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
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
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
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
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
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!