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Champions of the Heart

cardiac surgeon at torrance memorial One in every four deaths in America is caused by heart disease—now the largest health threat for men and women—resulting in 600,000 deaths annually. The Centers for Disease Control and Prevention (CDC) recently calculated that more than 720,000 Americans have a heart attack each year. Of these annual attacks, 515,000 are a first heart attack and 205,000 are repeat attacks.

As one might imagine, the financial, emotional and physical burden of this disease to our nation is immense. The CDC estimates that coronary heart disease, the leading type of heart ailment, costs the United States $108.9 billion each year—including the cost of health care services, medications and lost productivity.

To combat America’s heart disease epidemic, Torrance Memorial Medical Center has assembled a world-renowned team of cardiac physicians. Each one specializes in unique procedures, techniques and heart conditions—providing critical and timely care. Torrance Memorial’s cardiac physicians give us better insight into how they fight heart disease.

R. MICHAEL WYMAN, MD
DIRECTOR OF CARDIOVASCULAR INTERVENTIONAL RESEARCH

It’s amazing how technology is improving and how you are at the forefront of treating Chronic Totally Occluded Arteries (CTO). CTOs, or fully blocked arteries, are typically difficult to treat via percutan-eous revascularization—the process of restoring blood flow to the heart via a procedure done through the skin, rather than through open surgery. (Percutaneous coronary revascularization procedures are typically performed through a catheter [a thin, flexible tube] that is threaded through a blood vessel. With CTOs, this can become hazardous due to the fact that the plaque build-up in the artery is so large, it literally creates a wall within the artery. A physician, while trying to clear the artery, doesn’t want to puncture the outside artery wall, causing an arterial collapse.)

Can you explain the highly specialized procedure you do that has dramatically improved the way CTOs are treated today?

The current method of percutaneous revascularization, required for chronic total occlusions, depends not on a single device or technology but on a combination of approaches that we refer to as “the hybrid strategy.” The techniques used have been refined over the last several years, based on collaboration amongst high-volume CTO specialists, into a seamless and efficient approach that results in high success rates with minimal complications.

This technique, however, requires the ability to use both antegrade (approaching the total occlusion from the “forward” direction) and retrograde (approaching the occlusion from the “backward” direction using small collateral channels) techniques. Cardiologists also use devices in order to clear the blockage of the artery. We have been teaching this strategy to interventional cardiologists from around the country at specialized courses at several sites, including Torrance Memorial.

What are some of the warning signs for CTO?

The symptoms associated with a CTO are the same as for any coronary artery blockage, including exertional chest discomfort, shortness of breath and fatigue. However, the symptoms can cause lethargy because of the severity of the block-age, and it is not unusual for patients to “accommo-date” by decreasing their activity levels to lessen any discomfort.

Often patients’ families report noticing a significant difference in their loved one’s ability to exert themselves or exercise like they used to. The patient, however, often only complains of minor problems as he/she has lessened the amount of physical activities or intensity of exertion.

SANG YONG JI, MD
CARDIOLOGY AND ELECTROPHYSIOLOGY SPECIALIST

Do Americans have a misconception regarding heart arrhythmias?

There are a few, and the “skipped heartbeat” is one of the most common complaints among the patients presenting to the Arrhythmia Clinic. Although most of them are due to benign conditions such as premature atrial or ventricular complexes (premature heartbeats originating from the upper or lower chamber of the heart), I noticed that the fear about sudden cardiac death is significant in this patient population.

A detailed discussion about the symptoms and simple, non-invasive tests such as electrocardiogram and echocardiogram can help rule out many dangerous conditions and reassure the patients about the benign nature of their symptoms. These tests can also help diagnose some dangerous conditions that can be treated.

People old and young, overweight and fit can all develop arrhythmias. Does this make it harder to diagnose and treat?

Yes. Although the symptoms of arrhythmia could be similar across different stages of life, many arrhythmic conditions have increased preva-lence in specific age groups. Therefore comprehen-sive discussion about the symptoms and a tailored diagnostic approach are essential for a successful treatment of different arrhythmic conditions.

While the diagnosis and treatment in young and fit patients can be straightforward, the symptoms of patients with older age and multiple comorbidities (obesity, obstructive sleep apnea, coronary artery disease) can be multifactorial in origin, hence making the diagnosis more challenging and the treatment less satisfying. The importance of a thorough history-taking and tailored treatment approach can’t be over-stressed as we dedicate.

JACK SUN, MD
CARDIOVASCULAR SURGEON USC KECK SCHOOL OF MEDICINE

Welcome! Torrance Memorial is pleased to have someone with your caliber of expertise on staff. With a post-graduate Transcatheter Cardiovascular fellowship from Harvard, extensive experience at University of Washington Medical Center and your support of Torrance Memorial’s new affiliation with USC Keck School of Medicine, the South Bay now has the best and most varied of cardiac surgery resources.

You specialize in all aspects of adult cardiac surgery, but can you tell us what your specific research interests are?

Thank you. I am thrilled to be here! I have both clinical and research interests. I do perform all aspects of heart surgery to treat valvular, aortic and coronary disease but also for atrial fibrillation as well.

My greatest interests currently include mitral valve repair and transcatheter aortic valve replacement (TAVR). Repairing a patient’s mitral valve allows them to keep their own valve without needing an artificial one. TAVR is allowing us to replace the aortic valve for severe aortic stenosis without traditional open heart surgery and is a great option for patients who are either very high risk or too high risk for open surgery.

My research interests have mostly involved looking at antithrombotic therapies in cardiac surgery. I have been involved in multiple studies looking at antithrombotic drug effects in coronary bypass surgery, and I was a member of the panel and writing committee for the American College of Chest Physicians Guidelines for Antithrombotic Therapy for Valvular Heart Disease.

Is there anything you’d like the public to know about aortic disease/dissection, like advances in technology to treat aortic disease?

Aortic dissection can be a quick killer. The public needs to know the signs: chest or back pain that is often tearing in nature. Get to the ED as soon as possible to be assessed. For some types of thoracic aortic dissection and aortic aneurysm, repair can now be performed using catheter-based devices that allow stents to be placed inside the aorta to exclude the aneurysm or dissection. This can be done through an artery in the groin rather than through a large, open operation—a technique called Thoracic EndoVascular Aortic Repair (TEVAR).

J. CHRISTOPHER MATCHISON, MD
INTERVENTIONAL CARDIOLOGY

Echocardiography is routinely used in the diagnosis, management and follow-up of patients suspected to have or with known heart diseases. Besides providing information such as the size and shape of a heart, its pumping capacity and the location and extent of any tissue damage, what other information can an echocardiogram provide physicians?

One of the most exciting uses for echocardiography is as it pertains to complex procedures such as TAVR. Echo, in this case trans-esophageal echo, is utilized throughout the procedure and is indispensable as an imaging modality. Pre-procedurally, we use the 3-D tech-nology to determine what size valve should be implanted and to evaluate for potential pitfalls such as excessive calcium deposition on the native valve leaflets. 3D is a new and challenging technology for physicians to interpret but provides invaluable information about valve structures. Intra-procedurally echo is used in conjunction with fluoroscopy (X-ray imaging) to confirm appropriate valve placement and position. Finally, at the time of valve deployment, echo can be used to rapidly evaluate for procedural complications.

Do you often use a stress echocardio-graphy test?

Stress echocardiography is a fantastic tool—particularly when exercise is used as the physical stressor (instead of medication). Besides being an effective, reliable way to evaluate for ischemia (compromise of blood flow to the heart), it is very safe for the patient and does not necessitate exposure to drugs or radiation.

SALMAN M. AZAM, MD
INTERVENTIONAL CARDIOLOGIST

Can you explain what the Transcatheter Aortic Valve Replacement (TAVR) technique is and who benefits the most from it?

TAVR is a procedure approved in the past couple of years that allows the Torrance Memorial cardiologists and cardiac surgeons to come together as a team and offer a cutting-edge treatment option to patients with severe symptomatic aortic stenosis. Simply put, this procedure involves mounting a bioprosthetic valve on a balloon catheter, which is delivered via one of three different access sites to the patient’s stenotic aortic valve and deployed inside the native valve, pushing the patient’s own valve leaflets to the side. The end result is a fully functioning bioprosthetic aortic valve, making it significantly easier for the heart to pump blood to the rest of the body.

Amazingly this procedure is performed on a beating heart, unlike traditional surgical aortic valve replacement, which involves stopping the heart from beating (circulatory arrest) and using a cardiopulmonary bypass machine. This procedure is currently approved by the FDA for patients who are at high risk or inoperable candidates for traditional surgical aortic valve replacement, placing them at very high risk for mortality over the next one or two years. This procedure provides new hope and treatment options for patients where none existed previously.

Is there ever an ethical issue when choosing patients to undergo TAVR?

The evaluation process for TAVR is complex, and the goal is to provide treatment options for patients who will derive mortality benefit and an improved quality of life. At times it is difficult to evaluate patients with multiple severe medical illnesses in addition to severe symptomatic aortic stenosis. When other severe medical problems exist—for example, active cancer or end-stage lung disease—it is very important to assess whether the patient’s mortality rate will remain high even after treatment of the aortic valve stenosis.

In such cases, it is unethical to put a patient through an invasive aortic valve procedure and hospitalization when in fact the patient will not derive a meaningful benefit. Such ethical scenarios are addressed at our multidisciplinary conferences where a team decision is made regarding pursuing an invasive treatment strategy or more conservative management.

JOHN STONEBURNER, MD
CARDIOTHORACIC SURGEON

What would you say your specialty within cardiac surgery is?

Within cardiac surgery my specialties include minimally invasive techniques in adult cardiac surgery, mitral valve repair, on and off pump coronary artery bypass, aortic valve repair and replacement, repair of complex thoracic aortic aneurysms, and transcatheter aortic valve replacement.

Can you describe one patient situation/ scenario that brought you the most challenge and the most reward?

One patient who comes to mind was an 84-year-old male. Back in December of 2008, the patient underwent emergency repair of a ruptured ascending aortic dissection with tamponade (pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle and the outer covering sac of the heart), and repair of aortic valve under circulatory arrest and cardiopulmonary bypass. The patient came to the ER unconscious, with no blood pressure, therefore requiring inotropic agents (use of drugs to affect the strength of the heart muscle’s contractions) for resuscitation and resolution of neurological status. I felt the patient would not survive without high risk surgery to repair the ascending aorta. There was much dialog amongst the surgical team and family members regarding the risk of the procedure given the man’s age. Supportive family members were present, understood the seriousness of the situation, and wanted to proceed with the operation. The patient tolerated the procedure well and the surgery team was pleased with the results. I recently saw the patient in my office, 5 1/2 years post-surgery. An annual magnetic resonance angiogram of his chest showed no evidence of recurrent aneurysm and the patient said he feels great!

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