NON-PROFIT ORG. U.S. POSTAGE UAB Insight on and Vascular Disease PAID PERMIT NO. 1256 410 • 500 22nd Street South BIRMINGHAM, AL Insight 1530 3rd ave s ON HEART AND VASCULAR DISEASE birmingham al 35294-0104

UAB Division of Cardiovascular Disease medicine.uab.edu/cardiovasculardisease

UAB Division of medicine.uab.edu/cardiothoracicsurgery

UAB Section of Vascular Surgery and Endovascular Therapy medicine.uab.edu/vascularsurgery

Combined Therapy UAB Ambassador Program for Peripheral Vascular Disease The Ambassador Program gives referring physicians complete access to patient notes, letters, reports, and other data through a of secure Web portal. To join this program, please contact Physician Tachycardia Services at 1.800.822.6478. Minimally Invasive Pulmonary Thromboendarterectomy Clinic welcome 3 contents UAB Insight Welcome to the first issue of UAB Insight on Heart and Vascular on Heart and Disease, designed to keep you informed about UAB’s leading role in Cardiothoracic Surgery Vascular Disease evaluation and treatment of cardiac and vascular diseases. UAB con- FALL 2009 sistently ranks among the top 30 cardiac programs rated in U.S. News Minimally Invasive Cardiac Surgery.... 2 & World Reports, and is a regional, national, and international referral volume 1, number 1 center for cardiac and vascular disease diagnosis and treatment. Adult Congenital Heart Disease...... 3 With expertise in every major area of heart and vascular diseases, and James Kirklin, MD e d i t o r i n c h i e f as home to the Southeast’s largest and most technologically advanced Pulmonary Thromboendarterectomy Julius Linn, MD Heart and Vascular Center, we offer innovative, scientifically based Clinic...... 4

treatments, providing patients with better outcomes, improved quality of E x e c u t i v e E d i t o r Advanced Heart Failure Therapy and Emily Delzell life, and access to the latest translational research. UAB is Alabama’s major referral center for complex cardiac and vas- Mechanical Support...... 5 M a n a g i n g E d i t o r cular disorders and the only hospital in the state that offers heart trans- Peaches Scribner plantation and long-term mechanical circulatory support. UAB is the state’s only facility for surgery for complex congenital heart diseases, Cardiovascular Disease contributor s and our clinicians also provide care for adults with congenital heart Suzanne Parker Robert Bourge, MD Sleep Apnea and Resistant Peaches Scribner disease. Our vascular surgeons offer advanced surgical and endovascular ...... 6 Creative Director stenting technologies for aortic aneurysms, carotid occlusive disease, Ron Gamble peripheral vascular disease, and venous disease. Cardiac Rehabilitation...... 7 UAB also provides comprehensive care for pulmonary hypertension, Art Director of Ventricular including surgery for chronic pulmonary thromboembolism. One of the Jessica Huffstutler world’s most active clinical and research programs, UAB’s Pulmo- Tachycardia...... 8 2 Illustration nary Vascular Disease Clinic has participated in the development and Echo Medical Media evaluation of virtually all new therapeutic avenues for pulmonary arter- Vascular Surgery ial hypertension in the last 15 years. William Jordan Jr, MD Our minimally invasive and state-of-the-art robotic surgery programs Vascular Medicine...... 9 offer minimally invasive treatments for and valve repair and replacement. Published by the Working collaboratively, cardiothoracic surgeons and cardiologists have developed a variety of hybrid UAB Health System Aneurysm Repair...... 10 minimally invasive approaches for ischemic heart disease. Our valve program provides percutaneous 500 22nd Street South balloon valvuloplasty for selected cases of aortic, mitral, pulmonic, and tricuspid valve repair using Combined Therapy for Peripheral Birmingham, AL 35233 10 intracardiac , percutaneous repair of atrial septal defects and patent foramen ovale, Vascular Disease...... 11 ©2009 by The Board of Trustees and for hypertrophic obstructive . UAB’s pioneering cardiac service is a regional referral center for electrodiagnos- of The University of Alabama tic and therapeutic care of patients with common and complex arrhythmias, including radiofrequency Heart and Vascular Faculty for the University of Alabama at ablation for . Ablation of ventricular tachycardia is now highly successful in carefully Birmingham. Second class postage 8 selected cases of structural heart disease and idiopathic ventricular tachycardia (VT). Patients with Heart and Vascular Faculty...... 12 paid by UAB Bulk Mail Dept. implantable cardioverter-defibrillators who experience repeated shocks can benefit from VT ablation, Postmaster: address changes to: as can patients with idiopathic VT or dilated cardiomyopathy-associated VT. UAB physicians also offer advanced therapies for heart failure, resistant hypertension, and hyper- UAB Insight lipidemias, as well as unique diagnostic echocardiography, cardiographics, and imaging studies. UAB Insight Online 410 • 500 22nd Street South Our collaborative approach to heart and vascular diseases is designed to provide timely, seamless 1530 3rd Ave S care that serves our patients and referring physicians, to everyone’s benefit. We look forward to work- .Visit UAB Insight online (uabmedicine.org/insight) to request a second issue of UAB Insight on Birmingham AL 35294-0104 ing with you. Heart and Vascular Disease, request our other referring physician magazines, or to sign up for Or call the toll-free MIST line: electronic delivery. The site also offers breaking news, referring physician resources, and new 1.800.822.6478 faculty announcements. It features videocasts of our physicians discussing the latest procedures [email protected] available at UAB, CME opportunities, information on the Ambassador Program for referring James K. Kirklin, MD Robert C. Bourge, MD William D. Jordan Jr, MD physicians, and more. Cardiothoracic Surgery Cardiothoracic Surgery Robotic-Assisted and Minimally Adult Congenital Heart Disease Clinic Invasive Cardiac Surgeries A Continuum of Multidisciplinary Care Is Crucial

Riding the Wave of the Future Approximately 800,000 US adults are enced interventional cardiolo- living with congenital heart disease (CHD). gists, electrophysiologists, surgeons, perfusionists, an- Cardiac procedures comprise a large “Hybrid procedures offer exponential perform all complex repairs with the system, Advances in diagnosis and therapy have esthesiologists, intensivists, portion of ever-increasing options for mini- benefits to patients who may be able to including chordal placement, leaflet resec- substantially reduced CHD mortality rates, obstetricians, operating mally invasive and robotic-assisted surgery avoid multiple surgeries, extended hos- tion, and ring annuloplasty. and large numbers of young people with room and intensive care at UAB, one of five pilot institutions desig- pital stays, and downtime from work. “This totally endoscopic approach al- complex diagnoses, such as tetralogy of unit staff, and social nated to train residents on the da Vinci ro- It is a quality of life issue,” he says. lows patients to return to work in about 2 Fallot, transposition, and single , services staff. UAB’s bot, a minimally invasive surgical system. “Patients request the robotic approach weeks with much less discomfort, blood survive into adulthood. The number of Adult Congenital Robotic-assisted surgical techniques, because they can return to work in just 2 loss, and morbidity than with traditional adults with CHD has surpassed the number Heart Disease Clinic’s performed at UAB since 2001, offer at- weeks — rather than 8 — with no activity procedures.” He performs aortic valve of children with the condition. Many of synergistic care ad- tractive advantages over traditional ap- restrictions. They appreciate the superior replacement as a minimally invasive proce- these adults have residual heart problems dresses all aspects of proaches. Hybrid surgeries, which address cosmetic effects: no large chest scar and dure using a 1- to 2-inch parasternal inci- requiring ongoing follow-up and treatment CHD. “Mapping out multivessel disease, are the wave of the no scar down their leg.” sion with no sternal incisions. by specialists. an appropriate treatment future, says UAB cardiothoracic surgeon Akins also has begun a program for total Other procedures Akins does robotically As they age, these adults are at risk for course for patients with Christopher W. Akins, MD. endoscopic bypass surgery, or “port access are atrial septal defect repair, tricuspid CHD as well as the same adult illnesses that complex disease requires Compared with traditional open proce- surgery,” which requires one to four very valve repair, combination mitral and tri- affect the general population. Consequently, extensive experience in dures, robotic-assisted surgeries have many small (5-10 mm) incisions in the chest cuspid valve repair, and ablation of atrial comprehensive care must address congenital pediatric and adult cardiol- advantages: smaller incisions, reduced wall. He plans to offer this keyhole ap- fibrillation. “A robotic approach using cardiac issues and general health issues, ogy,” Johnson says. postoperative pain and medication use, proach to select patients for CABG, valve the achieves results including preventive efforts to avoid obesity, A minority of patients less blood loss, decreased risk of infection, surgery, and epicardial lead placement for equivalent with ,” a sedentary lifestyle, and smoking. “Adults may present in later teen- shorter hospital stays and recovery times, cardiac resynchronization therapy. he says. with congenital heart disease have a pedi- and in some cases, improved mortality rates. atric condition but are no longer pediatric age years or as adults with Valve Repair, Replacement; patients, and thus need care from a multidis- disease that necessitates a CABG Atrial Fibrillation ciplinary team that includes adult cardiolo- primary operation. “As children, FOR MORE Dr. Ch r i s t o p h e r Ak i n s gists and cardiologists with expertise in con- some patients have had palliative Using the da Vinci system, Akins per- “Anyone with isolated INFORMATION Dr. Co n s t a n t i n e Athanasuleas genital heart disease,” says UAB pediatric operations that were not durable, forms coronary artery bypass graft (CABG) disease of any etiology is a candidate for 1.800.UAB.MIST cardiologist Walter H. Johnson Jr, MD. such as those requiring extracardiac design. MD , contributed to this illustration’s U AB pediatric cardiologist M ark A . L aw, surgery for patients with blockages in robotic or replacement,” [email protected] the left anterior descending artery and its Akins says. The largest incision made dur- The broad spectrum of CHD requires conduits with valves,” says UAB cardio- branches. ing these procedures is different levels of care. Patients with simple thoracic surgeon James K. Kirklin, MD, This procedure requires one small (4-5 about 1 cm. “The So- problems, such as small atrial or ventricular director of UAB’s Division of Cardiotho- cm) incision and three ports on the left ciety of Thoracic Sur- septal defects or isolated valvular disease, racic Surgery. The image illustrates treatment of an adult born side of the patient’s chest. The internal geons national database may not need to see a specialist except for “They may need five or six operations with transposition of the great arteries who mammary artery is grafted to the diseased reports a greater than an annual checkup. during their lifetime. This realm of multiple underwent a Mustard-type atrial switch pro- coronary artery on the beating heart, cir- 90% chance for suc- Cardiologists in UAB’s Adult Congenital reoperative cardiac surgeries is a specific cedure early in life and had a small baffle leak. cumventing the need for external harvest- cessful valve repair [in- Heart Disease Clinic follow patients with area of expertise found at UAB and is un- Arrhythmias and sinus node dysfunction devel- ing of blood vessels, cardiopulmonary stead of valve replace- moderately complex congenital disease common in other centers,” he says. Some oped with narrowing in the superior vena cava. bypass, , and the result- ment] with the da Vinci closely, working with referring primary care patients eventually will have problems that UAB surgeons placed a stent in the superior ing extensive recovery. robot. With sternotomy physicians and cardiologists to design and can be helped only with heart or lung trans- vena cava and positioned an Amplatzer ASD to Many patients present with multivessel chances of a success- implement treatment plans that anticipate plantation. For these patients UAB has a occlude the baffle leak prior to placement of a problems and emphasize prevention. “Pri- renowned team of transplant surgeons. disease. To meet their needs Akins and ful repair rather than biventricular pacemaker. UAB cardiologists have adopted a hybrid replacement are greater mary care physicians need to keep patients’ “UAB’s multifaceted enterprise has a approach, combining robotic-assisted than 50%,” says Akins. congenital heart disease history in mind long history of caring for the full range of CABG for left anterior descending lesions Robotic technology when treating routine health issues and ad- congenital cardiac abnormalities in children vising lifestyle adjustments,” says UAB pe- and adults. We provide a continuum of care FOR MORE Dr. Ja m e s Ki r k l i n with angioplasty and percutaneous coro- provides superior visu- INFORMATION diatric cardiologist Edward V. Colvin, MD. to keep patients healthy and preserve good Dr. Ed w a r d Co l v i n nary intervention for other coronary artery alization and dexterity, Dr. Wa l t e r Jo h n s o n People with complex congenital disease quality of life for as many years as pos- blockages. allowing surgeons to Christopher Akins, MD, one of the foremost authorities on robotic- 1.800.UAB.MIST assisted heart surgery, with one of UAB’s da Vinci robots. require a well-coordinated team of experi- sible,” Kirklin says. [email protected]

2 uab insight on heart and vascular disease • FALL 2009 uab insight on heart and vascular disease • FALL 2009 3 Cardiothoracic Surgery Cardiothoracic Surgery

section. The diagnostic algorithm includes pulmonary function tests, echocardiogram, Ventricular Assist Device Therapy computed tomography angiogram, an as- thromboendarterectomy say to detect a hypercoagulable state, and for Advanced Heart Failure pulmonary arteriogram. Patients with multiple occluded seg- mental pulmonary arteries or with Successful Outcomes Merit Earlier Treatment obstructive scars are candidates for surgery. Proximal loca- With its Mechanical Circulatory Sup- data, that outcomes are poor,” Pamboukian tently or continuously. To discuss therapy tion of the obstruction port Device (MCSD) Program UAB is the says. Recent data show 2-year survival for a potential patient, contact Pamboukian is key, McGiffin says, state’s first and only destination therapy rates approach 70% with implantation and through MIST at 1.800.822.6478. “UAB’s because more distal center certified by The Joint Commission. management at an experienced center such multidisciplinary team-oriented approach disease may not be The UAB MCSD Program has the highest as UAB’s, where survival rates exceed this can support patients to successful out- resectable Coronary volume in the region, accepting referrals percentage (J Thorac Cardiovasc Surg. comes,” she says. artery disease or from southeastern states and beyond. 2008;135[6]:1353-1361). A fluid research pipeline of improved valvular defects are Ventricular assist device (VAD) therapy “This therapy should not be reserved technology produces new devices, and UAB not contraindications is appropriate for patients with endstage as the last step before hospice or death,” participates in multiple studies of these novel and can be addressed heart failure (HF) and depressed systolic says UAB cardiothoracic surgeon James K. tools. “The new generation of continuous during PTE. function, either as a bridge to cardiac trans- Kirklin, MD, director of UAB’s Division flow pumps has increased the time devices plantation or as permanent therapy. “No of Cardiothoracic Surgery. “Patients must can support patients,” says Kirklin. “Unlike PTE longer reserved mainly as a bridge to trans- be robust enough to survive surgery and the the pulsatile pumps, newly developed rotary PTE is a highly sub- plant, VAD therapy is a viable long-term postoperative period.” pumps provide continuous flow throughout specialized procedure re- option for patients who are not candidates “Recognizing that a patient has reached the cardiac cycle.” Consequently, pumps are quiring a median sternotomy for transplant and have exhausted optimal the end of conventional therapy can be dif- more durable, and patients rarely require for bilateral access and cardio- medical management,” says UAB cardiolo- ficult,” Pamboukian says. “We partner with reoperation. The device and its drive line are Pulmonary pulmonary bypass. Hypothermic gist Salpy V. Pamboukian, MD, MSPH, referring physicians to identify appropriate smaller, resulting in fewer infections, and it arrest creates a bloodless surgical field medical director of the MCSD Program. patients, and treatment is a cooperative can be used in patients who are too small for for complete visualization of the pulmo- Experts estimate that in 2008 as many effort between referring cardiologists and implantation of larger pulsatile pumps. Thromboendarterectomy nary vasculature. The complex procedure as 250,000 US patients were in the termi- MCSD Program physicians.” The pump, called the HeartMate II and long-term follow-up require the care of nal phase of systolic HF with symptoms Physicians should consider referring (Thoratec, Pleasanton, CA), is Food and Restores Near-Normal Pulmonary Artery Pressure an experienced multidisciplinary team. refractory to medical therapy. Fewer than patients with New York Heart Association Drug Administration-approved for bridge- The surgery carries the same risks as 1000, however, received mechanical device class III or IV disease who have recurrent to-transplant therapy, and surgeons use it for open-heart procedures; additional periopera- therapy. “This population is underserved, hospitalizations, cannot tolerate medica- destination therapy under the Food and Drug The UAB Pulmonary Thromboendar- patients often present with nonspecific tive complications can include hemorrhage possibly because of a perception, based on old tions, and who require inotropes intermit- Adminstration Continuing Access Protocol. terectomy Clinic provides comprehensive complaints such as exertional dyspnea and injury to the lung during reperfusion. Kirklin is principal investigator of a clinical and surgical care to patients with and exercise intolerance,” says UAB pul- Follow-up includes monitoring of hemody- study consortium that has established a pulmonary vascular disease due to chronic monologist Keith M. Wille, MD. namic recovery and return of exercise capac- Risk Factors for Increased Mortality in multi-institutional registry and database of thromboembolic pulmonary hypertension Treatment has evolved from a strategy ity. Patients require lifelong anticoagulation VADs and total artificial heart devices, the Consider Referral for VAD Therapy (CTEPH), which causes pulmonary arte- that emphasized anticoagulation and lung after PTE. UAB physicians refer individuals Advanced Heart Failure Interagency Registry for Mechanically As- rial occlusion, impaired gas exchange, and transplant to surgical resection and novel who are not surgical candidates to the Pul- sisted Circulatory Support. Inability to take neurohormonal antagonists or beta-blockers right heart failure. Medical therapy aims vasodilator agents when feasible. monary Hypertension and Lung Transplant The database coordinates data from more to prevent further embolization and risk of “Pulmonary thromboendarterectomy clinics to explore alternative treatments. (a very high risk group) than 100 clinical facilities, tracking out- local thrombus, but survival rates are poor. [PTE] is potentially curative for chronic “In patients with favorable surgical Need for intermittent or continuous inotropes comes in patients implanted with new de- Patients with mean pulmonary artery pres- thromboembolic pulmonary hypertension, anatomy, PTE often restores near-normal vices. The registry is designed to facilitate sure >30 mm Hg have a 5-year survival of providing immediate relief of pulmonary pulmonary artery pressure and pulmonary Cardiorenal syndrome investigations and improvements in me- 30%, and 5-year survival for those with hypertension associated with pulmonary vascular resistance,” McGiffin says. “The Need for escalating diuretic dosage chanical circulatory support as long-term pressure >50 mm HG is 10%. thromboembolic disease,” says UAB cardio- reversible nature of chronic thromboem- therapy and increase duration and quality The disease is uncommon, though some thoracic surgeon David C. McGiffin, MD. bolic pulmonary hypertension warrants Frequent hospitalizations of life for patients with advanced HF. experts suspect it is not as rare as has been Patient selection is complex. Wille and increased recognition of the disorder.” Hyponatremia while taking neurohormonal antagonists thought. Many cases are asymptomatic and McGiffin employ an evaluation protocol FOR MORE Dr. Ja m e s Ki r k l i n go undetected until advanced stages, when using an established clinical pathway to FOR MORE Dr. Da v i d McGi f f i n Poor nutritional status with weight loss and low prealbumin INFORMATION Dr. Wi l l i a m Ho l m a n signs of right heart failure emerge. “Pa- determine the diagnosis, obtain baseline INFORMATION Dr. Ke i t h Wi l l e First discharge of implantable cardioverter defibrillator placed Dr. Sa l p y Pa m b o u k i a n tients may have silent chronic thromboem- data required for monitoring, and assess 1.800.UAB.MIST 1.800.UAB.MIST bolic disease for years, and symptomatic the likelihood of successful surgical re- [email protected] for primary prevention [email protected]

4 uab insight on heart and vascular disease • FALL 2009 uab insight on heart and vascular disease • FALL 2009 5 Cardiovascular Disease Cardiovascular Disease Obstructive Sleep Apnea and Cardiac Rehabilitation Program

Resistant Hypertension Underutilized Despite Proven Benefits

Uncovering Underlying Mechanisms Comprehensive cardiac rehabilitation (CR) substantially improves outcomes. It Percentage of Individuals Receiving Guideline-Based Care at Discharge achieves optimal results by combining ex- From 156 American Heart Association Get With the Guidelines Obstructive sleep apnea (OSA) is po- but who elect not to use it will serve as induced sodium retention increases neck Hospitals, 2000-2007 ercise training with multifaceted strategies tentially lethal in patients with treatment- controls. If OSA stimulates aldosterone edema, which contributes to upper airway aimed at reducing modifiable cardiovas- resistant hypertension ( release, CPAP should reduce urinary aldos- resistance. cular risk factors, such as smoking, hyper- >140/90 mm Hg or >130/80 mm Hg in terone levels. The American Heart Association in its tension, diabetes, dyslipidemia, obesity, people with diabetes or chronic kidney The second approach is a randomized 2008 Scientific Statement on Resistant and stress, says UAB cardiologist Vera A. disease who are refractory to a regimen crossover study comparing 24-hour uri- Hypertension recommended that physi- Bittner, MD, MSPH, medical director of of optimal doses of ≥3 antihypertensive nary aldosterone excretion before and cians evaluate all subjects with resistant Percentage UAB’s CR program. Participation in CR is medications). These patients frequently after withdrawal of CPAP use in patients hypertension for primary aldosteronism associated with lower mortality and recur- have additional cardiovascular risk factors, already receiving the therapy. (Partici- and consider mineralocorticoid-receptor rent (MI) rates. A including obesity and diabetes. pants with excessive daytime sleepiness antagonists for routine use in patients recent study in the Journal of the American “Research shows 50% of patients with [Epworth Sleepiness Scale score >10] are whose blood pressure remains uncontrolled College of Cardiology found CR participa- hypertension have sleep apnea, and half of excluded.) Calhoun will evaluate effects of despite use of multidrug regimens (Circu- tion among Medicare patients after hos- individuals with apnea have hypertension,” CPAP withdrawal on aldosterone, cortisol, lation. 2008;118:1080-1111). pitalization for coronary heart disease or says UAB hypertension specialist David and plasma adrenocorticotropic hormone “Physicians should question all resistant coronary revascularization was associated A. Calhoun, MD. “Our studies confirm the (ACTH) levels. ACTH stimulates aldoster- hypertension patients about signs of sleep with mortality rates 21% to 24% lower prevalence of obstructive sleep apnea in pa- one and cortisol production, and sleep dis- apnea and consider evaluating them for that than those among comparable patients who tients with treatment-resistant hypertension ruption adversely affects ACTH release. condition as well as for aldosterone ex- did not attend CR far exceeds that of other adult populations.” The second arm is a randomized parallel cess,” Calhoun says. Hypertensive patients (J Amer Coll Cardiol. says. In 35% of hospitals, <20% of eligible rehabilitation programs. Moreover, benefits . In a National Heart, Lung, and Blood comparison of spironolactone and conven- whose blood pressure is severe and uncon- 2009;54[1]:25-33) patients were referred, and only a third of extended to the oldest patients — those Institute-funded study at UAB, Calhoun un- tional antihypertensive agents to determine trolled despite optimal medical manage- physicians referred >60% of eligible per- older than 75 years — many of whom Services Are Underutilized veiled a direct relationship among plasma if the aldosterone antagonist decreases ment may benefit from evaluation through sons. Physicians referred patients undergo- had a higher comorbidity burden than did “Despite proven efficacy, cardiac re- aldosterone elevation, the severity of OSA, OSA severity. Investigators will measure UAB’s Hypertension Program. If OSA un- ing coronary artery bypass grafting most younger patients,” Bittner says. “A recent habilitation programs are underutilized,” and hypertension-associated cardiovascu- changes in OSA severity using the apnea- derlies resistant hypertension, patients have frequently. Other factors independently analysis of Medicare data also shows older says UAB cardiologist Todd M. Brown, lar changes, particularly left ventricular hypopnea index, which is calculated by increased risk of cardiac complications and associated with referral included younger patients accrue a mortality benefit.” MD, MSPH. “Physician awareness about remodeling, a known risk factor for heart dividing the number of apneas and hypo- may benefit from spironolactone. age, ST-segment elevation MI, and a history UAB’s Cardiopulmonary Rehabilita- benefits of cardiac rehabilitation is lower failure . pneas by hours of sleep. Researchers also of dyslipidemia or smoking. tion Program combines comprehensive (Chest. 2007;131[2]:453-459) than for other interventions.” Guidelines Researchers now are investigating causal will measure change in anterior-posterior FOR MORE Dr. Da v i d A. Ca l h o u n Individuals with comorbidities and older medical management, patient education, INFORMATION issued by the American Heart Association relationships among those factors. upper airway dimension by helical comput- 1.800.UAB.MIST patients were less likely to be referred de- and research to speed recovery, improve [email protected] (AHA), American College of Cardiology, “Obstructive sleep apnea may stimulate ed tomography to determine if aldosterone- spite recent evidence that these populations individuals’ overall physical and mental and American Association of Cardiovascular aldosterone release, or aldosterone excess benefit from CR. functioning, and slow or reverse disease and Pulmonary Rehabilitation recommend may worsen apnea — either scenario sug- “A wider range of patients benefit from progression. CR for patients after MI or revasculariza- gests a need for new treatments,” he says. cardiac rehabilitation than has previously Patients also may consult with dietitians, Obstructive Sleep Apnea Syndrome tion with coronary artery bypass or coro- To determine the underlying mechanism of Diagnostic Criteria been described,” says Bittner. In a recent diabetes educators, psychologists, and nary angioplasty, as well as for individuals OSA-related hyperaldosteronism in people study UAB medical student Sanjay Maniar, other health care specialists. with stable angina. with resistant hypertension, Calhoun is working with Bittner and colleagues, found “Our ultimate goal is to help patients Polysomnographic monitoring demonstrates: In a recent data analysis from the AHA’s recruiting participants for a two-arm clini- that age was not a significant predictor reach their risk-reduction goals and effec- Get With the Guidelines (GWTG) pro- cal trial. More than five obstructive apneas >10 seconds in duration per hour of of achieving secondary prevention goals tively achieve optimal health outcomes,” gram, Brown et al found only 56% of eli- The trial’s first arm has two approaches. sleep, and one or more of the following: of CR. Researchers compared changes in Bittner says. gible individuals received referrals to CR First, to determine if OSA stimulates al- • Frequent arousals from sleep associated with the apneas selected measures between CR entry and programs. Of 72,817 people discharged dosterone release, researchers will measure completion among younger (<65 years) • Bradytachycardia from 156 GWTG hospitals from January 24-hour urinary aldosterone excretion prior • Arterial oxygen desaturation in association with the apneic episodes and older (≥65 years) patients (J Cardio- 2000 to September 2007, only 40,974 were FOR MORE Dr. Ve r a Bi t t n e r to and then 6 and 12 weeks after starting pulm Rehabil Prev. 2009;29:220-229). referred to CR. “Substantial variation ex- INFORMATION Dr. To dd Br o w n treatment with continuous positive airway Multiple Sleep Latency Test may or may not demonstrate a mean sleep “Both groups experienced significant ists among hospitals in the percentage of 1.800.UAB.MIST pressure (CPAP). Participants with resistant latency of <10 minutes. improvements upon completing cardiac eligible patients referred to CR,” Brown [email protected] hypertension who are prescribed CPAP

6 uab insight on heart and vascular disease • FALL 2009 uab insight on heart and vascular disease • FALL 2009 7 Cardiovascular Disease Vascular Medicine Catheter Ablation of Ventricular Vascular Medicine: Conditions Tachycardia and Medical Management

Epicardial Access Produces High Level of Success Risk Factors, Intervention

Vascular medicine encompasses Although implantable cardioverter- offers an alternative to drug therapy, says Catheter Ablation for screening, diagnostic evaluation, and Ankle-Brachial Index defibrillators (ICDs) save lives, many pa- UAB electrophysiologist G. Neal Kay, MD. Idiopathic VT surgical treatment or medical management tients with these devices experience recur- The type of VT determines the approach Idiopathic VT accounts for about 50% of the . “Medically rent shocks for ventricular tachycardia to mapping and ablation. The majority of of all patients referred for VT evaluation. manageable vascular disease risk factors The ankle-brachial index (ABI) can be used as reliable cost-effective screen- (VT) or fibrillation that markedly reduce VTs considered for ablation are monomor- Most common is idiopathic right ven- include coronary artery disease, diabetes, ing tool for lower extremity PAD or to monitor effectiveness of therapy. quality of life. Antiarrhythmic drugs — phic, with a clearly defined fixed origin that tricular outflow VT, for which ablation is dyslipidemia, kidney dysfunction, hyper- The ABI involves using a blood pressure cuff and Doppler probe to mea- primarily sotalol or amiodarone — can can be targeted for ablation. In most VTs straightforward. However, many forms tension, obesity, tobacco use, and physical sure systolic pressure from both brachial arteries in each leg and from both decrease recurrent shocks, but high failure that develop after myocardial infarction, the of idiopathic VT arise from the ostium of inactivity,” says Bart R. Combs, MD, the dorsalis pedis and posterior tibial arteries after the patient has been at rates and adverse effects, including pro- ablation strategy is endocardial in the isch- the left ventricle (LV), often from foci in assistant professor in UAB’s Section rest in the supine position for 10 minutes. arrhythmias, limit clinical tolerance. emic substrate; success rates exceed 80%. the aortic root or mitral annulus, or from of Vascular Surgery and Endovascular ABI: Ankle systolic pressure divided by highest brachial systolic pressure. . Radiofrequency (RF) catheter ablation However, in dilated cardiomyopathy, the re- the epicardial surface of the left ventricle. Therapy. “Aggressive medical management is an excellent option for reducing the need entrant circuits are usually on the epicardial These patients have no indication for an of atherosclerosis-associated risk factors Resting ABI <1 is abnormal for ICDs in patients with recurrent VTs and surface of the heart. ICD, and ablation should be considered improves patients’ quality of life, reduces “Recognizing this dif- early in the patient’s therapy because of repeat events, and may prevent onset or ABI <0.95 indicates significant narrowing of≥ ≥1 vessels ference has led to epicar- high success rates and low risk of compli- progression of vascular disease.” dial ablation techniques cations. For these patients, successful abla- Cardiovascular disease, cerebrovascu- ABI <0.8 indicates intermittent claudication may occur with exercise that have dramatically tion is curative and antiarrhythmic medica- lar disease, abdominal aortic aneurysm, improved the success of tions are unnecessary. lower extremity peripheral arterial disease ABI <0.4 indicates symptoms may occur at rest ablation,” says Kay. If the VT arises from an epicardial focus, (PAD), varicose veins, deep vein throm- ABI <0.25 indicates severe, possibly life-threatening PAD Epicardial ablation a percutaneous epicardial approach is ap- bosis (DVT), vascular neuropathy, and involves entering the propriate. “Careful cardiac mapping is in- pulmonary embolism are common vascular pericardial space through tegral to pinpoint the precise site of origin,” disorders. the subxiphoid area to Kay says. Medical management by a vascular spe- “The ankle-brachial index [ABI] is an ef- or both. Previous history of DVT, surgical reach the area of inter- In a recent paper, Kay and colleagues cialist can improve outcomes and reduce fective and noninvasive method for PAD intervention, trauma, pregnancy, obesity, est. Important precau- detailed the electrocardiographic, electro- incidence of many of these conditions. screening,” Combs says. “ABI testing oral contraceptive use, the presence of tions include reversal of physiological, and angiographic character- Patients with Buerger disease and Raynaud sensitivity is 90% and can substantiate the lupus anticoagulant or anticardiolipin anti- anticoagulation, careful istics relevant to epicardial mapping and phenomenon, two poorly understood non- presence and severity of PAD.” Treatments bodies, and other factors such as congenital definition of coronary ablation of idiopathic ventricular arrhyth- atherosclerotic conditions, also benefit from include cholesterol-lowering and antihyper- or acquired deficits are associated with anatomy and the left mias from the LV (Circ Arrhythmia Elec- appropriate medical management and a re- tensive or antiplatelet medications in ad- DVT and hypercoagulable states. phrenic nerve to avoid trophysiol. 2008;1:396-404). duction of risk factors for vascular disease. dition to counseling on smoking cessation Ultrasound, venograms, and extensive injury, and continual as- They found that the left ventricular The prevalence of PAD, extracranial and increasing physical activity. blood assays are used to evaluate suspected Cranial CT image at the level of the aortic root dem- piration of the pericardial ostium is a common site of origin for idio- carotid artery disease, and renovascular Cerebrovascular disease is the third lead- hypercoagulable states. Therapeutic options onstrating bifurcation of the left main coronary artery space during the proce- pathic ventricular arrhythmias. These foci disease is increasing along with the aging ing cause of US deaths and causes more include short- or long-term use of anticoag- dure to minimize fluid are accessible from the aortic sinuses of of the US population. PAD affects up to 10 than 2500 a year in Alabama alone. ulants, percutaneous insertion of vena cava (LMCA) into the left anterior descending (LAD) and accumulation. Valsalva or from a point adjacent to the mi- million Americans, most of whom are older Evidence suggests therapeutic intervention filters, or both. left circumflex (LCx) . The LCx artery “With these precautions, tral annulus, and these approaches produce (> 60 years) and asymptomatic. Many do targeting carotid blockages may prevent or “Vascular specialists can medically man- courses posteriorly and beneath the left atrial append- epicardial ablation has good results, Kay reports. not get optimal care. Patients with coronary reduce incidence. Aggressive risk age and treat many risk factors for heart age (LAA). Note that the LMCA travels from the LCC (left a very low complication artery disease, for example, receive inter- factor reduction, antiplatelet therapy, and, disease, stroke, and multiple vascular con- coronary cusp) over the left ventricular (LV) summit. The rate and is more than 85% vention more often than patients with PAD, for some patients, intervention with percu- ditions,” says Combs. anterior interventricular cardiac vein (AIVV) lies on the successful,” says UAB despite the condition’s prevalence and its taneous angioplasty or endarterectomy may electrophysiologist H. associated cardiovascular morbidity and reduce incidence of primary or secondary epicardial surface of the LV summit. (NCC=noncoronary FOR MORE Dr. Ne a l Ka y Thomas McElderry, MD. mortality (JAMA. 2001;286:1317-1324). events, Combs says. FOR MORE Dr. Ba r t Co m b s cusp; RCC= right coronary cusp.) INFORMATION Dr. To m McEl d e r r y Although there are noninvasive methods Risk factors for thromboembolitic disease INFORMATION Dr. Br u c e Lo w m a n 1.800.UAB.MIST for diagnosing PAD, the condition is or hypercoagulable states may be inherited [email protected] 1.800.UAB.MIST

A n natomic C oncept Ostium: L itovsky S H , Kay GN . The eft Ventricular T, Yamada A rrhythmias. Circ Arrhythmia Electrophysiol. 2008;1:396-404. R elevant to I diopathic Ventricular underreported in primary care settings. or acquired and affect the vasculature, blood, [email protected]

8 uab insight on heart and vascular disease • FALL 2009 uab insight on heart and vascular disease • FALL 2009 9 Vascular Surgery Vascular Surgery Abdominal Aortic Aneurysm Repair Hybrid Vascular Procedures

More Robust Screening; Interventional Flexibility Expand Options

Abdominal aortic aneurysm (AAA) re- Combining Open Surgery with Endovascular Therapy mains a significant cause of morbidity and mortality in US patients aged > 65 years. Ruptured AAAs cause approximately Increasingly sophisticated technol- 15,000 deaths a year, making the condition ogy emerging during the last decade has one of the leading causes of US deaths. made minimally invasive endovascular Diagnosis of AAA prior to rupture has procedures available for complex vascular been problematic as the condition often problems, often as an alternative to open is asymptomatic. “Screening patients surgery. Yet some patients have vascular younger than 65 years may be indicated pathoanatomy or risk factors that make an after consideration of mitigating risk fac- exclusively endovascular or open approach tors,” says UAB vascular surgeon William less favorable. D. Jordan Jr, MD, chief of the UAB Sec- Hybrid vascular surgical intervention, a tion of Vascular Surgery and Endovascular combination of conventional open surgery Therapy. Clinicians should evaluate patient and catheter-based therapies, expands age, sex, comorbidities, family history, and patients’ options for treatment of vascular manifestation of other vascular diseases disease. “In select patients surgeons can when selecting patients for AAA screening use a hybrid approach or a combination of and subsequent surgical options. vascular surgical techniques when catheter- In February 2009, the Screening Ab- based interventions are inappropriate or an Superficial femoral artery before Superficial femoral artery after dominal Aortic Aneurysms Very Efficiently open procedure involves excessive risk,” treatment. angioplasty and stent. (SAAAVE) Act introduced legislation to says UAB vascular surgeon Steven M. Endovascular repair of an infrarenal abdominal aortic aneurysm expand future Medicare benefits. If ap- Taylor, MD. as now used in the majority of repairs done at UAB. proved, the legislation will eliminate current Depending on the nature and location vascular lesions or younger patients in need these patients expands intervention options restraints limiting ultrasound screening to the of the occluded vessel, comorbidities, and of durable revascularization are potential rather than replacing standard open surgery, initial Medicare physical. In addition, at-risk EVAR is consideration of anatomic suit- eurysm is 5 to 5.5 cm and opting for a pe- other risk factors, surgeons can perform candidates for hybrid procedures. Combi- he says. Postoperative hospitalization is Medicare beneficiaries, including men with a ability,” Jordan explains. Vessel tortuosity, riod of careful monitoring and observation an open bypass with endovascular therapy nation procedures for this population are not necessarily shorter following hybrid smoking history and women with a positive neck angle, and access vessel size may before considering surgical intervention, during the same surgical procedure. If pa- less extensive, require less operative time, procedures, because many of these patients family history, will be eligible for screening. limit the use of EVAR in some patients. he says. However, study data indicate some tients have extensive aortic disease accom- and may reduce perioperative risk (Ann have extensive comorbidities. The postsur- Close proximity to renal arteries, for individuals with aneurysms 4.5 to 5 cm panied by respiratory and cardiac disease, Vasc Surg. 2009;23:414-424). gical surveillance program and need for Treatment Options example, often restricts the use of a stent- are optimal surgical candidates and have hybrid procedures allow surgeons to offer Endovascular repair of thoracoaortic lifestyle modifications to reduce vascular Increasingly, vascular surgeons offer graft reliant on springs or staples to secure the best postsurgical outcomes. Patients staged surgical intervention. aneurysm can be paired with surgical re- risk are the same for hybrid and traditional carefully selected patients endovascular the graft. Use of a “chimney graft,” cre- who underwent EVAR for aneurysms <5.0 “A hybrid procedure lets surgeons opti- construction of aortic vessels in single pro- procedures. aortic aneurysm repair (EVAR) as an ap- ated by inserting a second graft high up in cm had the best long-term outcomes, with mize surgical intervention in patients with cedure or in multiple stages (Circulation. Evaluating all options — endovascular propriate alternative to an open surgical the renal artery parallel to the stent-graft, 99% freedom from AAA death at 5 years complex pathology and limited options for 2005;112:2619-2626). “Traditionally, tho- therapy, open surgery, and hybrid tech- procedure. Traditional aneurysm repair overcomes EVAR limitations by extend- (J Vasc Surg. 2006 Nov;44[5]:920-929). an autologous graft,” explains Taylor. “In- racoabdominal and aortic arch procedures niques — results in the best treatment plan involves repair of the diseased vessel with ing the fixation zone to hold the original These data underscore the need for im- dividuals with a history of coronary bypass are physiologically stressful operations,” for each patient. “Hybrid techniques allow a graft. EVAR deploys a stent-graft to the graft in place. After more than 10 years proved screening and increased physician or previously failed bypass procedures Taylor says. “Aortic arch replacement sur- surgeons to help an expanded pool of pa- affected site using a minimally invasive of experience, UAB vascular surgeons are awareness and patient education about risk often have limited autogenous veins and gery typically requires hypothermic circu- tients and can potentially decrease mortal- catheter-based approach. Patients who adept at tailoring graft selection to meet factors for AAA, Jordan says. are potential candidates for a hybrid proce- latory arrest; hybrid techniques avoid this, ity and morbidity,” Taylor says. undergo EVAR for AAA have a lower rate patient needs and are using endovascular dure, for example.” decreasing stress on patients.” of short-term complications, shorter hospi- techniques for more than 60% of patients Hybrid carotid revascularization also is talizations, and lower perioperative mortal- treated for AAA at UAB. an alternative for persons with occlusive ca- Potential Application FOR MORE Dr. St e v e n Ta y l o r ity compared with those undergoing open “New data suggest earlier treatment Hybrid intervention can provide revas- rotid disease and accompanying aortoiliac INFORMATION FOR MORE Dr. Wi l l i a m Jo r d a n 1.800.UAB.MIST surgery (Ann Surg. 2003;5:623-630) and of AAA may result in improved patient INFORMATION 1.800.UAB.MIST cularization for persons with lower limb occlusive disease or difficult aortic arch [email protected] (N Engl J Med. 2008;358:464-74). outcomes,” Jordan says. Many vascular [email protected] ischemia. Older patients with complex anatomy. Utilizing a hybrid technique in “A key to optimal patient selection for surgeons recommend waiting until an an-

10 uab insight on heart and vascular disease • FALL 2009 uab insight on heart and vascular disease • FALL 2009 11 Heart and Vascular Faculty Heart and Vascular Faculty UAB Heart and Vascular Faculty at a Glance

Cardiothoracic surgery mapping of cardiac arrhythmias; device disease and guide therapies; exercise Alan S. Gertler, MD Steven M. Pogwizd, MD Pediatric Cardiology Cardiovascular Surgery: Surgery for therapy including implantable cardio- echocardiography; contrast (bubble) Himanshu Gupta, MD Edlue M. Tabengwa, PhD Pediatric Cardiology: Diagnostic congenital heart disease, adult congeni- verter defibrillator (ICD) and biventricu- echocardiography. Ami E. Iskandrian, MD Patrick K. Umeda, PhD and interventional catheterization for tal heart disease, acquired heart dis- lar pacemaker/ICD implantation. Steven G. Lloyd, MD, PhD Gregory P. Walcott, MD congenital heart disease; treatment of Pohoey Fan, MD ease, advanced heart failure, coronary Suzanne Oparil, MD Peipei Wang, MD, PhD rhythm disturbances, pediatric and adult Sharon M. Dailey, MD Navin C. Nanda, MD artery disease, and cardiac arrhythmias; Gilbert J. Perry, MD Chih-Chang Wei, PhD congenital heart disease, pulmonary Harish Doppalapudi, MD Gilbert J. Perry, MD acute and chronic mechanical circula- Steven M. Pogwizd, MD C. Roger White, PhD hypertension, fetal arrhythmias, cardiac Hugh Thomas McElderry, MD Frank F. Seghatol-Eslami, MD tory support; heart and lung transplan- Robert P. Robichaux, MD Paul E. Wolkowicz, PhD valvular and structural disease. G. Neal Kay, MD Srinivas Vengala, MD tation (adult and pediatric); pulmonary William J. Rogers, MD Dongqi Xing, MD, PhD Vance J. Plumb, MD Gilbert Zoghbi, MD thromboendarterectomy; robotic and Frank F. Seghatol-Eslami, MD Takumi Yamada, MD, PhD Edward V. Colvin, MD minimally invasive cardiac surgery, James L. Taylor, MD Martin E. Young, PhD Walter H. Johnson, MD Interventional Cardiology: Innovative Preventive Cardiology: Cardiac rehabili- valve surgery, thoracic aortic surgery. Yung R. Lau, MD technology and complex cardiovascular tation and preventive interventions for Cardiac MRI and CT Imaging: Noninva- Mark A. Law, MD James K. Kirklin, MD interventions including catheter-based hyperlipidemias, coronary heart disease sive imaging including cardiovascular Vascular Surgery and William S. McMahon, MD Chris W. Akins, MD closure of atrial septal defects, ventricu- in women, and congestive heart failure. MRI and computerized x-ray tomogra- Endovascular Therapy Bennett F. Pearce, MD lar septal defects, and patent foramen Constantine L. Athanasuleas, MD phy; cardiac metabolism studies. Vascular Surgery and Endovascular Robb L. Romp, MD ovales; percutaneous bypass, angiogen- Vera A. Bittner, MD, MSPH Robert J. Dabal, MD Therapy: Treatment for aortic, carotid, esis, cardiac angioplasty, and stenting; Todd M. Brown, MD Himanshu Gupta, MD James E. Davies, MD renal, mesenteric, and extremity disease Pediatric Interventional Cardiology: William L. Holman, MD . Steven G. Lloyd, MD, PhD William S. McMahon, MD Hypertension: Diagnosis and man- with open reconstructions and catheter- David C. McGiffin, MD based therapy including lytic therapy, Mark A. Law, MD Brigitta C. Brott, MD agement of systemic, complex, and Nuclear Cardiology: Nuclear cardiac Octavio E. Pajaro, MD angioplasty, atherectomy, stents, and William B. Hillegass, MD refractory hypertension and hyperaldos- imaging; exercise testing; myocardial Russell S. Ronson, MD endografts for arterial treatment for Pediatric Electrophysiology: Vijay K. Misra, MD teronism. viability; cardiovascular positron emis- Wade C. Lamberth, MD venous disease; deep venous thrombo- Yung, R. Lau, MD Silvio E. Papapietro, MD sion tomography; new therapeutic and David A. Calhoun, MD sis prophylaxis including inferior vena Gilbert J. Zoghbi, MD diagnostic nuclear cardiology studies. Thoracic Surgery: Surgery for benign Suzanne Oparil, MD cava filters. Pediatric Transplant and Pulmonary and malignant diseases of the trachea, Hypertension: Advanced Heart Failure/Pulmonary Vera A. Bittner, MD, MSPH bronchi, lungs, esophagus, and medi- William D. Jordan Jr, MD Bennett F. Pearce, MD Hypertension: Cardiac transplantation Cardiographics: , Jaekyeong Heo, MD astinum; hyperhidrosis. Marc A. Passman, MD for congestive heart failure, pulmonary event electrocardiogram (ECG) monitor- Ami Iskandrian, MD Mark A. Patterson, MD Congenital Heart Disease: vascular disease, cardiomyopathy; me- ing, remote ECG and blood pressure Robert J. Cerfolio, MD Steve M. Taylor, MD Edward V. Colvin, MD chanical circulatory support (ventricular monitoring; metabolic exercise testing for Cardiovascular Research: Douglas J. Minnich, MD Walter H. Johnson, MD assist devices); advanced diagnostic and unexplained dyspnea; and external elec- Xun Ai, MD Vascular Medicine: Treatment of Mark A. Law, MD therapeutic medications and devices; re- tromechanical counter pulsation therapy. John C. Chatham, PhD Cardiothoracic Research: hypertension and diabetic and vascular mote hemodynamic monitoring devices. Yiu-Fai Chen, PhD James F. George, PhD Sharon M. Dailey, MD neuropathy; wound care; perioperative Fetal Echocardiography: Louis J. Dell’Italia, MD David C. Naftel, PhD John H. Holt, MD vascular medical management; throm- Edward V. Colvin, MD Robert C. Bourge, MD Derek J. Dosdall, PhD Gilbert J. Perry, MD botic risk assessment and treatment; Walter H. Johnson, MD Martin Cadeiras, MD William T. Evanochko, PhD Ferdinand Urthaler, MD prevention of contrast nephropathy. Bennett F. Pearce, MD Cardiovascular Disease Salpy V. Pamboukian, MD Joel N. Glasgow, PhD Robb L. Romp, MD Electrophysiology: Diagnosis, evaluation Barry K. Rayburn, MD Hernan E. Grenett, PhD General Cardiology: Bart R. Combs, MD of drug therapy, and catheter ablation Jose A. Tallaj, MD Fadi G. Hage, MD Vera A. Bittner, MD, MSPH Bruce G. Lowman, MD Pediatric MRI and CT Imaging: for atrial fibrillation, supraventricular Jan den Hollander, PhD Todd M. Brown, MD Robb L. Romp, MD tachycardias, and ventricular tachy- Echocardiography: Noninvasive car- Jian Huang, PhD David A. Calhoun, MD cardia (endocardial and epicardial); diac imaging, new echocardiographic Raymond E. Ideker, PhD Louis J. Dell’Italia, MD experimental antiarrhythmic drugs; techniques to better delineate heart Cheryl R. Killingsworth, DVM Leland W. Eaton, MD

12 uab insight on heart and vascular disease • FALL 2009 uab insight on heart and vascular disease • FALL 2009 13