THE WWW.SANGERHEART.ORG WINTER 2010-11/VOL. 1/ISSUE 4 Patent Foramen Ovale INSIDE ... A 32-YEAR-OLD WOMAN SUDDENLY The vast majority of people with Ñ Letter from the President became aphasic while speaking on PFO will never have an associated the phone. She was fully alert and had symptom. However, not all PFOs Ñ SHVI Awards no weakness, sensory deficit or head- are benign. PFO has clearly been ache. The aphasia resolved fully within implicated in the pathogenesis of some Ñ 3D and 4D Echocardiography: 15 minutes. She has never had a similar ischemic strokes and other arterial Further Revolutionizing Cardiac episode. She had no prior history of thromboembolic events. In platypnea- Imaging migraine headache, thromboembolism, orthodeoxia, a rare syndrome, it William E. palpitations or cardiac disease. An MRI produces substantial arterial hypoxemia Downey, MD, of the brain with diffusion-weighted upon standing. More commonly, right Ñ Surgical Options for Patients FACC Who Have Lung Cancer Interventional imaging demonstrated a small acute to left atrial shunting through a PFO Cardiologist infarct in the left frontal lobe. Magnetic can potentiate hypoxemia in the setting resonance angiography of the brain and of pulmonary hypertension. Some neck was normal. A transesophageal data suggest a potential contribution NEW! FREE ONLINE CME echocardiogram showed a structurally of PFO to migraine headaches and Free CME credit is now available normal heart with the exception of a decompression illness in scuba divers. for noted presentations. Visit patent foramen ovale. How should she www.sangerheart.org and click on be managed? CRYPTOGENIC STROKE the “Charlotte AHEC Connect” logo Three-quarters of a million people to see the archived and live CME A CONGENITAL CONDITION in the United States suffer from presentations available. During fetal development, the stroke each year. Even after extensive foramen ovale is a physiologic conduit evaluation, about 16 percent remain Sanjay R. SIGN UP TO RECEIVE THE for shunting blood from the right to unexplained. Among patients with Patel, MD, SANGER REPORT VIA E-MAil FACC, FASE the left atrium, thereby bypassing cryptogenic stroke, the prevalence If you’re interested in receiving Adult pulmonary circulation. At birth, the of PFO is about 40 to 50 percent, Cardiologist shift to lower right than left atrial twice that of the general population. a copy of The Sanger Report via www.sangerheart.org pressure closes a flap valve consisting In some of these, the PFO is clearly e-mail, visit of overlapping layers of the septae contributory. In a few patients with and fill out the short sign-up form primum and secundum. In most acute stroke, echocardiography has located on our home page. Your people, these layers then fuse, creating demonstrated a large thrombus in information will not be used for a complete partition between the atria. transit across the PFO. Based on this third-party distribution. Please see However, in about one-fourth of the observation, researchers hypothesize CHS marketing privacy policy for population, this potential interatrial that many cryptogenic strokes are complete details. communication persists throughout caused by small emboli that travel life—the patent foramen ovale, or PFO. across a PFO into the left atrium and then travel to the brain. A presumption of this hypothesis “In about one-fourth of the population, is that the stroke is preceded by deep this potential interatrial communication vein thrombosis (DVT). Though most persists throughout life ...” Continued on page 6 THE LATEST NEWS AND BEST PRACTICES FROM SANGER HEART & VASCULAR INSTITUTE Innovations in SANGER HEART & VASCULAR INSTITUTE AwARDS Cardiovascular Ñ Aetna Institutes of Ñ B. Hadley Wilson, MD, Care Quality Cardiac Rhythm presented a lecture at a recent recently designated Carolinas Transcatheter Cardiovascular Medical Center (CMC) as an Therapeutics meeting entitled I CAN’T BELIEVE THIS IS THE FOURTH ISSUE OF “Institute of Quality” hospital “Enhancing Outcomes in The Sanger Report. This will conclude our first year based upon an evaluation of Acute Myocardial Infarction: of publication and complete Volume 1. This issue the clinical performance and The Systems Approach.” features three clinical articles. overall value of the facility. Dr. Wilson also co-authored Continuing our focus on adult and congenital CMC is now listed as a a paper entitled “Improved heart disease, members of our adult cardiology team, participating facility in the Late Clinical Safety with William E. Downey, MD, and Sanjay R. Patel, MD, Aetna Institutes of Quality Zotarolimus-Eluting Stents spotlight a condition known as patent foramen ovale Cardiac Rhythm online Compared with Paclitaxel- (PFO). They review the high prevalence of PFO and provider directory. Eluting Stents in Patients the potential medical complications associated with it. with De Novo Coronary They outline the current therapeutic options available Ñ Sangeev Gulati, MD, Lesions: Three Year Follow- to patients, including the risks and benefits of PFO recently presented two up from the ENDEAVOR IV closure. abstracts at the Heart Failure Trial,” which was published Geoffrey A. Rose, MD, director of Sanger Heart Society of America meeting in the Journal of the American & Vascular Institute’s (SHVI’s) Cardiac Ultrasound in San Diego: “Relationship College of Cardiology: Laboratory, details the evolution of echocardiography Between Intrathoracic Cardiovascular Interventions. from single plane M-mode to now 3D and 4D imaging. Impedence, BNP and He also details the utility of these advanced images in 6-Minute Hall Walk” and Ñ John Symanski, MD, preoperative assessment of patients and intraoperative “Timecourse of Weight and had a letter published assessment of surgical success. Intrathoracic Impedence in The American Journal Mark K. Reames Sr., MD, a member of the Changes During Volume of Cardiology entitled Department of Cardiothoracic and Vascular Surgery, Overload.” Dr. Gulati spe- “The Coronary Collier.” reviews the history of surgery for lung cancer and cializes in adult cardiology thoracoscopy. He also reviews the experience with and heart transplantation Ñ Francis Robicsek, MD, and video-assisted thoracic surgery for lung cancer, which for Sanger Heart & Vascular Michael Rinaldi, MD, has become the treatment of choice for patients with Institute (SHVI) at CMC in represented SHVI at the resectable primary lung cancer at SHVI. Charlotte. South Atlantic Cardiovascular We continue to innovate with better diagnostic Society meeting presenting tools and less-invasive and improved methods to cases related to avoidance manage both lung and heart disease. I hope you of litigation and STEMI, enjoy reading this issue of The Sanger Report. respectively. Sincerely, Ñ Congratulations to Rohit Mehta, MD, who was selected as a Fellow of the Heart Rhythm Society. Thinkstock Paul G. Colavita, MD, FACC 11 President © 20 Sanger Heart & Vascular Institute Trophy image 2 THE SANGER REPORT n WWW.SANGERHEART.ORG 3D and 4D Echocardiography: Further Revolutionizing Cardiac Imaging Geoffrey A. Rose, MD, FACC, FASE Director, Cardiac Ultrasound Laboratory SINCE ITS INTRODUCTION, THE short of revolutionary. However, the “The ability to obtain use of cardiac ultrasound (also known shortcomings inherent in using a one- as echocardiography) has consistently images with this degree dimensional modality to evaluate a 3D advanced the care for patients with of anatomic detail has object (i.e., the beating heart) were readily cardiovascular disease. In the 1950s, further transformed apparent. The cycle of innovation began. Dr. Inge Edler recognized that high assessment of patients Two-dimensional echo was the result frequency sound waves—at the with mitral valve disease.” of those innovative efforts. Figure 2 time a new technology harnessed to demonstrates an example of MVP using identify structural defects in the steel 2D echo; this is the same patient as of ships—could be applied to study in Figure 1. In the 2D image, cardiac cardiac motion in real time. From A CHANGING TECHNOLOGY structure is represented in a manner more this key insight, a cycle of technical Displaying a single ultrasound scan- intuitive than its M-mode counterpart. and clinical innovation emerged. As line over time created the first echo The image is easier for the clinician to newer imaging data were integrated images. This was known as M-mode comprehend, thus leading to greater into clinical decision-making, these imaging (with “M” signifying motion), and understanding of the nature of the now more complicated decision it provided the first noninvasive means underlying disorder. In the case of MVP, pathways spurred development of more to identify MVP (see Figure 1) as well as such insights from 2D imaging led to pio- sophisticated imaging techniques. The many other cardiac conditions. Although neering efforts to repair damaged valves, incremental information thus gained in quite simple by today’s standards, rather than replacing such valves with a turn served to further advance those M-mode echo nevertheless represented prosthesis. This noninvasive technology clinical care algorithms. This concept a true breakthrough. It became possible enabled clinicians to obtain information can be illustrated by reviewing how to validate and quantify those clinical about a patient’s heart without use of mitral valve prolapse (MVP), a common impressions formulated from the history radiation and at the bedside, which cardiac condition, has been approached