,M.D.,ProfessorandChiefofCardiologyatGeorgiaRegentsUniversity,hasspecialexpertiseandinterestinthesubjectandhaswrittenanoverviewinthiseditionofthenewsletter.I knowyouwillfinditinterestingand informative. • BloodlessMedicine • AdultCongenitalHeart • Disease • FellowshipHighlights • Conferences MaryArthur,M.D.,AssociateProfessorofAnesthesiology,shareswithusthebenefitsofusingbloodless medicineasanalternative todonorblood.Almostevery week,we discovernew complications andsideeffects ofbloodtransfusions.Assuch,itbehoovesustouseallpossiblemeans tominimizeuseofblood and bloodproductswithout compromisingpatientoutcomes.Iampleasedtoreportthat,owingtoourevidenced­ basedguidelinesandateamofdrivenindividuals,bloodutilizationrates inourcardiac surgerypatientsareoneofthelowestinthecountry. ,_ Asweencounteranincreasingnumberofagedpatients withconcomitantadvanced diseases,wefindourselvesperforming stagedprocedurestoallowthesepatientstimetorecoverfromtheirmultipleproblems.PaulPoommipanit, M.D.writesaboutonesuch temporizing measure,balloonaorticvalvuloplasty,inpatientswithsevereaorticstenosistoo illt·oundergodefinitivesurgery.Aclosecoordinationbetweenvariousspecialistsisessentialforoptimaloutcomes. M.VinayakKamath,M.D. Director,Heart and Asalways,weare proudofourfellowsintrainingand someoftheiractivitiesare outlinedinside.Iamsureyouwillagreethat theyare allmultifacetedandtalentedindividualswithconsiderablepromise. Cardiovascular Servicesand Chief,CardiothoracicSurgery GeorgiaRegents University112015thStreetBA-4300 Augusta,GA30912 706-721-3226 kamath@gru.edu I I. Wehavea busyyear ofCMEactivitiesaheadofus(scheduleattached).Ifyouhave suggestionsfornewtopicsoradifferentformatpleaseletusknow. GHealth GEORGIA REGENTS HEART&CARDIOVASCULAR SERVICES Wishingyouandyours thebestfortheNewYear, M.VinayakKamath,M.D. Director,HeartandCardiovascularServicesandChief,CardiothoracicSurgery

  2. AssistantProfessorof Forpatientswithsevereaorticstenosis,the optionofaless-invasiveprocedureisbecomingmorecommonatGeorgia RegentsMedicalCenter'sHeartandCardiovascularCenter.Subsequently,welearnedthatrestenosiswithinsixmonthsiscommon.Today,balloonaorticvalvuloplasty isincreasinglyusedas a"bridge"tomoredefinitivetherapy. Balloonaorticvalvuloplasty(BAV)increasesthe aorticvalveareabyinflatingaballoonwithinaseverelystenoticaorticvalve.Historically,thisprocedurewasdoneinhopesofprovidingadurable,less-invasivesolutionforaorticstenosis. WiththeadventofTAVR,BAVis beingperformedmorefrequently. tolerateopen-heartsurgeryandthe decision wasmadetoperformBAVas abridgetofutureAVRorTAVR. Thepatientwasbroughttothecardiaccatheterizationlab,graciouslyprovided bythepediatriccardiovascular service.Cardiacanesthesia and hemodynamic support were provided.Transesophageal echocardiography demonstrated avalveareaof0.8-0.9cm2(severeaorticstenosis).Oneballoon inflationwas doneandrepeat echocardiographydemonstratedavalveareaof1.2cm2(moderateaorticstenosis).ThepatientthenhadaSOpercent decreaseinthepressuregradientacrossthevalve.Givenhisothercriticalillnesses,theteamdecidedtoterminate theprocedure.Thepatienthasslowlyrecoveredandisworkingwithphysicaltherapytoimprovehisconditioning. BAVforsevereaorticstenosisisusedtotemporizepriortosurgicalAVR,assessforresponseandasanalternativeinseverelysymptomaticpatientswhoarenotcandidatesforotherproceduressuchasAVRorTAVR.Amultidisciplinary approachatGeorgiaRegentsUniversityinvolvingcardiacanesthesiologists, cardiac surgeons, interventionaI cardiologists and cardiovascular imaging specialistsimprovedthe patient'squality oflife. Sincesurgicalaorticvalvereplacement(AVR)providesadurable,long-lastingsolutionforaorticstenosis,BAVhasinfrequentlybeenperformed.But,withtheadventoftranscatheter aortic valve replacement (TAVR), inwhichanaorticvalvecanbeimplantedpercutaneously, BAVisbeingperformedmorefrequently,providing analternativetreatmentforsevereaorticstenosis.AttheGeorgiaRegentsMedicalHeartandCardiovascularCenter,an84'-year-oldmanwithend-stagerenaldisease recentlyunderwent BAV.Thispatienthascardiomyopathywithanejectionfractionof30 percentandmoderateaortic stenosis.Hepresentedwithanon-STelevationmyocardial infarction,classIVheartfailureandhypotension.Acardiaccatheterization revealedsignificantcoronary arterydiseaseoftherightcoronary arteryand leftanterior descending artery.Surgerywasdeemedtoo riskysincehis EFwasnow20-25percentwithsevereaorticstenosisandseveremitralandtricuspid regurgitation. Thepatientunderwenthigh-riskstentingofhisRCAand LADandthepreviouslyplacedintra-aorticballoonpumpwasremovedthefollowingday.Weekslater,thepatientimproved,butwas stillhavingclassIII-IV heartfailure andreceivingdaily hemodialysiswhilehavirigepisodes ofhypotension.Thispatient wastoo deconditionedto -2-

  3. MaryE.Arthur,M.D. AssociateProfessor,Anesthesiology andPerioperativeMedicine BloodEnhancesOxygen Bloodenhances oxygen-carrying capacity,improveswound-clottingandprovidesvolumesupportforcardiac output.Nevertheless,moreandmorepatientsareseeking safeandeffectivealternativestobloodtransfusionsduringsurgery-evencardiac surgery-becauseofreligiousconvictions, medicalconcerns orpersonal preference. Religious objections tend to be limitedto primarycomponents(packedredbloodcells, plateletsandfresh frozen plasma)whilesecondary componentssuchasalbuminandfactorconcentratesaregenerallyacceptable. Physiciansareincreasinglyaccommodating patients'preferencesforbloodlesssurgerybecauseofmountingevidencethatbloodtransfusionsportendworseoutcomes. Minimizingbleedingandlimitingbloodtransfusions have becomeimportantelementsofquality improvementprograms. Bloodless cardiacsurgicalproceduresrequire specialexpertise, precisemonitoring,state-of-the-artequipmentand innovativetechniques. TheGRUBloodlessMedicineandSurgeryProgramwas designedexpressly forthesereasons. Why dowecare? Concernsregardingthesafetyandefficacyofallogeneic bloodtransfusions,theimpactonpatientoutcomes andtheastounding costsandchallenges associated withmaintaininganadequatesupplyofbloodproductshasrenewed aninterest in alternatives to transfusion. In additiontotransfusion-related riskssuchasinfections I respiratoryfailureandthromboembolic complications,redbloodcelltransfusions mayalter immunefunction, impactinglong-termsurvival. Whatdoweknow? Mostcardiopulmonarybypasspatientshavesufficientwound-clottingafterreversalofheparinanddonotrequire transfusion.Evidencesuggeststhattransfusionsmightnotimprovetheoutcomesofstablenon-bleedingpatientsinnearly90percentofthecommontransfusionscenarios reviewed.Transfusions areonlydeemedappropriateforpatients65andolderwithcomorbiditiesandahemoglobinof<8g/dl. Severaltoolsareavailabletoaccommodatetheneedor preferenceforbloodlesssurgery,coveringallphasesoftheprocedure:preoperative, intraoperativeandpostoperative. Howbigistheproblem? Almost 15millionunits ofpackedredbloodcellsare transfusedannuallyintheUnitedStatesduring surgery, withcardiacoperationsconsuming asmuchas15percent ofthenation'sbloodsupply.Thispercentageisgrowing,largelybecauseoftheincreasingcomplexityofcardiac surgicalprocedures. 1)Patient'sbloodcollected 2)Bloodvolumerestoredusingplasmaexpanders(Albumin,HetastarchorCrystallods). ANHAcuteNormovolemicHemodilution Oneimportantstrategyis acute normovolemichemodilution,aprocessincreasingthevolumeofthepatient's ownstoredbloodusingexpanderssuch asalbumin,hetastarchandcrystalloids.The 1bloodisreturned, tubingremainsconnectedtothepatientat 3) OffCPB, thepatient's alltimes,maintainingaclosedcircuit.The patient'sstoredblood,whichhasallthe connedionmaintains majorclottingfactorsaswellasplatelets,is closedcircut. returnedtothepatientafter weaningfromcardiopulmonarybypass. -3-

  4. How doweinvolvethepatient? Beforesurgery,amemberofthebloodconservationteamgivesthepatientaformlistingallthefactorconcentrates. Thepatientthendecideswhichconcentratescanbeused duringtheprocedure. Our multidisciplinary blood management teamworkstogetherto limitblood transfusions anddecreaseperioperative bleeding while still maintaining safe outcomes.AtGRU,about25 inpatientandoutpatient casespermonthutilizebloodlessmedicinetechniquesacrossallspecialtyareas. Foursuccessfulbloodlesscardiacsurgeryprocedureshavebeendoneinthelastfew months. Morethan 180community members attended aBloodlessMedicineandSurgeryProgramseminarlastfallhighlightingtechniquesthatenablemedicalandsurgicaltreatmentwithoutbloodtransfusions,attestingtotheacuteinterestandgrowingawarenessofthisburgeoningfieldofmedicine.GRUishappytofillthisvitalnicheinthecommunity. Ollrl"U.-\II U">#Aol D ...,":_'"N" -""'·- 90o --- Boo . - - ---- - ..., Cardiovasculardiseaseistheleadingcauseof deathworldwide.Inadditiontoacquireddiseasesassociatedwithaging,heartdiseasecanbepresentfrom birth.Becauseofsteadyadvancesinmedicine,mostpatients withcongenitalheartdiseasetodaysurviveintoadulthoodandmanyhavenormallifespans.Patientswithcongenitalheartproblemsarelikelytobenefitfromconsultationorongoingcarefromacardiovascularclinicianorteamwithspecialinterestortraininginthisarea. Themostcommoncongenitalheart conditionisthebicuspidaorticvalve. B A Themostcommoncongenitalheartconditionisthebicuspidaorticvalve.About1in100peoplehaveabicuspid aortic valve.Theaorticvalvenormallyhasthreedistinctleaflets(Figure1A).Eachleaflet,orcusp,isassociatedwithasinusofValsalva(Figure1C)intheaorticroot.Therightandleftcoronaryarteriesarisefromtherespective right andleftsinusesofValsalva.The noncoronarysinusdoes notgiverisetoacoronaryartery.Thethreeleafletsofthe aorticvalveopentoproduceatriangle-shapedorifice (Figure1A)andwhenclosed,appear likea"Mercedes"sign(Figure 1B).Patientswithbicuspidaorticvalveshave c D -4-

  5. c A B onlytwoleaflets(Figure2Avalve open, Figure28valveclosed).Insomecases,thisresultsfromfusionofthecommissure betweentwoleafletsproducingaraphe(Figure28). Innormal individuals,the cellophane-thinvalveleafletsperform admirably overthecourseof80-plusyears. However, bicuspidvalves produce turbulentflow patternsthat likelycontributeto earlydamageoftheleaflets.Degenerativechangesofthe leaflets,includingprolapseorcalcification(Figure20),maycauseregurgitationorleakage(Figure2E)orstenosis(Figure 2A).Theseconditionstypicallydonotbecome evidentuntiladulthood.Echocardiographyisgenerally performedonadultpatientswithbicuspidvalveseveryonetotwoyearstolookfor regurgitationorstenosis.Oncetheseabnormalitiesbecomeclinicallysignificant,surgicalvalve replacementisusuallyrecommended(Figure3C). D Bicuspidaortic valveisalsolinked toabnormalitiesoftheaorta. Bicuspidaorticvalvealsoisalsolinkedtoabnormalities oftheaorta.Coarctationoftheaorta,anarrowingofthe descendingthoracicaortajust afterthetake-offoftheleftsubclavianartery (Figure3D)occursinupto40 percent ofpatientswithbicuspidvalves.Suchnarrowingshaveanumberofadverseeffects,particularlyhypertensionoftheupperbody.Inadditiontoaorticcoarctation,thewall oftheentireaortamaybeabnormal.Thismaylead toenlargementand/ordissectionoftheascendingaorta. Forthisreason,aorticimagingwithMRIorCTis oftendoneperiodicallyinpatientswithbicuspidvalves(Figure3Aang B).Thenaturalhistoryofpatientswithbicuspidvalvesandaorticenlargementissimilartothatofpatients withMarfan'ssyndrome.Aorticrootreplacementmayberecommendedatthetimeofvalvereplacementsurgery inthosewithbicuspidvalves,orsometimesevenbeforethevalveitselfrequiressurgicalintervention.Angiotensinreceptorblockingagentsareincreasinglybeingusedtoprotecttheaortafromexpansioninpatientswithvarious aortopathies,includingthosewithbicuspidaorticvalves. Beingbornwith2ratherthan3leafletsoftheaorticvalve requires lifelong monitoring.To effectivelydiagnoseandtreatthesignificantvalvularandvascular complicationsthatcanariseinpatientswith bicuspidaorticvalve,referraltocenterswithspecializedinterest inmedicalcare,imagingandsurgicaltherapyforpatients withadultcongenitalheart diseaseisappropriate. B A Figure3.AandB.Twoviewsofaorticrootaneurysm(arrowwith dissectionofdescendingaorta(arrowheads).C.CTimageof mechanicalaorticvalveinopenposition.D.Imageofrepairedaortic coarctationwithnativeaorta (arrow)andgraftgoingaroundcoarct (arrowhead).

  6. FethiBenraouane,M.D. 3rdYear AdultCardiologyFellow JustinMackenzieVining,M.D.2ndYear PediatricCardiologyFellow AminYehya,M.D.3rdYear AdultCardiologyFellow MicheleMurphy,M.D. 1stYear AdultCardiologyFellow laurenHolliday,M.D. 1stYear AdultCardiologyFellow AlbertoMorales-Pabon,M.D.3rdYearChief AdultCardiologyFellow I '( " SyedS.Zaidi,M.D. 2ndYear AdultCardiologyFellow RodEvanPellenberg,M.D. 2ndYear PediatricCardiologyFellow JoseCuellar,M.D.3rdYear AdultCardiologyFellow AdultCardiologyFellowship Highlights PediatricCardiologyFellowshipHighlights August2012 ·AminYehya,M.D.,waselected PresidentoftheHousestaffOrganizationfor2012-13. November2012 ·RodEvanPellenberg,M.D.,submittedthemanuscript, "PapillaryFibroelastomaofTricuspidValveinaPediatricPatient"andwasacceptedto AnnalsofThoracicSurgery. ·RodEvanPellenberg,M.D.,lecturedforfirst-yearmedicalstudents' embryologycourse. ·JustinMackenzieVining,M.D.,wasselectedaGRUFellowRepresentativeNonvotingmemberoftheGeorgiaChapteroftheACC. • October2012 • AminYehya,M.D.,AlbertoMorales-Pabon,M.D.andFethiBenraouane, • M.D.passedtheEchocardiographyBoardsontheirfirstattemptinJuly.This100percentpassrateforourfellowswasalsoassociatedwithsomefellowsscoringinthe901hpercentile. • ·The12adultcardiology fellows completed their first nationwideAmericanCollegeofCardiologyIn-ServiceExam. Overallprogramscore wassignificantlyabovethenationalaverage.The finalyeartraineesscored100pointsabovethenationalaverageforallotherthirdyearcardiology fellowshiptraineesnationally. December2012 ·JustinMackenzieVining,M.D.,wasboardcertifiedingeneralpediatricsbytheAmericanAcademyofPediatrics. 201.3 PediatricFellowshipProgramMatch ThePediatricFellowshipProgramishappytoannouncethematch foranewfellowwhowillstartJuly1,2013. November2012 ·FourofourcardiologyfellowspresentedtheirresearchpostersattheAnnual GeorgiaChapteroftheAmericanCollegeofCardiology. ·LaurenHolliday,M.D.wasselectedto betheFellowRepresentativeNonvotingmember oftheGeorgiaChapteroftheACC. StefaniM.Samples,M.D.-MedicalCollegeofGeorgiaatGRU. 2013 AdultFellowshipProgram Match :"'::oo!!•-· ·Amin Yehya, M.D.,organized thecollectionoftoysfortheJamesBrownToyDriveforlocalneedychildrenattheJamesBrownArenaonDecember20. TheCVDiseaseFellowshipProgramhadahighlysuccessfulmatchfornew fellowswhowillstartJuly1,2013. RebeccaNapier,M.D. -GRUResidencyProgram PratikChoksy,M.D.,M.B.B.S.-GRUResidencyProgramAmudhanJyothidasan,M.D.-UniversityofMassachusettsLorenMorgan,M.D.-UniversityofSouthCarolina report.gru.edu/archives/13424

  7. 'I ! 1 Pleasecontactusformore information 106-72-2136'. - . . . . '" ,, -CME-- LeCtures' . ·, February22 Speaker: MichaelLuc,M.D.,2ndYearGRUCardiologyFellow Topic: "StressTesting" March8 Speaker: SimiKumar,M.D.,1stYear GRUCardiologyFellow Topic: "CardiacCT/CardiacMRI" March15 Speaker: AshkanAttaran,M.D.,/ndYear GRUCardiologyFellow . Topic: March22 Speaker: "ChronicHeartFailure" LaurenHolliday,M.D.,1stYear GRUCardiologyFellow "Intra-aorticBalloonPumps" Topic: March29 May3 Speaker: VincentRobinson,M.D., Program Director,CVDisease Topic: "TheNewACGME" May24 Speaker: FethiBenraouane,M.D., 3rdYear GRUCardiology Fellow Topic: "RecanalizationofChronicallyOccluded Graft:Isit a ParadigmShift? Speaker: AlbertoMorales,M.D.,3rdYear GRUCardiologyFellow Topic: "DiastolicHeartFailure" April12 Speaker: MicheleMurphy,M.D.,1stYear GRUCardiologyFellow "WomenandHeartDisease" Topic: April19 Speaker: Reza Amini,M.D.,2ndYear, GRUCardiologyFellow Topic: "Novel Anticoagulation Therapy" April26 Speaker: JoseCuellar,M.D.,3rdYearGRUCardiologyFellow Topic: "ComprehensiveApproachtoSyncope" CardiovascularConferences ' GRUCoronaryRevascularizationSymposium CardiovascularUpdateforPrimaryCareProviders October26-27,2013·MarriottRiverfront Augusta,GA June6-9,2013 Kiawah Island,SC GRUCardiacConference October9-13,2013ChateauElanBraselton,GA 7

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