SUMMER 2015

JOURNAL OF THE KANSAS CITY MEDICAL SOCIETY

SPECIAL SECTION: Cardiac Expertise in Greater Kansas City

PAGES 11 - 41 • Transcatheter Aortic Valve Replacement • Bicuspid Aortic Valve: Treatment and Replacement • Adult Extracorporeal Membrane Oxygenation • Increased Coronary Artery Plaque Volume Among Male Marathon Runners

WORK-LIFE BALANCE: Young prioritize family, fitness and organized Managed with Care We provide the personal attention that leads to a healthy bottom line.

At Country Club Bank, one of our specialties is managing the special financial needs of Kansas City area medical professionals. We provide all of the personal and business banking services you need to succeed, with expertise born of experience. After all, our group of professionals has had a healthy amount of success helping medical groups just like yours. Stop by or give us a call today.

To learn first-hand how we serve medical professionals like you visit our website at www.countryclubbank.com/drbatlle.

816-931-4060 www.countryclubbank.com — summer 2015 —

News Special Section 3 Conference Explores Impact of 11 Cardiac Expertise in Greater Kansas City Value-Based Care 12 Evolving and Future Challenges in the Treatment of Aortic 3 KCMS Annual Meeting Oct. 21 Stenosis By George L. “Trip” Zorn, III, MD 4 Graduates Will Be Eligible for License as Assistant 17 Current Status of Transcatheter Aortic Valve Replacement (TAVR) Physicians Under New By Keith B. Allen, MD, et. al. Law 22 Bicuspid Aortic Valve: Treatment and Replacement 6 John O. Stanley, MD, Serving as By Gregory Muehlebach, MD, FACS MSMA President 27 Adult Extracorporeal Membrane Oxygenation By Michelle Haines, MD 6 Charles Van Way III, MD, Receives Arthur Gale Freedom of Expression 32 ECMO in Adults Award By Jeffrey B. Kramer, MD, FACS

16 Take an Art Fair Break at KCMS 37 Increased Coronary Artery Plaque Volume Among Male Marathon Office Runners By James O’Keefe, MD, et. al. speaking

7Editorially VA Hospital Crisis Caused Outrage But Little Action 42Features Finding Time, Finding Meaning, Finding Satisfaction By Charles W. Van Way III, MD Young physicians strive to achieve balance of time to include family, fit- ness and organized medicine By Jim Braibish, Kansas City Medicine

9Commentary Match Day 2015 48 Health-Care Specialists: Your Personal Consultants By Charles W. Van Way III, MD By Tom McNeill, The Keane Insurance Group, Inc.

issue

NextIn the Next Issue of Kansas City Medicine Trends and techniques in in the Kansas City area

kansas city medicine 1 (USPS 227-680) Volume 109, Number 2

Official publication of the Kansas City Medical Society Editor www.metromedkc.org Charles W. Van Way, III, MD

Kansas City Medicine (ISSN 0894-508x) is published five times Associate Editors a year by the Kansas City Medical Society. Contents of the Nate Granger, MD, MBA publication are protected copyright, and no part or portion may John C. Hagan, III, MD be reproduced without permission of the publisher. Periodical Michael O’Dell, MD postage paid at Kansas City, MO (USPS 227-680) and at other John Sheldon, MD mailing offices. Subscription price to physicians, $10.00 per Karl Stark, MD year; to all other persons, $50.00 per year. Managing Editor The Kansas City Medical Society in no way endorses opinions James Braibish or statements contained in this publication except those that accurately reflect official action of the Society. Acceptance of ad- Staff vertising in this publication in no way constitutes professional Angela Broderick-Bedell, CAE, Executive Director approval or endorsement of products or services which may be Stacy DeMeyer, Manager, Membership & Events advertised. The Kansas City Medical Society reserves the right to Jessica Barrett, Communications Coordinator reject any advertising material submitted for publication. Send all advertising inquiries to: Angela Broderick-Bedell All communication should be sent to: Kansas City Medical Phone: (816) 531-8432, Fax: (816) 531-8438 Society, 315 Nichols Road, Suite 250, Kansas City, MO 64112, Phone: (816) 531-8432, Fax: (816) 531-8438. Postmaster: Please send address changes to Kansas City Medicine at the above address

Kansas City Medical Society Board of Directors

Michael O’Dell, MD, President Other Representatives (non-voting) Lancer Gates, DO, Past President James DiRenna, DO, MSMA Councilor Rob Caffrey, MD, Treasurer Josephine Doo, UMKC student Michelle Haines, MD, Secretary Betty Drees, MD, MSMA Councilor Stephen Salanski, MD, President-Elect Mark Flaherty, JD, Legal Counsel Thomas Allen, MD, St. Joseph & St. Mary’s Medical Centers Mike Haines, CPA, Financial Counsel Anthony Fangman, MD, Saint Luke’s North Hospital Rebecca Hierholzer, MD, AMA Alternate Delegate Carole Freiberger-O’Keefe, DO, Saint Luke’s Hospital of Kansas City Karen Highfill, Medical Group Management Association of Kansas City Alan Forker, MD, John Locke Society Ashley Huppe, MD, KUMC Resident John Gianino, MD, Truman Medical Centers Scott Kuennen, MD, Mid-America Coalition on Health Care John C. Hagan III, MD, Discover Vision Centers Corey Offut, MD, Truman Lakewood Resident Rahul Kapur, MD, Kindred Hospital Kansas City John O. Stanley, MD, MSMA President-Elect Scott Kujath, MD, North Kansas City Hospital Tony Sun, MD, Chair, Medical Directors Council Thomas Lovinger, MD, Saint Luke’s East Hospital Marc Taormina, MD, MSMA Vice Councilor Joshua Mammen, MD, University of Kansas Medical Center Charles W. Van Way III, MD, AMA Alternate Delegate Jimmer Miller, MD, Olathe Medical Center Vernon Mills, MD, Kansas City Medical Society Scott Roethle, MD, Anesthesia Associates of Kansas City Keith Sale, MD, Kansas City Society of & Otolaryngology Jon Schultz, MD, Truman Medical Centers Blake J. Williamson, MD, MS, At-Large Casey Willimann, MD, Liberty

2 summer 2015 Newskansas city medicine Conference Explores Impact of Value-Based Care

KCMS members are invited to a director of global health-care transfor- Karen Johnson and David Olson of Blue special late afternoon and evening con- mation for IBM, where he develops and Cross and Blue Shield of Kansas City; ference on Tuesday, Sept. 22, “Getting to executes strategies that support IBM’s Betsy Green of Commerce Bank; and Value: The Future of Com- health-care industry transformation KCMS Past President Bridget McCand- pensation,” exploring the impact of the initiatives. Dr. Grundy is also an adjunct less, MD, of the Healthcare Foundation movement toward value-based care. The professor at the University of Utah of Greater Kansas City. program will be held from 4 to 9 p.m. Department of Family and Preventive Conference objectives include in- at the Intercontinental Hotel, 401 Ward Medicine. He was elected to the Insti- creasing understanding of value-based Parkway. tute of Medicine in 2012. health care including quality measure- Featured speakers are Paul Grundy, Dr. Nielsen will kick off the after- ment and cost reduction, learning how MD, MPH, FACOEM, FACPM, and noon program from 4:00 to 6:30 p.m. value-based health care will be disrup- Marci Nielsen, PhD, MPH, both with discussing “The Medical Neighborhood: tive to the current systems of health the Patient-Centered Primary Care Delivering the Value.” She previously care, and exploring what transitional Collaborative (PCPCC), a Washington, served as vice chancellor for public measures are needed for the health-care DC-based not-for-profit membership affairs and associate professor at the system to move into full implementa- organization dedicated to advancing University of Kansas School of Med- tion of value-based care. an effective and efficient health system icine, and as executive director of the Watch your KCMS email and www. built on a strong foundation of primary Kansas Health Policy Authority. She is metromedkc.org for announcement of care and the patient-centered medical on the board of directors of the Amer- the opening of registration. There is no home. ican Board of Family Medicine and charge to attend, thanks to support from Dr. Grundy will keynote the dinner the National Academy for State Health event sponsors Merck and Blue KC. program which will open at 6:30 p.m. Policy. with cocktails and networking. He is the Other speakers for the afternoon founding president of the PCPCC and session include Gregg Laiben, MD,

KCMS Annual Meeting Oct. 21 Oct. 21 from 5:30 to Physician members may bring a 8:00 p.m. guest or spouse. Dress is business casu- At the 5:30 p.m. al. As a benefit of attendance, portrait opening recep- artists will offer realistic sketches of tion heavy hors those in attendance. d’oeuvres and cock- Thanks to Tesla Motors for again tails will be served in serving as a sponsor. Watch your lieu of dinner. At 6:30 KCMS email for further announce- p.m., the program ments of event details and registration. will begin featuring presentation of the Lifetime Achievement The spectacular Kauffman Center and Friend of Medicine awards, along for the Performing Arts will be the with a main speaker to be announced. site of the 2015 Kansas City Medical The incoming and outgoing KCMS Society annual meeting on Wednesday, presidents also will give remarks.

kansas city medicine 3 Medical School Graduates Will Be Eligible for License as Assistant Physicians Under New Missouri Law

kcms board endorses proposed regulations

In a move designed to extend is for the Board for the Healing Arts novices are prepared to provide clinical medical care to underserved areas, to submit proposed regulations to care on their own in a rural area where medical school graduates who have not the Secretary of State and the Joint any medical condition could present completed training will be Commission on Administrative Rules, itself.” eligible for license as Assistant Physi- after which several more steps in the The ACGME suggested that efforts cians under a 2014 Missouri law being approval process will take place. should be intensified to increase the prepared for implementation. number of residency positions. Also The law provides that—after 30 AIMED AT PHYSICIAN SHORTAGE IN speaking out against the law were days of supervision by a collaborative UNDERSERVED AREAS associations representing physician as- physician and with the physician’s The law was first proposed by the sistants and nurse practitioners, saying authorization—Assistant Physicians Missouri State Medical Association’s they should be called upon to help ease could treat patients in settings up to Legislative Committee and Council, the shortage. 50 miles away and would be able to and MSMA was the main advocate At the AMA House of Delegates, prescribe Schedule III, IV and V drugs. for the legislation at the Capitol. Jeff opposition was strong in 2014 but They would provide only primary care Howell, MSMA general counsel and lessened considerably in 2015 as the services and only in medically under- government relations director, noted focus shifted to increasing the number served rural or urban areas of the state that Missouri recently was listed by the of GME resident positions, accord- or in any pilot project areas. An assis- federal government as one of the 10 ing to AMA delegate Charles W. Van tant physician is defined as any medi- most medically underserved states in Way, III, MD, of Kansas City. (See his cal school graduate who has passed the the nation. “Patients in these areas ar- article on the GME residency shortage prescribed medical examinations and en’t getting any care now. Our attitude on page 9 of this issue of Kansas City who has not entered into post-gradu- is that some care is better than no care. Medicine.) ate residency training. We hope this law will be a trailblazer The concept is spreading to other Currently, regulations have been for other states,” Howell said. states. and Kansas passed proposed that will govern how assis- The other argument for the law is assistant physician laws in their 2015 tant physicians will be licensed and that it helps provide work for medical legislative sessions. Legislation was monitored. In May, the KCMS Board school graduates who are unable to also introduced this year in Oklahoma. of Directors sent a letter (facing page) secure residency positions because to the Missouri Board of Profession- the number of graduates exceeds the REFERENCES 1. Full text of Physician Assistant bills. SB 754, http://www.sen- al Registration for the Healing Arts number of available positions. ate.mo.gov/14info/BTS_Web/Bill.aspx?SessionType=R&Bil- endorsing draft regulations covering The assistant physician law received lID=28627659; SB 716, http://www.senate.mo.gov/14in- supervision, continuing education and extensive national criticism after its fo/BTS_Web/Bill.aspx?SessionType=R&BillID=28296866. mentoring that would be required of passage. Most outspoken was the 2. Missouri Board of Professional Registration for the Healing assistant physicians. Academic phy- Accreditation Council for Graduate Arts, Draft regulations: http://www.pr.mo.gov/boards/heal- sicians from Kansas City and across . Its CEO Thomas ingarts/DRAFT%20Assistant%20Physician%20rules.pdf. Last accessed July 9, 2015. Missouri worked with the Board in Nasca, MD, told Medscape Medical drafting the proposed regulations. News, “Physicians in the United States 3. “Missouri Law Creates New ‘Assistant Physician’ Designation” Medscape.com. http://www.medscape.com/viewarti- The draft regulations were available are not trained to enter practice upon cle/828255. Last accessed July 9, 2015. for public comment from April 30 to graduation from medical school. … July 10. The next step in the process It’s a flawed assumption to suggest that

4 summer 2015 May 14, 2015

Missouri State Board of Registration for the Healing Arts 3605 Missouri Blvd. P.O. Box 4 Jefferson City, MO 65102

This is a letter from the Kansas City Medical Society Board of Directors in support of recommendations sug- gested by Academic Physician members of the Society regarding implementation of the Assistant Physician Licensure legislation. This recommendation specifically relates to work of Academic Physicians in the State of Missouri with the Board of Healing Arts to develop and implement educational methods and programs relating to the collaborative practice service with an Assistant Physician.

The recommendations for consideration by the Board of Healing Arts are: 1. Require a defined period of time when the Assistant Physician (AP) must be mentored directly by the Collaborative Physician (CP) to determine a level of competence before allowing the AP to prac- tice independently—with every patient seen by the AP also seen by the CP during that mentoring period. 2. Continue an ongoing, once a week direct mentoring of the AP by the CP for continued education and evaluation of competence. 3. Require the AP to take specific educational courses prior to independent practice such as BLS, Medi- cal Record Documentation, REMS Training (for controlled substance prescription privileges), and Basic Medical Bioethics. 4. Require the AP to obtain 30 additional hours of CME each year related to primary care medicine. 5. Encourage CP to become educated regarding the six ACGME Core Competencies and how to evalu- ate mentored physicians regarding their level of competence.

We appreciate the opportunity to work with the Board of Healing Arts to suggest opportunities for further education of Assistant Physicians in order to better prepare them for the safe collaborative practice of medi- cine in underserved rural and urban areas of the State of Missouri.

Please contact Angela Bedell, Executive Director, at [email protected] or 816-531-8432 if you have any questions.

Michael O’Dell, MD Stephen Salanski, MD President President-Elect Truman Lakewood Research Medical Center

kansas city medicine 5 Newskansas city medicine John O. Stanley, MD, Serving as MSMA President

Congratulations to Kansas City’s John O. Stanley, MD, who is serving as Mis- souri State Medical Association president for the 2015-16 year. He is a board-cer- tified family physician with Meritas Health based at North Kansas City Hospital. A KCMS past president, Dr. Stanley also is a member and past president of Kansas City Academy of Family Physicians. A native of Omaha, Neb., Dr. Stanley obtained his undergraduate education at Missouri Western State University and his medical degree from University Autonoma of Guadalajara in Guadalajara, Mexico. He completed his fifth pathway and internship, then his residency, at Prince George’s General Hospital in Cheverly, Md. Dr. Stanley worked in the Washington, D.C., area for three years before moving back to Kansas City in 1987. Medicine runs in the Stanley family. His brother Gerard Stanley, Sr., MD, is a family physician in Iowa, and their father was a family physician in Kansas City. Dr. Stanley and his wife, Kath, have five children, John, Suzanne, Ken, Tom and Luke.

Photo Copyright Missouri State Medical Association.

Charles Van Way, III, MD, Receives Arthur Signature Medical Group Gale Freedom of Expression Award Adds Independence Surgical Clinic Kansas City Medicine Editor Charles Van Way, Independence Surgical Clinic III, MD, received the 2015 has joined Signature Medical Group Arthur Gale Freedom of effective May 1, 2015. The practice Expression Award for a comprises general surgeons Pascal E. commentary he wrote for Spehar, MD, FACS; Jared B. Smith, Missouri Medicine, the MD, and Mindi S.T. Beahm, MD. journal of the Missouri All three are certified by the State Medical Association. American Board of Surgery and are The award is presented members of the Kansas City Medical annually to the author Photo Copyright Missouri State Medical Association. Society. Dr. Spehar and Dr. Smith and of what is judged as the are Fellows of the American College of journal’s best commentary article. Dr. Van Way’s contribution, “Secondary Gain, Surgeons; Dr. Beahm is a member of Gone With the Wind and the SGR,” appeared in the May/June 2014 issue. the America Society of Breast Sur- St. Louis internist Arthur Gale, MD, a frequent contributor to Missouri Medi- geons. cine and St. Louis Metropolitan Medicine, created the award to encourage physi- Signature Medical Group includes cians to write for the journal. more than 130 multi-specialty pri- vate-practice physicians in 28 medical practices in the Kansas City and St. Louis areas and in Bolivar, Mo.

6 summer 2015 speaking Editorially

VA Hospital Crisis Caused Outrage But Little Action By Charles W. Van Way, III, MD, Editor, Kansas City Medicine

From May through July of 2014, much testimony which documented large stage. The costuming wasn’t up to we lived through a media frenzy over continuing problems. The sad truth is, Japanese standards, but we can’t have the Veterans Health Administration we’ve been here before, and more than everything. (VHA). You may want to consult once. The VHA is, of course, a large Wikipedia for details, or perhaps One of the most distinctive part of the Department of Veterans CNN.1,2 Briefly, the VHA was found to elements of Japanese culture is Kabuki, Affairs (VA). And one thing the VA be poorly run, with long waiting times a performance art of great antiquity. It does well is to outlive scandal. The and inadequately staffed facilities. has elements of dance, music, drama, Kabuki-like performance has been Not only that, but VHA officials pageantry and ritual. It is highly repeated many times. There have were gaming a system that was put stylized, rigidly plotted and elaborately been about one major scandal and in place specifically to correct some several minor scandals per decade. of the same problems. Bureaucrats President Truman fired the head of were systematically lying to their the (then) Veterans Administration superiors and being given bonuses. A grand total of five in 1945. Multiple commissions and Their superiors then turned around bureaucrats lost their investigations followed. President and took credit and received their jobs, and the Secretary Nixon’s presidential investigation in own bonuses. Patients languished on 1974. Congressional investigations waiting lists. Politicians were shocked, of Veterans’ Affairs in 1983 and 1994. President Bush’s shocked! There was soul-searching resigned. So … has there presidential commission in 2003. The and hand-wringing. The President firing of the head of the Miami VA in made statements. Congress held been great improvement? 2009.2 hearings. The FBI investigated. Then Has anything changed? It’s not even a funding problem. Congress passed a $16 billion extra The overall VA budget has grown appropriation and went home for the dramatically over the past few years. rest of the summer. Who says Congress From 2009 to 2012, the total VA can’t get anything done, eh? And costumed. All of the plays are well- budget went from $87 to $132 billion. the President took executive action. known, with the artistry being in the And that’s just recently. From 2001 to A grand total of five bureaucrats presentation and the spectacle. Perhaps 2013, funding for the VHA by itself lost their jobs, and the Secretary of the closest Western art form is grand alone rose 250%. Funding per patient Veterans’ Affairs resigned. So … has opera, but by comparison with Kabuki, nearly doubled, as did funding per there been great improvement? Has opera is free-form and unstructured. enrollee in the system.3,4 anything changed? The response of the media and So what’s wrong? Well, that depends The answer depends on your the political system to the VHA on whom you ask. To some, there isn’t frame of reference. Overall, across the scandal was very like a Kabuki play. enough money. To others, this scandal country, a lot of veterans receive pretty There was the stylized astonishment. is an indictment of all government-run good care in the VHA. But in terms of The ritual outrage. Actors hiding health care. Still others, looking for the specific problems turned up last behind masks. The dance. The ritual causes, blame a sclerotic bureaucracy. year? There hasn’t been much done. executions. The denouement, with Too many managers. Inappropriate At this year’s 2015 American Medical Congress throwing money from the management incentives. Perhaps there Association meeting, there was stage. It was a drama acted out on a continued on next page

kansas city medicine 7 VA CRISIS (continued) effect is to slow things down. deteriorated seriously, and is no longer were simply too few caregivers, i.e., There is, indeed, a strong case to serving our needs. doctors and nurses. Of course, that be made for beginning to dismantle But we won’t really know. That’s the last one is pretty easy to get people to the whole system. The population point of the Kabuki dance. Everyone agree on. Hey, we’ll just throw a few of veterans is slowly decreasing, wears a mask and puts on an elaborate more docs and RNs into the mix! The despite the wars in the Middle East. costume for the occasion. The main question of whether the doctors and Today, veterans comprise 7% of the players are all actors in a scenario, nurses are organized and supported population, and less than half are everyone knows the story, and the well enough to take care of patients enrolled in the VHA. And yet, the resolution is the same every time. Is is more subtle, and gets lost in the VHA is still growing, at 8.6% per year. this time different? Not so far. And so details. The truth is, we don’t know. Weeks and Auerbach have suggested far, it’s ending the same way as all of The VHA throws off these scandals that we begin to replace the bricks and the others. Investigate, show outrage, about like trees drop their leaves in the mortar with subsidies for premiums, retire a few bureaucrats, throw money, fall, and nearly as often. Given the size deductibles and co-payments for and take your bow. It’s just political of the system and the intensive media veterans who need to use the system.4 show business. and political attention, perhaps that’s We could reserve the VHA facilities Charles W. Van Way, III, MD, is editor of not as surprising as it seems. for those areas in which it has Kansas City Medicine and is emeritus professor The VHA is huge. There are 150 real expertise, like post-traumatic of surgery at the University of Missouri-Kansas VHA medical centers, plus about psychiatric care, chronic sequelae of City. He can be reached at [email protected]. 1,400 individual outpatient clinics neurologic injuries, amputee care and and clinical facilities throughout the rehabilitation. The process would take REFERENCES U.S. It cares for 8.3 million veterans many years. But perhaps, it’s time to 1. Veterans Health Administration Scandal of 2014, Wikipedia. each year.5 Putting it another way, start. To be sure, the forces opposing http://en.wikipedia.org/wiki/Veterans_Health_ Administration_scandal_of_2014 Accessed June 22, 2015. every state has on average 10 VHA any such changes are … formidable. facilities, and every Congressional I have to admit to nostalgia. I 2. The VA’s Troubled History. Pearson, M. CNN. May 30, 2014. http://www.cnn.com/2014/05/23/politics/va-scandals- district has two. In effect, the VHA spent about a third of my training timeline/ Accessed June 22, 2015. has a board of directors consisting of at the Nashville VA Medical Center, 3. Chickenhawks and cheapskates. Perr J. Daily Kos. 535 senators and representatives. Each and then was on faculty part-time at May 25, 2014. http://www.dailykos.com/ and every one likes to take credit for the Denver VAMC. They were great story/2014/05/25/1301363/-Chickenhawks-and- anything the VHA does, and all tend to places to work. True, the bureaucracy cheapskates# Accessed June 22, 2015. micromanage. Veterans’ organizations drove us nuts, and the inefficiencies 4. Weeks WB, Auerbach D. A VA Exit Strategy. New Engl J Med. watch over the system with hawk- were annoying, but … we took care 2014; 371:789-91. like attention. Moreover, the VHA of a lot of patients, nearly all of whom 5. About VHA. VHA website. http://www.va.gov/health/ is a large bureaucracy, embedded did well. All appreciated the care they aboutvha.asp Accessed June 22, 2015. in the giant VA bureaucracy. The received. The career professionals at Department of Veterans Affairs has the VHA were dedicated, experienced 280,000 employees, with multiple and hard-working. Honestly, I have layers of oversight and management. trouble believing it’s all that different Within that, VHA facilities, because today. Now, most of my experience they’re federal, are subject to all of the is 30 to 40 years past. While I’ve had multiple rules of civil service. There privileges at the Kansas City VAMC are thousands of little inefficiencies, more recently, I’ve done very little ranging from personnel policies patient care there. Personally, I think to procurement and even to the the VHA is still filled with dedicated centralized design of VHA facilities. professionals. But that doesn’t mean Whether all of these things are good that the system works well. It’s or bad by themselves, the net overall entirely possible that the system has

8 summer 2015 Commentary

Match Day 2015 medical school graduates being denied residency positions is a tragedy that should haunt us By Charles W. Van Way, III, MD, Editor, Kansas City Medicine

Every March, I find myself espe- biggest match ever, with 41,334 appli- case. There are over 5,000 osteopathic cially grateful to be a senior physician. cants and 30,212 positions available. graduates per year. Of these, nearly That’s because I’ll never have to go Of those, 27,253 positions were for 3,000 applied through the NRMP. through the Match again. Yes, the first-year residents, and only 398 were There is also an American Osteopathic National Resident Matching Program unfilled at the end of the match. These Association match, which places 2,179 announces its results in March. Match figures, it should be noted, are nearly graduates this last year. There were 939 Day this year was March 20. Actually, the same as last year and are typical of positions left open after the match, and it’s a whole Match Week. If you’re a se- the last several years. the post-match is still going on.2 For nior student, you found out on March There are some other categories, so this year, osteopathic students could 16 if you’ve matched (but not where). these numbers don’t add up. There are apply to both matches. Combined fig- ures are not available. The osteopathic fig. 1 “no match” rate is probably about the same as it is for allopathic graduates. Number of Number matched Percentage matched Probably. Currently, all osteopathic programs Total applicants 41,334 are joining allopathic programs under Total active applicants* 34,905 the Accreditation Council for Grad- uate Medical Education (ACGME). Positions matched 26,252 After the merger the separate match US seniors, allopathic schools 18,025 16,932 94% will presumably go away. (For further discussion on the joining of osteopath- US seniors, osteopathic schools 2,949 2,339 79% ic and allopathic programs, see article US citizens, international schools 5,014 2,660 53% in the April Kansas City Medicine by John J. Dougherty, DO, of the Kansas Non-US citizens, international schools 7,366 3,641 49% City University of Medicine and Bio- Previous graduates, allopathic schools 1,520 662 44% sciences.)

* Those who submitted a rank order list. If you are a U.S. senior in an allo- pathic school, you have a 94% chance If you didn’t match, then you went several caveats, as well. The biggest one of matching. Even if you complete the through a secondary match (called is that a sizeable number of applicants application process, and do everything SOAP, for some reason). Then on don’t complete the process. Overall, of you should, you have a 6% chance March 20, everyone found out where 41,334 applicants, only 34,975 fin- of not having a job at the end of the they matched. Although some found ished. Who drops out? Why? Maybe match. Maybe you’ll find something out they’re not going to have a job. they didn’t get interviews and became to do between the end of March and So, what are the results of the discouraged. We don’t know. But it’s the end of June. Maybe you’ll find a match? They’re available from the reasonable to assume that if someone residency job after the match is over. NRMP.1 There is a lot of data. And the applied in the first place, they’d like to And maybe not. To be as optimistic as data are subject to some qualifiers—a have a residency slot. possible, most graduates of American lot of qualifiers, in fact. It was the Osteopathic graduates are a special (continued on next page)

kansas city medicine 9 MATCH DAY (continued) national graduates were being turned ical student in every medical school. MD and DO schools appear to find away, but at least they could continue We cannot afford to keep ignoring. training jobs by June. But it may not to practice in their home countries. And that’s how it was … a normal be a job they really want, and it may be Today, some of our own students are Match Day, in March. for only one year. being turned away. American gradu- REFERENCES It is very much worth noting that ates of international schools are simply 1. Advance Data Tables: 2015 Main Residency Match. National the match rate for international grad- in a lottery. And if a new graduate Resident Matching Program, Washington, DC, 2015. http:// uates is much lower, around 50%. U.S. doesn’t get a residency, his or her www.nrmp.org/match-data/main-residency-match-data/ Last citizens who are graduates of interna- career comes to an abrupt halt. It’s a accessed May 3, 2015. tional schools do very little better than personal tragedy. 2. 2015 AOA Match Results. American Osteopathic Association. non-U.S. citizens (53% to 49%). These Moreover, it’s a failure of our med- http://www.osteopathic.org/inside-aoa/Education/students/ match-program/Pages/match-results.aspx Last accessed May figures are not broken down by coun- ical education system. We talk about 3, 2015. try of schooling. There are currently personal responsibility. We may point 3. List of Caribbean medical schools. Wikipedia. http://en.wiki- about 37 proprietary medical schools out that students attending schools in pedia.org/wiki/List_of_medical_schools_in_the_Caribbean. other countries assume some risk. But Last accessed May 3, 2015. really, now. We’ve depended for many 4. Van Way, III, CW. Where Shall We Put All of Our Students? Mis- years on international graduates, of souri Medicine, 110:177-78, May/June 2013. Greater Kansas If a new graduate both U.S. and foreign birth. Some 25% City Medical Bulletin (Kansas City Medicine) Summer 2013. doesn’t get a of physicians practicing in the U.S. are 5. Inglehart, JK. The Residency Mismatch. NEJM. 2013, international graduates. They are our 369:297-299. residency, his or her colleagues. “They” are us. Besides, it’s not just international graduates. This career comes to an year, a thousand MD graduates of U.S. abrupt halt. It’s a schools didn’t get training positions. Plus as many as a few hundred DO personal tragedy. graduates. Plus over 2,000 IMGs of U.S. origin. Plus nearly 4,000 IMGs of international origin. Bottom line: We need to train more residents; it’s as in the Caribbean, in which English simple—and as difficult—as that. Nei- is the language of instruction.3,4 They ther an MD nor a DO degree should graduate several thousand new phy- be a $200,000 lottery ticket. sicians each year, many of whom are There aren’t enough teaching hospi- from the U.S.3 Their chances of obtain- tals; of 5,000 acute-care hospitals, only ing residency training are, as they say 600 have residents, and only 300 are in Las Vegas, even odds at best. major teaching hospitals. More hospi- From the standpoint of training tals must step up and train residents. programs, this situation is pretty good. We need more practicing physicians Virtually all major specialties fill over to train residents. If increased federal 95% of their offered positions, usually funding isn’t going to be available— 98 or 99%. From the standpoint of the and it won’t be—then we have to find medical student, this is not so good. other ways to finance training. As To be sure, we’ve had more applicants John Inglehart put it, “The absence than positions for many years. Ten or of health-workforce planning ... may fifteen years ago, complacency was come back to haunt policymakers. …”5 perhaps understandable. U.S. gradu- Yes, it will. And it should haunt all of ates were all getting jobs. Some inter- us, today. Just as it haunts every med-

10 summer 2015 CARDIAC SURGERYSpecial Section EXPERTISE IN GREATER KANSAS CITY

The Kansas City area is fortunate to have many outstanding medical institutions and expert physicians. In this issue of Kansas City Medicine, physicians from the programs at Saint Luke’s Hospital and The University of Kansas Hospital dis- cuss several key elements in cardiac care. Articles highlight the approaches of both groups to extracorporeal membrane oxygenation, aortic valve replacement and oth- er topics. Let us know your comments on these articles. Send comments to editor@ metromedkc.org. continued on next page

Your Articles Wanted Kansas City Medicine will regularly publish in-depth articles from our local physicians on the latest advancements in medicine and treatment procedures in our region. If you have a topic about which you would like to write, please contact us. We are always looking for review articles about problems of medical interest. To get started, just write up an abstract of a paragraph or two, and then work with one of our associate editors to prepare the final article. We use standard AMA formatting for references. Do you have a medical topic you would like to write about for Kansas City Medicine? Send your concept to [email protected]. Special section

Evolving Therapy and Future Challenges in the Treatment of Aortic Stenosis By George L. “Trip” Zorn, III, MD, The University of Kansas Hospital

BACKGROUND tients over age 60 receive tissue pros- Edwards’ Sapien valve in the treatment Since the first transcatheter valve thesis. Even younger patients often re- of severe symptomatic aortic stenosis. was implanted in the pulmonary valve ceive tissue valves with the knowledge The Sapien valve is a balloon expand- of a 12-year-old boy by Dr. Philllip a second procedure will ultimately be able valve that can be delivered either Bonhoffer in France in 2000, phy- necessary. The influence of TAVR is transfemorally or through the apex sicians have imagined what could strongly felt in these discussions with of the left ventricle. We can now also be accomplished with less invasive younger patients. The initial place- place it directly through the aorta, but therapy for their aortic stenosis pa- ment of a tissue valve, with the fall this was not available at the time of the tients. Aortic stenosis is primarily a back of a TAVR if the valve fails in the trial. Sapien had been used extensively disease of the elderly, with frailty and long term, is an increasingly common in Europe at the time of the trial, but comorbid conditions making interven- pathway. It is important to note that there were no rigorous randomized tional therapy more complex. Surgical there is very little data on outcomes trials conducted. PARTNER filled a aortic valve replacement (SAVR) has from placing a transcatheter valve into huge knowledge void on many fronts. remained the cornerstone of therapy a surgically placed tissue valve (often PARTNER was actually two simul- for patients with severe symptomatic referred to as valve in valve). taneous trials. PARTNER A focused aortic stenosis, but the introduction of Despite the enthusiasm for less on patients eligible for surgery but at transcatheter aortic valve replacement invasive therapy, surgery remains the increased risk. It randomized patients (TAVR) in the U.S. has transformed gold standard for aortic valve replace- in a 1:1 fashion to either surgery or the options for our patients. TAVR has ment therapy. Modern surgical results1 TAVR. PARTNER B addressed patients gone from being a novel technique to show 30-day mortality rates as low as considered inoperable for conventional a procedure with well-defined risks 0% and actuarial survival at one and AVR. Chronologically, PARTNER B and benefits. The next generation of three years of 97% and 94%. Yet in completed enrollment first and thus I technology holds promise to further those patients over age 80, the length will discuss it first. reduce procedural risk. Clinicians are of stay was seven days and only 50% PARTNER B provided many land- increasingly faced with expanding this were discharged to home. In appro- mark observations. I will present the technology into lower-risk patients, as priately selected patients, SAVR is recently updated three-year results.2 well as determining who is too sick to extremely safe and effective. TAVR Patients were screened by a heart team benefit from any intervention. has a very high bar to match clinical consisting of both cardiologists and outcomes. Yet, it is our elderly patients surgeons and were felt to have a surgi- SURGICAL AORTIC VALVE REPLACEMENT who survive the operation but are left cal risk of death or irreversible mor- (SAVR) with lengthy recoveries that they are bidity of greater than 50% with SAVR, Surgical technique has evolved not well equipped to handle. truly a very sick population of patients. much since the first SAVR in 1960 us- Patients once admitted to the trial were ing a mechanical valve. Not only have TRANSCATHETER AORTIC VALVE randomized to either transfemoral mechanical valves improved, but tissue REPLACEMENT (TAVR) TAVR or optimum medical therapy valve options have relieved the burden Any discussion of TAVR has to (OMT) which could include balloon of lifelong anticoagulation for many include mention of the PARTNER aortic valvuloplasty (BAV). patients. In our practice, almost all pa- trial conducted in the U.S. to evaluate As you can see in Figure 1, all-cause

12 summer 2015 Special section that appropriate anatomical evaluation A 100 HR [95% CI] = 0.53 [0.41, 0.68] Standard Rx p (log rank) <0.0001 is essential to good patient outcomes. TAVR 80.9% Since the publication of these 80 68.0% landmark trials, the next generation 26.8% 60 Sapien XT balloon expandable valve 50.8% 25.0% 54.1% was approved in June 2014, based on 20.1% 40 NNT = 3.7 pts the randomized data available from 43.0% NNT = 4.0 pts PARTNER II trial. Sapien XT allows

All Cause Mortality (%) 30.7% 20 NNT = 5.0 pts for a larger range of sizes to be treat- ed as well as a lower delivery profile 0 0 6 12 18 24 30 36 allowing for smaller sheath sizes. This

Numbers at Risk Months should allow more patients to receive Standard Rx 179 121 85 62 46 27 17 TAVR therapy with potentially fewer TAVR 179 138 124 110 101 88 70 vascular complications.

B 100 HR [95% CI] = 0.41 [0.30, 0.56] The next catheter-based valve Standard Rx p (log rank) <0.0001 to enter trial in the U.S. was the Core- TAVR 74.5% 80 Valve. It is a self-expanding valve based 62.4% on a nitinol frame. The delivery sheath 60 44.6% 33.1% required is 18F, allowing for delivery 31.7% transfemorally, via the axillary artery 40 24.1% 41.4% or by directly aortic cannulation. It is NNT = 3.0 pts a porcine pericardial tissue valve that 20 30.7% 20.5% NNT = 3.2 pts when deployed actually sits above the Cardiovascular Mortality (%) Cardiovascular NNT = 4.1 pts 0 native aortic annulus. 0 6 12 18 24 30 36 The CoreValve pivotal trial started Months Numbers at Risk after the initial reports on PARTNER Standard Rx 179 121 85 62 46 27 17 TAVR 179 138 124 110 101 88 70 B. It was thus felt unethical to ran- domize to medical therapy. Therefore Figure 1. 36-Month Results of PARTNER B. the results of the TAVR cohort were mortality and cardiovascular mortality randomization of high-risk patients compared to an objective performance were significantly improved for TAVR eligible for surgery to either TAVR or goal (OPG). This OPG was derived compared to medical therapy. One of SAVR. Two-year results3 showed that by taking contemporary results from the most striking numbers from this death from any cause was similar in PARTNER B medical therapy patients study was the mortality in the medical both groups. The frequency of strokes and seven other BAV studies. arm, 50.8% at one year and 80.9% at did not differ between the groups. The 12-month results showed for three years. Medical therapy truly is Improvement in valve area was similar those patients considered extreme for patients with severe and maintained at two years. Paraval- risk for SAVR (inoperable), the rate symptomatic aortic stenosis. TAVR vular leak (PVL) was more common in of all-cause mortality or major stroke significantly decreased these numbers the TAVR group. was 26% with TAVR versus 43% in to 30.7% and 54.1% at one and three The conclusion from this trial is the OPG group. The frequency of years respectively. The take-home mes- that SAVR and TAVR both have excel- moderate or severe PVL was 4.2% at sages from PARTNER B trial are the lent outcomes in patients with severe 12 months. Based on these results, lethality of severe aortic stenosis and AS that are at high risk for SAVR. It CoreValve has received FDA approval the benefit of TAVR therapy for this is important to note that the trial also and was the second commercial valve very sick cohort of patients. highlighted that complications with in the U.S. market. PARTNER B involved the 1:1 TAVR therapy can be devastating, and (continued on next page)

kansas city medicine 13 Special section

Figure 2. 36-Month Results of PARTNER A.

AORTIC STENOSIS (continued) rate of strokes between the two groups. These patients should be referred to a The CoreValve4 trial also included an Permanent pacemakers were more multidisciplinary valve clinic includ- arm randomizing patients considered common in the TAVR group compared ing surgeons and cardiologists. This high risk for SAVR to either SAVR or with SAVR (22% vs 11% at one year). “heart team” concept is very important TAVR in a 1:1 fashion. This trial was Bleeding, acute kidney injury, and to providing patients with a balanced notable for several important findings. new-onset or worsening atrial fibrilla- look at treatment options. Both quality First, it showed that current surgical tion were significantly more common and length of life are improved with results are excellent. The predicted risk in the surgical group than in the TAVR TAVR for those patients who can- of 30-day mortality for these patients group. This was the first randomized not tolerate open surgery. For those with SAVR was 7%; the observed rate trial to demonstrate superiority of patients at high risk for open surgery, was 4.5%. TAVR over SAVR in a high-risk cohort TAVR has demonstrated equal if not This provided a rigorous compar- of patients. superior results compared with SAVR. ison group for TAVR. Yet, even with These landmark trials (PARTNER These patients also benefit from refer- these excellent open surgical results, and CoreValve) have greatly increased ral to a center with the full spectrum of the rate of death from any cause at our understanding of the natural therapeutic options. one year, which was the primary end history of severe aortic stenosis and its point, was lower in the TAVR group treatment options. Severe symptom- FUTURE CHALLENGES than in the surgical group (14.2% vs. atic aortic stenosis is a lethal disease CASE SELECTION 19.1%). There was no difference in the with a one-year mortality rate of 50%. As with any intervention, patient

14 summer 2015 Special section ACCESS ALTERNATIVES Transfemoral delivery remains the most common route for TAVR, but technologic and procedural advances have opened up opportunities for pa- tients with inadequate femoral arte- rial anatomy. Access is available now via the axillary artery or by directly cannulating the aorta. Transapical access, cannulation of the apex of the heart via limited thoracotomy, remains a lower-volume option due to higher procedural risk. It is very appealing as an avenue for future aimed at the mitral valve. As the delivery profile of the next generation of devices gets smaller, many centers are performing TAVR Figure 3. One-Year Results of CoreValve High-Risk Trial. without general anesthesia. In com- bination with healthier, lower-risk selection is critical. The very nature of equation are the intermediate-risk patients this procedure may truly the disease leads to a number of elder- patients. Currently in the U.S. both approach outpatient therapy. ly, frail patients. The concept of frailty Sapien XT and CoreValve are approved versus futility has been discussed since for patients at high and extreme risk STROKE the inception of the technology. In for SAVR. There are trials underway Many patients are more concerned essence, it is trying to determine which evaluating intermediate-risk patients with stroke than death. Strokes in the patients are dying with aortic stenosis, in a randomized fashion in the U.S. perioperative setting contribute to not from it. Current risk assessment and Europe. However, the line be- decreased quality of life and increased tools do not include several important tween high risk and intermediate risk mortality. Recent reviews have found factors including frailty, pulmonary is very blurry, perhaps even invisible. acute and subacute CVAs in 3-6% of hypertension and cirrhosis. The term Patients are increasingly well informed patients after TAVR.5 Approximately “Cohort C” refers to the subset of pa- of TAVR and often refuse SAVR even 45% of these events occur within two tients who have both poor survival and when low risk. CMS and insurance days of the procedure, and an addi- quality of life even after a technically companies are refusing reimbursement tional 28% between three and 10 days. successful TAVR. Common clinical for patients without severe risk. It is Important predictors of early CVAs parameters in these patients include very important to complete these trials include small aortic valve area, new extreme comorbidities (STS >15), to better understand the role of TAVR onset atrial fibrillation, and balloon severe pulmonary or liver disease, in these patients. Medical history is post dilation. Late CVAs are most severe dementia, and living in a nurs- littered with instances of gold standard commonly associated with chronic ing home. The increasing technical therapy abandoned for less invasive atrial fibrillation, prior cerebrovascular success rates of TAVR, and the dismal procedures that ultimately led to disease and transapical approach. outcome with medical therapy, lead to patient injuries. As we drop down to There is little doubt that technolog- some very difficult clinical decisions lower-risk patients, the bar is set very ical and procedural advances have re- on offering TAVR therapy. high with modern surgical results. duced the rate of CVA compared with We must be careful to not abandon earlier experience. Rates of CVA with INTERMEDIATE RISK well-established therapy for the “next TVAR are comparable with SAVR. On the other side of the risk best thing.” (continued on next page)

kansas city medicine 15 Special section AORTIC STENOSIS (continued) early results have been very promising. of both surgeons and cardiologists Much of the focus of future technology The speed of progress in this area may to achieve the best outcomes. It is an centers on reducing CVA. This tech- mean the problem is resolved before exciting time for clinicians treating nology involves better TAVR devices as we are fully able to describe its clinical patients with aortic stenosis. well as adjunctive measures to deflect importance. Once described as the or capture cerebral emboli. “Achilles heel of TAVR,” it is clear that George L. “Trip” Zorn, III, MD , is a cardiotho- racic surgeon at The University of Kansas Hospi- better preoperative planning and better tal. He can be reached at [email protected]. PARAVALVULAR REGURGITATION devices will significantly decrease the Paravalvular regurgitation (PVL) is importance of PVL for our future REFERENCES more common after TAVR than con- patients. 1. Malaisrie SC(1), McCarthy PM, McGee EC, et al. Contemporary ventional surgery. There is little doubt perioperative results of isolated aortic valve replacement for aortic stenosis. Ann Thorac Surg. 2010 Mar; 89(3):751-6 that mortality is increased in patients SUMMARY with moderate to severe PVL after TAVR has emerged as the pro- 2. Kapadia SR, Tuzcu EM, Makkar RR, et al. Long-term outcomes of inoperable patients with aortic stenosis randomly assigned TVAR. There is also little doubt that cedure of choice for those patients to transcatheter aortic valve replacement or standard therapy. rates of PVL are decreasing with better without surgical options. Better preop- Circulation. 2014 Oct 21; 130(17):1483-92. technology and better understanding erative and procedural techniques have 3. Kodali SK, Williams MR, Smith CR, et al.Two-year outcomes of preoperative sizing measurements. improved procedural success to the after transcatheter or surgical aortic-valve replacement. N Engl The impact of mild PVL on quality of point that TAVR is now an acceptable J Med. 2012; 366(18):1686. life and mortality after TAVR is less alternative for SAVR in high-risk pa- 4. Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter understood. Heterogeneity of meth- tients with severe AS. Ongoing studies Aortic-Valve Replacement with a Self-Expanding Prosthesis. N ods to evaluate and quantify PVL has will help us understand the role of Engl J Med. 2014; 370:1790-1798. confused the issue. TAVR in intermediate- and lower-risk 5. Mastoris I, Schoos MM, Dangas GD, Mehran R. Stroke After The next generation of TAVR de- candidates for surgery. It is important Transcatheter Aortic Valve Replacement: Incidence, Risk Factors, Prognosis, and Preventive Strategies. Clin Cardiol. vices includes technology specifically that clinical decisions are made in 2014 Nov 17. designed to combat this issue, and the the setting of a heart team comprised

Take an Art Fair Break at the KCMS Office

The 84th annual Plaza Art Fair re- turns to Country Club Plaza Sept. 25- 27. On the first night of the fair, Friday, Sept. 25, KCMS will open its office to members as a place to take a break from the crowds. Cool beverages will be available. The office, 315 Nichols Rd., Suite 250, above one of the fair’s main avenues, will be open from 6 to 8 p.m. Cool off and enjoy a few minutes of relaxation with your fellow Medical Society members. The fair today features over 240 artists covering nine city blocks and welcomes a crowd of over 250,000. For more information on the Plaza Art Fair, http://countryclubplaza.com/ event/plaza-art-fair/. photo by Tim Samoff 16 summer 2015 Special section

Current Status of Transcatheter Aortic Valve Replacement (TAVR) By Keith B. Allen,1 Adnan K. Chhatriwalla,2 A. Michael Borkon,1 David J. Cohen,2 Sanjeev Aggarwal1, J. Russell Davis1, Anthony Hart,2 Suzanne Baron,2 Michelle Haines,3 and Ken Huber2(On behalf of the structural heart team), Depart- Keith B. Allen, MD ments of Cardiovascular and Thoracic Surgery,1 Cardiology2 and ,3 Saint Luke’s Mid America Heart Institute, Kansas City.

ABSTRACT aortic valve replacement (SAVR), TAVR was first performed 13 years Surgical aortic valve replacement regardless of age, remains the gold ago and has evolved rapidly in all (SAVR) remains the standard of care standard in patients with severe aortic facets from device design, indication, for patients with severe aortic stenosis stenosis who are at low or intermediate and implantation technique. Delivery who are at low to intermediate risk for risk for surgery and carries a Level I platforms provide for both balloon surgery. However, transcatheter aortic recommendation with grade A evi- expandable and self-expanding valves valve replacement (TAVR) is now dence from multiple medical societ- mounted within either cobalt chromi- generally accepted as the new standard um or nitinol frames. Unlike SAVR, of care for patients with symptomat- where the diseased valve is excised and ic aortic stenosis who are either not a new valve sewn in place, the tran- candidates for open surgery or who scatheter valve displaces the diseased are considered high risk because of native leaflets; outward radial force comorbidities or specific anatomic and from the metal frame secures and seals technical issues. In 2008, Saint Luke’s the valve at the annular or sub-annular Mid America Heart Institute was level (Figure 1). TAVR is typically per- the first center in the region to im- formed through a low profile delivery plant a transcatheter aortic valve and sheath (16-19 French) introduced continues to expand the indications into the femoral artery. Our preferred for TAVR for its patients using both technique is percutaneous placement FDA-approved and investigational of the sheath into the common femoral valves. Our multidisciplinary structur- artery using conscious sedation, how- al heart program has expanded its use ever, surgical cut down under general Figure 1. Transcather aortic valve replacement (TAVR) is a 2 of transcatheter technology beyond less invasive alternative to traditional sternotomy and car- anesthesia is sometimes required. Al- the aortic valve to treat mitral and diopulmonary bypass. Currently approved for patients who ternatively the delivery sheath can be pulmonary valve disease, intra cardiac cannot have or are considered high risk for conventional placed surgically in the left ventricular aortic replacement. shunts, paravalvular leaks and the left apex or ascending aorta. atrial appendage. This article summa- ies.1 There remain patients, however, The intuitive appeal of TAVR is tied rizes the current status of transcatheter because of extreme comorbidities or to its less-invasive nature compared aortic valve replacement and provides frailty, who are considered inoperable with surgical aortic valve replacement. insight into ongoing research. or at extremely high risk (surgical mor- The true success of TAVR, however, tality estimated to be >10%) for SAVR. owes more to its strong evidence-based INTRODUCTION Historically these patients were rarely support derived from well-designed, Aortic stenosis is a progressive offered surgery and, in many cases, multicenter, randomized trials. The disease that results in functional were not even referred for evaluation. Saint Luke’s Mid America Heart limitation leading to symptoms such The evolution of TAVR now affords Institute has provided cutting-edge as syncope, angina, heart failure and these patients a reasonable therapy technology to its patients supported ultimately premature death. Surgical where once their options were limited. (continued on next page)

kansas city medicine 17 Special section

250 100 Abstracts/presentations Hazard ratio, 0.56 (95% CI, 0.43-0.73) 90 P<0.001 Peer Reviewed 200 Publications 80 70 68.0 Standard therapy 150 60 50 43.3 40 100 30 TAVR Death from Any Cause (%) Death from 20 50 10 0 0 0 6 12 18 24 2012 2013 2014 Months since Randomization

Figure 2. Number of yearly Abstracts and Publications submitted by Saint Luke’s Mid Figure 3. PARTNER trial demonstrating improved two-year survival in inoperable patients America Heart Institute. with aortic stenosis who undergo TAVR compared to continued standard medical therapy.

All-Cause Mortality | CoreValve US PIVOTAL TRIAL

40 Transcatheter 35 Surgical Δ = 6.5

28.6% 30 Δ = 4.8 25 18.9% 20 22.2%

15 Log-rank P=0.04

All-Cause Mortality (%) 14.1% 10

5 Figure 5. Commercially available Transcatheter Aortic Valves. On left, balloon-expand- 0 able Edwards Sapien XT; on right, self-expanding Medtronic CoreValve. 0 6 12 18 24 Months Post-Procedure

Figure 4. CoreValve trial demonstrating improved two-year survival in high-risk pa- tients with aortic stenosis who undergo transcatheter aortic valve replacement (TAVR) compared to surgical aortic valve replacement (SAVR).

TAVR (continued) medical therapy (Figure 3), and both vival at one and two years compared by a strong tradition of research and transfemoral and transapical TAVR with surgical aortic-valve replacement, innovation (Figure 2). In 2008 the were found to be equivalent to surgical making TAVR the preferred approach landmark PARTNER trial was initiated aortic valve replacement in patients for that patient population (Figure at 22 U.S. centers including the Saint at high operative risk.3,4 These bene- 4).6,7 Luke’s Mid America Heart Institute fits for both inoperable and high-risk Although mortality is undoubtedly to evaluate the safety and efficacy of but operable patients have now been a critical endpoint for patients under- TAVR in patients with severe aortic shown to be durable through five-year going aortic valve replacement, many stenosis considered inoperable or at follow-up.5 other factors must be considered in high surgical risk for conventional More recently, studies using a this treatment decision. Appropriate aortic valve replacement. In the PART- self-expanding transcatheter valve patient selection for this rapidly evolv- NER trial, transfemoral TAVR using demonstrated that in patients with ing procedure relies on a clearer un- a balloon expandable transcatheter severe aortic stenosis who are at high derstanding of the risks and benefits in valve demonstrated improved survival surgical risk, TAVR was associated particular patient subgroups. We have in inoperable patients compared with with a significantly higher rate of sur- recently demonstrated that TAVR not

18 summer 2015 Special section

Figure 6. Edwards Sapien S3 Valve Smaller 14 French profile and added ‘skirt’ to reduce perivalvular leaks.

Figure 7. Vascular access options TAVR, Saint Luke’s Mid America Heart Institute. only improves mortality for inoperable high surgical risk (mortality estimat- (TVT) Registry. and high-risk patients but also leads ed >10%). Further label expansion Access to next-generation investi- to important and sustained quality has subsequently allowed TAVR to gational transcatheter valves is crucial of life benefits as well.8-10 In addition, be performed via a variety of alterna- for the structural heart team. With the Saint Luke’s health economic and tive approaches for patients who are refinements in both device size and technology assessment research group not suitable for transfemoral delivery development of sophisticated methods has examined the cost-effectiveness and, most recently, has allowed TAVR for imaging the three-dimensional of TAVR—the positive result of which to be used “valve-in-valve” to treat structure of the native aortic valve, has helped to support appropriate failing stenotic or regurgitant surgical adverse events associated with TAVR insurance coverage for this costly new aortic bioprostheses. Saint Luke’s Mid such as permanent pacemaker, peri- technology.11,12 Finally our research America Heart Institute continues valvular regurgitation and vascular has focused on refining our under- to evaluate the safety and efficacy of access complications have continued to standing of which patients do (and do TAVR in intermediate surgical risk decline. Reducing the delivery profile not) derive meaningful survival and patients (mortality estimated at 3-8%) to 14 French and adding a “skirt” to quality of life benefits after TAVR.13,14 through participation in the Medtronic the bottom of the valve to prevent This information is critical for both SuriTavi Trial and the Edwards Sapien perivalvular insufficiency are two such patients and physicians who are trying S3 Trial. innovations currently under investiga- to decide whether to undergo what is In the U.S., two transcatheter aortic tion at Saint Luke’s Mid America Heart still a major procedure. valves are currently FDA-approved Institute (Figure 6). Based on the results of the PART- and commercially reimbursed by most NER trial, the U.S. Food and Drug payers including Medicare (Figure ACCESS SITE STRATEGY SELECTION Administration (FDA) approved 5). To meet coverage requirements as Patient selection for TAVR re- TAVR for the treatment of severe, outlined by the Centers for Medicare quires a multidisciplinary heart team symptomatic aortic stenosis in patients & Medicaid Services (CMS) National approach involving cardiac surgeons, considered inoperable in November Coverage Determination, centers per- interventional cardiologists, cardiac 2011. The indication for TAVR was ex- forming TAVR must meet quality and imaging specialists and anesthesi- panded in September 2012 to include volume benchmarks and participate ologists.15,16 Transfemoral access is patients considered operable but at in the Transcatheter Valve Therapy (continued on next page)

kansas city medicine 19 Special section routine. Ultimately, long-term dura- bility and economics will dictate the future expansion of TAVR as a primary strategy for aortic valve replacement for most patients.

Keith B. Allen, MD, is a director of cardiovas- cular and thoracic surgical research at the Saint Luke’s Mid America Heart Institute. He is board certified in cardiothoracic, vascular and . Dr. Allen maintains an active clinical and research practice and has over 100 publi- cations in journals such as the New England Journal of Medicine, Journal of Thoracic and Cardiovascular Surgery, JAMA, Circulation and The Annals of Thoracic Surgery. He is currently serving as an ad hoc member of the FDA’s Cir- culatory Device Panel and has been a principal investigator in over 40 FDA clinical trials. He is a member of the American Association of Thoracic Surgeons (AATS), Society of Thoracic Surgery (STS), Society of Vascular Surgery (SVS), and the International Society for Minimally Invasive Surgery (ISMICS). He can be reached at kallen@ mahls.com

REFERENCES 1. Holmes DR Jr., Mack MJ. Transcatheter valve therapy: A professional society overview from the American College of Foundation and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;58:445–55. Figure 8. Valve in Valve TAVR using trans carotid vascular access. A 75-year-old male, four prior open heart procedures including cardiac transplantation, underwent valve-in-valve us- 2. Huang P, McCabe J, Kaneko T, et al. Incidence of Vascular ing a CoreValve (white arrow) implanted inside a severly stenotic surgical aortic bioprostheses (black arrow). Vascular Complications in Transfemoral Transcatheter Aortic Valve access was obtained via the right carotid artery (insert). Previously implanted functioning surgical mitral bioprosthe- Replacement According to Femoral Artery Access Technique. ses (dashed white arrow) can also be seen. Patient discharged to home three days following surgery. JACC. 2014;63(12):A445. TAVR (continued) patient should be denied TAVR due to 3. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve our preferred approach for TAVR inadequate vascular access (Figure 8). implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597– 607. but despite a continuing reduction in delivery sheath profile up to 30% CONCLUSION 4. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J of patients still require alternate non Currently, SAVR remains the Med. 2011;364:2187–98. femoral access for device delivery standard of care for the majority of 5. Mack MJ, Leon MB, Smith CR, et al. 5-year outcomes of (Figure 7). Alternative access strategies patients with symptomatic severe transcatheter aortic valve replacement or surgical aortic valve have allowed the heart team to expand aortic stenosis who are at low to in- replacement for high surgical risk patients with aortic stenosis the TAVR technology to even more pa- termediate risk for surgery. However, (PARTNER 1): a randomised controlled trial. Lancet. 2015 Mar tients.17-22 Until recently, if TAVR could TAVR has emerged as the preferred 15. pii: S0140-6736(15)60308-7. doi: 10.1016/S0140- 6736(15)60308-7. not be performed using transfemoral, choice in patients for whom surgical transapical, direct ascending aortic or risk is deemed high or prohibitive. 6. Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter Aortic-Valve Replacement with a Self-Expanding Prosthesis. N subclavian access patients could not The collaboration between the cardiac Engl J Med 2014; 370:1790-1798. be treated. Our growing experience surgeons, cardiologists, anesthesia and 7. CoreValve US Pivotal High Risk Trial. Presented at American 21 with trans carotid, direct descending critical care on the heart team allow Cardiology Conference 2015. thoracic aorta,19 iliac,18,22 trans septal for optimal care of a wide spectrum of 8. Reynolds MR, Magnuson EA, Lei Y, et al. Health related and even trans caval access means no patients, from the most complex to the

20 summer 2015 Special section quality of life after transcatheter aortic valve replacement in Circ Cardiovasc Qual Outcomes. 2013; 6:591-7. Ann Thor Surg. 2015;100:723-7. inoperable patients with severe aortic stenosis. Circulation 14. Arnold SV, Reynolds MR, Lei Y, et al. Predictors of poor 21. Allen KB, Chhatriwalla AK, Hart A, et al. Transcarotid TAVR 2011;124:1964-72 outcomes after transcatheter aortic valve replacement: Results Utilizing EEG Guided Selective Cerebral Perfusion. Presented to 9. Reynolds R, Magnuson EA, Wang K, et al. Health-Related from the PARTNER Trial. Circulation. 2014;129:2682-2690. C3 Conference, Orlando, FL, June 2015. Quality of Life After Transcatheter or Surgical Aortic Valve 15. Baron SJ, Arnold SV, Herrmann HC, et al. Impact of 22. Allen KB, Gerdisch M, Borkon AM, et al. Direct Iliac Artery Replacement in High-Risk Patients With Severe Aortic Stenosis. Baseline Left Ventricular Function and Aortic Valve Gradient Puncture Without A Conduit During TAVR. Innovations. J Am Coll Cardiol. 2012;60:548-558. on Outcomes in Patients treated with Transcatheter Aortic 2014;9(3):245. 10. Arnold SV, Reynolds MR, Wang K, et al. Health status after Valve Replacement: Results from the TVT Registry. JACC. transcatheter or surgical aortic valve replacement in patients 2015;65(10):A497. with severe aortic stenosis at increased surgical risk. Results 16. Allen KB. Frailty: It’s Hard to Define But You Know It When from the CoreValve US Pivotal Trial. J Am Coll Cardiol Intv. You See It. JTCVS. 2014;148(6):3117-3118. 2015 (in press). 17. Allen KB, Davis JR, Cohen. Critical Aortic Stenosis and Acute 11. Reynolds MR, Magnuson EA, Wang K, et al. Cost effectiveness Ascending Aortic Penetrating Ulcer Managed Utilizing Tran- of transcatheter aortic valve replacement compared with sapical TAVR and TEVAR. Catheterization and Cardiovascular standard care among inoperable patients with severe aortic Interventions. 2015;10.1002/ccd.25816. stenosis: Results from the PARTNER trial (Cohort B). Circula- tion. 2012;125:1102-9 18. Allen KB, Borkon AM, Aggarwal S, et al. Direct Iliac Artery Puncture During Endovascular Procedures: Are Conduits Really 12. Reynolds MR, Magnuson EA, Lei Y, et al. Cost-effectiveness Necessary? JACC. 2014;63(12):A451. of transcatheter aortic valve replacement compared with surgical aortic valve replacement in patients with severe aortic 19. Allen KB, Borkon AM, Laster S, et al. The Descending Thoracic stenosis: Results from the PARTNER Trial (Cohort A). J Am Coll Aorta: Forgotten Access for Endovascular Device Delivery. Cardiol. 2012; 60:2683-2692. Innovations. 2014;9(3):245. 13. Arnold SV, Spertus JA, Lei Y, et al. How to define a poor out- 20. Allen KB, Johnson LM, Borkon AM, et al. Combined come after transcatheter aortic valve replacement: Conceptual Transcatheter Aortic Valve Replacement (TAVR) and Thoracic framework and empirical observations from the PARTNER trial. Endovascular Aortic Repair (TEVAR) Using Transapical Access.

PRIVATE BANKING | FIDUCIARY SERVICES | INVESTMENT MANAGEMENT | FINANCIAL PLANNING | SPECIALTY ASSET MANAGEMENT | INSURANCE

Just As Important As Healthy Patients Is A Healthy Practice. We’re a partner with the industry experience and know-how to tailor a plan that meets your individual needs. For both your practice and your personal life. Give us a call, or better yet, let us come see you.

www.bankofkansascity.com | 913.307.1800

© 2015 Bank of Kansas City, a division of BOKF, NA. Member FDIC. Equal Housing Lender. Private Bank at Bank of Kansas City provides products and services through BOKF, NA and its various affiliates and subsidiaries. Investments and insurance are not insured by the FDIC; are not deposits or other obligations of, and are not guaranteed by, any bank or bank affiliate. All investments are subject to risks, including possible loss of principal. Securities offered through BOSC, Inc. Member FINRA/SIPC.

kansas city medicine 21 Special section

Bicuspid Aortic Valve: Treatment and Replacement By Gregory Muehlebach, MD, FACS, The University of Kansas Hospital

Bicuspid aortic valve is Before calcification occurs the most common congenital there are smooth cusp margins heart abnormality, occurring distinguishing each leaflet as in 0.5 – 2.0% of the population. opposed to rheumatic or other There is a known male pre- inflammatory valvular disease. dominance. It is also one of the The most common finding most frequently encountered is fusion of the left and right valvular abnormalities seen coronary cusps with a separate in daily practice. The clinical noncoronary cusp. All three presentation of patients with configurations of fused left and bicuspid aortic valves is quite noncoronary cusps, fused right varied both in time and type of and noncoronary, and fused left presentation. Pediatric patients and right have been reported. Coronal image dilated ascending aorta with preserved can present at birth with severe sinotubular junction. There are also bicuspid valves regurgitation. Yet, an octoge- with truly just two leaflets, but narian can also present with these do not pertain to this regurgitation. Patients in their discussion. Many of these other late teens and early 20s can be abnormalities have the same seen with either aortic regur- consequences (endocarditis, gitation or aortic stenosis but AS, AR and aneurysms). also can be affected by endo- Bicuspid valves can be iden- carditis. There are some who tified by the auscultation of a are diagnosed but never require murmur but diagnosis depends intervention. These variations, on the echocardiogram. Trans- both in presentation and course thoracic echocardiogram can of the disease, make it import- accurately identify over 95%, ant to understand this valvular but it is less accurate when

abnormality. Residual ascending aortic aneurysm after prior AVR. there is heavy calcification of Adding to the complexity of the valve with difficulty dis- this disease is the association with must be recognized so that appropriate tinguishing a tricuspid from aortic aneurysms. There is uncertain- measures can be taken to treat it. a bicuspid valve. Transesophageal ty whether the cause is post-stenotic echocardiogram can help, but it also dilatation or an inherent abnormality BICUSPID VALVE ANATOMY may have difficulty distinguishing in the aortic wall, whether the entire A true bicuspid valve is one in the two. Intraoperatively this is more aorta is affected, and whether the which there is fusion of two cusps obvious, but often the presentation of risk of rupture is the same as that of a with a raphe between them, a separate the patient (younger age 40-60) and Marfan’s aorta. These are all important more normal appearing cusp, often a other aortic abnormalities can help to considerations, but the most important more elliptical opening vs. a more oval confirm the diagnosis. aspect of the aortic dilatation is that it opening (as seen in a tricuspid valve). The importance of distinguishing

22 summer 2015 Special section bicuspid valve vs. other has TREATMENT OF THE AORTIC VALVE gradient 60 mm Hg or higher; clinical implications for treatment. If Treatment of the bicuspid aortic and identified in a child, one should also valve is well documented and there are c. A low surgical risk. rule out a coarctation of the aorta be- well defined guidelines to timing of 2. AVR is reasonable in apparently cause it is commonly associated. Other treatment. Whether it is regurgitation asymptomatic patients with severe aortic abnormalities should be con- or stenosis, the guidelines should be AS with: sidered. Often an echocardiogram can followed as they are for all aortic valve a. A calcified aortic valve; identify proximal aortic enlargement pathology. The guidelines per the 2014 b. An aortic velocity of 4.0 m per but does not evaluate the remaining AHA/ACC Executive Summary are as second to 4.9 m per second or ascending aorta well. Transfemoral follows: mean pressure gradient of 40 mm aortic devices initially were felt unsuit- Hg to 59 mm Hg; and ed to treat bicuspid valves because of Class I c. An exercise test demonstrating their elliptical orifice. This prohibition 1. AVR is recommended in symptom- decreased exercise tolerance or has changed for some but not all trans- atic patients with severe AS with: a fall in systolic blood pressure femoral devices. a. Decreased systolic opening of a (BP). calcified or congenitally stenotic 3. AVR is reasonable in symptomatic AORTIC ANEURYSMAL DISEASE aortic valve; and patients with low-flow/low-gradient Patients with bicuspid pathology b. An aortic velocity 4.0 m per sec- severe AS with reduced LVEF with: have an inherent risk of associated ond or greater or mean pressure a. Calcified aortic valve with re- aortic disease. Marfan’s disease patients gradient 40 mm Hg or higher; and duced systolic opening; have cystic medial degeneration and a c. Symptoms of HF, syncope, exer- b. Resting valve area 1.0 cm2or less; decrease in their fibrinillin-1 in their tional dyspnea, angina, or pre- c. Aortic velocity less than 4.0 m aortic wall, which cause an increased syncope by history or on exercise per second or mean pressure gra- risk of aneurysm formation, rupture testing. dient less than 40 mm Hg; and dissection. Patients with bicuspid 2. AVR is recommended for asymp- d. LVEF less than 50%; and aortic valves have also been document- tomatic patients with severe AS e. A low-dose dobutamine stress ed to have cystic medial degeneration. and an LVEF less than 50% with study that shows an aortic veloc- This may be the cause of their aortic decreased systolic opening of a ity 4.0 m per second or greater or disease, as opposed to the post stenot- calcified aortic valve with an aortic mean pressure gradient 40 mm ic dilatation theory proposed earlier. velocity 4.0 m per second or greater Hg or higher with a valve area Given this information, many have or mean pressure gradient 40 mm 1.0 cm2or less at any dobutamine begun to more aggressively treat the Hg or higher. dose. aneurysmal disease associated with a 3. AVR is indicated for patients with 4. AVR is reasonable in symptomatic bicuspid valve. severe AS when undergoing cardiac patients with low-flow/low-gradient Some observations about the an- surgery for other indications when severe AS with an LVEF 50% or eurysmal disease process are unique there is decreased systolic opening greater, a calcified aortic valve with to bicuspid valves. Often the coronary of a calcified aortic valve and an significantly reduced leaflet motion, sinuses are spared, especially early in aortic velocity 4.0 m per second or and a valve area 1.0 cm2or less, the process. The sinotubular junction greater or mean pressure gradient only if clinical, hemodynamic and is preserved, and the dilatation occurs 40 mm Hg or higher. anatomic data support valve ob- beyond this point. Some will have a struction as the most likely cause of more diffuse process but can be isolat- Class IIa symptoms and data recorded when ed to the noncoronary sinus sparing 1. AVR is reasonable for asymptomatic the patient is normotensive (systolic the left and right coronary sinus. And patients with very severe AS with: BP <140 mm Hg) indicate: finally, the dilatation tends to extend a. Decreased systolic opening of a a. An aortic velocity less than 4.0 to the innominate artery but does not calcified valve; m per second or mean pressure extend into the distal aortic arch or the b. An aortic velocity 5.0 m per sec- gradient less than 40 mm Hg; and descending aorta. ond or greater or mean pressure (continued on next page)

kansas city medicine 23 Special section BICUSPID AORTIC VALVE (cont’d) Class I sion [LVESD] >50 mm or indexed b. A stroke volume index less than 1. AVR is indicated for symptomatic LVESD >25 mm/m2). 35 mL/m2; and patients with severe AR regardless 2. AVR is reasonable in patients with c. An indexed valve area 0.6 cm2/ of LV systolic function moderate AR while undergoing m2or less. 2. AVR is indicated for asymptomatic surgery on the ascending aorta, 5. AVR is reasonable for coronary artery bypass graft patients with moderate AS (CABG), or mitral valve sur- with an aortic velocity be- gery. tween 3.0 m per second and 3.9 m per second or mean Class IIb pressure gradient between 1. AVR may be considered 20 mm Hg and 39 mm Hg for asymptomatic patients who are undergoing cardiac with severe AR and normal surgery for other indica- LV systolic function at rest tions. (LVEF ≥50%) but with pro- gressive severe LV dilatation Class IIb (LV end-diastolic dimension 1. AVR may be considered for >65 mm) if surgical risk is asymptomatic patients with low. severe AS with an aortic velocity 4.0 m per second CHOICE FOR VALVE REPLACE- or greater or mean pres- MENT sure gradient 40 mm Hg Choice for valve replacement or higher if the patient is at is an ongoing discussion which low surgical risk and serial covers a wide range of topics testing shows an increase and many varying opinions. In in aortic velocity 0.3 m/s or the simplest of terms, the choice greater per year. comes down to mechanical vs. tissue valves. With this comes REPLACEMENT the long debated discussion Replacement is the gold stan- of anticoagulation vs. repeat dard in all situations. Some sur- Moderately enlarged ascending aorta; note size compared to operation. geons employ repair techniques. descending aorta. Mechanical valves all This is primarily for regurgitant valves patients with chronic severe AR require anticoagulation. Today, this and should be reserved for those that and LV systolic dysfunction (LVEF means warfarin. There are ongoing are not calcified and require minimal <50%) at rest if no other cause for studies comparing antiplatelet therapy manipulation to obtain a competent systolic dysfunction is identified vs. warfarin, but antiplatelet therapy valve. The long-term results are mixed, 3. AVR is indicated for patients with has not yet received FDA approval. and many do not see such repair as severe AR while undergoing cardiac The patient should understand that permanent. Repair is not indicated for surgery for other indications. this will be a lifelong commitment to a stenotic valve except in the pediatric anticoagulation at some level. Al- population. If the valve is calcified, re- Class IIa though mechanical valves have not pair will almost universally fail, usually 1. AVR is reasonable for asymp- been shown to wear out, this does not early. The AHA/ACC Executive Sum- tomatic patients with severe AR exclude these patients from reopera- mary for the guidelines for the treat- with normal LV systolic function tion. Other complications including ment of aortic regurgitation and the (LVEF ≥50%) but with severe LV endocarditis, pannus formation and timing of replacement are as follows: dilation (LV end-systolic dimen- intolerance to anticoagulation can lead

24 summer 2015 Special section to removal. function but yet have an aneurysm Any discussion about aneurysms Tissue valves do not require anti- which requires intervention. Know- assumes that one understands the coagulation except for aspirin thera- ing that bicuspid valves have aortas physics behind aneurysm growth and py. There is some retrospective data with cystic medial degeneration is an potential for rupture. The Law of La- which would suggest that a statin will important point to understand when place is usually cited when discussing extend the life of a tissue valve, these issues. However aneurysms but yet there has been no pro- are not true spheres, they have spective study to prove this. All noncylindrical shapes, their wall tissue valves have structural valve thickness can vary, and compo- deterioration. There are many sition of the aorta (calcified) is charts and studies to compare non-homogeneous—all of which and contrast various valves but in can all have effects on growth the end they all have a failure rate. of aneurysms. Other factors There are many factors, including are also important to consider. age, infection, hypertension and Regurgitant valves have a much need for hemodialysis. Despite higher stroke volume and can these known risks there is no way create higher wall tension. This is to accurately predict who will apparent in a wide pulse pressure fail, or when. There has been a but even more obvious in vivo clear change in practice patterns observation with large changes over the past 10 years, shifting in aortic size with beat-to-beat away from mechanical valves to Residual ascending aortic aneurysm noted one year after AVR for variation. tissue valves. However, there are bicuspid AV. Recommendations for aortic no strong studies or clinical data replacement based on size have to support that any one particu- come under scrutiny because of lar valve is better than the other. lack of data to support prior rec- Each case has unique circum- ommendations. Aortic aneurysms stances. measuring 5.5 cm have been A new consideration in the frequently cited, as a criterion to use of tissue valves is replacement suggest elective repair. However, with a transfemoral route using a this recommendation is based on valve-in-valve technique. This is outdated material and on limited routinely in use in Europe today, Axillary cannulation via right axillary artery; patients head to left of series. When considering surgical page, midline sternal incision. but less so in the U.S. Other factors repair, one should always weigh are important to consider, including treating these aortas. Some, although the surgical risks of repair vs. the risk valve size and potential for a high pres- not all, believe that the risk of rupture of rupture or dissection with medical sure gradient because of a small (<23 or dissection is higher for these pa- therapy. Autopsy studies on ruptured size) prosthesis needing to be replaced. tients compared to the tricuspid aortic ascending aortas have shown that The long-term outcome of transfemo- population. The pulmonary artery in almost 15% are less than 5 cm. Inter- ral replacement is still undetermined. these patients may also have cystic estingly, more than 60% of aneurysms medial degeneration. This becomes an greater than 5 cm did not rupture, and REPLACEMENT OF THE ASCENDING important point to consider in patients 50% of those greater than 7 cm did not AORTA who may undergo a Ross procedure rupture. This continues to add to the More often than not, aortic valve (replacement of the aortic valve/root confusion. One must continue to disease is the driving force for sur- with the pulmonary autograft) and understand that the bicuspid aorta is gery in these patients. However, there the potential that the autograft will different from normal aortas. are those that have reasonable valve become aneurysmal. (continued on next page)

kansas city medicine 25 Special section BICUSPID AORTIC VALVE (cont’d) it is safe to replace just the noncoro- thology is commonly associated with The more difficult question becomes nary sinus with the ascending aorta. these valves. Proper evaluation includ- what to do with a moderately enlarged Follow up studies have demonstrated ing transthoracic echocardiogram and aorta (4cm) in the face of stability of this repair. This also allows CT scanning of the chest are excel- severe aortic stenosis (AS) and bicus for maintaining the annular size so lent screening tools prior to making pid aortic valve. There are many series that one does not have to downsize the decisions about surgical procedures. of patients with functional prosthet- aortic prosthesis. Valve choice is a personal and lifestyle ic valves who have later developed Circulatory arrest is also an im- decision, but the realistic outcomes aortic aneurysms. Many have come to portant procedure to understand when with all valves should be understood recommend replacement of the mod- treating these aneurysms. It is com- and discussed with the patient well in erately enlarged aorta when address- mon to see 4-4.5 cm aneurysms left advance of surgery. Aortic resection ing severe AS. This is based on lower behind at the distal ascending aorta should be considered even in marginal- surgical complication rates, differing to avoid circulatory arrest. These have ly enlarged aortas, especially in younger cannulation techniques which allow been shown to continue to increase in patients. Patients should be reassured for safer circulatory arrest, and the fact size, again remembering the age of this that surgical outcomes are excellent and that many of these patients are young patient population. Use of circulatory should be pursued when guidelines for (40-60) and have a long life expectancy arrest has significantly improved over replacement have been met. and potential for continued aneurys- the years. Newer cannulation tech- mal growth. A more recent retrospec- niques with axillary artery cannulation Gregory Muehlebach, MD, FACS, is a cardio- have allowed for continuous antegrade thoracic surgeon at The University of Kansas tive review suggests that these aortas Hospital. He can be reached at gmuehlebach@ do not behave in a malignant fashion perfusion during distal aortic work. kumc.edu. and that they do not require aggressive This has also eliminated retrograde management or intervention. Al- perfusion with its risk of emboliza- REFERENCES though interesting, many believe this is tion. It has allowed for less aggressive 1. Siu SC, Silversides CK. Bicuspid aortic valve disease. J Am Coll difficult to defend in the face of known cooling of the patient and subsequent- Cardiol. 2010; 55:2789–2800. 2. Russo, Mazzetti S, Garatti A, et al. Aortic complications after ly decreased the risks associated with rupture and the potential for severe bicuspid aortic valve replacement: long-term results. Ann Thorac complications and death with acute cooling, including coagulopathy and Surg. 2002; 74:S1773–S1776, discussion S1792. aortic rupture or dissection. RV dysfunction. We have also insti- 3. Svensson LG, Adams DH, Bonow RO, et al. Aortic valve and Replacement of the aorta is per- tuted the use of fresh frozen plasma ascending aorta guidelines for management and quality measures: executive summary. Ann Thorac Surg. 2013; 95:1491–1505. formed with a Dacron graft. These during the cooling and rewarming 4. Guntheroth WG. A critical review of the American College of do not wear out and do not require phase of the operation to help mini- Cardiology/American Heart Association practice guidelines on anticoagulation. The aortic tissue mize the coagulopathy which is com- bicuspid aortic valve with dilated ascending aorta. Am J Cardiol. is usually reasonable and does not monly encountered. These measures, 2008; 102:107–110. 5. Ashikhmina E, Sundt TM 3rd, Dearani JA, Connolly HM, Li Z, Schaff require reinforcement with felt strips, in addition to advances in cardiopul- HV. Repair of the bicuspid aortic valve: a viable alternative to unless the aorta has become thinned. monary bypass and anesthesia, have replacement with a bioprosthesis. J Thorac Cardiovasc Surg. 2010; Replacement can include total aortic led to lower operative risks and shorter 139:1395–1401. root replacement with reimplantation ICU and hospital stays. 6. Opotowsky AR, Perlstein T, Landzberg MJ, et al. A shifting approach of the coronary arteries, circulatory to management of the thoracic aorta in bicuspid aortic valve. J Thorac Cardiovasc Surg. 2013; 146:339–346. FINAL RECOMMENDATIONS arrest with extension of the graft into 7. Hardikar AA1, Marwick TH. Surgical thresholds for bicuspid aortic the aortic arch, or simply replacement The bicuspid aortic valve is the valve associated aortopathy. JACC Cardiovasc Imaging. 2013 Dec; of the ascending aorta at the sinotubu- most common congenital cardiac le- 6(12):1311-20. lar junction done distally below a cross sion encountered. Its expected progres- 8. Neragi-Miandoab S. Management of bicuspid aortic valve with or without involvement of ascending aorta and aortic root. J sion to aortic stenosis or regurgitation clamp. Cardiovasc Surg (Torino). 2014 Jun; 55(3):435-44. As noted previously, it is common is often the driving force in making a to see that the noncoronary sinus decision about intervention. During enlarges sparing the left and right the evaluation of these patients, it coronary sinuses. In this circumstance, should be kept in mind that aortic pa-

26 summer 2015 Special section

Adult Extracorporeal Membrane Oxygenation By Michelle Haines, MD, Saint Luke’s Mid America Heart Institute

INTRODUCTION CASE hypoxemic. An ECG revealed sinus Extracorporeal Membrane Oxygen- A 21-year-old otherwise healthy male tachycardia with a right bundle branch ation (ECMO) is an advanced short- presented with an onset of acute febrile block (RBBB). An echocardiogram term mechanical support modality illness that began approximately 72 to was performed and revealed a severe used for patients with severe acute 96 hours prior to admission while on a decrease in left and right ventricular life-threatening cardiac and/or pul- hunting trip in Texas. Initially, he was contractility with an estimated ejec- monary dysfunction refractory to slightly short of breath and had a mild tion fraction of 25% with mild mitral conventional management. ECMO cough. In the ensuing 24-72 hours, the regurgitation. Throughout the day the rapidly restores vital oxygen delivery to patient developed fevers up to 104°F patient’s oxygen requirements contin- cells and manages all com- ued to increase and eventu- ponents of gas exchange. ally required endotracheal ECMO can fully support intubation and mechanical the heart and/or lungs until ventilation. Following the underlying problem is intubation, a wide complex resolved or if indicated, de- tachycardia developed with vice implantation or organ hemodynamic decompen- transplantation can occur. sation. This was successfully There are two primary types cardioverted after two 300 J of ECMO cannulation: DC shocks. He was started veno-venous (VV ECMO), on norepinephrine, dobu- which is used solely and tamine and amiodarone preferentially for isolated drips and airlifted to Saint pulmonary support, and Lukes’s Mid America Heart veno-arterial (VA ECMO), Institute. used primarily for cardiac Figure 1. Avalon™ elite bi-caval dual lumen catheter is designed for single site percutaneous Upon arrival the pa- failure but can also support right internal jugular vein insertion. The distal port of the cannula is positioned in the IVC and the tient was hypotensive, proximal port in the SVC allowing drainage of deoxygenated blood, while the infusion port, for the pulmonary system. oxygenated blood, is positioned in the right atrium. tachycardic and febrile at An advantage of ECMO 103.1°F. He was transported support is that the harmful effects of along with chills, myalgia and head- to the cardiac catheterization lab for extremes of conventional management ache. Initial workup for viral and bac- placement of an intra-aortic balloon are avoided, allowing organ rest and terial causes of this acute febrile illness pump. After arrival in the cardiac recovery. ECMO utilization has grown were negative, and he was empirically catheterization lab, his hemodynamics in popularity over the last decade due started on Azithromycin. The next further deteriorated with the develop- to major advances in circuit technolo- day the patient was admitted to the ment of ventricular tachycardia (VT). gy and safety combined with sophisti- hospital with a working diagnosis of Cardioversion was unsuccessful, and cated critical care expertise in manag- acute febrile illness with dehydration cardiopulmonary resuscitation (CPR) ing these very sick patients. and started on IV fluids. The follow- was performed for 36 minutes while ing day, he became hypotensive and (continued on next page)

kansas city medicine 27 Special section ADULT ECMO (continued) orthotopic heart transplant on hospital as the cannulation method of choice emergent VA ECMO was initiated for day 104. The patient was subsequently for respiratory failure which has been cardiopulmonary rescue. discharged 112 days after admission shown to have fewer associated com- In an effort to protect neurologic with only a mild neurologic deficit, re- plications. Lower levels of anticoagu- integrity post cardiac arrest, hypother- turned and graduated from college and lation are needed due to circuit design mia to 34°C was initiated for 24 hours is a fully functioning and productive improvements, and importantly, followed by gradual rewarming at member of society. patients are placed on lung rest ventila- 0.5°C per hour. After 24 hours seda- tory settings to reduce ongoing injury tion was weaned and he was able to ECMO FOR RESPIRATORY SUPPORT and promote healing. These important follow all commands. The patient de- ECMO was first successfully utilized in advances in knowledge and technolo- veloped acute kidney failure requiring 1971 to support an adult patient with gy make early experiences in ECMO hemodialysis. He was placed on a lung respiratory failure due to acute respi- incomparable to the present day. The protective strategy of low most recent and largest tidal volume ventilation. multi-centered random- After extensive discus- ized controlled trial (RCT) sion among cardiovascu- to date, Conventional lar surgery, heart failure Ventilation or ECMO for cardiology, critical care Severe Adult Respiratory and the transplant team, a Failure (CESAR) trial, was para-corporeal bi-ventric- conducted in the United ular assist device (Bi-VAD) Kingdom between 2001 was placed five days after and 2006. CESAR com- admission as a bridge to pared patients with severe either recovery or heart reversible respiratory transplant. Upon wean- failure who were random- ing from cardiopulmo- ized to an ECMO referral nary bypass after BiVAD center to patients man- placement, the patient was aged with conventional unable to be adequately Figure 2. CXR of a typical ARDS patient receiving VV ECMO support. Arrow -31 F right internal ventilation at tertiary care oxygenated using conven- jugular dual stage cannula used for veno-venous ECMO. centers, which encouraged tional mechanical venti- the use of lung protective lation due to severe acute pulmonary ratory distress syndrome (ARDS) after ventilation. This study showed survival edema. Therefore, VV ECMO was a traumatic aortic injury.1 In 1979, a without severe disability at six months initiated for pulmonary support. After landmark randomized controlled trial was 63% for those patients referred to one week, he was removed from VV performed by Zapol et al, compared the ECMO center and 47% for those ECMO and maintained on low me- ECMO to conventional ventilatory treated at tertiary care centers.3 This chanical ventilation support until lung therapy in patients with ARDS.2 This was an intention to treat analysis, and recovery. Myocardial biopsy showed trial showed a poor survival in both not all patients randomized to the severe myocardial necrosis with exten- arms with no benefit for ECMO. Of ECMO referral arm actually received sive lymphocytic infiltration consistent note, all patients were managed on VA ECMO as some patients improved with fulminant myocarditis. Over the ECMO, high levels of anticoagulation and some died before ECMO could be next several weeks, the patient’s kid- were used, lung protective ventilation initiated. This was an important study ney, liver, lung and neurologic function was unknown, and all patients were because it represents modern-day markedly improved. However, with managed on very high levels of venti- practice realities and will encourage no improvement in heart function latory support in excess of seven days further study into the potential benefit the patient was listed for heart trans- before they were randomized. Mod- of early VV ECMO for severe refracto- plantation and received a successful ern-day ECMO utilizes veno-venous ry respiratory failure.

28 summer 2015 Special section The use of VV ECMO for respira- lung injury and eventual multi-or- Membrane Oxygenation for Severe tory salvage dramatically increased in gan dysfunction. VV ECMO restores Acute Respiratory Distress Syndrome 2009, mainly due to the effects of Influ- oxygen delivery to cells and prevents (EOLIA) trial (NCT01470703) show enza A H1N1 and the predilection for ongoing iatrogenic injury, providing benefit for early use in patients with severe respiratory failure in a young time for lung repair and recovery. severe respiratory failure refractory to population. Retrospective analysis in Extremes of patient management such escalating treatment. this cohort showed better than expect- as excessive ventilator settings, inotro- Implementation of modern VV ed survival when VV ECMO was im- pes, vasopressors and fluids can create ECMO most commonly involves per- plemented early in both the Australian ongoing organ injury and promote cutaneous insertion of a dual lumen and North American experiences.4, 5 iatrogenic harm. Recent advances in cannula into the right internal jugu- The influenza season of lar vein directed into 2013-2014 also showed Return cannula the inferior vena cava a predominance of the Drainage cannula (Figures 1 and 2). This 2009 H1N1 subtype cannula removes venous with preferential severe blood by a centrifugal respiratory failure in Oxygenator pump with flows up to young otherwise healthy 7 L/min. The blood is patients. At Saint Luke’s then directed through we placed a total of 10 a polymethylpentene patients on VV ECMO membrane oxygenator support due to severe where gas exchange hypoxemia from influ- occurs and then through enza A with a greater a heat exchanger where than 80% survival to dis- the blood temperature is charge. The longest du- Pump controlled. Oxygenated ration of support was 48 blood is then returned to days with survival in this the right atrium through patient. It is important the inner cannula (Fig- to recognize that these ure 3). Insertion can also patients were refractory be achieved through a to the extremes of con- femoral vein–femoral Figure 3. Veno-Venous ECMO. ventional management vein approach. With VV such as proning maneuvers, inhaled VV cannulation technology enable ECMO the membrane oxygenator and pulmonary vasodilators, increased patients to ambulate and even liberate the patient’s lungs function in series positive end expiratory pressure from mechanical ventilation while on and the resulting saturation of arterial (PEEP) and mean airway pressure, and ECMO support, thus decreasing all blood in the patient is determined by a had a very high likelihood of death the known complications associated combination of the saturation of ve- without rescue on VV ECMO. with an intubated, sedated and supine nous blood returning to the heart, the VV ECMO can be a life-saving patient. VV ECMO also allows for saturation of blood returning from the therapy for patients with acute severe rapid weaning of cardiovascular sup- ECMO circuit (always 100%), ECMO respiratory failure unresponsive to port due to an immediate reduction flow rate, the patients cardiac output the limits of lung protective ventila- of intra-thoracic pressure. Although and any residual lung function. Recent tion and other advanced therapies to ECMO is still considered an exper- innovations in cannula, tubing, pump improve oxygenation. The causes of imental therapy and should only be and oxygenator technology have im- respiratory failure may vary, but the used in patients with a high likelihood proved durability, simplicity, efficiency forces used to provide for adequate of death, it will be interesting to see if and safety. The main complications oxygen delivery can lead to further future studies like the Extracorporeal (continued on next page)

kansas city medicine 29 Special section ADULT ECMO (continued) VA ECMO is much less expensive status.7 Unfortunately, there have with VV ECMO include hemorrhage than other ventricular assist devices been no randomized controlled trials and cannula perforation during inser- options and can provide biventricu- evaluating the efficacy of VA ECMO tion. in adult patients. Also Arterial-venous important to note is that ECMO (AV ECMO) is survival with VA ECMO a form of ECMO sup- is poorer than with VV port utilized for carbon ECMO, and the associat- Oxygenator dioxide (CO2) removal. ed complications can be Typical indications may more severe and require include acute severe aggressive management. asthma or COPD ex- The Extracorporeal Life acerbations. Current Support Organization membrane oxygenators (ELSO) has collected are extremely efficient at outcome data since

CO2 removal, allowing 1989 on over 4,000 adult significantly lower flow cardiac ECMO patients Pump rates than what is re- by diagnosis. ECMO to quired for oxygenation. Drainage cannula support acute myocarditis This allows for smaller Return cannula shows the highest surviv- cannula use. This form of ability. These patients are ECMO support has not typically young without gained wide popularity in comorbid disease. Overall

the United States. Figure 4. Veno-Arterial ECMO. survival to discharge is 40% for all adult cardiac ECMO FOR Typical Cases of Acute Cardiac Failure ELSO Survival Rates ECMO support (Table CARDIOPULMONARY 1). The major complica- SUPPORT Myocarditis 66% tions associated with VA VA ECMO can provide Cardiomyopathy 49% ECMO include hemor- immediate return of rhage, thromboembolic oxygen delivery to cells Post-cardiotomy shock 38% events, left ventricular in patients suffering from Cardiac arrest 31% distension, pulmonary acute cardiogenic shock edema and limb ischemia. due to multiple etiolo- Overall survival 40% Systemic anticoagula-

gies. It is intuitive that the Table 1. Typical cases of and ELSO survival rates of acute cardiac failure. ELSO Registry 2014. tion is required with VA longer patients remain in ECMO especially with shock and cells are starved of criti- lar temporary support while serving lower flow rates. Anticoagulation is cal oxygen, the result is that cellular as a bridge to decision, mechanical recommended but not mandatory for functions cease, acidosis worsens, support, recovery or heart transplant. VV support and has been used suc- multi-organ system failure develops The International Society for Heart cessfully on patients with poly-trauma and death ensues. VA ECMO can be and Lung Transplantation Guidelines and intercerebral hemorrhage where instituted expeditiously and when ini- endorse a high recommendation (Class anticoagulation was contraindicated.8 tiated early and managed by a critical 1A) for utilizing temporary short-term VA ECMO cannulation is common- care team with ECMO experience, it support as opposed to more long-term ly performed peripherally utilizing has been shown to be extremely useful VAD support in patients “in extre- the femoral vein and femoral artery for hemodynamic rescue in patients mis” with multi-organ failure to allow (Figure 4). Central cannulation is most with refractory cardiogenic shock.6 successful optimization of clinical often employed after cardiac surgery

30 summer 2015 Special section with failure to wean from cardiopul- around the world. intervention and should be considered monary bypass. There are advantages We believe that when ECMO is ini- early for the best outcome. and disadvantages of both cannulation tiated early, before organ systems fail, techniques that are beyond the scope the best outcomes can be achieved. We CONSENT of this article. With VA ECMO, venous have an exceptionally engaged, col- Written informed consent was ob- blood is removed from the patient and laborative and highly functional team tained from the patient for publication flows through the same apparatus and involved in the care of these patients, of this report and any accompanying at the same rate of flow as VV ECMO. which include cardiovascular surgery, images. The difference is that oxygenated blood cardiac anesthesiology, 24/7 intensivist is then returned to the arterial side of lead critical care, heart failure cardi- Michelle M. Haines, MD, is a cardiac anesthe- siologist and intensivist, and is medical director the circulation. The heart and lungs are ology, 24/7 perfusionist support, and of the Cardiovascular Intensive Care Unit and in parallel to the circuit, which reduces ECMO specialty trained nurses. The ECMO program at Saint Luke’s Mid America pulmonary blood flow, significantly team has extensive training in ECMO Heart Institute. augments perfusion, and provides management and troubleshooting. Our bi-ventricular support. The manage- clinical experts work together to create REFERENCES 1. Hill JD, O’Brien TG, Murray, JJ, et al. Prolonged extracorporeal ment of these patients is therefore a comprehensive care plan for each oxygenation for acute post-traumatic respiratory failure (shock- more complex than with VV ECMO. individual, ensuring the best possible lung syndrome). Use of the Bramson membrane lung. N Engl J The main contraindication for ECMO treatment outcomes. Med. 1972; 286:629. support is irreversible organ failure One of the most difficult tasks for 2. Zapol WM, Snider MT, Hill JD, et al. Extracorporeal membrane and non-candidacy for device or trans- a referring physician and a consult- oxygenation in severe acute respiratory failure. A randomized plantation. ing ECMO physician is to determine prospective study. JAMA. 1979; 242:2193. VA ECMO during CPR is termed when a patient should be transferred 3. Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic extracorporeal cardiopulmonary to an ECMO center. Transporting such assessment of conventional ventilatory support versus extra- corporeal membrane oxygenation for severe adult respiratory resuscitation (E-CPR) and has shown a sick patient is not without risk but failure (CESAR): a multicentre randomized controlled trial. improved survival compared to con- may be the only option for a favorable Lancet. 2009; 374:1351–63. ventional CPR especially when im- outcome. The decision to transfer is 4. The Australia and New Zealand Extracorporeal Membrane 9 plemented in under 60 minutes. The an enormous responsibility that can Oxygenation (ANZ ECMO) Influenza Investigators. Extracorpore- ability to perform successful ECPR re- be eased by early consultation with al Membrane Oxygenation for 2009 Influenza A (H1N1) Acute quires a highly coordinated effort with the ECMO center. This allows early Respiratory Distress Syndrome. JAMA. 2009;302:1888-95. early identification and notification planning for transport before a patient 5. ELSO Unpublished. of the ECMO team and effective CPR becomes so unstable that transport 6. Francis D. Pagani, MD, PhD, et al. Extracorporeal Life Support while awaiting full ECMO support. cannot occur. to Left Ventricular Assist Device Bridge to Heart Transplant; A strategy to optimize survival and resource allocation. Circula- tion. 1999; 100:II-206. ECMO AT SAINT LUKE’S MID AMERICA CONCLUSION HEART INSTITUTE Over the last decade ECMO support 7. 2013 ISHLT Guidelines for Mechanical Circulatory Support (Con- sensus Document). J Heart Lung Transplant. 2013;32:157- The case used in this publication has increased for both cardiac and 187. was our first patient placed on ECMO respiratory failure, and outcomes 8. Muellenbach RM, et al. J Trauma Acute Care Surg. 2012; support using modern-day technolo- continue to improve. This is likely the 72(5):1444-7. gy. Since then we have placed over 80 result of improved technology, reduced 9. Chen YS, Lin JW, Yu HY, et al: Cardiopulmonary resuscitation patients on ECMO for respiratory and/ complications and improvements in with assisted extracorporeal life-support versus conventional or cardiac support. Our program is a and recognition of the importance of a cardiopulmonary resuscitation in adults with in –hospital member of and actively participates highly skilled critical care team man- cardiac arrest: an observational study and propensity analysis. in the Extracorporeal Life Support aging these patients. ECMO can be a Lancet. 2008; 372: 554-61. Organization (ELSO) data registry life-saving therapy for patients with for national and international ECMO acute severe cardiac and/or respiratory Centers. ELSO monitors quality failure failing conventional medical standards for member ECMO Centers management but is a time-critical

kansas city medicine 31 Special section

ECMO in Adults By Jeffrey B. Kramer, MD, FACS, The University of Kansas Hospital

The advent of Extracorporeal Life ically improved outcomes.2 Undoubt- ECMO circuit is in reality a highly effi- Support (ECLS) in the latter half of the edly, lives have been saved as a result cient “gas exchanger” which introduces 20th century was a watershed moment of early and aggressive implementation oxygen into the perfused blood while

in the history of modern medicine. of ECMO. The role of this modality is removing CO2. This task is facilitated Following John Gibbon, MD (Figure under active investigation at numer- by placing large-bore wire-wrapped 1), in development and first successful ous major medical centers around the cannulas into central blood vessels and implementation of cardiopulmonary world. This review aims to provide a positioning them in such a way as to bypass technology in 1953, surgeons brief overview of ECMO technology, establish optimal support. Cannulation have vigorously explored is routinely performed in the limits of this modali- the OR at our institution, ty in the hope of treating but in certain circumstanc- patients with grave cardiac es, it can be accomplished in and pulmonary conditions. an intensive care or cardiac Initial use was “short-term” catheterization laboratory and confined to procedures setting. Accurate position- taking place in the operat- ing of the cannulas is critical ing room (OR). But some and this can be challenging intrepid physicians, first and at times. Thus, access to flu- foremost Robert Bartlett, oroscopy, trans-esophageal MD, from the University echocardiography (TEE), of Michigan, extrapolated Figure 1. Dr. John Gibbon (1903-1973) developed cardiopulmonary bypass and performed the and optimal anesthetic sup- first successful intracardiac repair utilizing ECLS. their operative experience port in a specially equipped to successfully treat infants suffering the types of patients that may benefit “hybrid OR suite” greatly facilitates from cardiorespiratory failure in the from ECMO, and the challenges and this task. Intensive Care Unit setting. In these questions that remain on the horizon Practically speaking, there are two cases, critically ill pediatric patients for this promising modality. basic configurations of ECMO circuits: were placed on ECMO (Extracorpo- Veno-arterial (VA) and veno-venous real Membrane Oxygenation) circuits, WHAT IS ECMO? (VV), each having a specific role. VA essentially cardiopulmonary bypass, ECMO refers to the method of ECMO is by and large utilized in situ- for hours or days at a time, often with temporary replacement of the lung ations in which both gas exchange and profound success. However, the initial and/or heart functions by connecting cardiac function are failing, and me- experience utilizing ECMO to treat patients to extracorporeal perfusion chanical support is necessary to main- adult patients with respiratory fail- circuits. The term “ECMO” itself is a tain hemodynamic stability. In this ure was dismal, with mortality rates bit incomplete, since the circuit that scenario, blood is drained from the exceeding 90% in a multicenter NIH provides support in these patients venous system into the ECMO circuit study published in 1979.1 with severe cardiorespiratory embar- where gas exchange occurs, and then Since that time, new and better sur- rassment serves not only to oxygenate directed by a centrifugal pump into the

gical techniques, as well as advances in blood, but also to exchange CO2. Thus, arterial system in order to support a circuit technology, have led to dramat- the “oxygenator” component of the patient’s hemodynamics. Cannulation

32 summer 2015 Special section can be accomplished either peripher- venous system. This allows oxygenat- blood through the TV and into the ally (femoral or internal jugular vein ed blood from the pump to enter the RV. Optimal positioning of this device ECMO in Adults [IJ] and femoral artery) or centrally via right side of the heart before traversing can be somewhat challenging, even By Jeffrey B. Kramer, MD, FACS, The University of Kansas Hospital a sternotomy (right atrium [RA] and the pulmonary circuit and entering requiring periodic adjustment in the ascending aorta). Peripheral arterial the left atrium. This technique almost ICU. But this cannula confers some cannulation does have the advantage always can be performed peripherally, distinct advantages. First, by avoiding of not requiring re-entry into the chest utilizing a variety of cannula configu- femoral perfusion lines, patients can for decannulation, however this is rations. A sternotomy is not required, be more easily and safely repositioned balanced by technical problems that a major advantage of the technique. in the ICU bed. At some centers, can result from this approach, such as Cannulation may be either multiple or patients who have been on ECMO for distal limb ischemia and retrograde single. The former requires percuta- multiple days, for instance patients dissection of the iliofemoral arterial neous cannulation of the femoral and being bridged for lung transplantation, system. Another potential concern IJ veins. In this procedure, the drain- have even been weaned off sedation with peripheral cannulation for VA age cannula is directed into the iliac and ambulated with these devices ECMO is the phenomenon of upper vein or IVC while the ECMO outflow in place, while on ECMO. Another body hypoxemia,2 the so-called “Har- cannula is positioned in the RA. An advantage is that decannulation can be lequin Syndrome,” in which accomplished very simply in the oxygenated blood returning majority of cases with minimal from the oxygenator serves risk of hemorrhage afterwards. to perfuse mainly the lower The ECMO circuit itself is body (via the femoral can- comprised of several major com- nula) while deoxygenated ponents that are assembled and blood ejected from the heart controlled by cardiac perfusion- perfuses the upper. None- ists who have extensive experi- theless, there are institutions ence using and trouble-shooting throughout the country cardiopulmonary bypass circuits in which surgical teams in the OR. In most hospitals em- are routinely dispatched ploying this modality, a portable throughout the hospital to setup (Figure 3) is assembled Figure 2. AVALON cannula placed in right internal jugular vein percutaneously. establish ECMO peripherally Posteriorly disposed limb drains blood from IVC while anterior limb returns blood to accomplish the task. The key in patients suffering sudden from the oxygenator. components in these systems cardiac deterioration from include: a hollow-fiber membrane potentially reversible processes (such additional drainage cannula is some- oxygenator (Figure 4), the magneti- as acute myocardial infarctions in the times necessary in larger patients to cally-driven roller pump, heating and catheterization laboratory). provide adequate ECMO circuit flow, cooling elements, a gas blender unit In cases in which cardiac func- thus requiring bilateral femoral venous and various inline monitors to detect

tion is good, but the lungs are failing cannulation. Optimal positioning of O2 saturation and other parameters. from an acute disease process (such the cannulas is assured by TEE and/or Miniaturization is on the horizon. as ARDS or overwhelming infection), fluoroscopic guidance. Macquet Cardiopulmonary has recent- VV ECMO is the modality most fre- Recently, a dual lumen ECMO ly developed the “Cardiohelp” system, quently employed. This avoids arterial cannula (Avalon Laboratories, Rancho a small, portable, fully functional cannulation and perfusion, thereby Domingo, CA) inserted percutane- device that can be used to retrieve and significantly ameliorating the risks ously into the right IJ vein has been transport patients to regional ECMO associated with ECMO (discussed utilized effectively for VV ECMO centers sometimes hundreds of miles below). VV ECMO is accomplished by (Figure 2). The distal tip of the can- away from the patient’s primary facility. placing both the drainage and per- nula lies in the intrahepatic IVC while (continued on next page) fusion limbs of the circuit within the the proximal (inflow) channel directs

kansas city medicine 33 Special section ECMO IN ADULTS (continued) treatment and in precipitous clinical experience must determine that the WHO WILL BENEFIT FROM ECMO? decline, when should ECMO be a patient is on an unfavorable trajectory, The precise role of ECMO is still consideration? There is some indica- keeping in mind the extremely toxic somewhat ill-defined. A recent me- tion, if controversial, that the earlier a effects of barotrauma and high oxygen ta-analysis 3 of 10 separate studies patient is placed on ECMO, the better concentrations on the diseased lungs. comparing ECMO and conventional the chance of survival. On the other The aim is to intervene early enough mechanical ventilation for acute respi- hand, if ECMO is initiated too early for salvage, but not without giving con- ratory insufficiency failed to demon- before a good effort at ventilation has ventional less-invasive strategies some strate an overall mortality benefit for run its course, one could argue that the time to succeed. ECMO. Still, there is some promising While the role of VV ECMO in the favorable data utilizing VV ECMO in clinical armamentarium has yet to be select patients. The most compelling determined, the current status of VA evidence that ECMO could likely play ECMO is still more uncertain. The a salutary role is derived from the most common scenario in which VA CESAR trial, a British study published ECMO comes under consideration, 2009.4 In this study, 180 patients with is in cases involving postcardiotomy severe respiratory failure were ran- patients in the OR who have developed domized to receive either “conven- refractory cardiogenic shock. Typically tional” medical treatment or ECMO. in these cases, conventional inotropic Of these, 63% of patients allocated to support including intra-aortic bal- consideration for treatment by ECMO loon counterpulsation is insufficient survived 6 months, compared to 47% to allow for successful weaning from who received conventional manage- cardiopulmonary bypass. The surgeon ment. This trial has been criticized can be faced with the difficult decision for several reasons.2,5,6 There was lack of instituting ECMO or facing intra- of standardization of “conventional” operative demise of the patient. The therapy. Only 75% of patients ran- evidence for the efficacy of ECMO in domized to the ECMO group actually this setting is from anecdotal reports ended up receiving this therapy. There and small observational studies. De- have been several observational series spite utilization of the latest in oxygen- showing successful ECMO treatment ator and pump technology, in-hospital of patients during the deadly 2009- mortality rates in this setting are 2010 H1N1 Influenza Pandemic. The reported consistently to be upwards Figure 3. ECMO cart. CESAR study, together with the more of 75%.8 This makes casual implemen- anecdotal H1N1 reports, have led to patient has been placed at unnecessary tation of ECMO technology in this a continued enthusiasm for and belief risk by instituting ECMO prematurely. scenario imprudent unless there is a in this modality to treat refractory This is the dilemma that faces intensiv- reasonable expectation of success. respiratory insufficiency.2,6 It appears ists who routinely care for these very that lives have been saved by prudent ill patients. The literature is replete CONDUCT OF ECMO utilization of ECMO in cases of respi- with recommendations and criteria AND COMPLICATIONS ratory failure. However, with excellent to facilitate arriving at this decision.6,7 Once ECMO has been initiated, pa- outcomes resulting from modern “lung Most of them involve examining met- tients are normally cared for in an ICU protective” ventilation modalities, the rics of progressive respiratory insuffi- specifically designated for this purpose

advantage of ECMO in this setting ciency, such as a PaO2/FiO2 ratio < 80 and by nursing staff who have been remains debatable. despite high PEEP or uncompensated trained and certified in their man- In patients with refractory respira- hypercapnia with acidosis. Ultimate- agement. At our institution, patients tory failure, unresponsive to ventilator ly, clinical judgment tempered with are transferred to our cardiothoracic

34 summer 2015 Special section intensive care unit where intensivists, chest radiographs herald clinical re- blood flow downstream and result surgeons and perfusionists are readily covery. ECMO support can be gradu- in distal limb-threatening ischemia. available. Each patient is assigned two ally weaned to the point where it is no Even venous cannulation can lead to ICU nurses, at least one of whom is longer necessary. Normally, perfusion problems however; perforation of the

ECMO-certified, around the clock. at low levels of supplemental FiO2 will heart and great vessels has occurred. Patients are sedated, and ventilation be continued for several hours prior Once the cannulas are safely in place, is reduced to “rest” levels, minimizing to removing the patient from ECLS thrombotic problems often arise, inter- the effects of high settings while allow- and decannulating. ECMO perfusion fering with the oxygenator function – ing for airway expansion. Management can last a matter of days or even weeks even despite systemic anticoagulation is by protocol, with careful monitoring as long as there is some indication of with heparin and careful monitoring. of hemoglobin (Hb) levels, platelet This problem is usually detected by counts, arterial blood gasses, chest ra- careful visual inspection of the circuit diographs and coagulation studies on and measurement of the oxygenator a regular basis. Since there is admixing “reserve,” taking into account the of deoxygenated blood from the lungs oxygen delivery relative to the circuit’s and blood from the oxygenator, the post-oxygenator PaO2 measurement. usual target SaO2 is in the 85-92 % Once discovered, prompt replacement range.2 This can be modified by chang- of the oxygenator is required to ad- es in such factors as pump flow, FiO2 dress this problem. provided to the oxygenator, cannula Since these patients are fully antico- position and patient position. One agulated and may be so for some time, common problem leading to systemic bleeding problems are particularly hypoxemia is the phenomenon of “re- worrisome and dangerous. Not only circulation,” in which close proximity can bleeding be related to cannulation between the delivery and return lines sites, but it can occur at surgical or causes recently oxygenated blood from procedure areas, the GI tract, pulmo- the pump to be immediately captured nary system, or, most catastrophically, Figure 4. Quadrox D Oxygenator (Macquet). Highly efficient by the drainage port or cannula. Once polymethylpentene (PMP) gas exchange unit composed of intracranial. Patients on VA ECMO this is detected (by comparing pre- and hollow fiber membrane that reduces chance of micro bubbles in require greater degrees of anticoag- the circuit. This unit will provide up to two weeks of perfusion post-oxygenator saturations), cannula support. ulation, therefore their risk of com- repositioning will usually correct this plications is greater. ECMO requires problem. reversibility. Oftentimes, the pallia- assiduous monitoring of ACT, INR Since the oxygenator and circuits tive care team will be asked to assist and platelet levels. More sophisticated tend to collect thrombus, patients are when the time on ECMO becomes studies might be indicated to make fully anticoagulated during the ECMO prolonged, particularly if there is very sure that anticoagulation is therapeutic period. Because of this, every addition- little improvement or even worsening but not supra-therapeutic. In a crisis al invasive procedure contemplated of the clinical situation. situation, the patient on VV ECMO for these patients (such as central line The risks associated with ECLS can even be run without heparin for placement, drainage of pleural effu- are certainly not trivial, which makes up to 48 hours2 without adverse effects, sions, and tracheostomy for example) the initial decision to institute ECMO though this is far from ideal. must be carefully considered, weighing difficult. In addition to cannulation the risk vs. the benefit of the interven- problems already mentioned, ma- THE FUTURE OF ECMO tion. jor concerns in these patients relate Over 40 years following the first ECMO is continued as long as the to bleeding and thrombosis. This is successful ECMO procedure reported respiratory and/or hemodynamic dif- particularly true when peripheral by Dr. Bartlett in 1972,9 determining ficulties persist. Most often, improve- arterial access is necessary because the precise role of this modality still ment of the arterial blood gasses and the presence of such lines can inhibit (continued on next page)

kansas city medicine 35 Special section ECMO IN ADULTS (continued) Jeffrey B. Kramer, MD, FACS, is a cardiothorac- for Adult Respiratory Failure. Respiratory Care. 2013; 58(6): presents a challenge, at least in the case ic surgeon at The University of Kansas Hospital. 1038-49. He can be reached at [email protected], 7. Brodie D, Bacchetta M Extracorporeal Membrane Oxygenation of adult patients. Despite technological 913-588-9792. advances in ECLS circuitry which have for ARDS in Adults. N Engl J Med. 2011; 365: 1905-14. already taken place and are bound to REFERENCES 8. Pokersnik JA, Buda T, Bashour CA, et.al. Have Changes in 1. Zapol WM, Snider MT, Hill JD, et.al. Extracorporeal Membrane accelerate with time, this modality will ECMO Technology Impacted Outcomes in Adult Patients Oxygenation in Severe Acute Respiratory Failure; A Randomized Developing Postcardiotomy Cardiogenic Shock? J Card Surg. probably not enjoy wide applicability. Prospective Study. JAMA 1979; 242(2): 2193-6. 2012; 27: 246-252. ECMO is a labor intensive and ex- 2. Sidebotham D, Allen SJ, McGeorge A, et.al. Venovenous Extra- 9. Annich G (ed.). ECMO Extracorporeal Cardipopulmonary Sup- pensive modality. However, in certain corporeal Membrane Oxygenation in Adults: Practical Aspects port in Critical Care. Ann Arbor, MI: Extracorporeal Life Support specialized centers, some patients with of Circuits, Cannulae, and Procedures. J Cardiothorac and Vasc Organization; 2012. no other option will survive due to the Anesth. 2012; 26(5): 893-909. fact that ECMO is available—we have 3. Munshi L, Telesnicki T, Walkey, et.al. Extracorporeal Life seen that. The key to successful use of Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis. Ann Am Thorac Soc. 2014; 11(5): 802-10. this modality probably lies in a multi- disciplinary, protocol-based approach 4. Peek G, Mugford M, Tiruvoipati R, et.al. Efficacy and Economic Assessment of Conventional Ventilatory Support versus Extra- to these very ill patients by teams of corporeal Membrane Oxygenation for Severe Adult Respiratory caregivers experienced in the nuanc- Failure (CESAR): a Multicentre Randomized Controlled Trial. es of ECLS in the intensive care unit Lancet. 2009; 374: 1351-63. setting. They will be able to determine 5. Shekar K, Mullany DV, Thomson B, et.al. Extracorporeal Life who the appropriate candidates for Support Devices and Strategies for Management of Acute ECMO are, and how it can be imple- Cardiorespiratory Failure in Adult Patients: a Comprehensive Review. Critical Care. 2014; 18:219-28. mented in an effective and favorable manner. 6. Turner DA, Cheifietz IM Extracorporeal Membrane Oxygenation

UMKC Graduate Study Demonstrates Potential of Rapid Earns National Award Whole-Genome Sequencing in Critically Megan Litzau, a May 2015 graduate Ill Infants of the UMKC School of Medicine, has been selected as a winner of the 2015 A study published in April in The Lancet Respiratory Medicine and presented American College of Emergency Physi- at the annual Pediatric Academic Societies Meeting reveals the early results of the cians National Outstanding Medical Stu- clinical usefulness of rapid whole-genome sequencing in neonatal and pediatric dent Award. The honor will be presented intensive care units (NICUs and PICUs). Children’s Mercy Kansas City’s STAT-Seq in October at the organization’s annual test helped diagnose a genetic disease in more than one half of 35 critically ill infants scientific assembly in Boston. tested, compared to just nine percent with standard genetic tests. The award recognizes a medical As a result of receiving a specific disease diagnosis, clinical care was refined in student who intends to pursue an 62 percent of infants, including 19 percent who had a markedly favorable change in career and has treatment, and palliative care was initiated in 33 percent. Lead authors of the study displayed outstanding patient care and were Laurel Willig, MD; Josh Petrikin, MD (KCMS member); and Stephen King- involvement in medical organizations smore, MB, ChB, BAO, DSc, FRCPath, of Children’s Mercy Kansas City. and the community. Litzau will continue “Genomic diseases are the leading cause of death in NICUs and PICUs, but a her training in emergency medicine with timely and accurate diagnosis can significantly improve the precision of the care a residency at the Indiana University we provide. We’ve shown that rapid diagnosis using whole-genome sequencing is School of Medicine. feasible and changed management for a majority of infants that were diagnosed,” said Dr. Willig, a pediatric nephrologist. “We hope STAT-Seq will be instrumental in introducing precision medicine into the NICU and PICU.”

36 summer 2015 Special section

Increased Coronary Artery Plaque Volume Among Male Marathon Runners By Robert S. Schwartz, MD; Stacia Merkel Kraus, MPH; Jonathan G. Schwartz, MD; Kelly K. Wickstrom, BS; Gretchen Peichel, RN; Ross F. Garberich, MS; John R. Lesser, MD; Stephen N. Oesterle, MD; Thomas Knickelbine, James H. O’Keefe, MD MD; Kevin M. Harris, MD; Sue Duval, PhD; William O. Roberts, MD; & James H. O’Keefe, MD

Reprinted with permission. Missouri Medi- INTRODUCTION significant for those obtaining mod- © cine 2014 Regular physical activity is a key erate doses of running; individuals component of a healthy lifestyle. chronically performing high-intensity Background Vigorous aerobic exercise is con- long-distance running appeared to lose Long-term marathon running improves many sidered protective against coronary the mortality benefit.10, 11 Indeed, an cardiovascular risk factors, and is presumed artery plaque development based on emerging body of scientific data sug- to protect against coronary artery plaque its favorable effects on many cardio- gests that chronic, excessive, high-in- formation. This hypothesis, that long-term marathon running is protective against coro- vascular (CV) risk factors including tensity exercise may induce oxidative nary atherosclerosis, was tested by quantita- lower resting blood pressure and heart stress and myocardial fibrosis, accel- tively assessing coronary artery plaque using rate, improved lipid profile and glucose erate atherosclerosis, increase vascular high-resolution coronary computed tomograph- metabolism, reduced body mass index wall thickness, and increase cardiac ic angiography (CCTA) in veteran marathon run- (BMI), and association with healthier chamber stiffness.12, 13 Demand isch- ners compared to sedentary control subjects. lifestyles such as eating a nutritious emia related to significant coronary diet and avoiding tobacco.1-3 Daily narrowing may also occur in endur- Methods physical activity and high levels of car- ance running, and rarely this may Men in the study completed at least one mara- diorespiratory fitness are also associ- even result in myocardial infarction thon yearly for 25 consecutive years. All study ated with lower inflammatory markers and cardiac arrest.14, 15 Male marathon subjects underwent CCTA, 12-lead electrocar- and better life expectancy.4-8 runners have also been shown to have diogram, measurement of blood pressure, heart Four decades ago, Thomas Bassler, paradoxically increased coronary rate, and lipid panel. A sedentary matched MD, an American physician, notably artery calcified plaque as measured by group was derived from a contemporaneous hypothesized that marathon running computed tomography (CT) coronary CCTA database of asymptomatic healthy indi- 16 viduals. CCTAs were analyzed using validated confers immunity against coronary calcium scoring. However, a study us- 9 plaque characterization software. atherosclerosis. Exercise might be best ing high-resolution coronary comput- understood as a drug with powerful ed tomographic angiography (CCTA) Results benefits, especially for CV health. As for quantifying coronary artery plaque Male marathon runners (n = 50) as compared with any potent drug, establishing volume in marathoners has not been with sedentary male controls (n = 23) had the safe and effective dose range is previously performed. increased total plaque volume (200 vs. 126 critically important—an inadequately Recent advances in CCTA provide mm3, p < 0.01), calcified plaque volume (84 vs. low dose may not confer full benefits, quantitative, noninvasive assessment 44 mm3, p < 0.0001), and non-calcified plaque whereas an excessive dose may pro- of coronary artery plaque, and per- volume (116 vs. 82 mm3, p = 0.04). Lesion area duce adverse effects that outweigh its mit accurate measurement of plaque and length, number of lesions per subject, and benefits. volume and location. In this study diameter stenosis did not reach statistical Two recently published long- we used CCTA to examine whether significance. term large observational studies long-term marathon running in men is Conclusion independently showed that runners, associated with quantitative coronary Long-term male marathon runners may have as compared to non-runners, have artery plaque differences compared to paradoxically increased coronary artery plaque increased life expectancy. However, a sedentary control group. volume. these longevity benefits were most (continued on next page)

kansas city medicine 37 Special section

Lesion Prevalence - Men

Characteristic Sedentary (n=23) Marathon (n=50) p value

Number of lesions 47 95 —

Lesion prevalence 12 (52.2) 30 (60.0) NS

Table 2

Lesion Prevalence - Men

Characteristic Sedentary Marathon p value (n=47 lesions) (n=95 lesions)

Lesion area* 43.4 ± 26.0 (44) 46.9 ± 24.2 (94) NS

Lesion diameter* 42 ± 22.4 (43) 41.7 ± 19.9 (94) NS

Lesion length* 15.1 ± 8.0 (43) 20.0 ± 17.3 (94) NS

Plaque volume* 125.5 ± 80.5 (46) 200 ± 144.2 (95) 0.002

Calcified plaque volume 44.0 ± 36.8 (46) 83.8 ± 67.7 (95) <0.0001 mm3*

Non-calcified plaque 81.5 ± 58.1 (46) 116.1 ± 95.7 (95) 0.039 volume mm3*

p values from T-test/Wilcox test for non-normal data. Table 3 * Indicates failure of the normality assumptions based on Shapiro-Wilk test.

Table 1

MARATHON RUNNERS (continued) sedentary controls for coronary disease pressure, resting heart rate, serum lipid METHODS risk factors. panel, historical lifestyle and risk factor The study was approved by the questionnaire, and serum creatinine. Institutional Review Board of Abbott INCLUSION CRITERIA Northwestern Hospital (Minneapolis, All subjects signed informed con- DATA ANALYSIS Minn.). It was a single-center obser- sent. Exclusion criteria were those who CCTA scans were evaluated for vational study of male long-term, very declined to participate, were allergic to all measurable plaque, both calcified long-distance runners who partici- x-ray contrast, and had serum creati- and non-calcified. Plaque was man- pated in the Twin Cities’ Marathon nine ≥ 2.0. Scans were not scheduled ually identified and characterized for (Minneapolis-St. Paul, Minn.). Eligible if a subject had run a marathon within volume and stenosis severity using individuals were identified and invited the previous two weeks or intended to validated, commercial software on a to participate by reviewing marathon run a marathon within the following commercial CCTA 3-D workstation race records. After reviewing eligible two weeks (to avoid potential nephro- (Vitrea, Vital Images, Minnetonka, subjects, participation thresholds were toxic effects from intravenous contrast, Minn.). chosen as a minimum of 25 consecu- since marathon running is associated Descriptive statistics were calculated tive races for men. with a transient creatinine rise).19 and included means and standard devi- A sedentary group of men was ations or numerical counts and per- obtained from a coronary screening PROCEDURES centages. Chi-squared or Fisher’s exact study of individuals who underwent CCTA was performed per standard tests were used to assess the statistical CCTA scanning for clinical indica- clinical practice using Siemens Dual significance of categorical variables and tions.17, 18 All subjects in this group Source or FLASH CT in a minimum t-tests or Wilcoxon tests were used for were self-reported to lead sedentary x-ray dose protocol. At or near the continuous variables where appropri- lifestyles. Attempts were made to time of the CCTA, the following pro- ate. The Shapiro-Wilk test was used to match the marathon runners to the cedures were performed: 12-lead elec- test for normality of continuous data. If trocardiogram, height, weight, blood normality assumptions failed, conclu-

38 summer 2015 Special section sions were based on non-parametric subjects and 95 lesions in 30 of the 50 the contrary, this study found that comparisons. A p value of ≤ 0.050 was marathon participants. There was no long-term participation in marathon considered statistically significant, and difference in lesion prevalence between training/racing is paradoxically asso- all reported p values were two-sided. groups. Male marathon runners how- ciated with increased coronary plaque Statistical calculations were done with ever had paradoxically increased total volume (despite comparable plaque SAS software version 9.2 (SAS Institute plaque volume (200 vs. 126 mm3, p = prevalence). Inc., Cary, N.C.). 0.002), calcified plaque volume (84 vs. A recent study found the incidence 44 mm3, p < 0.0001), and non-calci- of sudden death in marathon running RESULTS fied plaque volume (116 vs. 82 mm3, p is approximately 1 in 100,000 partici- Fifty male marathon runners and = 0.04) (See Figure 1). Lesion area, di- pants, 15 with coronary artery disease 23 sedentary male control subjects ameter stenosis, and length differences (CAD) accounting for the majority of were enrolled. All male runners re- did not reach statistical significance fatalities.14 Fortunately, these deaths, though tragic and disturbing, are rare. However, the bigger concern may be the fact that excessive exercise ulti- mately deprives the individual from reaping the significant longevity bene- fits conferred by moderate exercise. The Copenhagen City Heart Study followed 1,878 runners and 10,158 Table 3 non-runners for up to 35 years.10 The runners had an impressive 44% lower risk of mortality during follow-up, with an increase in life expectancy of about six years for both genders. Importantly though, U-shaped curves were apparent for mortality with re- spect to dose of running, whereby the benefits of running were most signif- Figure 1 icant for those who jogged between ported no CV symptoms and had no between the two groups. 1 to 2.5 hours per week, at a slow to CV or coronary history. The mara- moderate pace, with a frequency of thoners and controls were similar in DISCUSSION about three times per week.10 In those age, resting blood pressure, height, The association of decades-long runners who were performing higher smoking history, serum creatinine, marathon training/racing with cor- volume, higher-intensity running, the total cholesterol and low density onary artery plaque was examined long-term mortality rates were not lipoprotein (LDL) cholesterol (p = NS in this study. Few prior studies have significantly different from non-run- for all) (See Table 1). Marathoners had focused on this association, and none ners. In other words, excessive running significantly lower resting heart rate, using plaque quantitation by CCTA. may have abolished the remarkable weight, BMI and triglyceride levels, but We found that long-term marathon improvements in longevity conferred had higher high density lipoprotein running in men may not engender by lower doses of running. (HDL) levels, and were less likely to protection against coronary artery Strikingly concordant data were have a history of diabetes and hyper- plaque development, despite confer- seen in a large decades-long observa- tension (See Table 1). ring advantages in many traditional tional study of 54,000 Americans.11 Tables 2 and 3 summarize coro- coronary risk factors including favor- Highly significant mortality reductions nary CT lesion analysis. There were able changes in lipid levels, glucose were seen in the runners compared to 46 lesions in 12 of the 23 sedentary metabolism and blood pressure. To (continued on next page)

kansas city medicine 39 Special section MARATHON RUNNERS (continued) aware of the potential adverse cardiac lactic acidosis, and other metabolic the non-runners, but U-shaped curves effects of chronic extreme endurance derangements.12, 13, 19 again showed that the lowest mortality efforts. rates were seen in those running 5 to The metabolic and mechanical LIMITATIONS 20 miles/week, and that the longevity stresses produced by excessive running The control group, although benefits of running completely disap- could constitute a causal role in accel- matched for age, gender and sever- peared with distances greater than 25 erated atherosclerosis. Runners who al CV risk factors, was unable to be to 30 miles/week. Still, the mortality train and race over very long distances matched to the marathoners for resting rates in the high-mileage runners were experience protracted elevations in heart rate, weight and HDL levels, like- ly the result of chronic high-intensity aerobic exercise. Still, these differences would be expected to protect against atherosclerosis, thereby favoring the marathoners. However, the sedentary controls had significantly less coronary plaque despite the marathoners’ more favorable CV risk factors. This was a single-center observa- tional study, based on recruitment from known runners who chose to participate. However, a study that randomly assigned individuals to either run marathons for 25 years or be sedentary for 25 years is practically impossible, and will never be done. Thus, a cause-and-effect relationship between marathon running and accel- Figure 2. Participation in Marathon Running. erated coronary plaque development similar to but did not exceed those for heart rate, blood pressure, cardiac out- cannot be established. Nonetheless, sedentary individuals).11 put, and atrial and ventricular volumes multicenter studies comparing coro- Cardiac over-use injury is a term for up to several hours per day. Intense nary plaque volume in larger numbers that we have proposed for problems exercise generates large quantities of of marathoners and matched seden- that arise with chronic excessive high free-radicals that outstrip the buffering tary control subjects would be of great intensity exercise. Reports have docu- capacity of the system after approxi- interest. mented myocardial fibrosis and scar- mately one hour of vigorous continu- ring, potentially dangerous rhythms, ous exercise, leaving these individuals CONCLUSION and accelerated coronary atherosclero- susceptible to oxidative stress, athero- Long-term training for and com- sis (a constellation of pathology which genic modification of cholesterol par- peting in marathons may in men be has been labeled Pheidippides’ Car- ticles, and endothelial dysfunction.20 paradoxically associated with acceler- diomyopathy by Peter McCullough, Ultra-endurance efforts also cause ated coronary artery plaque formation. MD).12, 13, 19 The number of individu- multiple other disturbances within the als running in marathons and other system including sustained elevations ACKNOWLEDGMENTS extreme endurance events has been of catecholamines and resultant coro- Presented in abstract at the Amer- rising dramatically during the past 40 nary vasoconstriction, protracted sinus ican Heart Association Scientific Ses- years (See Figure 2).12, 13 We suspect tachycardia which reduces the diastolic sions, November 2011. This work was some runners might choose shorter, filling time of the coronary arteries, supported in part by the Ken Rome less exhausting challenges if they were changes in free fatty acid metabolism, Foundation, Minneapolis, Minn.

40 summer 2015 Special section James H. O’Keefe, MD, is with Saint Luke‘s 6. Swift DL, Lavie CJ, Johannsen NM, Arena R, Earnest CP, O’Keefe 15. Kim JH, Malhotra R, Chiampas G, d’Hemecourt P, Troyanos C, Mid America Heart Institute and is a Missouri JH, et al. Physical activity, cardiorespiratory fitness, and exercise Cianca J, et al. Cardiac arrest during long-distance running races. Medicine Preventive Medicine Editorial Board training in primary and secondary coronary prevention. Circula- NEJM. 2012;366:130-40. Member. tion. 2013;77:281-92. 16. Mohlenkamp S, Lehmann N, Breuckmann F, Brocker-Preuss M, 7. Wen CP, Wai JP, Tsai MK, Yang YC, Cheng TY, Lee MC, et al. Nassenstein K, Halle M, et al. Running: the risk of coronary REFERENCES Minimum amount of physical activity for reduced mortality and events : Prevalence and prognostic relevance of coronary 1. Lippi G, Schena F, Salvagno GL, Montagnana M, Ballestrieri F, extended life expectancy: a prospective cohort study. Lancet. atherosclerosis in marathon runners. Europ Heart J. 2008; Guidi GC. Comparison of the lipid profile and lipoprotein(a) 2011;378:1244-53. 29:1903-10. between sedentary and highly trained subjects. Clin Chem Lab Med. 2006;44:322-6. 8. O’Keefe JH, Patil HR, Lavie CJ. Exercise and life expectancy. 17. Elashoff MR, Wingrove JA, Beineke P, Daniels SE, Tingley Lancet. 2012;379:799; author reply 800-1. WG, Rosenberg S, et al. Development of a blood-based gene 2. Lynch NA, Ryan AS, Evans J, Katzel LI, Goldberg AP. Older elite expression algorithm for assessment of obstructive coronary 9. Bassler TJ. Marathon running and immunity to atherosclerosis. football players have reduced cardiac and osteoporosis risk artery disease in non-diabetic patients. BMC Med Genom. Annals NY Acad Sci. 1977;301:579-92. factors. Med Sci Sports Exerc. 2007; 39:1124-30. 2011; 4:26. 10. O’Keefe JH, Schnohr P, Lavie CJ. The dose of running that best 3. Mitsuzono R, Ube M. Effects of endurance training on blood lipid 18. Rosenberg S, Elashoff MR, Beineke P, Daniels SE, Wingrove confers longevity. Heart. 2013;99:588-90. profiles in adolescent female distance runners. The Kurume Med JA, Tingley WG, et al. Multicenter validation of the diagnostic J. 2006;53:29-35. 11. O’Keefe JH, Lavie CJ. Run for your life ... at a comfortable accuracy of a blood-based gene expression test for assessing 4. Lavie CJ, Church TS, Milani RV, Earnest CP. Impact of physical ac- speed and not too far. Heart. 2013;99:516-9. obstructive coronary artery disease in nondiabetic patients. Ann Int Med. 2010;153:425-34. tivity, cardiorespiratory fitness, and exercise training on markers 12. Patil HR, O’Keefe JH, Lavie CJ, Magalski A, Vogel RA, of inflammation. J Cardiopulm Rehab Prev. 2011;31:137-45. McCullough PA. Cardiovascular damage resulting from chronic 19. McCullough PA, Chinnaiyan KM, Gallagher MJ, Colar JM, Geddes 5. Kaminsky LA, Arena R, Beckie TM, Brubaker PH, Church TS, excessive endurance exercise. MO Med. 2012;109:312-21. T, Gold JM, et al. Changes in renal markers and acute kidney injury after marathon running. . 2011;16:194-9. Forman DE, et al. The importance of cardiorespiratory fitness 13. O’Keefe JH, Patil HR, Lavie CJ, Magalski A, Vogel RA, in the United States: the need for a national registry: a policy McCullough PA. Potential adverse cardiovascular effects from ex- 20. Michaelides AP, Soulis D, Antoniades C, Antonopoulos AS, Miliou statement from the American Heart Association. Circulation. cessive endurance exercise. Mayo Clinic Proc. 2012;87:587-95. A, Ioakeimidis N, et al. Exercise duration as a determinant 2013;127:652-62. of vascular function and antioxidant balance in patients with 14. Albano AJ, Thompson PD, Kapur NK. Acute coronary thrombosis coronary artery disease. Heart. 2011;97:832-7. in Boston marathon runners. NEJM. 2012;366:184-5.

200 NE Missouri Rd | Suite 281 Lee’s Summit, MO 64086 www.keanegroup.com P 816.474.4473 F 866.350.1333

kansas city medicine 41 time fitness medicine practice family home community

TIME FINDING MEANING SATISFACTION By Jim Braibish, Kansas City Medicine

42 summer 2015 Today’s younger physicians expect She also noted that the definition of most critical tasks of the day more than 12-hour days that leave them balance can change over time. “When • Know your limits with too little time to spend with their you are 30 and have a young family, the • Consider delegating lower-priority families or get involved in activities priorities and how you spend your time tasks outside of work. Many also recognize the are different than when you are 50 or • Outsource such tasks as housekeeping importance of getting involved in orga- when you are single.” and lawn maintenance nized medicine to help shape the future The level of balance fluctuates day-to- • Make time for self-care outside of work working environment of health care. day, with some days requiring long work • Let go of something before you take on Achieving balance is not easy, and hours and others where family issues or more takes effort. A study of 4,000 business events draw priority, Grimm said. “But • Be present and focus on the moment, executives published in the March 2014 when you look at life with a wider lens, whether it be at home or at work Harvard Business Review concluded, “By there is balance, optimal performance, “Balance is the foundation to being a making deliberate choices … leaders and fulfillment.” good and productive physician,” Grimm can and do engage meaningfully with Younger physicians are part of a concluded. “Physicians need downtime work, family and community. They’ve generational shift in which younger from work to recharge; they need a solid discovered through hard experience that workers place greater importance on and harmonious family life in order to prospering is a matter of carefully com- travel, hobbies and personal downtime be a good and empathetic physician.” bining work and home so as to not lose and not waiting until they are retired to Iris Grimm offers a confidential and themselves, their loved ones, or their enjoy these, according to Grimm. “Many individualized coaching program for foothold on success.” young doctors come from physician physicians, The Balanced Physician. For The definition of work-life balance families where they saw and experienced further information, visit www.balanced- varies widely according to one’s indi- (mostly) their fathers missing their ma- physician.com. TIME Young physicians strive to achieve MEANING balance of time to include family, fit- SATISFACTION ness and organized medicine.

vidual goals and outlook. “Work-life jor life events, leaving the dinner table REFERENCES 1. Interview with Iris Grimm, July 6, 2015. balance basically comes down to being to respond to an emergency situation or fulfilled and successful in personal life being on call frequently. But back then 2. Groysberg B, Abrahams R. Manage Your Work, Manage Your Life. Harvard Business Review, March 2014. https://hbr. and at work,” said Iris Grimm, an Atlan- physicians also received greater finan- org/2014/03/manage-your-work-manage-your-life. ta-based physician coach. cial reimbursements and it was a highly 3. 18 Work-Life Balance Tips for Physicians. Physicians Practice. “Balance is personal—everyone has recognized profession.” http://www.physicianspractice.com/great-american-physi- a different perspective of what life is In the face of day-to-day demands cian-survey/eighteen-work-life-balance-tips-physicians. Accessed supposed to look like,” she said. “Some and on-call schedules, what are some June 30, 2015. physicians want to make their profession tactical ways physicians can help main- 4. Berry E. Achieving work-life balance: More than just a juggling act. American Medical News. Jan. 4, 2010. their life and that is what makes them tain balance? http://www.amednews.com/article/20100104/busi- happy. And others like to have more The website Physicians Practice offers ness/301049968/4/. Accessed June 30, 2015. variety, have a big family, make time 18 work-life balance tips for physicians. for hobbies and practice medicine that Among them: supports this lifestyle.” • Carve out time to accomplish your

kansas city medicine 43 LANCER GATES, DO

Age: 44 The idealized vision of work-life Practice: Hospitalist, Gates Hospital- balance is one of smooth sailing, but ists LLC the real-life version for him is more complicated, says Lancer Gates, DO. Years in practice: 15 “From day to day, moment to mo- Family ment, it often feels like there are many Participating in organized medi- Wife, Stacey; Children, Ethan (16), balls in the air,” he said. “It would cine, Dr. Gates said, allows him to help Carson (14), Mason (11), Ava (10), Ella be nice to keep everything even, but address systemic problems that can (8) and Scarlett (5) generally it’s not. You just want to try hinder the delivery of care. Professional activities and come back to level as much as He offers several insights into his 2014 President, Kansas City Medical possible.” ability to manage work, family, and Society With six kids, Dr. Gates and his outside activities. First, is a solid sup- wife, Stacey, spend a lot of time shut- port network that includes an under- Personal activities tling the children between extracur- standing wife, kids and colleagues. Exercise, family time ricular activities that include tennis, Multi-tasking is also important, Dr. piano, and ballet. Stacey also serves as Gates said. Advice for aspiring leaders the manager of his medical practice. A former high school distance run- “Remember that important tasks, And then, of course, come the ner, he still tries to run a few times a such as getting through school or parenting responsibilities of providing week. He incorporates family time into raising good kids, do not happen over- a homework-friendly environment his running by bringing the kids along night, and (leaders) should continue and keeping an eye on the kids as they to the track so they can run along at to use that approach with every aspect mature. their own pace. He also plays tennis of life. It’s going to take that long to So why, then, does Dr. Gates take with the kids occasionally. develop other interests in organized on the added responsibility of being “In that way, we can all get in shape medicine or whatever else. It is not heavily involved with the Kansas City together,” Dr. Gates said. “I have to in- going to come easy, and it’s an invest- Medical Society? It all comes down to corporate the two things. There is not ment—one day at a time.” taking better care of patients, he said. time enough to watch them exercise and me exercise at a different time.” And finally, he said, he acknowledg- es the boundaries of his own time. His rule is that he does not take on a new responsibility without freeing him- self up from another one. Certainly one can learn and grow by becoming involved in outside activities, but you have to be realistic about your capabil- ities, he said. “You have to keep a close eye on how much you have committed to do and how much you can deliver,” he said, “and if you are having a hard time, and there will be times, you have to step back, you have to know in your own mind what is your priority.” The fine line is this, he said: “You don’t just want to be busy. You want to be effective.”

44 summer 2015 SARAH LOVINGER FLORIO, MD

Age: 34 Sarah Lovinger Florio, MD, re- Practice: Saint Luke’s Medical Group– minds herself every day of what is Lee’s Summit most important to her: family and church. Years in practice: 5 Working four days a week, 7:30 a.m. Family to 5:30 p.m., she arrives home from the Fortunately, she credits her husband Husband, Rev. Andrew Florio office by 6 p.m. for family dinner and “who makes regular sacrifices to sup- Son, A.J. (2) time with her husband and son. After port our common goals.” Professional activities play, bath and stories, she will often Getting involved in organized medi- Vice Councilor, MSMA Young Physician spend another two or more hours fin- cine has been modeled for her by other Section; Early Career Physician, Coun- ishing notes, verifying labs and return- family members including her father, cil Representative, Missouri Chapter, ing emails. Warren Lovinger, MD, who is current- American College of Physicians; Exec- Completing work late in the eve- ly chair of the Missouri State Medical utive Committee, Saint Luke’s Medical ning is preferable to staying longer at Association Council. Her brother Group–Lee’s Summit the office. She said, “I choose to bring Thomas Lovinger, MD, is a member of Personal activities work home because missing time with the KCMS Board of Directors. Minister’s wife, Chapel Hill Presbyteri- my son in the morning and dinner “Young physicians (and society in an Church; Member, Junior League of with my family in the evening are sac- general) seem to be pulled in a mil- Kansas City, Mo. rifices I am not willing to make.” lion directions personally, and thus Nevertheless, working mother’s our generation of physicians does not Advice to aspiring leaders guilt is a challenge. “I’ve missed things seem to understand the importance “We are the future of medicine. with my son that I will never get back of involvement,” Dr. Florio said. “We Positive changes—for ourselves as in order to care for my patients. There practice in ‘the age of the employed physicians, and for our patients—will always is more to do for work, and it is physician;’ this reality has made young only occur if we have a voice. Getting hard for me to say ‘no’ when asked to physicians significantly less likely to involved in leadership is the only way be on a committee or take on addition- participate in leadership positions. It to have that voice heard”. al responsibility.” can be difficult to establish one’s voice within the complexities of a hospital system. However, for a young physi- cian who has an interest in leadership, there are opportunities available if one is willing to put in the extra time and energy.” Does maintaining balance make her a better doctor? Absolutely. She concluded, “I am happiest when I feel like I am maintaining good bal- ance. Happy doctors are good doctors. My patients appreciate that church and family are important to me. It makes them feel better about me as a physi- cian to know that there is more to me than just my job.”

kansas city medicine 45 SCOTT ROETHLE, MD

Age: 37 Scott Roethle, MD, strives to make Practice: Anesthesiologist with An- time for family alongside medical esthesia Associates of Kansas City practice while also being active in (AAKC); Director of OB Anesthesia, Fe- leadership in the medical profession. tal Health Center at Children’s Mercy In 2015, he has added membership on Hospital the Kansas City Medical Society Board Dr. Roethle credits his wife, Alana, of Directors to his activities. for allowing him to juggle his personal Years in practice: 5 “My family is most important, and professional priorities. He said, Family but they also understand that other “She is very understanding and giving, Wife, Alana; Children, Taggart (8), responsibilities might take short-term which allows me to get involved in Thatcher (6), Scarlett (4) and Eliza (2) priority and I might be gone for work leadership and advocacy activities. She Professional activities and meetings several nights a week,” he knows that some sacrifices now should Member, Kansas City Medical Society said. “Luckily I am able to spend a lot gain huge benefits in the future for us Board of Directors; AAKC Executive of time with the family, and we make and our family.” Board; AAKC Center Chief 2012-2015; intentional efforts to be involved with He also is bullish on the benefits of Secretary, Kansas Society of Anesthe- the kids.” regular exercise and was a triathlete in siologists; Kansas Delegate, American With so many changes ahead in medical school. Today he focuses on Society of Anesthesiologists medicine, it is critical for physicians to weightlifting. make their voices heard. “I just want “Exercise makes me feel better. It Personal activities to be involved in helping to maintain helps me mentally,” he said, adding, Spending time with family, exercising, and shape our specialty. If you are not “We also use exercise as a family activi- weightlifting, church, playing pok- involved, then you are going to have ty to encourage a healthy lifestyle.” er; children’s activities include bible things done to you, instead of being How does he keep everything in school, piano, swimming, Spanish; proactive and help shape it for the balance? “My biggest keys are commu- wife Alana is involved in local politics future,” he noted. nication, understanding and selfless- ness. In our family Advice for aspiring leaders we have a great team “Find a mentor, if you can, and also, mindset which works don’t dawdle. Just jump in and start well for us. We expect doing something—that is the key. It to be busy but wel- might take a while to catch on or really come relaxation as find a role that you enjoy or can make w e l l .” work.” He concluded, “It is hard to keep the scale perfectly bal- anced at all times, as certain things come up or fill the schedule, but I always remem- ber our priorities and maintain balance overall in my life.”

46 summer 2015 KORTNEE LANNING SORBIN, MD

Age: 40 The support of her family and Practice: Anesthesiologist with An- co-workers is key for Kortnee Lanning esthesia Associates of Kansas City Sorbin, MD. (AAKC) “Ideally, I would like to be every- Years in practice: 8 where I need to be … attending all the kids’ activities, doing Pilates three daughter Aubree while Dr. Sorbin was Family nights a week, having family dinners in residency. Husband, Mike; Children, Evan (20), every night, doing all my nonclini- She also praises her colleagues at Grant (16), Brady (14), and Aubree (8) cal work, having date time with my Anesthesia Associates. “I work with Professional activities husband and more,” she said. “But great, supportive people. My partners AAKC Cost Center Chief, Menorah there often are times when clinical are a lifeline at times and our nurse Medical Center; recently finished term work or on-call take away from these. anesthetists are very good at what they on executive board of AAKC; former That is why my husband and family do, which makes work much easier vice chair of the Anesthesia Depart- are so important to my success as an and less stressful. I truly am blessed.” ment at Menorah Medical Center anesthesiologist. Their support and Dr. Sorbin said she has missed her Personal activities understanding is THE KEY to making share of her boys’ sporting events, and Pilates, Legos, traveling in RV, spend- it all work.” she recalled a time she had to leave a ing time with family, learning to shoot Her husband Mike gave up his job school production when she was on a compound bow teaching and coaching baseball in the call and could not get phone service at Olathe School District to stay home the venue. Advice to aspiring leaders: with the kids. Not every husband But, Dr. Sorbin said, “I like to think “It is smart to take on executive could accept the role of having a wife of it as a lesson to (the children) to a positions in your organization. You certain extent, that you can’t get every- are going to make your workplace a as the family breadwinner, but Dr. better place to work and that is going Sorbin said Mike has embraced the thing handed to you. I really want my to make you happier. It may take a arrangement. Theirs is a blended fam- kids to grow up and be successful and little bit more time, but it’s just going ily with the two having brought three know that no job is a perfect job. It is to make your job more enjoyable. With children into the marriage. They added called ‘work’ for a reason.” the amount of time we are there, I Indeed, she has overcome several think that is very important.” challenges in her life. One was an un- planned pregnancy that left her raising her oldest son through college and medical school. She also has battled microscopic colitis, which has led her to commit to exercising regularly and maintaining a fresh, clean diet. “Healthy living helps me personally and improves how I handle things at work, even if it is a stressful day,” she said. “This in turn helps me function better as a leader.”

kansas city medicine 47 message Sponsor Health Care Specialists: Your Personal Consultants By Tom McNeill, The Keane Insurance Group, Inc.

When I meet someone new and ACCESS TO ALL INSURANCE CARRIERS covered under your policy. tell them that I’m an insurance bro- By working with an Independent An independent insurance profes- ker, they often change the subject as Insurance Agency that has access to all sional acting as a consultant will: soon as possible; that’s because people available insurance companies, physi- • Work for the client not the insurance don’t want to be sold to. Physicians cians will find a consultative approach carrier are no different when it comes to rather than a salesperson who only • Review the risks and exposures of the medical professional liability insur- wants to sell insurance. This is because practice and identify the carriers and ance. Health-care providers want and Independent Agencies employ brokers policies that cover these risks deserve a trained professional advisor who represent the client and have ac- • Solicit competitive quotes and gather who is on their side; someone who will cess to all the insurance carriers in the information on the insurance carriers guide them to the right buying deci- market. Insurance buyers need a fair • Educate the client about the differ- sion without pressuring them into a view of all the options in the market, ences between carriers and policies decision against their will. The amount and not just a “one size fits all” ap- • Let the client make the buying deci- of information at our fingertips has proach. An Independent Agency will sion changed the way physicians select guide the client through the process of • Provide proof of insurance and cop- insurance coverage, and they want to comparing coverage, policy features, ies of the policies work with someone who understands company financial strength and claims • Provide service throughout the their needs. handling. policy period and keep the client The Internet has changed the way Working with physicians on their informed and updated we all make buying decisions. Before medical professional liability needs is buying a car, new kitchen cabinets, much more than just finding the lowest COMMITMENT TO INTEGRITY AND or tickets to the theater, most people price, though saving money is always RESPECT do some research online. We used an important factor. To be effective, As one of the largest independent to live in a seller’s market where the your insurance advisor needs to think medical professional insurance agen- salesman had all the information, and outside the traditional box, and look cies in the nation, the Keane Insurance the consumer had to depend solely on for alternatives which maintain the Group works with both single physi- what information that salesman would integrity of coverage, while addressing cian practices and large groups as a share. In the last couple of decades, the needs of the ever-changing medical health-care practice consultant. Our however, with access to unlimited environment. For example, participa- commitment to our clients is to pro- information, the situation has changed tion in an accountable care organiza- vide service with the highest integrity and we now live in a buyer’s market tion or adding unique services or pro- and respect in the timeliest manner where both buyer and seller are on an vision of services in an unconventional possible. We offer creative, innovative even playing field. What this change setting may open your practice up to and cost-effective solutions for every means for physicians is that they now new and unforeseen liability risks. A physician and practice. need a consultant, an advisor, a re- part of the consultative approach is to The following are a few recent source rather than a salesman. ask discovery questions to find these success stories of how we were able to unique coverage challenges, and to help clients: make sure that these challenges are

48 summer 2015 1. A multi-physician specialty group fied at renewal time, but his current believes that focusing on one line of wanted to save money on their carrier was not admitted to Kansas coverage (in our case, medical profes- coverage. Not having a carrier that and did not want to provide coverage sional liability) and doing it extremely would offer a lower premium under for a practice largely dominated by well is more important than trying to their renewal quote from their nursing home care. On less than two be an expert in all lines. That is what existing carrier, we had to look for weeks’ notice, we found a new carri- we have done for over 20 years. As a another option. So we went to the er that would cover Kansas and the national agency we write business in underwriters at their existing carrier nursing home care and in addition, states across the nation and have the and worked with them to get the we were able to get the physician a opportunity to see liability risks and group “experience rated” instead of lower premium. trends often before they appear in book rated, which resulted in 28% Missouri and Kansas. This exposure savings over their renewal quote. Not 3. A physician decided to open a new helps us better serve physicians in the every group will qualify for expe- clinic that offers a variety of medical Midwest marketplace. rience rating or will be helped by services including some non-tra- experience rating, but some will. You ditional. The intent was to use a Tom McNeill is a health-care specialist with the Keane Insurance Group. He has over 30 years’ will not receive this option automati- number of physicians to provide the experience in the health-care industry includ- cally; your producer must be work- services, knowing that some of the ing serving in hospital and physician practice ing for you. physicians involved would be short- management, and most recently as COO of the term. We worked with the practice Missouri State Medical Association Insurance Agency. Physicians look to Tom for resources 2. A Kansas City-area physician client to design a package that provides the such as medical professional liability insurance recently moved his office to Kansas desired coverage in a cost-effective through NORCAL Mutual Insurance Compa- during the year and changed the manner that will eliminate the need ny, physician disability insurance, cyber and scope of his practice; over 80% of for expensive tail policies every time regulatory liability coverage, and HR guidance. He can be contacted at 314-966-7733, email tom. his patient visits are now in nursing a physician leaves. [email protected]. homes. These changes were identi- The Keane Insurance Group

Stress Triggers Key Molecule to Halt Transcription of Cell’s Genetic Code

Researchers at the Stowers Institute tion and gene expression is a very deli- of DNA in order to convert the genetic for Medical Research and elsewhere cate balancing act. If the machinery gets information in the DNA into a work- have uncovered new information about stalled on a gene it becomes a physical ing copy of RNA. Transcription doesn’t the role of the molecule elongin A in block to transcription. That can have a always go smoothly, and the machinery transmitting genetic code. When cells devastating effect if the gene is a tumor stutters occasionally when it gets a bit are normal and unstressed, the molecule suppressor gene or an essential survivor askew or off track. It can also stall or keeps transcription moving so that genes gene, and it can’t be transcribed until stop altogether when it hits a glitch—a are “expressed” and RNA is jotted down the machinery is removed,” says Juston section of DNA that is damaged from more quickly. When cells are stressed Weems, Ph.D., a postdoctoral research exposure to ultraviolet radiation or just and transcription runs into a glitch associate and lead author of the study. simple wear-and-tear. caused by damage to the DNA, it marks “Understanding how elongin A helps to The findings were reported in April the machinery to be disassembled. Now, disassemble the transcription machinery in the Journal of Biological Chemistry. Stowers scientists and their collabora- gives us insight into diseases like cancer Weems’ research mentors on the project tors have discovered how the molecule that can result when genes are inappro- were Joan Conaway, Ph.D. and Ronald morphs between these two alternate priately turned on or off.” Conaway, Ph.D., who have spent almost identities, one as facilitator and the other To turn a gene on, parts of the three decades studying the fundamental as destroyer. transcription machinery proceed in a mechanisms that drive transcription. “For any cell, transcriptional regula- stepwise fashion along specific sections

kansas city medicine 49 www.metromedkc.org

MARK YOUR CALENDAR GETTING 2 VALUE The Future of Physician Compensation

Tuesday, September 22, 2015 4:00 – 9:00 pm Intercontinental Hotel

Health care financing is quickly moving toward value-based care which rewards those that deliver health and wellness, and prevent illness among the population served. How can physicians prepare for these changes?

featured speakers Paul Grundy, MD, MPH, FACOEM, FACPM Founding President, Patient-Centered Primary Care Collaborative Director of Global Healthcare Transformation, IBM

Marci Nielsen, PhD, MPH Chief Executive Officer, Patient-Centered Primary Care Collaborative

No registration fee for physician members of KCMS. Watch your KCMS email for registration information.

KCMS Annual Meeting

wednesday, oct. 21, 2015 5:30 to 8:00 p.m. kauffman center for the performing arts

Watch your KCMS email for registration information