Spring 2011 - TriStar Health

Spring 2011
Volume 2, Number 2
INSIDE THIS ISSUE
01 Summit Medical Center:
Improving Heart Attack Care
TriStar Heart Journal Editorial Staff
01 Therapeutic Hypothermia
Following Sudden Cardiac Arrest
Jeffrey C. Webber, MD
02 From the Editor: The Engaged
Healthcare Provider
Steven V. Manoukian, MD
03 Heart Watch
TriStar Heart Journal Editorial Staff
05 Aquapheresis: Surpassing
Watered Down Heart Failure Care
Himanshu M. Patel, MD
06 View From Afar: Timely Surgery
Improves Outcomes in Mitral
Regurgitation
Vinay Badhwar, MD
09 SCRI CV Research Update: Who’s
the BOSS?
Steven V. Manoukian, MD
10 Fixing Holes in the Heart
John A. Riddick, MD
11 The Final Word: Prevention via
Risk Factor Modification
Timothy K. Kreth, MD
12 TriStar News
Summit Medical Center:
Improving Heart Attack Care
TriStar Heart Journal Editorial Staff
Serving residents within and beyond Wilson County, Summit Medical Center, a 188-bed facility
in Hermitage, Tenn., is continually enhancing its services and infrastructure to meet the
needs of the community. Wilson County, one of the fastest growing counties in the U.S., is located
immediately east of Nashville’s Davidson County and includes Mount Juliet, the fastest
growing city in Tennessee and 27th fastest growing city in the U.S.
“Given the continued growth in our immediate communities, it’s imperative that we provide
the appropriate healthcare services, particularly for emergent cases like acute myocardial
infarction,” says Jeff Whitehorn, CEO of Summit.
Continued on page 04
Therapeutic Hypothermia Following Sudden
Cardiac Arrest
Jeffrey C. Webber, MD, Centennial Medical Center jeffrey_webber_1999@yahoo.com
Jeffrey C. Webber, MD
Sudden cardiac arrest (SCA) is a formidable problem, as American Heart Association (AHA) data suggest that approximately
236,000 to 325,000 out-of-hospital arrests occur annually in the U.S. 1 More sobering is the relatively static
and abysmal overall survival rate of 6-7%. While survival depends upon the type of arrhythmia responsible and
time of onset to return of spontaneous circulation (ROSC), an integral feature of survival is the ability to limit central
neurologic damage. To combat this deadly side effect of SCA, mild hypothermia is becoming more accepted as appropriate
therapy.
Continued on page 08
Spring 2011 01

From the Editor
The Engaged Healthcare Provider
en·gaged adj. \in-’gãjd, en-\ greatly interested; committed
Steven V. Manoukian, MD, Medical Director of 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
Centennial Medical Center
Nashville, Tenn.
david.huneycutt@
hcahealthcare.com
Cardiothoracic Surgery
Davis C. Drinkwater, Jr., MD
Centennial Medical Center
Nashville, Tenn.
davis@ddrinkwater.com
Electrophysiology
Gregory G. Bashian, MD
Centennial Medical Center
Nashville, Tenn.
gregory.bashian@
hcahealthcare.com
General Cardiology
David E. Chambers, MD
Horizon Medical Center
Dickson, Tenn.
dchambers@dicksonmd.com
CONTACT US
TriStar Heart Journal
Editorial Staff
110 Winners Circle
Brentwood, TN 37027
thj@hcahealthcare.com
cardiac.tristarhealth.com
(800) 242-5662
The Free Merriam-Webster Dictionary defines engaged as “greatly interested” or “committed.”
Traditionally, healthcare providers have shown engagement by providing high-quality direct patient
care, in order to prolong and improve the quality of their patients’ lives.
In today’s healthcare, being an engaged provider extends beyond direct patient care. Providers
and their facilities are not only becoming more engaged with one another, but also more
aligned and accountable to further enhance the quality, cost-effectiveness and efficiency of
care. Eventually, new healthcare delivery systems, defined by the Centers for Medicare & Medicaid
Services as accountable care organizations (ACOs), may shape the new manner in which
healthcare is delivered. ACOs will link provider reimbursements to metrics assessing both quality
and cost. By definition, ACOs will need to be accountable for the care they provide to succeed
in the era of healthcare reform. Consequently, providers, healthcare administrators, third-party
payers, governmental bodies, industry and essentially all facets of U.S. healthcare will need to
become more engaged and aligned.
For providers, being engaged will require effort and possibly a change in mindset, since gaining
an understanding of future healthcare barriers, championing quality improvement programs, as
well as reducing unnecessary costs and clinical variation are new, challenging concepts.
However, providing top-notch direct patient care will always be important for caregivers and
administrators and will continue to require an extensive, up-to-date fund of knowledge. To this
end, TriStar Heart Journal (THJ) strives to be a valuable engagement tool, providing information
about new provider and facility strategies to enhance accountable care. Your engagement with
THJ has enabled the journal to grow to 12 pages, allowing for expanded content and new features.
Among the new features, Heart Watch will concisely highlight results from major scientific
meetings and recent journal publications. View From Afar will feature a national or international
expert from beyond TriStar. In this issue, Vinay Badhwar, a renowned cardiothoracic surgeon
from Osceola Regional Medical Center in Kissimmee, Fla., shares his expertise regarding the
timing and techniques to optimize surgical outcomes in mitral valvular disease.
Also in this issue is expert information from Jeffrey Webber from Centennial on therapeutic
hypothermia, who underscores that the neurologic impact of sudden cardiac arrest often rivals
or exceeds the cardiovascular manifestations. Next, Summit Medical Center describes its new,
comprehensive, 24/7 primary PCI program for patients with ST-elevation myocardial infarction,
in addition to its expansion of the emergency department. Aquapheresis, a valuable tool to improve
outcomes, decrease complications and perhaps reduce costs and prevent readmissions
in acute heart failure, is presented by Himanshu Patel, and includes his personal experience with
this new technology at Redmond Regional. Centennial’s experienced structural heart disease interventionalist,
John Riddick gives a primer on when percutaneous ASD/PFO repair should be
considered. In The Final Word, Summit’s Timothy Kreth shares his approach to the important
topic of risk factor modification, especially in the primary prevention setting. Lastly, in the SCRI
CV Research Update, the BOSS Trial, which is exploring the use of sodium bicarbonate to reduce
contrast-induced nephropathy, is reviewed, as well as other important trials being performed in
SCRI’s growing six-site cardiovascular strategic network.
THJ appreciates your readership and is committed to enhancing your ability to engage in accountable,
high-quality care.
For author inquiries, contact steven.manoukian@hcahealthcare.com
02 TriStar Heart Journal

Heart Watch
Atrial fibrillation mapping tool shows benefit
The use of a diagnostic mapping tool helped terminate or
slow atrial fibrillation (AF) with less than 10 minutes of ablation,
according to the late-breaking CONFIRM trial presented
May 5 at the 32nd annual Heart Rhythm Society (HRS) scientific
sessions. Researchers found that focal impulse and rotor
modulation (FIRM) ablation increased two-year freedom
of AF by 70%.
The study enrolled 103 patients; 67% of whom had persistent
AF and 33% had paroxysmal AF. The researchers split patients
into two groups to receive either FIRM-guided ablation
for less than 10 minutes per rotor focus followed by a wide-area
circumferential ablation (WACA) for pulmonary vein isolation
(32 patients) or WACA alone (71 patients).
According to the authors, acute AF termination or slowing
occurred in 88% of patients in the FIRM-guided arm compared
with 14% in the conventional arm. Additionally, the two-year
data showed that 84.3% of patients in the FIRM-guided arm
were free of AF compared with 50.5% in the conventional arm.
In the majority of patient cases sinus rhythm was achieved
in 10 to 15 minutes. The researchers also reported that FIRMalone
terminated AF to sinus rhythm in six minutes (17 patients)
and lengthened AF cycle length by more than 15%. Single
procedure freedom from AF at one year was 25% higher
for FIRM-WACA compared with WACA alone.
Subcutaneous ICDs prove effective
A subcutaneous implantable cardioverter-defibrillator (S-ICD)
system was 100% effective in converting and detecting induced
ventricular fibrillation (VF) through shock, according to
a study presented May 4 at HRS. Therefore, the researchers
concluded that the S-ICD system can therefore be comparable
to conventional ICD therapy.
Ninety-eight patients were implanted with S-ICDs in three
sites in the Netherlands. The devices were implanted according
to international guidelines and were tested using 65
shocks. After a nine-month follow-up, the researchers reported
that there were no hospitalizations due to heart failure and
no patients experienced episodes of sudden cardiac death.
Additionally, the systems acutely detected and converted episodes
of induced VF 100% of the time.
The researchers also reported that 34 sustained or non-sustained
spontaneous ventricular arrhythmias were detected in six
patients and 23 arrhythmic episodes were treated in three patients.
RIVAL confounds the transradial PCI debate
Radial access for percutaneous coronary intervention (PCI) in
patients with acute coronary syndromes (ACS) does not reduce
a combined endpoint of death, heart attack, stroke or major
bleeding compared with femoral access, according to the
late-breaking RIVAL trial presented April 4 at the 60th annual
American College of Cardiology (ACC) scientific sessions.
Access Site Major Bleeds
6* Allocated to Radial HR 0.50 (95% CI 0.19-1.33)
12
Between June 2006 and November 2010, RIVAL enrolled
7,021 patients from 158 hospitals in 32 countries and randomly
assigned them to radial (3,507 patients) or femoral access
(3,514). The primary outcome was death, MI, stroke or non-
CABG-related major bleeding at 30 days, which occurred in
3.7% in the radial access group compared with 4% in the femoral
access group. The rate of death, MI or stroke at 30 days
was 3.2% in the radial group compared with 3.2% in the femoral
group.
Allocated to Femoral
*All access site major bleeds actually occurred at femoral
arterial site (in radial group due to cross-over or IABP).
Source: RIVAL investigators, ACC11 Presentation.
Radial arteries best saphenous vein grafts for
CABG at 5 years
For coronary artery bypass graft (CABG) surgery, radial arteries
are associated with reduced rates of functional and complete
graft occlusion, as well as less graft disease, than saphenous
veins, according to the five-year results of the RAPS
late-breaking clinical trial, presented April 4 at ACC.
The study enrolled 561 patients who underwent CABG for
three-vessel disease. Each patient received both a radial artery
graft and a saphenous vein graft at two different diseased
vessel sites. The primary endpoint of functional graft occlusion
was determined through invasive angiography at least
five years after surgery. The secondary endpoint was complete
graft occlusion determined through invasive angiography
or computed tomography angiography.
The researchers conducted late angiography on 440 patients
alive at one year and on 269 patients at a mean of 7.6
years post-procedure. In the latter follow-up, they found that
significantly fewer radial arteries became partially occluded
than saphenous vein grafts, at 12% and 18.8%, respectively.
Significantly fewer radial arteries also became completely
occluded, at 8.9%, than saphenous veins, at 17.8%.
Spring 2011 03

Summit Medical Center: Improving Heart Attack Care
Continued from page 01
“Because Tennessee has very high, statewide rates of heart
disease, fueled by a tradition of unhealthy lifestyle habits,
proper services are needed to serve this population,” Whitehorn
adds.
In fact, more than one out of four deaths in Tennessee is
due to heart disease, according to the 2009 Centers for Disease
Control and Prevention report. And heart disease is the
leading cause of death for both women and men in the state.
To address these needs, Summit has renewed offering primary
percutaneous coronary intervention (PCI) services for
patients with ST-elevation myocardial infarction (STEMI), 24
hours a day, seven days a week (24/7). In order to provide
these services on a continuous basis, Summit hired two new
interventional cardiologists, for a total of four, allowing the
provider to begin offering 24/7 STEMI care in January 2011.
While the hospital performed six PCI procedures in January,
the PCI volume more than doubled in February to 14 procedures.
“When we previously offered 24/7 STEMI care, Summit
averaged 24 PCI procedures per month. In addition, in 2006,
we performed between 60 to 90 diagnostic catheterizations
monthly,” explains Holly Hill, RN, MSN, director of cardiac
services at Summit. “We hope to achieve those levels of volume
again with the renewal of this program.”
“We are excited to offer 24/7 PCI at Summit Medical Center,”
says Randy Farrar, RN, BSN, CEN, director of emergency and critical
care services at Summit. “Time is muscle; every minute saved
improves the chances of a better outcome for our patients.”
The American College of Cardiology recommends a doorto-balloon
time for primary PCI for STEMI of less than 90
minutes. The average door-to-balloon time at Summit is 64
minutes for STEMI and patients who require surgery are
transferred to Centennial Medical Center, which is 15 miles
away. During the fourth quarter of 2010, Summit’s door-toballoon
time averaged 56 minutes.
In an effort to shave off a few more minutes of their doorto-balloon
times, Summit evaluates each case to identify opportunities
for improvement. Methods put in place include:
activation of cath lab from the field via EMS, immediate triage
of chest pain patients and cross-training
of emergency department staff in the catheterization
lab.
Communication between the various provider
services and having the technologies to
make information accessible to the appropriate
caregivers is “extremely important, as this
will only serve to improve patient outcomes,”
Whitehorn says.
The emergency department has served approximately
48,000 patients over the past two
years. Summit is currently undergoing a $7
million expansion that will increase the number
of beds in the emergency department to
32, compared with its current number of 23
beds. The expansion is expected to be completed
by Aug. 1.
“One of the reasons for the renovation is to
meet the demands of the growing population,” says Farrar.
“This expansion has been implemented to better serve the
needs of our community. It will not only add rooms but will reduce
wait times as well.”
Within the emergency department expansion, Summit also
has dedicated a certain number of beds to an emergency department
fast track, which “allows us to see and treat those
patients who are more acutely ill in a faster, more efficient
manner,” Whitehorn explains. “These dedicated rooms will
improve the patient experience for all those who enter the
emergency department, as the workflow will be streamlined
based on the needs of the patient on arrival.”
Farrar believes this fast track process will result in an increase
in patient satisfaction, as this will lead to a decrease
in emergency department wait times for emergent and nonemergent
cases.
“Currently in healthcare, quality is measured and publicly
reported more frequently than ever, making our patients more
informed consumers,” Whitehorn says. “While that type of
transparency may be a hard adjustment for providers, it is our
responsibility to produce excellent patient outcomes across
the various specialties, including cardiology services.”
04 TriStar Heart Journal

Aquapheresis:
Surpassing Watered Down Heart Failure Care
Himanshu M. Patel, MD, Redmond Regional Medical Center hpatel@harbinclinic.com
Due to the prolongation of life resulting
from the advances in cardiovascular
therapeutic innovations
and the aging population, the prevalence
of congestive heart failure
(CHF) is increasing. Treatment strategies
for CHF vary widely, resulting
in mortality which remains exceedingly
high. The American Heart Association
estimated there were 5.8
Himanshu M. Patel, MD million people with CHF in the U.S.
in 2006. Furthermore, average survival
after a patient’s first hospitalization for CHF is alarmingly
low: 1.7 years for women and 2.3 years for men. Heart failure is
also one of the most common causes of hospitalization and readmission.
In 2006, the U.S. heart failure hospitalization rate was
23 per 1,000 for men over the age of 64 and 20 per 1,000 for women
over the age of 64, making it the leading cause of hospitalization
in this age group 1 . Lastly, about a quarter of those who are
hospitalized with heart failure are readmitted within 30 days 2 .
Despite the severity, inpatient CHF treatment has remained
relatively unchanged. Cornerstones of treatment include intravenous
diuretics, sodium and fluid restriction, ACE inhibitors
or ARBs, beta-blockers, BP control and aldosterone blockers.
Other useful tools include inotropic agents in low cardiac
output states and nesiritide infusions in hypertensive states.
A common complication of intravenous diuretic treatment
is a fall in cardiac output induced by loop diuretic therapy,
which has important implications for the time course of diuresis.
In both stable individuals and those with CHF, ensuing
activation of sodium-retaining mechanisms (angiotensin II,
aldosterone and norepinephrine), as well as flow-dependent
hypertrophy in the renal distal tubule limits the response to
continued diuretic therapy and can lead to prolonged hospitalization
and readmission for CHF.
This complication of diuretics and others limit their efficacy,
resulting in a need for new methods to remove fluid safely and
efficiently. In addition, there is a need to provide inpatient treatments
that have the potential to reduce re-hospitalization.
At Redmond Regional Medical Center in Rome, Ga., we
have initiated an alternative FDA-approved treatment to remove
fluid, called aquapheresis. We have been using this
method for more than 19 months with great success.
Also known as ultrafiltration, the technique involves the removal
of blood through a peripheral or central venous catheter. Salt
and water is filtered from the blood through a console containing
two pumps. Excess fluid and salt are removed and collected in a
bag and blood is returned to the body in less than a minute. Patients
are anticoagulated prior to and during treatment to prevent
clotting within the blood filter. Approximately 33 cc of extracorporeal
blood is extracted at any given time. An average of 100 cc to
500 cc of fluid can be removed per hour, which can be adjusted.
Electrolyte balance is easier to maintain than traditional diuresis.
Treatment duration depends on the patient’s condition, but average
procedure duration is 24-72 hours in the inpatient setting.
Redmond Regional Medical Center
Heart Failure Data
Readmission Rate (within 30 days)
Standard Heart Failure (HF) Treatment 20%
Aquapheresis 12%
Length of Hospital Stay
Standard HF Treatment
Aquapheresis
Aquapheresis within 24 hrs
The UNLOAD trial was the first study to demonstrate the
safety and efficacy of aquapheresis 3 . Emergency room patients
with acute, decompensated CHF were randomized to
standard treatment versus aquapheresis. At 90 days, patients
treated with aquapheresis had a 50% reduction in rehospitalization,
63% reduction in hospitalized days and a 52% reduction
in emergency room visits/clinic visits. The study concluded
that in decompensated CHF, ultrafiltration via aquapheresis
safely produces greater weight and fluid loss than intravenous
diuretics, reduces 90-day resource utilization for heart
failure and is an effective alternative therapy.
Utilizing this technique, Redmond has halved its 30-day readmission
rates at the hospital, compared with standard treatment
patients. Also, the length of hospital stay is almost 1-2 days less
compared with conventionally treated CHF patients.
REFERENCES:
6.2 Days
5.2 Days
3.9 Days
Source: Unpublished
1. Liu L. Changes in Cardiovascular Hospitalization and Co-morbidity of HF in the U.S.:
Findings from the National Hospital Discharge Surveys 1980-2006. Int J Cardiol
2011;149(1):39-45.
2. Jencks SF, Williams MV, and Coleman EA. Rehospitalizations among patients in the
Medicare fee-for-service program. N Engl J Med 2009;360(14):1418-1428.
3. Costanzo MR, Guglin ME, Saltzberg MT, et al. Ultrafiltration Versus Intravenous
Diuretics for Patients Hospitalized for Acute Decompensated HF. J Am Coll Cardiol
2007;49:675-683.
Spring 2011 05

View from Afar
Timely Surgery
Improves Outcomes in Mitral Regurgitation
Vinay Badhwar, MD, Osceola Regional Medical Center, Kissimmee, Fla. vbadhwar@heartsurgery-csa.com
Vinay Badhwar, MD
Many patients with heart failure
also have structural heart disease,
which can be coronary or valvular—the
latter of which is commonly
mitral-based. Mitral regurgitation
(MR) is increasingly prevalent in the
aging population, and may lead to
substantial all-cause morbidity and
mortality, particularly in those with
heart failure. Timely surgical referral
of these patients is truly important
for improved clinical outcomes.
The problem of MR can be divided into two broad etiologies:
primary leaflet-based pathology or ventricular-based pathology.
Leaflet pathologies consist of myxomatous degeneration
(or mitral valve prolapse with a problem of excess
This is the first installment in
our “View from Afar” series, in
which we will be inviting expert
physicians from beyond the
TriStar Health System to write on
a variety of cardiovascular topics.
leaflet), or fibroelastic deficiency
(or thin leaflets with flailed isolated
segment), the latter of which
is more common in the elderly.
Ventricular pathologies of dilated
or ischemic heart failure result
in functional MR caused by leaflet
tethering associated with ventricular dilation. Particularly for
this second subset, it is integral to intervene before the disease
has progressed too far, because even if the valve is fixed,
the ventricle still has the potential to fail.
When to intervene?
In triaging when a patient should be referred for an intervention
of the mitral valve, the recently updated ACC/AHA guidelines
point to specific symptoms related to dyspnea, such as
recurring congestive heart failure, NYHA Class of ≥3 or orthopnea
1 . Also, if a patient is asymptomatic, and develops atrial fibrillation,
it may be a marker of late progression of MR. Often,
these patients can be treated with concomitant atrial fibrillation
procedures at the time of mitral valve repair. There is increasing
evidence, based upon echocardiographic studies, that pulmonary
hypertension may also be a marker of late progression
of MR 2 . These patients should be referred for surgery earlier.
For those who are symptomatic and have severe MR, the
patient should be referred immediately. In fact, the natural
history of severe MR notes a seven-year survival benefit in
patients who are asymptomatic, and a five-year survival benefit
for those who are symptomatic. This is not a benign disease.
Patients with severe symptomatic MR, who are treated
with medical therapy fair quite poorly, not only in terms of
quality of life due to recurrent heart failure but also due to limited
short-term survival.
When to refer?
However, it is less clear for physicians when to refer asymptomatic
patients for intervention, which is why retrospective
and prospective studies have helped to inform the field. In
a recent longitudinal study, early surgical intervention was
compared with watchful waiting for 447 asymptomatic severe
MR patients. Estimated actuarial seven-year cardiac mortality
was 0% in the operated group and 5% in the conventional
treatment group, and for 127 propensity score-matched pairs,
the estimated actuarial seven-year event-free survival rate
was significantly higher in the operated than in the conventional
treatment group 3 .
Many global studies have consistently shown that early
intervention in severe valvular pathology not only improves
long-term quality of life, but also confers a significant survival
advantage. Patients who undergo mitral valve repair can resume
a normal life and anticipate a normal life expectancy.
Also, new longitudinal data indicate that if the valve is repaired
in a timely manner, the patient can achieve normalization
of ventricular function 4 . Of 1,063 patients who underwent
mitral valve surgery over a 20-year period, 87% of patients underwent
valve repair and 13% underwent replacement. Factors
including higher preoperative ejection fraction, smaller
left ventricular dimensions and performance of valve repair
(versus replacement) were associated with a higher ejection
fraction at follow-up. The researchers concluded that early repair
of MR caused by leaflet prolapse, before deterioration in
left heart size or function, increases the likelihood of subsequent
normalization of left ventricular ejection fraction.
In addition to symptomatic criteria, the guidelines also recommend
that patients should be assessed based upon anatomic
criteria, such as left ventricular end-diastolic dimension
or volume and referred before the heart dilates 1 . Left ventricular
end-diastolic dimension of 40 mm is the new bar which
confers advantage of mitral valve repair.
All of these symptomatic and anatomic factors can assist
physicians with knowing how to interpret MR and when to refer
patients for mitral valve surgery.
In summary, if a patient is even mildly symptomatic and the
patient has severe MR due to a flail mitral leaflet, he or she
06 TriStar Heart Journal

Normal
Infarct
(Left) Balance of forces acting on mitral leaflets in systole. (Right) Effect of papillary muscle displacement. Dark shading indicates
inferobasal myocardial infarction; and light shading indicates normal baseline.
Source: Di Salvo, T.G, Acker, MA, Dec, GW et al. Mitral Valve Surgery in Advanced Heart Failure. J Am Coll Cardiol 2010;55:271-282.
should be referred for surgical repair. If a patient is asymptomatic
with severe MR, then he or she should be followed until
their left ventricular end-diastolic dimension is greater than
40 mm or they develop pulmonary hypertension or any other
structural sign of deterioration of the heart such as atrial fibrillation
or right or left atrial enlargement.
However, if the patient is symptomatic, but the MR is not
severe on transthoracic echocardiography, further studies are
recommended such as transesophageal or stress echocardiography.
In these cases, quantification methods on echocardiography
are beneficial in examining the effective regurgitant
orifice of the mitral valve to assess the severity of the MR.
Early repair of MR can result in recovery of ventricular function
and restoration of normal life expectancy.
Dr. Badhwar is a renowned cardiothoracic surgeon, with
specialized training and expertise in surgical valvular repair
techniques. He is widely published in the medical literature,
active in research and lectures. Dr. Badhwar received his medical
degree in 1993 from the University of Ottawa, performed
his residency at McGill University and the University of Ottawa
Heart Institute and fellowship at the University of Michigan.
REFERENCES:
1. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 ACC/AHA 2006 guidelines for
the management of patients with valvular heart disease: a report of the American
College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice
Guidelines. J Am Coll Cardiol 2006;48:e1-e148.
2. Barbieri A, Bursi F, Grigioni F, et al. Prognostic and therapeutic implications of
pulmonary hypertension complicating degenerative mitral regurgitation due to flail
leaflet. Eur Heart J 2011;32:751-759.
3. Kang DH, Kim JH, Rim JH, et al. Comparison of early surgery versus conventional
treatment in asymptomatic severe mitral regurgitation Circulation 2009;119:797-804.
4. Suri RM, Schaff HV, Dearani JA, et al. Recovery of left ventricular function after
surgical correction of MR caused by leaflet prolapsed. J Thorac Cardiovasc Surg
2009;137:1071-1076.
Spring 2011 07

Therapeutic Hypothermia Following Sudden Cardiac Arrest
Continued from page 01
Research seeking to prevent neurologic injury from SCA
dates back nearly 50 years, but initiatives to pursue this therapy
were initially derailed by concern over potential therapeutic
side effects and lack of efficient, timely ways to achieve desired
core temperature. Two landmark randomized controlled
trials triggered a renewed interest in hypothermia that is now
being incorporated in hospitals across the U.S.
The data from these studies are compelling. First, the Australian
study of 77 comatose patients following ventricular fibrillation
(VF) arrest 2 assessed moderate cooling (33 °C, achieved
with ice packs and intermittent sedation/paralysis for 12 hours)
Mild Therapeutic Hypothermia to Improve the
Neurologic Outcome After Cardiac Arrest
and found that “good” clinical outcomes (discharge to home or
rehabilitation unit) were significantly better with hypothermia
vs. control (49% vs. 26%), as were death rates (51% vs. 68%).
In the second study, 275 patients with VF or ventricular
tachycardia (VT) arrest and ROSC within 60 minutes were randomized
to mild hypothermia (89.6-93.2 °F utilizing cold air
mattress, ice packs and sedation/paralysis as needed for 24
hours) vs. standard ICU care 3 and followed up to six months.
A favorable neurologic outcome was achieved in 55% of the
hypothermia-treated patients vs. 39% of control patients, with
mortality rates of 41% vs. 55%, respectively.
These promising results propelled a discussion regarding
appropriate policies for mild hypothermia therapy that culminated
in recommendations from the European Resuscitation
Council and the AHA in 2005. These statements recommend
mild hypothermia as one of many compelling treatments for
post-arrest patients presenting with VT or VF as their initial
arrhythmia.
Favorable
Neurologic
55%
Outcome
P=0.009 39%
Death
P=0.02
41%
55%
■ Hypothermia ■ Normothermia
Source: The Hypothermia after Cardiac Arrest
Study Group. N Engl J Med 2002;346:549-556.
Practical Considerations
Various methods of cooling are available. Most readily available
options for inducing hypothermia include ice packs about
the torso and head, infusion of chilled (4 °C) intravenous normal
saline or Lactated Ringers and utilization of cooling blankets.
More sophisticated therapies include intranasal evaporative
cooling techniques, localized external head cooling
apparatuses, specially built cooling beds, and even intravascular
catheter-based cooling technology.
Serious side effects of hypothermia therapy include refractory
ventricular arrhythmias, electrolyte imbalances, infection
and coagulopathies and are more frequent in patients
with cooling “overshoot” (which may occur in 13% of patients).
However, it is unclear that differences in complication
rates between hypothermia-treated and control
groups meaningfully alter outcomes 3 .
The efficacy of hypothermia in SCA patients
presenting with arrhythmias other than VT or VF
remains unclear, as data from limited retrospective
trials suggest a benefit of lesser magnitude.
As is frequently the case, converting trial-generated
data into practical day-to-day beneficial
results is proving to be a monumental task. Many
questions remain regarding further risk stratification,
optimal time of cooling and optimal methods
of achieving target temperatures.
Still, healthcare professionals are increasingly
embracing the concept of mild hypothermia in
post-arrest patients. Indeed, there is momentum
afoot to regionalize such care in an effort to decrease
inter-hospital variability in outcomes across the U.S.
City-wide efforts in this area are fully underway in New York, for
example. There, news attention recently focused on EMS personnel
now administering chilled IV fluids prepared in special
refrigerator-equipped ambulances to accelerate the process of
cooling in the field. In addition, the funneling of resources that
would lead to directing victims of SCA to regional centers was
proposed in a recent AHA policy statement 1 .
Implementation of therapeutic hypothermia is fast becoming
the standard of care. Policies and methodologies aimed
at decreasing time to cooling will be increasingly refined. As
doctors, nurses and EMS personnel become more comfortable
with and facile at delivering this therapy, we will also begin
to understand its limitations, as well as potentially be able
to extrapolate its benefits to patients in other scenarios.
REFERENCES:
1. Nichol, G, Aufderheide, TP, Eigel, B, et al. Regional Systems of Care for
Out-of-Hospital Cardiac Arrest: A Policy Statement from the AHA. Circulation
2010;121:709-729.
2. The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia
to improve the neurologic outcome after cardiac arrest. N Engl J Med
2002;346:549-556.
3. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-ofhospital
cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-563.
08 TriStar Heart Journal

SCRI CV Research Update
Who’s the BOSS?
Steven V. Manoukian, MD, Director of Cardiovascular Research, Sarah Cannon Research Institute (SCRI)
steven.manoukian@scresearch.net
“BOSS, a national, randomized trial, is powered to determine whether high-dose
Chronic kidney disease (CKD) affects 20% bicarbonate can prevent long-term loss of renal function (death, renal replacement
of patients with cardiovascular disease therapy or significant decrease in GFR persisting at six months) by preventing the
and nearly triples rates of short-term impact of arterial contrast on high-risk patients.”
mortality and adverse ischemic events Harold L. Dauerman, MD, U.S. Co-Principal Investigator for BOSS trial and Director of Cardiac
in acute coronary syndromes (ACS) and Catheterization Laboratories at the University of Vermont
percutaneous coronary intervention
(PCI). In addition to advancing age, anemia
and use of a standard regimen of a
glycoprotein IIb/IIIa inhibitor, CKD is a
powerful risk factor for bleeding 1-2 .
Beyond its adverse effects on ischemic
and bleeding events, CKD increases
the risk of contrast-induced nephropathy
(CIN), a form of acute renal failure in
patients undergoing cardiac catheterization
or PCI using iodinated contrast media.
CIN is associated with an increase
in adverse outcomes, including mortality,
need for dialysis, other adverse outcomes
and prolongation (and increased
cost) of hospital stay. Rates of CIN vary
widely depending upon baseline renal
Current SCRI Cardiovascular Research
TRIAL
ABILITY
AMGEN - HF
BOSS
BRADYCARE
HCRI-DAPT
HESTIA
ION
IRASE
LONGEVITY
PHOENIX
PREVAIL
PROMISE
QUICKFLEX
ROCHE - ACS
ROCHE - SURGERY
SAPPHIRE
STARFIX
THRIVE
USPELLA
Description
EP device lead follow-up
function (usually estimated by the glomerular
filtration rate, or eGFR) and how
CIN is defined 3 . The lack of consistent efficacy
has hindered consensus regarding
best practices for CIN prevention.
One promising CIN preventive strategy
being assessed in three of SCRI’s
cardiovascular strategic sites is intravenous
(IV) sodium bicarbonate (NaH-
CO 3
). The BOSS Trial (Evaluation of
Sodium Bicarbonate to Reduce Contrast-Induced
Chronic Kidney Injury
in Subjects with Advanced CKD who
are Undergoing Angiography) is comparing
IV NaHCO 3
to sodium chloride
(NaCl) prior to, during and after arterial
angiographic procedures, such as cardiac
catheterization and PCI, in patients
with advanced CKD (defined as eGFR of
Omecamtiv mecarbil in acute heart failure
NaHCO 3
to prevent CIN w/ any arterial contrast + eGFR ≤44
Pacemaker programming enhancement
Dual antiplatelet therapy with any BMS or DES
Dronedarone with pacemaker and atrial fibrillation
Paclitaxel-eluting DES
Atrial fibrillation ablation
EP device follow-up
Cangrelor antiplatelet therapy with any DES
WATCHMAN LA closure device in atrial fibrillation
Chest pain imaging study
EP device lead
RO4905417 in stable CAD following recent ACS
Human monoclonal P-selectin antibody with CABG
Carotid stenting
EP device lead follow-up
Aortic aneurysm repair
IMPELLA 2.5 cardiac support system
≤44 mL/min/1.73m 2 ).
Centennial Medical Center in Nashville,
Tenn., Redmond Regional Medical
Center in Rome, Ga., and Northside
Hospital in St. Petersburg, Fla., are three
of only a handful of sites participating in
this multicenter, randomized U.S. trial.
The BOSS Trial will determine if the use
of IV NaHCO 3
in patients with advanced
CKD will reduce the risk of CIN and related
complications. Furthermore, if the
results of BOSS are favorable, NaHCO 3
may form the standard-of-care for all patients
undergoing procedures utilizing
iodinated contrast media.
The SCRI network also includes:
Osceola Regional Medical Center in
Kissimmee, Fla., CJW Medical Center
in Richmond, Va., and Henrico Doctors’
Hospital in Richmond, Va.
SCRI’s cardiovascular vision is to be
a leader in cardiovascular research to
provide the foundation for evidencebased
strategies that facilitate optimal
and cost-effective patient care.
For more information on SCRI’s
cardiovascular research trials, visit:
www.sarahcannonresearch.com/
our-research/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. Mehran R, Nikolsky E, Lansky AJ, et al. Impact of
chronic kidney disease on early and late outcomes
of patients with ACS treated with alternative
antithrombotic treatment strategies: an ACUITY
substudy. JACC Cardiovasc Interv 2009;2:748-757.
2. Manoukian SV, Feit F, Mehran R, et al. Impact of
major bleeding on 30-day mortality and clinical
outcomes in patients with ACS: an analysis from the
ACUITY Trial. J Am Coll Cardiol 2007;49:1362-1368.
3. Jabara R, Gadesam RR, Pendyala LK, et al.
Impact of the definition utilized on the rate of
contrast-induced nephropathy in PCI. Am J Cardiol
2009;103:1657-1662.
Spring 2011 09

Fixing Holes in the Heart
John A. Riddick, MD, Centennial Medical Center john.riddick@hcahealthcare.com
A novel percutaneous technique
for repairing an atrial septal defect
(ASD) or patent foramen ovale
(PFO) presents an alternative to
surgery for many patients. ASD,
a congenital defect that occurs in
approximately four of every 10,000
births, is an opening in the atrial
septum, or dividing wall between
the two upper chambers of the
John A. Riddick, MD heart, the right and left atria.
PFO is more common (approximately
25% of the population) and occurs when the atrial
septum does not close properly. The latter defect may be
associated with cryptogenic stroke (stroke with no identifiable
cause).
Although there are currently no FDA-approved devices
for PFO closure, three approved ASD devices are widely
used to close either abnormality. The Amplatzer Septal
Occlusion device (AGA Medical, recently acquired by St.
Jude Medical) was the first catheter-delivered ASD closure
device approved in the U.S. Amplatzer utilizes the shape
memory of Nitinol, a wire made from an alloy of nickel and titanium.
The Nitinol wire mesh is shaped into two flat discs and a
middle connector to fit the defect size, with polyester fabric inserts
designed to help close the hole and provide a foundation
for the growth of tissue over the occluder after placement. The
device has a specific size limitation, as it only goes up to 38 mm
in diameter, so defects larger than this size cannot be closed
with this device.
Two other available devices are the Gore Helex Septal Occluder
(Gore Medical), which is a disc-like device that consists
of ePTFE patch material supported by a single Nitinol wire
frame and the STARflex Septal Repair Implant (NMT Medical),
which includes two umbrella shaped discs, one for each side
of the septum.
Currently, virtually all PFOs are repaired percutaneously,
despite its off-label status. However, percutaneous closure of
ASDs is only appropriate for 60-70% of ASDs which are of the
secundum type.
Unlike open-heart surgery, these minimally invasive, catheter-based
procedures typically require less than 24 hours of
post-procedure observation. Conversely, surgical repair often
requires a four- to five-day hospital stay, along with a longer
recovery time. In a single-center study of 1,268 patients,
length of hospital stay for percutaneous ASD closure was 2.8
days versus 3.2 days for surgical repair. The greatest benefits
of percutaneous ASD closure are decreased morbidity and
complications. In 1,268 consecutive patients with isolated secundum
ASD, 751 of whom underwent percutaneous closure,
the complication rate was lower in the percutaneous versus
surgical arm: 6.9% versus 44% 1 .
PFOs are most often percutaneously closed in patients with
cryptogenic stroke or transient ischemic attacks who have
failed medical therapy. In patients with cryptogenic stroke, the
prevalence of PFO increases from 25% to approximately 40%.
PFO is especially common in patients who have had a stroke
at age less than 55 years. For these patients, PFO closure is the
typical standard of care for this patient population.
The CLOSURE I trial randomized 909 cryptogenic stroke or
transient ischemic attack (TIA) patients with a PFO to receive
closure with the STARFlex septal closure device plus medical
therapy (447 patients) or medical therapy—24-month aspirin
or warfarin or combination—alone (462 patients) to
measure the prevention of recurrent stroke or TIA 2 . The researchers
found no increased benefit of combining PFO closure
and medical therapy and reported that two-year primary
composite endpoints were similar for both groups, 5.9% in the
STARFlex arm versus 7.7% in the medical therapy arm.
Several ongoing trials are evaluating the use of percutaneous
PFO closure, such as the RESPECT trial, which is comparing
device closure versus medical therapy for cryptogenic
stroke.
Following percutaneous ASD or PFO closure, patients are
routinely treated with aspirin indefinitely and clopidogrel for
six months, unless other anticoagulation is required for other
indications. In addition, endocarditis prevention is recommended
for at least six months following the device implant.
REFERENCES:
1. Butera G, Carminati M, Chessa M, et al. “Percutaneous versus surgical closure of
secundum ASD: comparison of early results and complications.” Am Heart J 2006
Jan;151(1):228-234.
2. AHA 2010 Presentation. Furlan et al.
Gore Helex Septal Occluder. Source: Gore Medical
10 TriStar Heart Journal

The Final Word
Prevention via Risk Factor Modification
Timothy K. Kreth, MD, Summit Medical Center timothy.kreth@hcahealthcare.com
Timothy K. Kreth, MD
How has the COURAGE trial
informed the treatment of
coronary disease?
As an initial management strategy
in coronary artery disease, COUR-
AGE reported similar outcomes
for patients treated with PCI or optimal
medical therapy 1 . As clinicians,
we need remember this important
finding because although
PCI and CABG are not cures for
the underlying problem, PCI is often
an effective alternative to CABG. In the early days with
bare-metal stents, restenosis rates were in the range of 20-
25%. With the newer drug-eluting stents that prevent intimal
hyperplasia, restenosis rates have been reduced to approximately
5%. However, some problems with drug-eluting stents
remain, such as the necessity for patients to take dual-antiplatelet
therapy consisting of aspirin and either clopidogrel
or prasugrel for one year, due to the risk of stent thrombosis.
Ongoing investigations into new technologies, such as bioabsorbable
stents, may make stents safer and more effective.
Yet, we still have to address the underlying problem that allowed
the disease to develop in the first place, which is where
risk factor modification could be a game-changer.
Which patients are appropriate for a risk factor
modification strategy?
It is necessary to apply a carefully planned risk factor modification
strategy to patients with diagnosed coronary disease,
called secondary prevention. However, it is also important for
those patients who are at risk for developing heart problems,
which is primary prevention. To better address these concerns,
we have launched the Risk Factor Modification Clinic at Summit
Medical Center in Hermitage, Tenn., which is an outlet for patients
who want to avoid having a heart attack or develop heart
disease, in addition to patients with known heart problems.
What types of modifications does the clinic focus on?
The caregivers at our clinic focus on a variety of risk factor
modifications, which are directly tailored to the needs of the
patient. For instance, smoking cessation is a first step. If an
individual only stops smoking, they will cut their risk of dying
from a heart attack in half. If a patient has elevated cholesterol,
we will work to get that tightly under control through statin
therapy. For diabetics, we ensure that the patients’ blood sugar
is under strict control and that their hemoglobin A1c is about
6-6.5%. If patients are sedentary or obese, we design exercise
programs, in order for them to achieve ideal body weight.
Also, we titrate medications to ensure that the patient’s blood
pressure is about 120/70 mm Hg. We aggressively attempt to
get our patient’s LDL below 70 mg/dL and HDL above 45 mg/
dL. Unfortunately, there aren’t particularly effective drugs for
raising one’s HDL, so exercise is crucial. It takes about 18-20
minutes of exercise for a person to achieve his or her aerobic
threshold, and HDL cholesterol production doesn’t start until
that threshold is reached. Therefore, we typically recommend
30 minutes of exercise at least three times a week.
While we can’t change a person’s family history, gender or
age, there are a number of risk factors that can be modified to
reduce the risk of the patient having a stroke, heart attack or
heart failure.
Categorical Levels of Major,
Causal Risk Factors
Risk Factor
Cigarette smoking
Blood pressure
Beyond the clinical considerations, are there any
additional benefits with risk factor modification
programs?
In addition to the long-term improvement of patient care, prevention
strategies also may save money for the U.S. healthcare
system. If you just assess cholesterol management,
the cost-benefit analysis suggests that statin therapy costs
$40,000 per year of life saved compared with annual mammography
which costs $150,000 per year of life saved for
women aged 55 to 65 2 .
This is certainly in line with other health prevention techniques
that Americans feel are appropriate.
REFERENCES:
Categorical Level
Any current
140 mm Hg systolic
90 mm Hg diastolic
LDL cholesterol 160 mg/dL
HDL cholesterol
Plasma glucose
126 mg/dL (fasting)
Source: Circulation 1999;100:988-998.
1. Boden WE, O’Rourke RA, Teo KK, et al. “Optimal Medical Therapy with or without PCI
for Stable Coronary Disease.” N Engl J Med 2007; 356:1503-1516.
2. Morrison AM, Glassberg H. “Determinants of the Cost Effectiveness of Statins.”
J Managed Care Pharmacy 2003; 9:544-551.
Spring 2011 11

110 Winners Circle Brentwood, TN 37027 thj@hcahealthcare.com cardiac.tristarhealth.com (800) 242-5662
TriStar News
››
Cartersville began its
percutaneous coronary
intervention program on Jan.
24, 2011. They performed 34
interventions since opening,
including 13 patients with STelevation
myocardial infarction
(STEMI). Their first quarter doorto-balloon
(D2B) time averaged
55 minutes.
››
Centennial continues to make
progress in improving its D2B
times for STEMI. A new facility
record was achieved earlier this
spring, resulting in a 17 minute
D2B time.
››
Greenview Hospital offers
a wide spectrum of services,
including EKG, holter monitoring,
echocardiography, stress testing,
cardiac catheterization and stent
placement.
››
The recent addition of a 64-slice
CT scanner to Hendersonville’s
diagnostic imaging arsenal
allows for faster, clearer
imaging of the heart, aiding
in the capability to detect
cardiovascular disease.
››
Horizon’s emergency
department recently expanded
by opening 10 new beds and
a new observation unit will be
completed this summer.
››
The cardiac rehabilitation
program at Parkridge, which
is accredited by the American
Association of Cardiovascular and
Pulmonary Rehabilitation, has had
a record number of participants
in 2010. The program has three
phases of rehabilitation including
inpatient, monitored outpatient
with physician supervision,
and a minimally supervised
maintenance exercise program.
››
Fifty-two minutes was the average
D2B time for Redmond Regional
for the first quarter of 2011.
››
Nashville Fire Department medics
Alex Spencer and Russ Wilson
recently performed a transfer of a
patient with 95% blockage of his
right coronary artery to Skyline.
Their early detection led to a D2B
time of 60 minutes.
››
The emergency and cardiology
teams at Southern Hills hold an
average D2B time of 55 minutes
compared with the national
benchmark goal of 90 minutes.
››
StoneCrest has acquired a new
cardiovascular and interventional
digital imaging system that
enables physicians to perform
both cardiac and vascular exams
on patients with a single system.
The new system can provide a
wide range of image-guided,
minimally invasive treatment
options that offer patients
advantages over traditional
surgery.
› › Summit recently completed the
second segment of its threephase
emergency department
expansion project. Projected
completion of the renovation
is scheduled for July and will
increase capacity to 32 beds.
In addition, Summit now offers
24/7 interventional cardiology
coverage and has implemented
new therapeutic hypothermia
protocols.
12 TriStar Heart Journal