Better Care, Through Better Technology | 2015 HEART and VASCULAR REPORT

Better Care, through Better Technology | 2015 HEART AND VASCULAR REPORT

HEART AND VASCULAR INSTITUTE 2015 HEART AND VASCULAR REPORT Better Care, through Better Technology Pittsburgh Heart, Lung, Blood, and Pittsburgh Heart,Lung,Blood,and The HeartandVascular Institute Vascular Medicine Institute Facts andFigures New Approaches Future andPast 14 18 4 6 2

Top-Ranked Education andTraining Techniques andDevices Community Locations UPMC Hospitals and UPMC Hospitalsand Trials andTactics 24 28 27 21

3 | 2015 HEART AND VASCULAR INSTITUTE REPORT

UPMC The Heart and 4 | Vascular Institute: The Vanguard of Research and Technology

Since the release of our inaugural report, the Heart and Vascular Institute (HVI) of UPMC has continued to lead the way in the provision of comprehensive cardiovascular care. This year and every year, our world-class cardiologists, cardiac and vascular surgeons, engineers, and allied practitioners have focused first on the wellbeing of our patients. And this year, we share with you our other passions: research and technology.

Research is what allows our organization to break through In 2014, Andrew Voigt, MD, became the first physician the boundary of what is considered possible. What we learn in the state of Pennsylvania to implant a wireless in the lab inspires us to develop fresh approaches to patient pacemaker. The catheter-delivered, leadless device care. New technologies allow us to take on challenges that is extremely small, allowing it to be implanted directly into once seemed insurmountable. By embracing new tools and the right ventricle. UPMC is one of only six health care novel techniques, we contribute to the advancement of the systems in the nation selected to participate in the art and science of cardiovascular medicine. Our partner international trial of this device. organization, the Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute (VMI), makes this marriage of research These stories are only a few of the many that illustrate and clinical practice particularly strong. Through a variety of the ingenuity of the Heart and Vascular Institute of UPMC. research initiatives, affiliations, and educational opportunities, With our ongoing commitment to research and technology we’re extending our knowledge and sharing it with and the development of novel approaches to cardiovascular physicians far and wide. care, we are well positioned to build upon our successes in the years to come. Since 2014, Catalin Toma, MD, and Conrad Smith, MD, have applied advanced techniques and technologies to treat more than 100 patients in the Chronic Coronary Total Occlusion Program — one of only a few dozen such programs in the nation and the most experienced in our region. Our dedicated interventional cardiology facility is fully equipped for the application of this high-tech, hybrid approach to angioplasty.

Stephen Chan, MD, PhD, recently joined the Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute (VMI) as the director of the Center for Pulmonary Vascular Biology and Medicine. His groundbreaking investigations into the molecular mechanisms of pulmonary vascular disease and pulmonary hypertension, combining network-based bioinformatics with unique experimental reagents, have placed him among the first scientists to identify the importance of microRNAs in processes critical to pulmonary hypertension progression. Joon Sup Lee, MD Michel Makaroun, MD Victor Morell, MD Our Star HVI Cardiology Director HVI Vascular Surgery Director HVI Cardiac Surgery Director Ratings UPMC PASSAVANT The multidisciplinary team at UPMC Passavant is an

integral part of the HVI, offering a full spectrum of options for every type of heart or vascular disorder — including coronary artery bypass grafting, for which the hospital earned The Society of Thoracic a three-star rating from the STS. The STS also recognized Surgeons (STS) awarded UPMC Passavant for heart attack and heart failure UPMC Passavant and mortality and readmission outcomes that were better than

UPMC Shadyside its the national average. REPORT INSTITUTE AND VASCULAR HEART 2015 highest rating — three 5 | stars — for heart surgery. The ratings, based upon data from 2014, place UPMC SHADYSIDE For 2014, the STS recognized UPMC Shadyside in the exceptionally favorable outcomes at UPMC Shadyside for heart top 9.9 percent of hospitals attack and heart failure mortality and readmission. The HVI nationally for aortic valve professionals who practice replacement procedures at UPMC Shadyside are also recognized experts in the and UPMC Passavant treatment of diseases involving the aorta. Our three-star ranking in the top 8.8 percent reflects our commitment to delivering optimal care with of hospitals nationally outcomes that exceed the national average. for coronary artery bypass grafting procedures.

CHILDREN’S HOSPITAL OF PITTSBURGH OF UPMC The Society of Thoracic Surgeons noted that the Cardiothoracic Surgery Program at Children’s Hospital of Pittsburgh of UPMC is tied with another institution for the lowest surgical mortality among high-volume programs in the country, based on a 2015 survey of programs performing congenital heart disease surgery.

Victor Morell, MD Our Star HVI Cardiac Surgery Director Ratings3

8 | UPMC to buildbridgesfrom new discoveries inbasicscience to applications intheclinic. and Vascular MedicineInstitute hasledto significantadvancements that inspire otherscientists the very edgeofscientificdiscovery. Our partnershipwiththePittsburgh Heart,Lung,Blood, leaders inacademicsandresearch, we are more than clinicians—we are alsopioneersat is necessarily concerned withthecare ofpatients. This isourprimaryfunction.But asglobal As avitalpartofworld-renowned healthcare system, theHeartandVascular Institute Inventing theFuture ofMedicine Institute (VMI) Blood, andVascular Medicine Pittsburgh Heart,Lung,

Through Research

the leapfrom benchto bedside. illustrates how originalthinkingmakes to cutting-edgeinvestigation and Synergy bringspractical application and illustrates how originalthinkingmakes theleapfrom benchto bedside. the Vascular MedicineInstitute —asynergy thatbringspractical applicationto cutting-edge investigation These scientistsandmany others represent thesynergy between andVascular theHeart Institute and research, detailedintheworld’s leadingscientificpublications: Over thepastseveral years, ourscientistshave secured significantgrants that have ledto groundbreaking together every day to create thefuture ofcardiovascular medicine. Our interdisciplinary teams ofresearchers, physicians, graduate students,andmedicalstudentswork organs. Their translational andbasicresearch have ledto novel therapies thatdirectly benefitpatients. metabolism, andtransfusion medicineto explore how molecularprocesses canaffect bloodflow to vital Institute (VMI) bringstogether internationally known incardiovascular experts biology, hemostasis, University ofPittsburgh SchoolofMedicine,thePittsburgh Lung,Blood,andVascular Heart, Medicine Under theleadership of treatment ofaspectrumdiseases.The NIHfundsthisongoing study. acids; thisresearch may pave theway toward theuseof targeted gene silencingfor the that occur between ultrasound andnovel microbubble formulations carryingthenucleic interfering RNAsandmicroRNAs to cells and cancer intheheart cells usingtheinteractions Liza Villanueva, MD a topical therapy thatusesthewound environment to enhance healing. other impaired wound-healing pathologies.These pathways thedevelopment support of Award to definealternative pathways of nitricoxide formation indiabeticwounds and Edith Tzeng, MD hydralazine inAfrican failure Americanswithheart andreduced ejectionfraction. marker ofenhanced therapeutic response to acombination ofisosorbidedinitrate and that examines whetheraspecifichaploid genotype associated withhypertension isa Dennis McNamara, MD valvewith bicuspidaortic syndrome. oxygen smoothmusclecells speciesinaortic mediates theaortopathy inpatients National Institutes ofHealth(NIH)to test thehypothesis thataccumulation of reactive Thomas Gleason,MD Mark T. Gladwin,MD , isleadinganeffortfundedby amultiyear Veterans Administration Merit , andhergroup are developing methodsfor delivering short , andhisteam are conducting amultiyear studyfundedby the , isleadingateam inanothermultiyear, NIH-sponsored study , whowas recently ofMedicine, namedchairman,Department

9 | 2015 HEART AND VASCULAR INSTITUTE REPORT 10 | UPMC of research. the HVI’s home Welcome to bring innovative solutionsinto play for many years to come. to ask questions together,organizations our areto poised of our more ideas. By and continuing more develop and we’ve secured significantfunding to allow us to study the best mindsinthefieldofcardiovascular research, and investigators into theHVIandVMI,representing someof In recent years, theVMIhasgrown. We’ve addedten new exists between researcher andclinician. distinction clear no relationships liesintheirflexibility:often, thought goesunexplored. The strength ofourmultidisciplinary Only by working together canwe ensure that nopromising innovative therapies andtreatments to ourpatients. always have shared thegoalofdelivering thebest andmost Heart, Lung,Blood,andVascular MedicineInstitute (VMI) As partnerinstitutions, theHVIandPittsburgh

Medicine Institute (VMI) Director, Pittsburgh Heart,Lung, Blood,andVascular Mark T. Gladwin,MD

RESEARCH SPOTLIGHT of research. the HVI’s home Welcome to

RESEARCH SPOTLIGHT Stephen Chan,MD, PhD| of PH.Understanding thegenetic underpinningsofthis the systems-level functionsofmicroRNAs asa root cause Dr. Chanwas one ofthefirst scientistsintheworld to identify application inmany diseases, includingPH. are leading theway initsongoing development and findings isaburgeoning field,andtheHVIVMI chemical activity. Personalized medicinebasedonsuch cells thatinfluence theirdevelopment andregulate their microRNAs —small,non-coding messengers withinthe Its molecularorigincanbetraced to theactionofcertain affects thelungvasculature, failure. canleadto rightheart Pulmonary hypertension (PH),arare condition that pulmonary hypertension clinic. at theVMI. Healsoseespatientsinourcomprehensive of theCenter for Pulmonary Vascular Biology andMedicine investigator onseveral projects aswell asbeingthedirector pulmonary hypertension (PH).Heserves astheprimary specializing intheinvestigation ofthemolecularbases Chan, MD, PhD, recently joinedtheVMI asaresearcher many oftheworld’s leadingresearchers to itsteam. Stephen have surged inrecent years, andtheorganization hasadded Lung,Blood, andVascularHeart, MedicineInstitute (VMI)

Research activitiesatthePittsburgh Cardiologist Stephen Chan,MD, PhD

in hypoxia andexercise. microRNAs andtheregulation ofcirculating microRNAs molecular regulation ofmitochondrial metabolism by pulmonary vascular disease,Dr. Chan’s labstudiesthe In additionto studyingthemolecular mechanismsof development oftherapies basedonmicroRNAs. their interactions (usingbioinformatics) may leadto the in thefieldofPH.Further analysis ofmicroRNA types and rodent andhumansubjectshasaccelerated discovery experimental reagents derived from genetically altered Their pioneeringcombination ofbioinformatics with scientists to make systematic senseofbiologicaldata. methods andsoftware tools thatmake itpossible for engineering, andbiologyto spurthedevelopment of combines thedisciplinesofcomputer science, statistics, analyze, andinterpret avast amountofdata.Bioinformatics in theirwork, anapproach thatallows themto amass, Dr. Chanandhisresearch team usebioinformatics novel treatments andprevention strategies. at riskfor PH;we canalsousethisinformation to develop disease hasenabledusto more easilyidentifythose

11 | 2015 HEART AND VASCULAR INSTITUTE REPORT RESEARCH SPOTLIGHT 12 | UPMC ultrasound fieldcanbeharnessed to therapeutic effect. study ofhow theuniquebehaviors ofmicrobubbles inan or function-specificepitopes possible to echocardiographically image disease-specific microbubbles bindto biologicalsurfaces, makingit She was thefirst to demonstrate thatmolecularlytargeted applications isthefoundation ofDr. Villanueva’s to of novel, precision-designed microbubble contrast agents ultrasound basedtechnologies to thebedside.The addition at theVMI, alabthatfocuses ontranslating preclinical Center for Ultrasound MolecularImagingandTherapeutics evolution. Liza Villanueva, MD, directs themultidisciplinary and scientistsattheVMI andtheHVIare influencingthat structure. Buttheapplicationsofultrasound are evolving, tested methodfor thedynamicvisualization ofanatomical Liza Villanueva, MD|

traditional microbubbles vibrating underultrasound genes anddrugs,break bloodclots. excitation. Microbubble oscillationcan million frames persecond, shows lipid (Chen

ultrasound enhance tissue permeability, deliver This seriesofimages, taken at25 et. al.,Rev SciInstrum Cardiologist Liza Villanueva, MD

Ultrasound imagingisatime-

in diagnosticandtherapeutic in vivo 2013; 84)

. Hergroup hasledthe

work.

mortality. The researchers have causedtheregression a condition associated withincreased cardiovascular in thetreatment ventricular ofleft hypertrophy (LVH), the useofnucleicacid-loadedmicrobubbles andultrasound For instance, Dr. Villanueva andhergroup are exploring with fewer sideeffects. the siRNAormiRNA,andhence achieve better results localize delivery, increase permeability ofthetarget cells to diseased tissue (e.g. muscle,tumor),we heart canspatially microbubbles withultrasound asthey pass through the on intravenously injected microbubbles, andbreaking the to diseasedcells. By loadingspecificsiRNAsormiRNAs major impedimentsto delivering themintactandspecifically historically beendifficultto translate into theclinicdueto personalized medicine.These nucleicacidpayloads have via microbubbles andultrasound are atthevery edge of itory RNAs(siRNAs) ormicroRNAs (miRNAs) delivered Modulation ofdisease-causinggenes usingsmallinhib to dissolve theseclots. microbubble vibrations are beingstudiedfor theirability obstructs flow muscle andultrasound-induced into theheart (Principal Investigator: JohnJ. Pacella, MD). This debris stenting forcapillaries after acute myocardial infarction destruction ofbloodclotsthatscatter into thetiny NIH-funded studyofultrasound-microbubble induced Other current research attheCenter includesanongoing is atreatment approach. diseases inwhichspecificgene-modulation orsilencing bedside, outpatientstrategy for treating avariety of payloads canultimately beanon-invasive, portable, Ultrasound-targeted microbubble delivery oftherapeutic a miRNAthatregulates thedevelopment ofLVH. delivering microbubbles loadedwithanantagonist to of LVH ofhypertensive inthehearts mice by acoustically

able to achieve high-quality results inaconsistent andtimelymanner. experts across several disciplines,butthestatisticians attheHVI-CBCspecialize incardiovascular research. they Becauseoftheirexpertise, are unique amongbiostatisticsorganizations and becauseitisspecificallydedicated to heart vascular projects; other research groups share biostatistics The HVIresearchers CBCsupports by providing high-quality datacollection, analysis, interpretation, maintenance, andpreparation. The CBCis who bringadeepknowledge ofbiostatisticsto theexploration ofcardiovascular science. specific disciplines. and The Heart Vascular Institute Clinical Biostatistics Core (HVI-CBC)harnesses the ofdedicated dataspecialists expertise As aresearch, academic,andclinicalentity, theUPMCandVascular Heart Institute counts amongitsranks peoplewhopractice avariety ofhighly Making SenseoftheScience: theHVIClinicalBiostatistics Core in theupperthigh.Mostpatients are senthomethenext day. stent graftthrough withintheaorta two smallincisions EVAR procedure involves theplacement ofanexpandable open surgery andbecome thetreatment ofchoice. The decades, endovascular aneurysm repair (EVAR) hasreplaced improve outcomes andreduce costs. will which the science ofpersonalized medicine, pharmacogenetic approach hasthepotential to advance of others. Dr. McNamara’s workNIH-supported onthis Americans butonlyabout15percent African of percent 50 haplotype associated withhypertension; itoccurs in from a combination drug therapy thanks to aracially linked Many African American menwithheart disease benefit pharmacogenetics cardiomyopathy. andperipartum McNamara, MD, conducts research related to FailureUPMC Heart Research Program, Dennis Dennis McNamara, MD| Abdominal aortic aneurysms affect aneurysmsAbdominal aortic affect endovascular techniques. in theuseofminimallyinvasive Shadyside, isknown for hisexpertise chief ofVascular Surgery atUPMC Singh, MD, whoserves theHVIas complex open operations.aortic Michael minimally invasive procedures to replace instrumental inthedevelopment of Michael Singh,MD deaths eachyear. Over thepasttwo aneurysms, leadingto about15,000 of thesepatientspresent with ruptured in theUnited States. Asmallcohort approximately 200,000 peopleannually

In additionto directing the |

The HVIhasbeen

North America. North facilitates clinicalinvestigation atmore than30sites in at thePeripartum Cardiomyopathy Network, Dr. McNamara dysfunction canaffect recovery. Inhisleadership role which revealed thatgenetic factors ventricular andleft “Investigations inPregnancy-AssociatedCardiomyopathy,” published Dr. McNamara’sNIH-sponsored study, American College ofCardiology In August 2015, the live intheUnited States. births occurs in1ofevery 3,000-4,000 Peripartum cardiomyopathy uses minimallyinvasive approaches isapossibility. who meetcertaincriteria, enrollment inaclinicaltrialthat aneurysms.for andiliacartery For patientswithaortic those variety oftraditional andstate-of-the-art treatment options The UPMC HVIprovides outstandingcare andoffers a aneurysms.aortic branched prosthesis for therepair oftype 4thoracoabdominal is evaluating theGORE®EXCLUDER® thoracoabdominal the superiormesenteric artery. Anotherongoing study covered stents to treat aneurysms thatoriginate below Study isevaluating thep-Branch endovascular graft with Theaorta. Zenith® p-Branch® Endovascular Graft Pivotal and thedescending thoracic, paravisceral, andjuxtarenal to repair aneurysms aortic thatinvolve arch theaortic in clinicaltrialsofseveral advanced endovascular devices Dr. Singhandhiscolleagues have beentakingpart Journal ofthe

13 | 2015 HEART AND VASCULAR INSTITUTE REPORT RESEARCH IN BRIEF 14 | UPMC Inhaled Nitrite for PulmonaryHypertension interventional cardiology. outcomes. AlthoughtheEchoCRT studyendedin2013, itsinfluence continues to shapethe face of research in in European Journal)andfound Heart thatpersistent orworsening dyssynchrony isassociated withunfavorable clinical that contributed to thelandmarkstudy’s findings. Samir Saba,MD whether CRT could helppatientswithmechanicaldyssynchrony withoutelectricaldelay. trial of809patients,theEchocardiography GuidedCardiac Resynchronization Therapy (EchoCRT) study, to discover patients withreduced ventricular left ejectionfraction andQRSwidening.UPMC recently inamulticenter participated Traditional cardiac resynchronization therapy (CRT) isaneffective approach failure, to heart butitsuseislimited to The EchoCRT Trial: ALandmarkofInterventional Cardiology stent to bepositionedinthebattlefieldthen removed rapidly by thesurgeon atthetimeofdefinitive repair. available, wheninventory islimited, orwhenthesite ofinjuryisnotknown. Ahandheldradiofrequency monitor willallow the will allow rapid control ofhemorrhage whileensuringperfusionto theorgans whenavascular surgeon isnotimmediately transplant. InaDoD-funded study, Dr. Tillman isinvestigating aballooncatheter for fieldhemorrhage control. The device of novel endovascular devices to prevent hemorrhage thoracic after trauma andimprove recovery ofdonororgans for to prevent restenosis, amajorcauseoffailure amongvascular bypasses andstents. Hestudiesthedesignanddevelopment Dr. Tzeng’s colleague, vascular surgeon this growing knowledge to clinicaluse. healing —thebeneficialeffects of CO andNOapply to both,andDr. Tzeng’s labwill continue to investigate how to apply vasculature isdirected toward bringingtheseagents to clinicalapplication.Cutaneous wound healingisrelated to vascular on theprevention ofintimalhyperplasia. This effortto understand themechanismsby whichthesemoleculesbenefitthe wound healing.Sheandhercolleagues are studyingtheeffect ofsmallmoleculeslike carbonmonoxide andnitricoxide A clinician,professor, andresearcher, Healing Innovations BAV patients. Dr. Gleasonandhiscolleagues maintainathoracic tissue bankof550samples,more aortic thanhalfofwhichare from of theascending thoracic inclinicaltrialsofnew Inadditionto leadingandparticipating approaches aorta. to BAV disease, an interdisciplinary basicscience laboratory thatstudiesthecellular andmolecularmechanismsthatgovern diseases Center for Thoracic Disease.The Aortic center provides comprehensive diagnosticandtreatment services; italsohouses Thomas Gleason,MD in stenosis andregurgitation withvarying degrees ofseverity. architecture are fused.Insomecases,theanomalyisnotproblematic —butinothers, thevalve may calcify, resulting most common cardiac valvular defect. InBAV syndrome, two oftheleafletsthatmake upthe valve’s normallytricuspid valveBicuspid aortic (BAV) diseaseaffects upto two percent ofthepopulation,makingthiscongenital anomalythe Understanding BicuspidAortic Valve Disease of theNOpathway, Dr. Simonandhiscolleagues have set thestage for ongoing research throughout thenation. ejection fraction. Clinical trialsofinhalednitrite for PHare currently underway. By introducing thisnovel clinical study extremely beneficialinthemanagement asa ofpulmonary particularly hypertension, result ofheart failure withpreserved Dr. Simon’s research translating Dr. Gladwin’s seminal findings to thebedsidehasshown thatthisapproach may be of settingtheprocess inmotion. vasorelaxation. Many therapeutic arisealongtheNOpathway; opportunities inhalednitrite isonepossible means synthase, whichconverts L-arginine to L-citrulline andNO. NOtheninitiates aseriesofevents resulting incalcium-mediated Nitric oxide (NO), avasodilator, occurs naturally invessels whenshearstress ontheendotheliumactivates nitricoxide findingsattheAmerican further Thoracic Society’s International Conference in2016. inhaled nitrite for theseconditions. In2014, Dr. Simonpublishedtheirearlyfindingsin Advances inPH, and willpresent to pressure overload failure. inpulmonaryhypertension andheart Heand Hemodynamics Core Facility. Hiswork focuses onthestudyofrightventricular structural and functionaladaptation Marc Simon,MD , andhiscolleagues implanted patientswithCRT-D devices andconducted blindedrandomizations , serves theVMI as director Failure of Heart Research andistheVMI’s director oftheClinical , serves theHVIaschiefofDivisionCardiac Surgery atUPMC andasthedirector ofthe Edith Tzeng Bryan Tillman, MD oversees alabthatspecializes intranslational studiesofvascular and John Gorcsan, MD , runsanactive research program thatinvestigates new approaches , thenperformed subsequentanalysis (published

Mark T. Gladwin,MD , have alsobeen studying

disease contexts. Dr. St.Hilaire’s laboratory will studytherole ofCD73 and adenosinesignalinginthesemore common vascular including calcificationandvessel remodeling —alsooccur inmore prevalent vascular diseasesandpathologies, experimentation hasproven thenovel linkbetween adenosine andectopic calcification. The phenotypes seeninACDC — hypothesized thatthedeleterious phenotypes inACDC vasculature are dueto alackofadenosinesignaling;subsequent cells to adaptto common vasculature conditions suchasmechanicalstress, inflammation,andhypoxia. Dr. St.Hilaire severely reduced mobility. MutationsinCD73alter adenosineproduction andsignaling,whichinhealthy vessels allows extremities alongwithmedialdysplasia, stenosis, andarteriomegaly, whichtogether result inchronic ischemicpain and Calcification dueto Deficiencyof CD73(ACDC). Patients withACDC have calcification inthevessels oftheirlower postdoctoral fellow atthe NHLBI,Dr. St.Hilaire and her colleagues discovered therare monogenetic disease,Arterial Cynthia St.Hilaire, PhD Genetic Approaches to Vascular Disease , isanassistant professor ofmedicineincardiology andaresearcher attheVMI. Whilea

Cynthia St.Hilaire, PhD Researcher

15 | 2015 HEART AND VASCULAR INSTITUTE REPORT 16 | UPMC Program at theHeartandVascular Institute, served asthelocalprincipalinvestigator for thestudy. Robert Kormos, MD the past year, beeninvolved intheclinicaltrialofanew device to supporttherightsideofheart. been available onlyfor thosewithleftventricular failure. The HeartandVascular Institute has,over bridges to transplantation, bridgesto recovery, ordestination therapy, this technology hashistorically Most ventricular assist devices (VADs) supportthefunctionofleftventricle. Whether usedas Heart Failure From Every Angle Side OfInnovation: Managing and Past Future

, director oftheArtificialHeartProgram and co-director oftheHeart Transplant On The Right

parents transplant until hisheart several days later. UPMC Presbyterian to live atFamily Housewithhis for thishistory-making discharge, andBrianleft with anLVAD stillinplace. The FDA granted approval decided hewould bethefirst patient ever discharged remarkably well —sowell, infact, thathiscare team received aNovacor LVAS implantandrecovered In 1990, BrianWilliams, whowas thenateenager, by discharging apatientwithanimplanted LVAD. 1,000 VADs, and,25years ago, we madehistory Since 1985,UPMC surgeons have implanted more than Heart History —AndaLook to theFuture its fullbenefits to theirpatients. sothatour colleaguessupport cansomeday offer body ofknowledge cardiovascular aboutartificial failure,heart andwe’re proud to add to theever-growing technology to better serve ourpatientswithcomplex all over the world. We lookforward to employing this other interventional cardiologists andcardiac surgeons physician-scientists oftheHVIare blazingatrail for By testing andaddingthisnew technology, the impede bloodflow to therightsideofheart. infarction, transplant, heart orotherconditions that decompensation following LVAD implantation,myocardial is indicated for failure patientswithacute rightheart or provide circulatory for support upto 14days. The system and pulmonicvalves, to andinto thepulmonaryartery the femoral artery, into therightatrium,across thetricuspid a rapidly deployable by pumpinserted catheter through The ImpellaRP®(RightPercutaneous) System is First discharge withimplanted VAD

with anLVAD still inplace. be thefirst patient ever discharged that hiscare team decidedhewould remarkably well —sowell, infact, LVAS implantandrecovered then ateenager, received aNovacor In 1990, BrianWilliams, whowas said, “We’re allvery excited, becauseit’s astep into the a family ofhisown. In1990, Brian isinhisearly40snow, healthy andhappy, with in cardiovascular medicine. we contributed to yet anotherinnovative development to lookbackonourpresent effortsandrecognize that and treatments. century Aquarter from now, we expect on through oursteadfast dedicationto new technologies future for us.” Today, thatsamepioneeringspiritlives Cardiac Surgeon Robert L.Kormos, MD Robert L.Kormos, MD

17 | 2015 HEART AND VASCULAR INSTITUTE REPORT

UPMC 18 |

Oscar C. Marroquin, MD, is a cardiologist at the UPMC Heart and Vascular Institute and the vice president for clinical analytics for UPMC. In his latter capacity, he leads a group of clinical analysts and data scientists who leverage the information within electronic health records to pave a path toward the practice of evidence-based medicine. The integration, management, and analysis of real-time data allow us to deliver high-value, cost-efficient care for improved outcomes. Data-driven decisions influence our work throughout the HVI. In the cath lab, we apply historical data to calculate and minimize procedural risks to prevent adverse outcomes. Proactive Data Analysis Our bleeding-risk algorithm lets us customize the use of The Heart and Vascular Institute, like many other anticoagulants and choose alternative access sites (like centers for cardiovascular care, collects vast quantities the radial artery, which is associated with a lower risk of data and submits it to national quality organizations. of bleeding) for certain patients. When quality performance measures come back to Data also informs our decisions regarding the use of us from the Society of Thoracic Surgeons National new and experimental devices. For instance, we track every Database and the National Cardiovascular Data Registry, patient who undergoes transcatheter valve replacement, we apply the lessons they convey toward improving which allows us to understand, in near-real time, the effect this our practices to provide better care. The difference technology has on outcomes and on the overall treatment of is that we don’t just wait for periodic information from patients with aortic stenosis. These observations complement outside organizations — we make active use of our the data we collect in our randomized controlled clinical trials. data every day so that we can implement positive We have taken a similar approach in understanding the changes immediately. This also allows us to evaluate effect that other surgical and nonsurgical procedures have the real-world performance of new technologies faster. on patient outcomes in the treatment of coronary artery Validated statistics collected over the course of several disease, congestive heart failure, and atrial fibrillation. In each months are useful; they facilitate the observation of instance, the use of our own data for analytics (identification trends, and they provide objectivity. But it’s the immediate of opportunities, risk prediction, etc.) has resulted in new application of what we learn through practice and observation insights that have the potential to improve patient outcomes. that enables us to implement the best care we can. Embedding point-of-care data collection and processing Seamlessly integrating what we learn into our practice into our practice allows us to use valuable information fuels an ongoing cycle of improvement.

QUALITY SPOTLIGHT QUALITY SPOTLIGHT QUALITY sooner. By maintaining an infrastructure to manage our data internally, we are able to communicate actionable information to clinicians and make meaningful use of the data we already have at our fingertips. and to share ourexpertisesothat others may benefit. to provide high-quality healthcare to ourpatients HVI team. The aim,asalways, is to improve ourability world-renowned cardiology professionals to jointhe Dr. Morell andhis colleagues are recruiting other In additionto inaugurating thenew venture inTampa, the healthsystems. instrumental insettingupthenew relationship between ofCardiothoracicDepartment Surgery, andhewas chair anddirector ofcardiovascular services for the of the UPMC andVascular Heart Institute aswell asvice of Pittsburgh ofUPMC. Henow serves astheco-director of Pediatric Cardiothoracic Surgery atChildren’s Hospital Children’s Hospitalin2004asthechiefofDivision Victor Morell, MD United States. cardiovascular care to even more children throughout the Together, we willhave theopportunity to offer exceptional mortality rate —1.5percent —amongsimilarprograms. high-volume program for lowest overall four-year surgical cardiovascular hospitals by UPMC isconsistently ranked amongthetop ten children’s state-of-the-art facility. Children’s HospitalofPittsburgh of St. Joseph’s Institute, anew Heart 35,000-square-foot, cardiovascular providers intheSoutheast,ishometo the St. Joseph’s Children’s Hospital,oneofthelargest pediatric familieswill support andcaregivers through telemedicine. patients ranging from prebirth to adult,ourrelationship and noninvasive cardiology services andguidance for practicing there. Inadditionto providing surgical and expertise withcardiologists andcardiac surgeons Children’s HospitalofTampa to share ourknowledge In 2014, we establishedapartnershipwithSt.Joseph’s beyond Pittsburgh. the pastyear, ourconnections have grown andextended that ourresources andinteractions are plentiful.Butover at Children’s HospitalofPittsburgh ofUPMC have ensured colleagues; traditionally, Institute ourclosetiesto theHeart Vascular Institute have always reached outto their Pediatric cardiology practitioners and attheHeart Pediatric Cardiology: Broadening OurHorizons

U.S. News &World Report, surgery program istiedwithanother , cameto UPMC from St.Joseph’s and ourpediatric

19 | 2015 HEART AND VASCULAR INSTITUTE REPORT 20 | UPMC success rate ofpercutaneous coronary intervention hasbeenonly60percent nationwide, therapy isnoteffective to control symptoms, revascularization isindicated. Historically the often insufficient, leading to symptoms ofchest painand dyspnea with exertion. Whenmedical artery diseasehave aCTO. Collateral bloodsupplykeeps themyocardium viable, butthisis with fibrosis andcalcification ofthe vessel. Approximately 15percent of patients with coronary coronary artery disease, plaquebuildup gradually leadsto complete occlusion oftheartery in thetreatment ofpatients withchronic total occlusions (CTOs). Inthisadvanced form of Catalin Toma, MD The HybridApproach Chronic Coronary Total Occlusion: New Approaches known asthehybrid approach, makes itpossible to achieve remarkably improved success rates. which iswhy these procedures are rarely attempted. Butanew setoftechniques andalgorithms, , and Conrad Smith,MD , are interventional cardiologists withexpertise

free ofanginasince hisprocedure. which openedhisoccluded artery. Heremains complex percutaneous coronary intervention Conrad Smith,right),whoperformed asuccessful program physicians (Drs. Catalin Toma, and left, despite medications andwas referred to CTO of therightcoronary artery. Hehadsymptoms for years caused by achronic total occlusion Dennis Polega (center) suffered from angina

coronary CTO artery Retrograde wiringofaright valve replacement. at oneyear post-surgery whencompared with surgical aortic open surgery, TAVR isassociated withahigherrate ofsurvival Intended for patients whoare poorcandidates for traditional a self-expanding transcatheter aortic-valve bioprosthesis. physician to repair valve theaortic withless riskby inserting to patientswithsevere stenosis. TAVR aortic allows the advanced, minimallyinvasive technique thatgives new hope Transcatheter valve aortic replacement (TAVR) isan TAVR: ANew Approach to Aortic Stenosis programs nationwide. at theHVIachieves results thatare onparwithotherCTO the specialized care they need.Asaresult, theCTO program program andwork withtheHVIto ensure thatthey receive and training. Otherphysicians refer theirCTO patientsto the institution, whichallows usto commit to thenecessary time resource-intensive procedures isthatwe practice inanacademic Part ofthereason theHVIisableto perform somany ofthese national registry ofhigh-volume CTO centers. patients withCTO, we inresearch participate ofa aspart 2013. Inadditionto providing effective care for symptomatic our experts have performed more than160casessince late in western Pennsylvania and oneofaselectfew nationwide; The HVI’s CTO program istheonlylarge-volume program specially trained teams, andahighlevel ofoperator skill. CTO program requires dedicated equipmentandfacilities, coronary laserdevices, andatherectomy devices. Anefficient advanced guidewires, microcatheters, specialized balloons, share theirexpertise to treat thelesionusingtechnologically anatomy. Duringthesecomplex procedures, thephysicians of navigating theoccludedbased onthepatient’s portion approach guidesthephysician’s choice ofthree different ways the reconstitution ofthevessel from collaterals. The hybrid of avisualpathway between thesite oftheblockage and lesion withaguidewire, whichischallenging given thelack The ofaCTO criticalpart intervention involves crossing the

Thomas Gleason,MD Valve andtheMedtronic CoreValve® inTAVR procedures. uses boththeEdwards SAPIEN Transcatheter Heart to offer thislife-saving procedure to more patients.UPMC incutting-edgeparticipation clinicaltrialsalsoenablesus now ourstandard ofcare for severe stenosis. Our aortic in thecountry to first offer thisapproach, andTAVR is experience. UPMC was oneofasmallnumberhospitals of onlyahandfulcenters nationwide withthislevel of center for this technique inwestern Pennsylvania andone 500 TAVR procedures, makingusthemostexperienced significant milestone: we have now performed more than The andVascular Heart Institute recently passed a to patientswho, inthepast,had noreal options. With TAVR ashislatest tool, heisnow ableto offer help and hasdeveloped novel techniques valve for aortic repair. Dr. Gleasonhasextensive experience invalve preservation to determine each patient’s optimaltreatment plan. surgery, heworks closelywithinterventional cardiologists Thoracic DiseaseattheHVI.Aspecialistincardiac Aortic Cardiac Surgeon Thomas Gleason,MD , isthedirector oftheCenter for

21 | 2015 HEART AND VASCULAR INSTITUTE REPORT

UPMC 22 |

Integrating Heart Health Care with patient monitoring (RPM) technologies. In 2014, they Remote Technologies initiated a remote monitoring program that compared the Heart failure management is a rapidly changing field. readmission rates for two cohorts of patients: one that used The ongoing development of new monitoring technologies RPM, and one that did not. A total of 850 patients were and an evolving approach to teamwork are transforming enrolled in the RPM cohort. the way we deliver care. In the future, the integration of In the RPM cohort, patient-reported weights, blood primary and secondary care with telemedicine will become pressure readings, and symptoms streamed directly to care commonplace — and the Heart and Vascular Institute providers, enabling early intervention while reducing time is shaping that future. and travel burdens. Blending this information with data from Ravi Ramani, MD, is the director of the Integrated Heart implantable cardioverter defibrillators and other devices, Failure Program. Under his leadership, the multidisciplinary EMR streams, other telemonitoring data, and lab results heart failure teams and technologists at the HVI have made allowed Dr. Ramani and his team to reduce readmission great strides in streamlining and integrating the provision rates to between 12 and 14 percent. In contrast, approximately of care to inpatients and outpatients. By facilitating structured, 20 to 22 percent of patients who did not participate in standardized interventions that include telemedicine, heart remote monitoring had to be readmitted. failure pathways, and behavioral health, they have significantly This research demonstrates the advisability of defining reduced readmissions and other morbidities. integrated heart failure management as the standard of care, In addition to creating pathways and protocols that foster an approach that will help organizations deliver better care interdisciplinary relationships among care providers, to their patients while reducing costs. Dr. Ramani and his colleagues are early adopters of remote

Ravi Ramani, MD Cardiologist in theUnited States, thepotential cost ofavoidable readmissions isstaggering. number isnearly50percent. With approximately eightmillionheartfailure patients 25 percent ofheartfailure patients are readmitted within30days. By sixmonths,the which reduces theprobability ofreadmission. After theirinitialadmission, nearly follow-up more convenient. Timely monitoring canalsoleadto earlierintervention, Remote monitoring reduces thetravel burden onthepatient andmakes routine it possible for physicians to keep better track oftheirpatients’ conditions remotely. In recent years, advancements inheartfailure managementtechnologies have made Keeping anEye ontheHeart Devices Techniques and Remote Surveillance:

23 | 2015 HEART AND VASCULAR INSTITUTE REPORT

UPMC 24 | 24

The Heart and Vascular Institute First Human Brachiocephalic Artery Repair Using employs a variety of wireless the GORE® TAG® Thoracic Branch Endoprosthesis surveillance techniques that Traditionally, the repair of aneurysms of the thoracic allow the physician to monitor aortic arch has required a major surgery with hypothermic the patient through implantable circulatory arrest. Recent advances in technology have cardiac defibrillators and cardiac given rise to a minimally invasive option — and the Heart resynchronization therapy and Vascular Institute was one of the first groups to put devices in order to catch it to the test. problems early. One of the latest The GORE® TAG® Thoracic Branch Endoprosthesis innovations, the CardioMEMSTM combines a traditional stent graft with an internal branch HF System, uses a tiny, battery- that expands the application of this minimally invasive repair free sensor implanted in the to the arch. Further demonstrating the HVI’s embrace of pulmonary artery via catheter. new technologies, our surgeons are involved in an FDA- An external electronic system, embedded in a pillow, approved clinical trial designed to investigate the use of charges the sensor as it transmits information to the this new device to treat aneurysms involving the aortic arch physician. CardioMEMS is the first and only system of its kind while perfusing any of the branches involved. An early approved for use in Class III heart failure. UPMC has used it feasibility study involving the subclavian artery included to monitor 12 patients since its approval in 2014. more than 20 patients. Michael Mathier, MD, director of the Section of Heart In April of 2015, Michel Makaroun, MD, director of Failure and Pulmonary Hypertension, participated in endovascular surgery at UPMC and co-director of the Heart early trials of the CardioMEMS system to evaluate the and Vascular Institute, enrolled the first patient requiring technology and assess its value. His efforts to bring this the use of this branched device in the innominate artery, the new technology to his patients and others reflect the most complex segment of the arch. HVI’s overall commitment to make innovation available This first-in-humans procedure was to all. He is also the director of the Community Outreach uncomplicated, demonstrating for and Cardiovascular Health (COACH) Program, which the first time the feasibility of bridges the gap between hospital and home by taking this approach. This was the first health awareness, education, and services to patients in brachiocephalic repair case in the their own neighborhoods. The COACH Program provides world to take advantage of the free heart-health resources like cardiovascular screenings, experimental technology. Since heart disease prevention presentations, and educational then, six more patients have had materials so that people who may be at risk for heart the same procedure nationwide. disease can get a head start on their care. By offering this Dr. Makaroun and his colleagues basic care outside of the hospital, the HVI is extending hope that this new approach will its ability to reach patients earlier and increase the odds make minimally invasive treatment of achieving better outcomes. of aortic arch aneurysms the new norm. LARIAT device, to accomplish the closure oftheLAA. technique, includingthe is oneofonlyafew approved to useevery available stroke riskwithoutsurgery orblood thinners. The department invasive closure atrialappendage oftheleft (LAA) to lower made great stridesandistheregional leaderintheminimally — thefirst center ofitskindinwestern Pennsylvania —has The department’s specialized Center for Atrial Fibrillation case ofatrialfibrillation. to disruptandredirect theheart’s electricalimpulsesinthe performs minimallyinvasive orsurgical maze procedures comes thatare amongthebestinnation;group also is hometo acatheter-based ablationprogram without able treatment forrhythm heart disorders. The department the foundation for arobust program thatoffers every avail A combination ofinterventional andsurgical approaches is patients withawidevariety ofconditions. and appliesemerging treatment technologies to care for researches rhythms theunderlyingcausesofabnormalheart —one ofthelargestdepartment intheUnited States — andVascularat theHeart Institute. This multidisciplinary Samir Saba,MD Advances inElectrophysiology Cardiologist Samir Saba,MD , isthedirector ofcardiac electrophysiology

WATCHMAN ™ device andthe

- -

All rightsreserved. ©Boston Scientific Corporation oritsaffiliates. Image provided courtesy ofBoston Scientific. Vascular Institute isthelargest andmostcomprehensive in The Cardiac Electrophysiology Program and attheHeart Pacing inMiniature clinical care. we translate ourresearch into theinvestigational arena of lead. By working together anddiversifying ourperspectives, like theS-ICDexemplifies ourwillingness to learnandto The HVI’s dedicationto thetesting ofrevolutionary technologies threatening complications associated withtransvenous leads. reducing theriskofpuncture, endocarditis, andotherlife- actually connecting orvasculature, to theheart greatly analyze andregulate ventricular tachyarrhythmias without of theribcage) withouttheneedfor fluoroscopy. Electrodes extrathoracically (i.e., underthepatient’s skinbutoutside invasive procedure involved thedefibrillator inserting to treat apatient’s rhythm. abnormalheart The minimally region to implant asubcutaneousdefibrillator, theS-ICD, In January2014, Dr. Sababecamethefirst physician inthe Transvenous Leads Behind Subcutaneous Defibrillation: Leaving trial ofthisinvestigational device. intheinternational participate first sixinthenationchosento Our healthsystem was oneofthe withtines. attaches to theheart of atraditional pacemaker, and approximately atenth thesize the world’s smallestpacemaker, Transcatheter Pacing System is catheter. The Medtronic Micra™ patient’s rightventricle via a wireless pacemaker into a physician inthestate to implant in 2014 whenhebecamethefirst elite group ofcardiac pioneers Andrew Voigt, MD for theworld. isshaping thefuturethe heart ofclinicalelectrophysiology treatment ofarrhythmias andotherproblems affecting and technologies. Ourwork withnovel approaches to the our physicians are asked often to evaluate new devices Because ofourlarge volumes andextensive experience, changing theway we treat patients. well known asearlyadopters ofthetechnologies thatare Pennsylvania, andtheprofessionals whopractice here are , joinedan

25 | 2015 HEART AND VASCULAR INSTITUTE REPORT 26 | UPMC established protocols designedto provide treatment asquicklypossible. This isnotalways true time isoftheessence. Emergency physicians, nurses,andheartspecialists allfollow efficient, When apatient presents withmyocardial infarction orastroke, everyone understands that AAA andthe RACE Trial Racing With Ruptures: Trials andTactics to intervention, themortalityrate canriseto 85percent. the hospital,around 50percent ofpatients survive, but,without ahighindex ofsuspicionleading in thecaseofruptured abdominal aorticaneurysms (AAAs), whichare highmortalityevents —in

endovascular aneurysm repair. treatment of AAAs,whetherby opensurgery or this studyrecognizes theexcellence oftheHVIin discharge.multiple timepointsafter Ourinclusionin measures alongwithadverse events andmortality at tracks timefrom presentation to ORandotherin-hospital establish protocols for improved outcomes. The study providers everywhere treatment to shorten timesand aimto enablecarestudy participants point alongthetreatment continuum, efficiency andtimingofeachcritical By measuringandevaluating the improve outcomes. all worked together repeatedly to and operating room staffwhohave other physicians aswell asnurses radiologists, anesthesiologists,and emergency room physicians, specially trained first responders, multidisciplinary approach includes involves intricate teamwork. Our Treatment ofAAAsattheHVI ruptured AAAs. algorithm for thetreatment of theimplementationofRACEafter research study, whichevaluates patientoutcomes RACE (Ruptured Centers Aorta ofExcellence Initiative) the principalinvestigator atUPMC for themulti-institution level ofurgency thataccompany MIandstroke. Heis of streamlined,the samesort structured protocols and UPMC Presbyterian, believes thatAAAsshouldreceive Rabih Chaer, MD , chiefofVascular Surgery at

disease demandprecisely chosenapproaches thattake valve diseaseiscomplex: bothdegenerative andstenotic than two millionpeopleintheUnited States, andmitral Mitral valve regurgitation iswidespread, affecting more Mitral Valve Disease:ModernApproaches mitral valve patients. through clinical trials,ourteam isopeningnew doors for more options andbetter access to developing technologies telemetry bed,bypassing theICU altogether. By offering transferand patientsoften directly from thecathlabto a and transesophageal echocardiography guidetheprocedure, patients whoare atprohibitive riskfor surgery. Fluoroscopy invasive transcatheter repair procedure holdspromise for clinical evaluation oftheMitraClip approach. This minimally Patients withFunctional Mitral Regurgitation) Trial, a of theMitraClip® Percutaneous Therapy Failure for Heart for surgical repair. into account thepatient’s anatomy andcandidacy (Cardiovascular Outcomes Assessment few nationalsites for the COAPT deficiencies. UPMC isoneofonlya only meansofcorrecting mitral valve and traditional repair are nolonger the degenerative disease.Valve replacement of 99to 100percent for patientswith yielded successful treatment rates invasive, androbotic techniques has in open,videoscopic, minimally each year. Ourhigh-volume experience minimally invasive mitral valve repairs solutions. We perform about200 side by sideto applyevidence-based work intervention, andreconstruction who includes expertsinimaging, HVI the at The multidisciplinarymitral valve team

27 | 2015 HEART AND VASCULAR INSTITUTE REPORT 28 | UPMC effective methodswithless risk. treat patients withaneye toward findingfaster andmore cardiologists, andcardiac andvascular surgeons who a jointeffort of pulmonaryspecialists, The multidisciplinarypulmonaryembolism(PE)team is focuses aspectofcardiovascular onaparticular care. organization for many specialized teams, each ofwhich The andVascular Heart Institute actsasanumbrella A Team Approach to Treating PulmonaryEmbolism simple blooddraw. cellby DNAfrom quantifyingtheamountofdonorheart a improvefurther thenoninvasive rejection detection ofheart the steering committee for anongoing studythathopes to of transplant dysfunction ordeath.Dr. Teuteberg isalsoon of gene expression profiling test scores canpredict therisk which hewas alsoinvolved, to test whetherthevariability Monitoring Attenuation through Gene Traditionally, physicians transplant assess heart patientsfor to thenoninvasive detection ofrejection. in cardiac transplantation, from novel immunosuppression transplant few has performed more than 1,400 transplants; adultheart transplantation. The UPMCTransplant Heart Program he oversees Program Heart boththeArtificial andcardiac FailureHeart andVascular attheHeart Institute, where Jeffrey Teuteberg, MD Foregoing Biopsy andEmbracing Genetics Tracking HeartTransplants:

programs canmatch ourvolume orexperience. Our physicians have beenactively involved inresearch the multicenter, multiyear IMAGE (Invasive their latest research revisits theresults of have expanded uponthatconcept: biopsies. Dr. Teuteberg andhiscolleagues of rejection to avoid routine surveillance to identifypatientswithalow probability This gene expression profiling isused of rejection. of white bloodcells to determine therisk the assessment ofthe gene expression introduced alternative to biopsiesinvolves and inconvenient for patients.Arecently test isnotonlyinvasive butuncomfortable to removeheart smalltissue samples.This requires placement ofacatheter into the rejection by endomyocardial biopsy, which , isthemedicaldirector ofAdvanced

Expression) interventional

Study,

possible to mechanicallyaspirate anintactclotrapidly system, alarge-bore suctioncannulathatmakes it the experimental AngioVac devices thatremove theclot mechanically. These include thrombolysis. Inthesecasesandothers, theteam employs with asignificantbleedinghistory orahistory offailed Thrombolytic treatment iscontraindicated inthose of thrombolytic agents may ormay notbeappropriate. Depending uponthepatient’s bleedingrisk,theuse pulmonary artery, andwithnewer devices. the delivery ofsmallerlyticagents directly to theclotvia treat PEwithcatheter-directed interventions, whichallow approach. history andimagingresults andrecommends thebest situation. Apulmonologistevaluates thepatient’s medical delivers optimalcare tailored to eachpatient’s individual By working together, theteam hasdeveloped aprocess that for theSociety for Vascular Surgery. including theirguidelinesfor thetreatment ofPEwritten extensive writingsonthetopic have beenwidelypublished, recognized inthearea ofpulmonaryembolism.Their UPMC’s PEteam hasbeennationallyinvolved and hypertension withpulmonarythromboendarterectomy. chronic pulmonarythromboembolic pulmonary failureheart withpulmonaryembolectomy, andto treat team are available to treat acute PEwithdecompensating For certainpatients,cardiac surgery members ofthePE aspiration thrombectomy device. without surgery orlytictherapy, aswell asthePenumbra sites intheMediterranean region for minimallyinvasive surgery. ISMETT to export ourtechniques —andtoday, ISMETTisbecoming oneoftheleading ISMETT, inPalermo, Italy. Over thepastthree years, we have worked withsurgeons at Our nationalandinternational education effortsincludeacollaborative project with Vascular surgeons TM and endovascular clotremoval interventional

cardiologists

cardiac care practitioners andresearchers oftomorrow. to avariety ofprograms andcurriculadesignedto impartthebest oftoday’s knowledge to the University ofPittsburgh SchoolofMedicineandtheVascular Medicine Institute, ishome as aleadingeducational institution. The HeartandVascular Institute, inassociation withthe In additionto world-class clinicalcare andinnovative research, UPMCisknown for itsrole who shapethe future ofcardiology. annually. UPMC HVIcardiology trainees become leaders nation, withmore than700 applicationsfor eight spots Ours isoneofthemostsought-out fellowships inthe management, criticalcare, andhigherlevel education. in globalhealth,technology development, healthsystems for cardiology; ourgraduates have assumed leadership roles encourage fellows to go beyond thetraditional career paths provide focused career development andmentorship. We physician-scientist orphysician-educator track, which Fellows may chooseextended training ineither the intensive instructioninthelatest theoriesandtechniques. Residency andFellowship Training Programs include Fellowship Training Program andtheCardiac Surgery andVascularwith theHeart Institute. The Cardiovascular University ofPittsburgh SchoolofMedicine inpartnership practice ofcardiology andcardiac surgery cantrain atthe Residents andfellows whoaspire to excellence inthe in federal grant andcontract support. of Medicineisalsoamongthetop 20schoolsnationwide top 20nationwide (out ofmore than170). The School the University ofPittsburgh SchoolofMedicineinthe of medicine,and first amonganelite group ofinstitutionsfor thestudy In 2015, are recognized asbeingsomeofthebestinworld. Firmly grounded inourvalues, oureducationalefforts USA Today U.S. News &World Report ranked theUniversity ofPittsburgh ranked

an even higherlevel. educational opportunity takes scholarship attheHVI to Named opportunity to learnfrom nationallyrecognized experts. which gives newly graduated cardiothoracic surgeons the the JamesL.Cox Fellowship inAtrial Fibrillation Surgery, our organization isoneofonlyeightnationalhostsites for In additionto ourestablishededucational programs, zero citations. Vascular Surgery’s training programs —alongwith resulted inafive-year accreditation for theDivision of review ofthevascular fellowship andresidency programs Accreditation Council for Graduate MedicalEducation grant from theNIHfor research training. The latest seven-year vascular residency by thatissupported aT32 traditional two-year fellowship aswell asanintegrated pass rate of100percent. The program includesthe at avariety ofUPMC facilities andanimpressive board in theUnited States, with18residents andfellows training on scientificdiscovery. The fellowship program isthelargest in arobust combination ofconcentrations withanemphasis surgery andresearch, offering residencies andfellowships The HVIalsowelcomes thebestmindsinvascular for the inventor Education and Education and of Top-Ranked the maze procedure, Training

this

exclusive

29 | 2015 HEART AND VASCULAR INSTITUTE REPORT 30 | UPMC Community Locations and UPMC Hospitals

Heart andVascular Institute Greentree SmartHealth Heart Institute at Children’s HospitalofPittsburgh Heart andVascular Institute Connellsville Heart andVascular Institute Downtown Heart andVascular Institute Greenville Heart andVascular Institute Jameson Heart andVascular Institute Clarion Magee-Womens HospitalofUPMC UPMC Horizon–Shenango UPMC Horizon–Greenville UPMC Presbyterian UPMC St. Margaret UPMC McKeesport UPMC Northwest UPMC Shadyside UPMC Passavant UPMC Altoona UPMC Hamot UPMC Hamot UPMC Mercy UPMC East of UPMC 20 20 10 10 14 14 13 13 12 12 19 19 16 18 18 15 17 17 11 11 4 9 6 8 5 3 2 7 1

Heart andVascular Institute Passavant Cranberry Heart andVascular Institute University Center Heart andVascular Institute Natrona Heights Donohue, Allen,andPensock, Washington Heart andVascular Institute Monongahela Heart andVascular Institute West Mifflin Heart andVascular Institute Monroeville Heart andVascular Institute OhioValley Heart andVascular Institute New Castle Heart andVascular Institute Uniontown Heart andVascular Institute White Oak Heart andVascular Institute SouthHills Heart andVascular Institute McMurray Heart andVascular Institute Somerset Heart andVascular Institute Robinson Heart andVascular Institute Wexford UPMC Power Cardiology, Bloomfield Heart andVascular Institute Latrobe UPMC FriedmanCardiology Floyd M.Casaday, Indiana 40 30 34 36 36 39 39 29 29 26 24 24 38 38 28 28 33 35 32 32 23 25 25 22 37 27 27 31 31 21 21

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WESTMORELAND

16 CLARION ARMSTRONG NEW YORK

15 23 21 13 WARREN FOREST SOMERSET INDIANA 38 27 30 and more, visitUPMC.com/HVI. materials, telemedicine resources, treatments, event listings, videos,patient education For detailedinformation aboutconditions and FOR PATIENTS Visit usat UPMCPhysicianResources.com/HeartAndVascular. can enhance your medicalpractice. podcasts, casestudies, andmore information that Our Physician Resources site offers free CME courses, FOR PHYSICIANS 39 26 CAMBRIA ELK 18 McKEAN 35 31 CLEARFIELD 10 34 17 8 BLAIR 1 11 CAMERON 1 14 4 33

40 12 39 HUNTINGDON

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CENTRE

CLINTON 7 COUNTY ALLEGHENY MIFFLIN 36 24 JUNIATA 2

31 | 2015 HEART AND VASCULAR INSTITUTE REPORT 32 | UPMC General Cardiology General MD Kathryn, BERLACHER, Electrophysiology BAZAZ, Raveen, MD Electrophysiology MD William, BARRINGTON, Catheterization Cardiac Cardiology Nuclear Echocardiography Cardiology General MD Khaled, BACHOUR, Clinic Device Cardiology Nuclear Cardiology General AWAN, Ihsan, MD Interventional Cardiology Cardiology General AROMATORIO, Interventional Cardiology MD Morteza, AMIDI, Interventional Cardiology Cardiology General ALLEN, Christopher, MD Cardiology Nuclear Echocardiography Cardiology General and Women’s MD Aryan, AIYER, Interventional Cardiology Cardiology General AHMED, Saleem, MD Electrophysiology ADHAR, Gur, MD Electrophysiology MD Evan, ADELSTEIN, Interventional Cardiology Cardiology General MD Sup, Joon LEE, Cardiac Surgery MD Danny, CHU, Cardiac Surgery MD Michael, BUTLER, Cardiac Surgery ANASTASI, John, MD Congenital Surgery Heart MD Victor, MORELL, CARDIAC SURGERY CARDIOLOGY George, MD George,

Interventional Cardiology Cardiology General MD Peter, COUNIHAN, Cardiology General MD Chelcie, COSTABILE, Cardiology Nuclear Cardiology General MD Jeffrey, COHEN, Echocardiography Cardiology Nuclear Vascular Intervention Cardiology General Interventional Cardiology MD Simon, CHOUGH, Cardiology General PhD MD, Stephen, CHAN, Cardiac Imaging Cardiology General MD João, CAVALCANTE, Cardiology General MD CASADAY, Floyd, Catheterization Cardiac Echocardiography Cardiology General MD Diana, CANTELLOPS, Cardiology Nuclear Echocardiography Cardiology General MD Sam, BUFFER, Cardiology General MD, Dennis, PhD BRUEMMER, Clinic Device Electrophysiology BRODE, Susan, MD Echocardiography Cardiology Nuclear Cardiology General Interventional Cardiology MD Stephen, BOWSER, Ventricular Assist Device Assist Ventricular TransplantCardiothoracic KORMOS, Robert, MD Surgery Aortic Cardiac Surgery MD Thomas, GLEASON, Cardiac Surgery MD Leo, FITZGIBBON, Cardiac Surgery MD Chris, COOK,

CURREN, Cardiology General Echocardiography Frederick,CROCK, MD GANDHI-KULKARNI, Cardiology General GABOS, Dennis, MD Cardiology Nuclear MD William, FOLLANSBEE, Interventional Cardiology MD Michael, FALLERT, Cardiology General MD Tulio, ESTRADA, Echocardiography Cardiology Nuclear Cardiology General Interventional Cardiology MD Francis, ERGINA, Echocardiography Cardiology Nuclear Cardiology Noninvasive EDWARDS, MD William, Cardiology Nuclear Cardiology General MD Dennis, EBERZ, Cardiology General DUEWEKE, Interventional Cardiology Cardiology General Bryan, MD DONAHUE, Cardiology General MD Lydia, DAVIS, Cardiology General Interventional Cardiology Cardiology General Rabindra,GIRDHAR, MD Cardiology General MD Thomas, GENERALOVICH, Cardiology General Aortic Surgery Aortic Cardiac Surgery MD Forozan, NAVID, Cardiac Surgery MD Venkat, MACHIRAJU, Cardiac Surgery MD Claudio, LIMA, Cardiac Surgery MD Luigi, LAGAZZI, Michael, MD Michael, Eric, MD Eric,

Rina, MD Rina,

Echocardiography Cardiology General Roy, MD LANDFAIR, Catheterization Cardiac Diagnostic Pacemaker Implantation Cardiology General MD William, KUNSMAN, Cardiology General Subramania, MD KRISHNASWAMI, Echocardiography Cardiology General MD Jeff, KRACKOW, Interventional Cardiology Cardiology General KLINER, Dustin, MD Echocardiography KATZ, MD William, Electrophysiology MD Sandeep, JAIN, Cardiology General MD Gavin, HICKEY, Echocardiography Cardiology Nuclear Cardiology Noninvasive MD Darla, HESS, Cardiology General Bradley,HEPPNER, MD Cardiology General HENRY, Brian, MD Echocardiography Cardiology General MD Matt, HARINSTEIN, Interventional Cardiology Cardiology General MD Vijay, GULATI, Echocardiography MD III, John GORCSAN, Congenital Surgery Heart MD Melita, VIEGAS, Cardiac Surgery Dhaval,TRIVEDI, MD Congenital Surgery Heart Mahesh,SHARMA, MD Cardiac Surgery MD Louis, RUSSO,

CARDIOLOGY Vascular Surgery CHAER, Rabih, MD Vascular Surgery MD Efthymios, AVGERINOS, Vascular Surgery MD Georges, AL-KHOURY, Vascular Surgery Michel, MD MAKAROUN, VASCULAR SURGERY Electrophysiology NEMEC, Jan, MD Cardiology Nuclear Interventional Cardiology Women’s Cardiology Cardiology General MD Suresh, MULUKUTLA, Cardiology General MD Matt, MULDOON, Electrophysiology Cardiology General MD Laura, Ure MEZU-CHUKWU, Electrophysiology MD Stuart, G. MENDENHALL, Cardiology General FailureHeart Dennis, MD McNAMARA, Pulmonary Hypertension FailureHeart MD Michael, MATHIER, Cardiology General Interventional Cardiology Oscar,MARROQUIN, MD Echocardiography Cardiology Nuclear Cardiology General Cardiology Invasive MD Avinash, LINGANNA, Echocardiography Cardiology Nuclear MD Jenifer, LEE, Cardiology Nuclear Cardiology General Interventional Cardiology MD Ashley, LEE, Echocardiography Cardiology Nuclear Cardiology General MD William, LAUER,

Vascular Surgery McENANEY, Ryan, MD Vascular Surgery MD Steven, LEERS, Vascular Surgery MD Eric, HAGER, Vascular Surgery DEMARSICO, Arthur, MD Interventional Cardiology Cardiology General MD Bryan, ROBERTSON, Echocardiography Women’s Cardiology Cardiology General MD Steven, REIS, Cardiology General MD P.S., REDDY, Cardiology General MD Shivdev, RAO, Cardiology General MD Venkat, B. RAO, Cardiology Nuclear Pacemaker Implantation Cardiology General MD Makum, RAMESH, Congestive Failure Heart Ravi,RAMANI, MD Interventional Cardiology MD Aref, RAHMAN, Cardiology General DO Martha, PULLINS, Interventional Cardiology Cardiology General MD John, POWER, Echocardiography Cardiology Nuclear Women’s Cardiology Cardiology General MD Elizabeth, PICCIONE, Interventional Cardiology Cardiology General PENSOCK, John, MD Cardiology General MD John, PACELLA, Interventional Cardiology MD Abena, OSEI-WUSU, Cardiology General MD Oladipupo, OLAFIRANYE,

Vascular Surgery MD Richard, SHEPPECK, Vascular Surgery MD Ulka, SACHDEV, Vascular Surgery MD Walter, RIZZONI, Vascular Surgery MD Richard, REDLINGER, Vascular Surgery NAIR, Madhusudanan, MD General Cardiology General Cardiology Nuclear PhD MD, Prem, SOMAN, Cardiology General MD Thomas, SMITHERMAN, Interventional Cardiology Cardiology General MD Conrad, A.J. SMITH, Pulmonary Hypertension Congestive Failure Heart MD Marc, SIMON, Interventional Cardiology Cardiology General MD Saul, SILVER, Interventional Cardiology Shushant,SHARMA, MD Echocardiography Cardiology Nuclear Cardiology General Brahma, MD SHARMA, Electrophysiology SHALABY, Alaaeldin, MD Interventional Cardiology Cardiology General MD Kim, Sun SCOLIERI, Electrophysiology SCHWARTZMAN, David, MD Cardiology Nuclear Cardiology General MD Mark, SCHMIDHOFER, Cardiology Nuclear Interventional Cardiology Echocardiography Cardiology General SCHINDLER, John, MD Resonance Imaging Cardiovascular Magnetic SCHELBERT, Erik, MD Electrophysiology MD Samir, SABA,

Vascular Surgery YUO, Theodore, MD Vascular Surgery MD Edith, TZENG, Vascular Surgery PhD MD, Bryan, TILLMAN, Vascular Surgery MD Michael, SINGH, Advanced Cardiac Imaging Cardiology General MD Timothy, WONG, Interventional Cardiology Cardiology General WENTZ, Christopher, MD Cardiology General DO John, WARD, Electrophysiology MD Norman, WANG, Electrophysiology MD Andrew, VOIGT, Echocardiography Cardiology Nuclear MD Flordeliza, VILLANUEVA, Interventional Cardiology Cardiology General VESIO, Kenneth, MD Interventional Cardiology Cardiology General TUMMALAPALLI, Krishna, MD Interventional Cardiology Cardiology General MD Catalin, TOMA, Congestive Failure Heart Jeffrey, TEUTEBERG, MD Cardiology Nuclear Echocardiography Cardiology General MD Edward, SZABO, Echocardiography Cardiology General SONEL, Ali, MD SONEL, SUFFOLETTO Cardiology Nuclear Echocardiography Cardiology General MD Robert, STAFFEN, Electrophysiology , Matthew

33 | 2015 HEART AND VASCULAR INSTITUTE REPORT UPMC HEART AND VASCULAR INSTITUTE 200 Lothrop St. Pittsburgh, PA 15213 1-855-UPMC-HVI (876-2484) UPMC.com/HVI

A world-renowned health care provider and insurer, Pittsburgh-based UPMC is inventing new models of patient-centered, cost-effective, accountable care. It provides more than $888 million a year in benefits to its communities, including more care to the region’s most vulnerable citizens than any other health care institution. The largest nongovernmental employer in Pennsylvania, UPMC integrates 60,000 employees, more than 20 hospitals, more than 500 doctors’ offices and outpatient sites, a 2.9-million-member health insurance division, and international and commercial operations. Affiliated with the University of Pittsburgh Schools of the Health Sciences, UPMC ranks No. 13 in the prestigious U.S. News & World Report annual Honor Roll of America’s Best Hospitals. For more information, go to UPMC.com. UPMC is an equal opportunity employer. UPMC policy prohibits discrimination or harassment on the basis of race, color, religion, ancestry, national origin, age, sex, genetics, sexual orientation, gender identity, marital status, familial status, disability, veteran status, or any other legally protected group status. Further, UPMC will continue to support and promote equal employment opportunity, human dignity, and racial, ethnic, and cultural diversity. This policy applies to admissions, employment, and access to and treatment in UPMC programs and facilities. This commitment is made by UPMC in accordance with federal, state, and/or local laws and regulations. For information about supporting the research efforts of the Heart and Vascular Institute, contact the Heart and Vascular Institute Development Office at 412-647-7781.