Spring 2012 - TriStar Health

Spring 2012 

Volume 3, Number 1 

INSIDE THIS ISSUE 

01 Revolutionizing Heart Care: 

TriStar Centennial Heart & 

Vascular Center 

TriStar Heart Journal Editorial Staff 

01 When Is It Best to Refer At-risk 

Asymptomatic Patients? 

Tracy Q. Callister, MD 

02 From the Editor: Here We Grow 

Steven V. Manoukian, MD 

03 Heart Watch 


05 ICDs: Preventing, 

Not Just Managing Events 

Christopher N. Conley, MD 

07 Structurally Speaking: 

TAVR: A New Wave in Heart Care 

John A. Riddick, MD 

08 Evidence Builds for 

Community-based PCI 

Maxwell A. Prempeh, MD 

09 SCRI CV Research Update: 

Savvy Performance of PCI 

Steven V. Manoukian, MD 

11 The Final Word: 

Road[map] to the Heart 

R. Christopher Jones, MD 

12 Fifth Annual TriStar CV 

Symposium, April 21 

Revolutionizing Heart Care: 

TriStar Centennial Heart & Vascular Center 


TriStar Centennial Medical Center in Nashville, Tenn., celebrated its ribbon-cutting ceremony on Feb. 

14, unveiling the newly completed TriStar Centennial Heart & Vascular Center. The 200,000 squarefoot 

center, which includes a 2,000-square-foot family waiting area, hybrid and cardiovascular operating 

rooms and cardiac catheterization, electrophysiology and endovascular labs, all with streaming 

video integration for real-time consultation and education, officially opened its doors in March. 

“I’m so pleased that the vision of TriStar Centennial Heart & Vascular Center has become a reality, 

bringing one of the most advanced heart facilities in the region to Middle Tennessee residents,” said 

Stephen E. Corbeil, president of TriStar Health. 

Continued on page 06 

When Is It Best to Refer At-risk Asymptomatic Patients? 

Tracy Q. Callister, MD, TriStar Hendersonville Medical Center ∣ tracycallister@comcast.net 

Tracy Q. Callister, MD 

An asymptomatic patient who is potentially at risk for myocardial infarction (MI) typically does not present to their physician, 

even if they aware of certain risk factors. However, more widespread education is necessary to inform the public about specific 

risk factors to ensure that the benefits of appropriate screening reach a greater portion of the population. 

For instance, not everyone is aware that heart disease is the number one killer in the U.S., affecting approximately 60 percent 

of Americans. Many patients with acute MI have very little warning prior to their event, or even suffer sudden cardiac death without 

antecedent symptoms. This is counterintuitive to the understanding applied to other deadly diseases, such as cancer, where 


Spring 2012 01

From the Editor 

Here We Grow 

Steven V. Manoukian, MD, Medical Director, Cardiovascular Services, Hospital Corporation of America ∣ steven.manoukian@hcahealthcare.com 

Editor-in-Chief 

Steven V. Manoukian, MD, 

Hospital Corporation of 

America 

EDITORIAL BOARD 

Cardiac Imaging 

David C. Huneycutt, Jr., MD 

TriStar Centennial Medical 

Center, Nashville, Tenn. 

david.huneycutt@ 

hcahealthcare.com 

Cardiothoracic Surgery 

Davis C. Drinkwater, Jr., MD 



davis@ddrinkwater.com 

Electrophysiology 

Gregory G. Bashian, MD 



gregory.bashian@ 


General Cardiology 

David E. Chambers, MD 

TriStar Horizon Medical Center 

Dickson, Tenn. 

dchambers@dicksonmd.com 

Structural Heart 




john.riddick@ 


CONTACT US 

TriStar Heart Journal 

Editorial Staff 

110 Winners Circle 

Brentwood, TN 37027 

thj@hcahealthcare.com 

cardiac.tristarhealth.com 

(800) 242-5662 

Welcome to Volume 3 of the TriStar Heart Journal! It is hard to believe that three years have passed 

since its inception. During that time, we have expanded from eight to 12 pages, and our editorial board 

has grown from one to six experts, now encompassing much of the cardiovascular spectrum. 

This issue, we are pleased to welcome Dr. John A. Riddick to THJ’s editorial board as structural heart 

editor. Dr. Riddick completed his general and interventional cardiology fellowships at Emory University 

School of Medicine in Atlanta. An accomplished interventional cardiologist with particular expertise in 

structural heart disease, he will be leading the transcatheter aortic valve replacement (TAVR) program 

at the TriStar Centennial Heart & Vascular Center. Consequently, his regular commentary on TAVR 

and other rapidly-developing areas of structural heart disease will be particularly informative, as is 

evidenced by his prior THJ contributions. 

In the last three years, THJ also has added other regular columns such as View From Afar, which features 

cardiovascular experts from beyond TriStar’s boundaries and Heart Watch, which succinctly reports and 

comments on timely cardiovascular publications and presentations from major scientific meetings. 

Growth also has occurred beyond THJ, with the naming of TriStar Health’s new president, Stephen E. 

Corbeil, an experienced healthcare executive who is firmly committed to the provision of high-quality 

healthcare. Paul Rutledge, president of the Hospital Corporation of America’s Central Group described 

Mr. Corbeil as an “outstanding multi-hospital leader with a proven track record.” Also, as we report 

in our Facility Spotlight cover story, the TriStar Centennial Heart & Vascular Center recently opened, 

following a ribbon cutting ceremony, 

which [appropriately] occurred on 

Valentine’s Day. This new center 

will allow top-notch clinicians 

to utilize state-of-the-art 

technology to enhance the 

already high level of patient 

care they provide for years 

to come. 

Lastly, SCRI’s 

cardiovascular research 

program also continues 

unprecedented growth, not 

only in its size and scope at 

TriStar Centennial and TriStar 

Redmond Regional Medical 

Centers, but beyond TriStar at its four additional research centers in 

Virginia and Florida, and two additional anticipated centers in Georgia 

and California. 

Although this unparalleled growth within TriStar Health and SCRI will 

no doubt continue, THJ’s vision always will remain the same, to provide the 

highest-quality, evidence-based cardiovascular literature to providers, in 

order to facilitate the enhancement of patient care. 

For author inquiries, contact steven.manoukian@hcahealthcare.com 

02 TriStar Heart Journal

Heart Watch 

AHA: Is triple therapy possible for post-PCI ACS patients? 

The lower of the two doses of the oral anticoagulant rivaroxaban 

(Xarelto, Bayer/Johnson & Johnson) evaluated in ATLAS ACS 2-TIMI 

51 showed promise, with a reduction in overall and cardiovascular 

(CV) mortality compared with placebo, despite an increased risk of 

bleeding and intracranial hemorrhage (ICH). The trial was presented 

at the 2011 American Heart Association (AHA) scientific sessions 

in Orlando, Fla. 

In this double-blind, placebo-controlled trial, Gibson et al. randomly 

assigned 15,526 patients with a recent acute coronary syndrome 

(ACS) to receive twice-daily doses of either 2.5 mg or 5 mg of 

rivaroxaban or placebo for a mean of 13 months and up to 31 months. 

Rivaroxaban significantly reduced the primary efficacy endpoint—a 

composite of death from CV causes, myocardial infarction 

or stroke—compared with placebo, with respective rates of 8.9% 

and 10.7%, and significant improvement for both the twice-daily 

2.5 mg dose (9.1% vs. 10.7%) and the twice-daily 5 mg dose (8.8% 

vs. 10.7%). The twice-daily 2.5 mg dose of rivaroxaban reduced the 

rates of death from CV causes (2.7% vs. 4.1%) and from any cause 

(2.9% vs. 4.5%), a survival benefit that was not seen with the twicedaily 

5 mg dose. Compared with placebo, rivaroxaban significantly 

increased the rates of major bleeding not related to coronary artery 

bypass grafting (2.1% vs. 0.6%) and ICH (0.6% vs. 0.2%), but 

not a significant increase in fatal bleeding (0.3% vs. 0.2%) or other 

adverse events. The twice-daily 2.5 mg dose resulted in fewer fatal 

bleeding events than the twice-daily 5 mg dose (0.1% vs. 0.4%). 

›› 

Commentary: “This trial is a provocative look at the addition of an 

oral factor Xa inhibitor to dual anti-platelet therapy in post-PCI ACS 

patients. While the efficacy is positive in reduction of the primary 

endpoint of CV death, MI or stroke, this came at the expense of increased 

intracranial and major bleeding.” ~ Gregory G. Bashian, MD 

TCT: Two-year mortality benefits hold strong for TAVR 

At two years, in patients with symptomatic severe aortic stenosis 

who are not suitable candidates for surgery, transcatheter aortic 

valve replacement (TAVR) remained superior to standard therapy 

with incremental benefit from one to one years, reducing the rates 

of all-cause mortality, CV mortality and repeat hospitalization, 

based on the PARTNER B data presented at the 2011 Transcatheter 

Cardiovascular Therapeutics (TCT) meeting in San Francisco. However, 

there were more neurologic events in the TAVR arm. 

Cohort B of the PARTNER trial, which included patients with severe 

aortic stenosis who were not candidates for surgery, randomized 

358 patients to transfemoral TAVR with an early generation 

balloon-expandable valve (Sapien, Edwards Lifesciences) or standard 

therapy (including balloon valvuloplasty) at 21 centers. 

Compared with standard therapy at two years, TAVR showed 

significant reduction in the rates of all-cause mortality (18.2% vs. 

35.1%), CV mortality (13.2% vs. 32.1%) and repeat hospitalization 

(35% vs. 72.5 %). 

Overall, there were significantly more neurologic events in TAVR 

patients compared to standard therapy (16.2% vs. 5.5%) with five 

new events (three strokes and two transient ischemia attacks) between 

one to two years in TAVR patients. 

›› 

Commentary: “In appropriate hands, TAVR offers a clear advantage 

for aortic stenosis patients who are inoperable or high-risk surgical 

candidates. As technology and experience mature, neurologic 

complications will decline, the procedure will become appropriate 

for a broader population and surgical aortic valve replacement will 

be obviated in the majority of patients. ~ Steven V. Manoukian, MD 

Hospitalization Through Two Years 

TAVI 

Standard Therapy 

Repeat Hospitalizations (No.) 78 151 

Repeat Hospitalizations (%) 35.0% 72.5% 

Days Alive Out of Hospital (Median) 699 355 

Source: 2011 Transcatheter Cardiovascular Therapeutics (TCT) conference. 

AHA: High-dose Lipitor, Crestor both shine in SATURN 

Both rosuvastatin (Crestor, AstraZeneca) and atorvastin (Lipitor, 

Pfizer) at maximum dose lowered LDL cholesterol levels, raised 

HDL levels and reduced atherosclerotic plaque in the SATURN trial, 

presented at the 2011 AHA scientific sessions. While the Phase II 

trial failed to find any significant difference between the two drugs 

to limit or reverse coronary artery disease (CAD) progression, it 

showed that a high-dose regime is safe and well tolerated. 

Nicholls et al. enrolled 1,385 patients with symptomatic CAD and an 

angiographically confirmed coronary stenosis of greater than 20% 

and LDL cholesterol levels of more than 80 mg/dl or, if untreated with 

a statin in the preceding four weeks, LDL cholesterol levels of more 

than 100 mg/dl. Patients were randomized to either a rosuvastatin 

group (694 patients, 40 mg dose daily) or an atorvastatin group 

(691 patients, 80 mg daily dose). An analysis of baseline cholesterol 

levels gave the edge to rosuvastatin over atorvastatin for LDL (62.6 

mg/dl vs. 70.2 mg/dl), and for HDL (50.4 mg/dl vs. 48.6 mg/dl). 

The percent of atheroma volume (PAV) decreased by 0.99% with 

atorvastatin and by 1.22% with rosuvastatin. The researchers 

found a statistically significant difference in total atheroma 

volume findings, with rosuvastatin at -6.39 mm 3 compared with 

atorvastatin at -4.42 mm 3 . 

›› 

Commentary: “Data are now mounting that high-potency statin 

therapy can lead to a reduction in atheroma volume. With a multitude 

of clinical trials showing positive effects on hard endpoints, this elegant 

study further underscores the importance of statins in the management 

of coronary artery disease.” ~ David C. Huneycutt, Jr., MD • 


When Is It Best to Refer At-risk Asymptomatic Patients? (cont’d) 

Coronary Death or Nonfatal MI 

20% 

16% 

12% 

8% 

4% 

0% 

Continued from page 01 

Predicted 7-year event rates from COX 

regression model for coronary heart 

disease, death or nonfatal MI for categories 

of FRS or CACS 

Pairwise analyses compared the highest CACS level (>300) 

with each of the lower levels of CACS within each FRS 

group. Analysis of variance with pairwise comparisons 

revealed a statistically significant difference between a 

CACS of >300 and each of the other three 

CACS groups for an FRS of >10% and 

between a CACS of >300 and a CACS of 

zero for an FRS of

ICDs: 

Christopher N. Conley, MD, TriStar Skyline Medical Center | christopher.conley@hcahealthcare.com 

Preventing, Not Just 

Managing, Events 

Sudden cardiac arrest is a major cause of death in the U.S. Annually, more than 

300,000 U.S. patients (about one patient every two minutes) suffer cardiac 

arrest and most (approximately 95% of out-of-hospital events) will succumb to 

this disease state. 

Sudden cardiac arrest (SCA) is defined 

as the onset of cardiovascular 

collapse within an hour of symptoms. 

Although these events are often the 

Christopher N. Conley, MD manifestation of acute myocardial infarction 

(MI), they may be the result of 

chronic conditions, particularly congestive heart failure (CHF) with 

associated impaired systolic function and ejection fraction, frequently 

as a consequence of prior MI(s). 

Mortality Rate 

0.4 

0.3 

0.2 

0.1 

0.0 

Additional conditions predisposing patients 

to cardiac arrest are genetic afflictions, 

such as the Brugada and long QT 

syndromes and hypertrophic cardiomyopathy, 

among others. 

In years past, the use of implantable 

cardioverter-defibrillators (ICDs) for the 

detection and treatment of SCA was 

limited to patients who were fortunate 

enough to have survived an initial event, 

(secondary prevention of sudden cardiac 

death [SCD]). However, most patients 

with an initial out-of-hospital event either 

do not survive and/or suffer significant 

neurologic impairment. 

Recent clinical practice strategies, 

based upon newer data, have focused on 

primary prevention of SCA; that is, identifying 

and targeting high-risk patients 

for ICD implantation prior to the occurrence 

of an event. 

The MADIT study 1 , published in 1996, 

is oft-cited as a turning point in this approach. 

Patients with prior MI and significantly 

reduced systolic function were 

randomized to ICD or no ICD, with an electrophysiologic 

study performed in each. In 

patients randomized to ICD implantation, 

a survival benefit was demonstrated. This 

was followed by other research, including 

the pivotal MADIT II study 2 , which again showed a survival benefit 

for ICDs in patients with coronary artery disease, prior MI and systolic 

heart failure, with no qualifying electrophysiologic study performed. 

Additional research has validated the benefit of ICDs versus medical 

therapy (with or without amiodarone) in systolic heart failure 

patients with or without coronary artery disease or in ischemic and 

non-ischemic patients (SCD-HeFT 3 ). 


Kaplan-Meier Estimates of Death from Any Cause 

Hazard Ratio (97.5% CI) P Value 

Amiodarone vs. Placedo 1.06 (0.86-1.30) 0.53 

ICD Therapy vs. Placebo 0.77 (0.62-0.96) 0.007 

Amiodarone 

(240 deaths; 5-yr rate, 0.340) 

0 12 24 36 48 60 

Months of Follow-up 

Placebo 

(244 deaths; 5-yr rate, 0.361) 

ICD Therapy 

(182 deaths; 5-yr rate, 0.289) 

No. at Risk 

Amiodarone 845 772 715 484 280 97 

Placebo 847 797 724 505 304 89 

ICD Therapy 829 778 733 501 304 103 

Bardy GH et al. N Engl J Med 2005;352:225-237. 


Revolutionizing Heart Care: TriStar Centennial Heart & Vascular Center (cont’d) 


“We are excited to offer Middle Tennessee communities access 

to the region’s most advanced heart care program led by a team of 

renowned heart and vascular specialists,” Thomas Herron, CEO of 

TriStar Centennial Medical Center, concurred. 

There are approximately 30-40 cardiologists, including 15 interventional 

cardiologists and five cardiothoracic surgeons. 

“TriStar Centennial’s new Heart & Vascular Center is a state-ofthe-art 

facility spanning the entire cardiovascular spectrum,” added 

Steven V. Manoukian, MD, medical director of cardiovascular 

services at Hospital Corporation of America (HCA), TriStar Centennial’s 

parent organization. “This new facility will move TriStar 

Centennial to the next level, by coupling the latest technology with 

well-trained, experienced providers in order to facilitate the highest 

quality of care, both from the patient outcomes and the patient 

satisfaction perspectives.” 

“Our vision was to create a heart and vascular center developed 

with our patients in mind,” Herron added. “This new facility, combined 

with the network of physicians at our TriStar family of hospitals, 

will greatly expand the quality and trusted care for our current 

and potential patients for decades to come.” 

While the cardiovascular services provided at TriStar Centennial 

Medical have grown over the past few years, these services were being 

delivered across the entire campus. “Our biggest desire in bringing 

all those imaging, surgical and cath lab procedures under one 

By the Numbers: Facility Fact Sheet 

✓ 32 Coronary Care Unit (CCU) 

Patient Rooms (16 of the rooms 

are new) 

✓ 28 Private Prep/Post Care 

(Recovery) Rooms (8 for 

overnight stay) 

✓ 6 PACU (Post Anesthesia Care 

Unit) beds 

✓ 16 New Cardiovascular 

Intensive Care Unit (CVICU) 

beds- directly adjacent to 

CVOR’s 

✓ 7 Procedure Rooms 

✓ 2 Electrophysiology Labs 

✓ 4 Catheterization Labs 

✓ 1 Endovascular Lab 

✓ 6 Open Prep/ PACU Bays 

✓ 4 Cardiovascular Operating 

Room (CVOR’s) with streaming 

video for consultation and 

education 

✓ 4 Echocardiogram Rooms 

(Two Stress Echo Rooms 

and Two Transthoracic Echo 

Rooms), Pulmonary Function 

Lab, Nuclear Cardiology Lab, 

Cardio-Pulmonary Exercise Lab 

and EKG Area 

✓ 3 Patient Holding Bays in Non- 

Invasive Cardiology 

✓ 3 Transesophageal 

Echocardiography (TEE) Rooms 

✓ 2 Private Family Waiting 

Rooms 

✓ 1 Hybrid Operating Room 

✓ 1 Central Pharmacy (new) 

✓ 1 Large Classroom & 2 

Education Classrooms 

✓ 2,000 square-foot Family 

Waiting Area with coffee 

bar and library, computers, 

televisions, two private consult 

rooms and patient tracker board 

roof is to deliver a more-integrated, uniform 

approach across the patient care 

continuum,” said James Drumwright, 

chief operating officer of the TriStar Centennial 

Heart & Vascular Center. 

In addition, the new hybrid operating 

room, along with multiple new technologies, 

will allow the facility to provide 

unique services to the Nashville region, 

such as transcatheter aortic valve replacement 

(TAVR), as well as endograft 

and peripheral procedures, which Centennial 

could not previously offer. 

TAVR is a recently approved procedure 

in the U.S. for patients with inoperable 

aortic stenosis, who previously 

had no other treatment option. However, 

the U.S. Food and Drug Administration 

and the Centers for Medicare & 

Medicaid Services have proposed stipulations 

about having appropriate equipment 

in the hybrid operating room and a 

designated heart team to ensure collaborative 

decision-making, such as the one 

designed at the new facility. 

“We are going to be a TAVR center, which will be one of the four 

functions of the hybrid operating room,” said Christopher Jones, 

MD, chair of cardiovascular medicine at the TriStar Centennial 

Heart & Vascular Center. The four disease states that the hybrid operating 

room will care for will be coronary artery disease, valvular 

disease, atrial fibrillation and vascular disease. 

Having all the cardiac surgeons, interventional cardiologists, cardiologists, 

cardiac nurses and medical professionals in one location 

allows for the entire cardiac team to execute on protocols in a unified, 

timely fashion. For example, if it is determined that a patient 

being treated in the catheterization lab requires surgery, there will 

be a new approach. “Previously, in this case, the interventionalists 

and the surgeons were located in different areas of the campus, so 

the procedure would need to stopped, the patient would be sent 

home with instructions to follow up with a surgeon on a different 

day,” said Drumwright. “Now, the surgeons are located next door to 

the cath lab, and can be called in to consult while the patient is still 

on the cath lab table.” This close proximity allows for more timely 

decision making, while enhancing the convenience of the patient. 

Also, greater collaboration between the various cardiac specialists 

only serves to propel the quality of patient care. 

At the TriStar Centennial Heart & Vascular Center, there are three 

dedicated areas of connectivity: cardiac specialists are all immediately 

accessible to one another; physicians and patients outside of 


Structurally Speaking 

TAVR: A New Wave in 

Heart Care 

John A. Riddick, MD, TriStar Centennial Medical Center 

john.riddick@hcahealthcare.com 

TriStar Centennial can obtain real-time support from the heart experts 

at TriStar Centennial; and finally, there are large areas of the 

facility, as well as specific policies, established for enhanced communication 

between physicians, patients and their families. 

Also, the physicians at TriStar Centennial Heart & Vascular Center 

can use handheld devices to access medical records or monitor 

cardiac and other vital signs of patients. However, to achieve true 

technological interoperability between facilities, Jones pointed out 

that Centennial benefits from is its affiliation with HCA. “In the near 

future, true electronic connectivity will be possible, so that patients 

at smaller facilities can receive real-time support from larger, more 

advanced centers,” he said. “Electronic connectivity is a key component 

to providing high-quality care—not only at TriStar Centennial—but 

throughout the U.S.” 

“Combined with the network of physicians at our family of hospitals, 

this new facility will greatly expand the quality and compassionate 

care that patients have come to know and trust from TriStar 

Centennial,” Corbeil said. “ Without a doubt, our commitment 

to quality patient outcomes and providing an unparalleled patient 

experience will make a difference in thousands of lives each year.” • 

On the Cover: Thomas Herron, CEO, TriStar Centennial Medical Center, (left-center) 

and Thomas A. McRae, III, MD, representing the multi-specialty team of TriStar 

Centennial Heart & Vascular Center heart care specialists, prepare to mark the facility 

grand opening with a ceremonial ribbon cutting Feb. 14. 

Above: Hybrid operating room at TriStar Centennial Heart & Vascular Center 

Aortic stenosis (AS) affects more than 

4% of the North American population 

age 75 years and older 1 and is associated 

with high mortality in untreated patients 

(approximately 50% in the first 

two years after symptom onset) 2 . Typical 

findings include a systolic murmur in 

the aortic area radiating into the neck, 

often associated with a delayed and/or 

diminished carotid pulse. Echocardiography 

confirms the diagnosis. 


Medical therapy is largely ineffective, 

due to mechanical obstruction of the aortic valve. Surgical aortic 

valve replacement (AVR) in appropriate settings is a Class I indication, 

although 30 to more than 40 percent of patients may be 

deemed inoperable, due to factors such as advanced age, comorbidities 

and poor heart function. 

In order to provide an option for inoperable patients with severe 

symptomatic AS, minimally invasive transcatheter aortic valve replacement 

(TAVR) became available in Europe in 2007 and was recently 

approved by the FDA in November 2011. TAVR is performed 

via the transfemoral (percutaneous) or transapical (minimally invasive 

surgical incision) approach. Randomized controlled trials in the 

U.S., including PARTNER A 3 , also have assessed the technology for a 

broader population of high-risk patients who are candidates for surgical 

AVR. In this trial, all-cause mortality was numerically lower for 

TAVR vs. surgical AVR (3.4% vs. 6.5% at 30 days and 24.2% vs. 26.8% 

at one year). Over time, it is anticipated that TAVR operators will become 

more proficient, devices will become more refined, outcomes 

will improve further and TAVR will be seen as a less-invasive alternative 

to surgical AVR. 

The TAVR program at TriStar Centennial Heart & Vascular Center 

features a state-of-the-art hybrid operating suite coupled with experienced 

and collaborative interventional cardiology and surgical 

teams. Patients referred for evaluation are first assessed to determine 

if aortic valve intervention is indicated and second to determine 

the best means to achieve a high-quality outcome. 

REFERENCES: 

1. Nkomo VT, Gardin JM, Skelton TN, et al. “Burden of Valvular Heart Diseases: A 

Population-based Study.” Lancet 2006;368:1005-1011. 

2. Bonow RO, Carabello BA, Chatterjee K, et al. “2008 Focused update incorporated 

into the ACC/AHA 2006 Guidelines for the Management of Patients with valvular 

heart disease.” Circulation 2008;118:e523-e661 

3. Smith CR, Leon MB, Mack MJ, et al. “Transcatheter versus Surgical Aortic-Valve 

Replacement in High-Risk Patients.” N Engl J Med 2011;364:2187-2219. 

For more information or to refer a patient, please contact: 

Emily Y. Bradley RN, ANP-BC, TAVR Coordinator, TriStar Centennial Heart 

and Vascular Center, (615) 515-1915, Emily.Bradley2@hcahealthcare.com 


Evidence Builds for Community-based PCI 

Maxwell A. Prempeh, MD, TriStar Cartersville Medical Center ∣ maxwell.prempeh@harbinclinic.com 

More than one million percutaneous coronary interventions (PCIs) are performed 

annually in the U.S., the majority of which are not emergent. For many years, 

the cardiovascular societies recommended that the procedure not be performed 

in institutions that did not offer back-up coronary artery bypass graft surgery 

(CABG) capabilities, in case of complications. This limited patient access to PCI in 

many communities. 

However, as success rates for PCI have 

Maxwell A. Prempeh, MD continued to climb and the need of 

emergency CABG has declined, the 

most recent American College of Cardiology/American Heart Association/Society 

for Cardiac Angiography and Interventions (ACC/ 

AHA/SCAI) guidelines, issued in November 2011, rectified that recommendation. 

The document reads that elective PCI might be considered 

in hospitals without on-site cardiac surgery, 

provided that appropriate planning for program development 

has been accomplished and rigorous clinical 

and angiographic criteria are used for proper patient 

selection 1 . This is now a Class IIb indication. 

Previously, multiple single-center studies have 

shown that there is no increase in complications if 

PCI is conducted without surgical backup. Adding to 

this evidence, the C-PORT E trial was presented as a 

late-breaking clinical trial at last year’s AHA scientific 

sessions 2 . C-PORT E, involving 60 centers and more 

than 18,000 PCI patients, compared the six-week and 

nine-month outcomes of non-primary PCI performed 

at hospitals with and without onsite cardiac surgery. 

The six-week mortality and the rate of emergency 

CABG were no different when PCI was performed at 

hospitals with or without onsite cardiac surgery. 

During the above AHA sessions, Thomas R. Aversano, 

MD, the lead investigator of the C-PORT E trial, said that he 

and his colleagues “do not support the spread of angioplasty to every 

hospital in the United States. However, it can be burdensome 

and costly for all medical centers to have cardiac surgery capabilities. 

And it doesn’t make sense to create more surgical programs 

just to support the angioplasty programs.” He added that in the 

1980s, the need for cardiac surgery was high, with 5 to 7 percent of 

PCI cases requiring CABG, but now the rate is closer to “one in 500 

or one in 1,000. It’s very uncommon.” 

As Dr. Aversano suggested, transferring patients who require interventional 

procedures to other facilities can add time, anxiety and 

costs for patients and their families, which can be alleviated by providing 

the services locally. Particularly with acute myocardial infarction, 

time is of the essence, as each minute of delay to the interventional 

procedure can cause muscle death—and even patient death. 

Many community hospitals throughout the U.S. are currently 

choosing to transfer PCI patients, and even if they devise a process 

to expedite the transfer, it can still result damage to the heart muscle. 

At TriStar Cartersville Medical Center, we recently began a program 

to treat our burgeoning local population that delivers PCI care 

Outcomes from C-PORT E Trial 

No Surgical 

Back-up 

With Surgical 

Back-up 

Patients 13,995 4,523 

P Value 

% male 63.9 63.2 0.36 

Age (mean) 63.9 64 0.40 

Left anterior descending (%) 46.2 45.4 0.35 

Right coronary artery (%) 38.7 39.4 0.43 

Left circumflex artery (%) 33 33.4 0.69 

Bypass graft (%) 4.93 4.89 0.90 

Mortality at six weeks (%) 0.91 0.93 0.93 

Emergent CABG (%) 0.14 0.22 0.26 

Source: American Heart Association 

for heart attack patients in a timely fashion. Prior to this program, 

patients were transferred to centers such as TriStar Redmond Regional 

Medical Center in Rome, Ga., nearly 30 miles away. 

As is the trend nationally, bolstered by data from organizational 

guidelines and the C-PORT E trial, our provision of communitybased 

PCI services should result in improved cardiac outcomes for 

the people of Cartersville, Ga., and surrounding communities. • 

REFERENCES: 

1. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, et al. “2011 ACCF/AHA/SCAI 

Guideline for Percutaneous Coronary Intervention: Executive Summary.” Circulation 

2011;124:2574-2609. 

2. Aversano TR, et al. “Randomized Comparison Angioplasty Outcomes at Hospitals 

With and Without on-Site Cardiac Surgery.” 2011 American Heart Association (AHA) 

scientific sessions. 


SCRI CV Research Update 

Savvy Performance of PCI 

Steven V. Manoukian, MD, Director of Cardiovascular Research, Sarah Cannon Research Institute (SCRI) ∣ steven.manoukian@scresearch.net 

Potent anticoagulation with intravenous 

antiplatelet and antithrombin medications 

is a cornerstone of the management of patients 

undergoing percutaneous coronary 

intervention (PCI) for acute coronary syndromes 

(ACS, including unstable angina 

and non-ST-elevation myocardial infarction 

[NSTEMI]) and those undergoing primary 

PCI for ST-elevation myocardial infarction 

(STEMI). 

Furthermore, anticoagulation is universally 

utilized during elective PCI. Commonly 

used intravenous antiplatelet agents include 

Current SCRI Cardiovascular Research 

TRIAL 

AAF 

ATOMIC 

AVOID 

Description 

EP lead follow-up 

Omecamtiv mecarbil in acute heart failure 

Aquapherisis vs. SOC in heart failure 

the glycoprotein IIb/IIIa inhibitors (GPIs): abciximab 

(ReoPro, Eli Lilly), eptifibatide (Integrilin, 

Merck) and tirofiban (Aggrastat, 

Medicure Pharma). In the most recent 2011 

ACCF/AHA Unstable Angina/NSTEMI 1 and 

2011 ACCF/AHA/SCAI Guideline for PCI 2 , all 

three of these agents are included and are 

given generally similar recommendations 

(Figure). GPIs are generally used in combination 

with an intravenous antithrombin, 

most commonly one of the indirect thrombin 

inhibitors (unfractionated heparin or a 

low-molecular weight heparin [enoxaparin]) 

BOSS NaHCO3 to prevent CIN with any arterial contrast + GFR

Savvy Performance of PCI (cont’d) 

Source: J Am Coll Cardiol 2011;58:44-122 

Intravenous Antiplatelet 

Therapy: SIHD 

I IIa IIb III In patients undergoing elective 

PCI treated with UFH and not 

B pretreated with clopidogrel it 

is reasonable to administer a 

GP IIb/IIIa inhibitor (abciximab, double-bolus 

eptifibatide, or high bolus dose tirofiban). 

I IIa IIb III In patients undergoing elective 

PCI with stent implantation 

B treated with UFH and adequately 

pretreated with clopidogrel it 

might be reasonable to administer a GP IIb/IIIa 

inhibitor (abciximab, double-bolus eptifibatide, 

or high bolus dose tirofiban). 

Continued from previous page. 

with lower rates of bleeding in an effort 

to maximize their risk/benefit ratio. Although 

this has led to a rapid rise in the use 

of bivalirudin monotherapy, due to its low 

bleeding risk, there are potential concerns 

that this approach may be associated with 

reduced efficacy. Consequently, exploration 

into optimal regimens of GPI use, particularly 

the use of an infusion of shortened 

duration, is one theoretical approach to attenuating 

bleeding risk while maintaining 

antithrombotic benefit 3 . 

In an effort to define the ideal duration 

of GPI therapy during elective or ACS-associated 

PCI, several SCRI sites are conducting 

the Shortened Aggrastat vs. Integrilin 

PCI (SAVI-PCI) trial. The trial will assess the 

efficacy and safety of tirofiban, administered 

as a high-dose bolus plus a shortened 

(one to two hour) infusion compared with a 

standard (18 hour) regimen of eptifibatide 

in approximately 600 patients undergoing 

elective or ACS-related PCI. It is anticipated 

that the shortened regimen will be associated 

with similar rates of ischemic events 

as eptifibatide (non-inferiority for efficacy) 

and reduced rates of bleeding (superiority 

for safety). Furthermore, this clinical 

use of this regimen will likely be associated 

with lower direct and indirect costs and 

a shorter length of hospital stay. Start-up is 

expected in the third quarter of 2012. 

SAVI-PCI will be the first, multicenter, 

industry-sponsored cardiovascular trial 

where SCRI will be involved at the scientific 

leadership level, serving as overall principal 

investigator and study chair. The trial is one 

of a broad spectrum of trials being conducted 

at SCRI’s six U.S. research sites. The network 

includes TriStar Centennial Medical 

Center in Nashville, Tenn., TriStar Redmond 

Regional in Rome, Ga., Osceola Regional in 

Kissimmee, Fla., Northside Hospital in St. 

Petersburg, Fla., and CJW and Henrico Doctors 

Hospitals in Richmond, Va. • 

For more information on SCRI’s 

cardiovascular research trials, visit: 

www.sarahcannonresearch.com/ourresearch/cardiovascular. 

To refer a patient 

or be added to our email list, contact us 

directly at (615) 329-7274 

or cvresearch@scresearch.net. 

REFERENCES 

1. Scott Wright R, Andersen JL, Adams CD, et al. “2011 

ACCF/AHA Focused Update of the Guidelines for 

the Management of Patients With Unstable Angina/ 

NSTEMI (Updating the 2007 Guideline)” J Am Coll 

Cardiol 2011;57:1920-1959. 

2. Levine GN, Bates ER, Blankenship, JC, et al. “2011 

ACCF/AHA/SCAI Guideline for PCI.” J Am Coll Cardiol 

2011;58:44-122. 

3. Manoukian SV, Feit F, Mehran R, et al. “Impact 

of major bleeding on 30-day mortality and 

clinical outcomes in patients with acute coronary 

syndromes: an analysis from the ACUITY Trial.” J Am 

Coll Cardiol 2007;49:1362-1368. 

4. Hanna EB, Rao SV, Manoukian SV, et al. “The 

evolving role of glycoprotein IIb/IIIa inhibitors in the 

setting of PCI strategies to minimize bleeding risk 

and optimize outcomes.” JACC Cardiovasc Interv 

2010;3:1209-1219. 

ICDs: Preventing, Not Just Managing, Events (cont’d) 


Therefore, ICDs are now the standard of care in primary and 

secondary prevention of SCD. A number of options exist when selecting 

a device, depending on clinical characteristics and patient 

needs. Beyond its defibrillator functionality, ICDs serve as pacemakers 

in a variety of modes. Defibrillators provide diagnostic tools 

to the clinician, including documentation of the burden of atrial and 

ventricular arrhythmias. In additional, these diagnostics assist in 

the treatment of previously undiagnosed arrhythmias, such as atrial 

fibrillation--another significant cause of morbidity and mortality. 

Many ICDs aid in the clinical management of CHF through the measurement 

of thoracic impedance, providing clues to the volume status 

of the patient. Thus, the device provides a window for medical 

management and avoidance of hospitalization (and readmission). 

The pacing function of the ICD is itself treatment for CHF. A significant 

step forward in CHF management is the ICD coupled with a 

bi-ventricular pacing system, often termed Bi-V ICD. The endocardial 

right atrial and right ventricular leads are coupled with a left ventricular 

lead, typically placed in a tributary to the coronary sinus for epicardial 

pacing. With these devices, the right and left ventricles are paced 

simultaneously following atrial systole. In appropriately selected patients, 

approximately two-thirds will experience an improvement in 

at least one New York Heart Association CHF class and clinical trials 

have even demonstrated an improvement in mortality. 

Over the past several years, the indications for ICDs have expanded 

from secondary prevention to a significantly larger primary 

prevention population. In addition, they have evolved from simple 

defibrillators, to devices that can improve outcomes in symptomatic 

heart failure. • 

REFERENCES: 

1. Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator 

in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter 

Automatic Defibrillator Implantation Trial (MADIT). N Engl J Med 1996;335:1933-1940. 

2. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic Implantation of a Defibrillator in 

Patients with Myocardial Infarction and Reduced Ejection Fraction (MADIT II). N Engl J 

Med 2002;346:877–883. 

3. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an Implantable Cardioverter– 

Defibrillator for Congestive Heart Failure. The Sudden Cardiac Death in Heart Failure 

Trial (SCD-HeFT). N Engl J Med 2005;352:225-237. 


The Final Word 

Road[map] to the Heart 

R. Christopher Jones, MD, TriStar Centennial Medical Center ∣ chris.jones1@hcahealthcare.com 

What are the clinical benefits 

of using mapping system 

prior to ablation procedures? 

Most electrophysiologists that were 

trained before the early 2000’s 

learned to diagnose and treat arrhythmias 

using deductive reasoning and 

analysis of electrograms taken from 

within the heart. While these techniques 

work well, many of us have 

R. Christopher Jones, MD found that even the most common arrhythmias 

can be treated more safely, 

quickly and effectively if we employ three-dimensional (3D) mapping 

systems. 

time, the exposure time is actually 15 minutes. Many centers opt for 

a CT scan before and after the procedure, as well as 45 minutes to 

one hour of fluoroscopy, which can add to an appreciable lifetime 

risk for cancer. 

What is required to utilize this 

advanced mapping technique? 

Hospitals pay a lot of money to have these systems 

available for their patients. Consequently, only the 

larger, most experienced, high-volume centers can 

afford to purchase them. Once installed, these systems 

require expert support from dedicated hospital 

technologists or industry representatives, or 

both. Patients considering invasive treatments for 

their heart rhythm disorder should inquire about 

whether a mapping system will be used and also 

how experienced the staff is with its use. 

The Carto system provides 

electroanatomical mapping 

used to reconstruct the 

cardiac chambers and to 

ablate common arrhythmias. 

What imaging modalities typically 

utilize the mapping system? 

Mapping can be simply utilized in conjunction with 

fluoroscopy. However, if a more complex case is 

anticipated, we also may merge images from intracardiac 

echocardiography and cardiac MR examinations. 

These additional image modalities allow 

electrophysiologists to anticipate abnormal anatomy, 

so we can plan our catheter position and we 

can plan the types of catheters and sheaths to use 

ahead of the procedure. Also, using this additional 

pre-procedural imaging reduces the amount of 

radiation that the patient receives. Radiation dose is an increasing 

concern given the amount of radiation that the patient receives during 

ablation procedures—particularly when an ablation procedure 

is not properly planned. 

By using MRI—which emits zero radiation dose—and intra-cardiac 

echocardiography, TriStar Centennial has reduced its routine 

fluoroscopy times to less than 20 minutes, and more than half the 

Can you explain the recent pilot project in which 

TriStar Centennial used the technology remotely? 

Creation of 3D maps of the heart using analysis of electrograms from 

inside the heart is not easy and has a lot of potential pitfalls. Also, a 

few misdirected points on a map can give a misleading picture of the 

patient’s problem. 

There are a handful of expert technologists in the U.S. that have 

the knowledge to dramatically increase the mapping and ablation 

procedure efficacy and safety. TriStar Centennial Medical was fortunate 

enough to be part of a three-center pilot where we performed 

more than 100 cases with the assistance of two of the best technologists 

in the U.S., operating our mapping system from the West Coast. 

This support was performed in real-time using tele-presence technology. 

The physicians and staff at TriStarCentennial got to know one of 

the technologists so well through tele-presence that when the pilot 

concluded, the technologist moved to Nashville to work in our lab. • 

Source: Biosense Webster 


F 

5th 

Tri 

P 

IN 

FO 

D 

M 

FR 

919 

2300 Patterson Street 

Nashville, TN 37203 

The Center for 

Research & Education 

John Riddick, MD 

Centennial Heart 

919 BROADWAY 

NASHVILLE, TN 37203 

2300 Patterson Street 

Nashville, TN 37203 

The Center for 

Research & Education 

110 Winners Circle Brentwood, TN 37027 thj@hcahealthcare.com cardiac.tristarhealth.com (800) 242-5662 

Symposium 

FOCUS FOCUS ON HEART ON HEART 

FOCUS ON HEART 

COURSE DIRECTOR 

Tom McRae, MD 



MD 

Huneycutt, David 

CO-DIRECTORS 

David Huneycutt, MD 


John Riddick, MD 


COURSE DIRECTOR CO-DIRECTORS 


MD 

McRae, Tom 

5th Annual 5th Annual 

TriStar CV Symposium: TriStar CV Symposium: 

PRACTICAL PRACTICAL 

INFORMATION INFORMATION 

FOR CLINICAL FOR CLINICAL 

DECISION DECISION 

MAKERS MAKERS 

6.0 CME 

6.0 CME 

6.0 CME 

TriStar CV Symposium: 

Annual 5th 

PRACTICAL 

INFORMATION 

FOR CLINICAL 

DECISION 

MAKERS 

GUEST SPEAKER 

Byron Robinson Williams III, MD, FACC 

Assistant Professor of Medicine 

Division of Cardiology 

GUEST SPEAKER 

Assistant Professor of Medicine 

FACC 

MD, III, Williams Robinson Byron 

Division of Cardiology 

Emory University School of Medicine 

Undergraduate: Princeton University, 1997 

Medical Graduate: Emory University School of Medicine, 2001 

Residency: Emory University School of Medicine, 2005 

Fellowship: Emory University School of Medicine, 2009 

Undergraduate: Princeton University, 1997 

Medicine 

of School University Emory 

Residency: Emory University School of Medicine, 2005 

2001 

Medicine, of School University Emory Graduate: Medical 

Fellowship: Emory University School of Medicine, 2009 

AP 

10 

APRIL 21, APRIL 2012 21, 2012 

10AM UNTIL 10AM 6PM UNTIL 6PM 

FRIST MUSEUM FRIST FOR MUSEUM THE VISUAL FOR THE ARTS VISUAL ARTS 

ART 

919 BROADWAY 919 BROADWAY 

February 3–May 6, 2012 | Exhibition 

NASHVILLE, NASHVILLE, TN 37203 TN 37203 

615-244-3044 

12 615-244-3044 

To See As Artists See: American 

TriStar Art 

Heart from 

Journal 

APRIL 21, 2012 

10AM UNTIL 6PM 

ON HEART 

FRIST MUSEUM FOR THE VISUAL ARTS 

FOCUS 

February 3–May 6, 2012 | Exhibition 

FRIST: 

THE AT 

615 

NA 

Register online: tristarhealth.com 

AT THE FRIST: 

615-244-3044 

The Phillips Collection 

FOCUS ON HEART 

The Phillips Collection 

See: American Art from 

Artists As See To 

F

Spring 2012 - TriStar Health

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?