Caring for Hearts

Find out how advancements in heart care are helping to save lives.

The American Heart Association describes the heart as an electrically-innervated, muscular pump that pushes blood throughout the body through blood vessels.
A specialized group of cells located in the upper chamber (atrium) of the heart act as a pacemaker that generates an electrical impulse. This impulse begins a sequential electrical stimulation of heart muscle that then contracts in a coordinated way.
Accordingly, first the upper chamber of the heart is stimulated to contract and send blood into the lower chambers (ventricles) of the heart. There is a slight delay in the electrical signal that allows the ventricles to fill. Then the ventricles contract, pumping blood throughout the body. Another slight delay then occurs, allowing blood to return to the upper chambers of the heart, refilling the heart for the next cycle.

Restoring Rhythms

Heart rhythm problems can occur because of a malfunction in the electrical system of the heart and can affect people of all ages. Among symptoms that may indicate a heart rhythm problem are palpitations, shortness of breath, fatigue, dizziness or fainting.
An electrophysiologist is a cardiologist who sees and treats patients with heart rhythm problems. This type of cardiologist has specialized training in the diagnosis and treatment of irregular heart beats (arrhythmias).
There are several types of arrhythmias that can occur, such as atrial fibrillation (a-fib), atrial flutter, supraventricular tachycardia (SVT), bradycardia (slow heart beat), ventricular tachycardia (VT) and ventricular fibrillation (v-fib), to name a few.
Lisa Larson, a nurse practitioner in Swedish American Hospital’s Midwest Heart Specialists, says that arrhythmias can occur in people of all ages, including the young. An arrhythmia is generally the cause of Sudden Cardiac Death (SCD) in young athletes.
“Normally, heart disease risk increases with age, and a risk for an arrhythmia increases in persons with heart disease,” Larson explains. “Men generally start developing heart disease in their 50s and 60s and women, because of the estrogen benefit, start developing heart disease about 10 years later.
“When a patient is diagnosed with a heart rhythm issue, we complete various tests to determine the risk associated with the arrhythmia. A monitor might be worn to capture irregular heartbeats. A stress test might be ordered, or an angiogram might be needed to evaluate coronary arteries to determine the source of an arrhythmia. An ultrasound of the heart (echocardiogram) is very helpful in determining the risk of arrhythmias as the ejection fraction (EF) can be measured to determine the squeeze of the heart. If the EF is significantly low, people could be at risk for arrhythmias and also congestive heart failure (CHF).”
Larson adds that the electrical impulses that regulate the heartbeat play a vital role in a person’s heart health. Getting the heart back into normal rhythm is the goal. If it’s not possible to keep the heart in normal rhythm, controlling the heart rate is essential. This may require medications, electrical cardioversion, placement of stents to open blocked arteries, the placement of a pacemaker to prevent low heart rates, the placement of an Internal Cardioverter Defibrillator (ICD) to shock people out of an arrhythmia, or an ablation procedure to interrupt the overactive electrical impulses. Even bypass surgery may be required.
A cardiomyopathy (weak heart) is caused by a diseased heart muscle that no longer functions adequately. It results in the heart’s failure to meet the body’s need for oxygen and remove waste from the blood. While there are several causes, the end result is a weak heart that can’t maintain a normal ejection fraction.
Screening for heart disease typically starts in older persons, but the routine sports physical for young athletes sometimes reveals heart problems. Questioning young people about “passing out with exercise” or primary relatives dying suddenly before the age of 50 can give doctors insight that there may be a problem.
“Electrocardiograms (EKG’s) are now a recommendation as a part of a school athlete’s physical if the questions regarding the above are answered as a yes,” Larson explains. “We’re finding these life-threatening conditions much earlier.”
Faintness, dizziness and passing out after exertion are signs that a child or an adult may have heart arrhythmia, Larson adds.
A current trend that’s cause for alarm is the increasing use of energy drinks by young people, says Larson.
“These highly caffeinated drinks can trigger arrhythmias in children and young adults,” she adds. “They’re not safe and can lead to severe heart problems.”
Left unchecked, faulty heart rhythms can lead to a higher risk of stroke and other serious health conditions.
“We can conduct a CHADS test that is used to estimate the risk of stroke in patients with A-Fib and if the CHADS results are greater than 1-2, blood thinners are usually recommended,” Larson says. “Others tests may be ordered as well. It’s imperative that people of all ages and genders follow up with their healthcare provider for any concerning symptoms regarding arrhythmias so that a diagnosis can be made and effective treatment rendered.”

Treating Atrial Fibrillation

One of the most critical arrhythmia conditions is atrial fibrillation (Afib). Dr. Madhusudan R. Malladi, a board-certified cardiologist with FHN in Freeport, says that while Afib is most often diagnosed in older patients, younger people also may be afflicted.
“Afib can result from various causes including uncontrolled hypertension (high blood pressure), thyroid disease, an underlying heart disease condition or from excessive alcohol consumption,” he says.
Afib can also be a manifestation of coronary artery disease.
“There are many other potential causes including infections that attack the heart’s coverings,” Malladi says. “Basically, in older patients, the cause is most likely high blood pressure, coronary artery disease or thyroid. But in younger patients, we look for alcoholism or a mitral valve malfunction that results in enlargement of the left atrium.”
While Afib in itself is not necessarily life-threatening, Malladi explains that it raises the risk of strokes significantly.
“Afib causes the heart to quiver instead of beating steadily, impeding the flow of blood,” Malladi explains. “Blood stays in the heart’s chambers and becomes stagnant. When that happens, clots can form, which may travel to the brain and trigger a stroke. Clots can also create problems in other parts of the body.”
Among the first line of treatments for Afib is blood-thinning medication. Newer blood thinners are expensive but don’t require patients to have frequent blood tests or restrict their diets as much as earlier medications did, Malladi explains.
When Afib is diagnosed, getting the patient’s heart rate under control is the first goal. The second is to prescribe blood thinners to prevent blood clots and strokes. Finally, it’s important to return the patient’s heart rhythm back to normal.
“We prescribe beta blockers to help control heartbeat and blood thinners to prevent clots,” he continues. “We work on converting the heartbeat to a steady normal rhythm, through several methods, including shocking it.”
Ablation (the surgical removal of tissue) may be needed to bring a heart with Afib back into normal rhythm. This involves mapping out the patient’s electrical system and finding points that can be ablated to interrupt erroneous signals.
“In general, 70 percent of these procedures will put the heart back into normal rhythm,” Malladi adds. “In about 30 percent of patients, the heart lapses back into Afib. It’s frustrating but not particularly dangerous. The best thing patients with Afib can do to help themselves is to take their medications consistently.”

Battling Blockages

The use of stents to open blocked arteries has proven to be a lifesaving, minimally invasive measure. Before stenting was introduced 20 to 30 years ago, patients were routinely referred to a cardiovascular surgeon for bypass surgery.
The use of angioplasty, to break open a blockage by threading an encapsulated balloon into it and releasing it, was the first step in what has become a standard in easing angina (chest pain) and anginal equivalents like shortness of breath, and in intervention of acute heart attacks.
But when the affected areas became reclogged, sometimes within six months, metal mesh stents were developed that not only opened the artery but also kept it open. This methodology reduced the potential for repeat blockage substantially. With the inclusion of medication infused into the stent to prevent future buildup, reoccurrence dropped to less than 5 percent.
Dr. Erbert Caceres, a board-certified interventional cardiologist with Mercyhealth, says that when patients come into the emergency room with symptoms of an impending heart attack, the first thing he suspects is blocked arteries.
“We get them into the cath lab immediately,” he says. “The goal is to open the arteries within 90 minutes.”
But when patients are referred to him with symptoms such as chest pain that don’t clearly point to blocked arteries, he first performs an electrocardiogram. If that fails to show the underlying cause, he may do additional tests, such as a stress test, depending on the patient’s history.
“If cardiac markers are abnormal or patient has an abnormal stress test, we then order an angiogram to take a closer look at what may be occurring,” he explains. “This is done in cases when the condition is not severe enough to be considered an emergency.”
When he sees blockage of 70 percent or more in one or two arteries, stenting is the next logical step.
“If, angiographically, the blockage is less than 70 percent, we usually leave it alone. In these cases, stenting probably won’t make a difference and we look at other ways to treat the symptoms, like optimizing medical therapy,” he says. “We can also use ultrasound to assess the severity of blockage, or other techniques, like fractional flow reserve, which is a functional test to assess the significance of the blockage.”
When all of these factors are taken into consideration, stenting may be recommended, says Caceres. “We have specific guidelines for when to stent and when to recommend bypass surgery. We can use stenting when a patient is diagnosed with one or two major arteries that have significant blockages. With three or more arteries compromised, bypass surgery might be the preferred treatment.”
Each patient’s condition must be evaluated carefully, says Caceres. Along with blocked arteries, the patient may have heart muscle weakness and valve disease. Other factors may include whether or not the patient is diabetic, has uncontrolled high blood pressure or low kidney function.
“Stenting can stop a heart attack in progress but does not, of itself, prevent heart attacks,” Caceres adds. “Also, the use of too many stents can interfere with the possible need to do bypass surgery later on. Having metal jackets the length of the artery leaves the surgeon no place to attach a graft.”
Stenting recently took another major step forward with the introduction of soft mesh stents that are absorbed into the patient’s vessel walls.
“These stents dissolve into the artery wall in two to three years, leaving the arteries clean and clear,” he says. “Add this to the advances in medicine and equipment that are helping patients with heart and vascular disease not only survive possible heart attacks, but also live full, active lives. At one time they might have been termed disabled.”
Caceres emphasizes that each treatment step should be fully discussed with the patient so that, ultimately, it’s the patient who makes a final decision, after he is informed of his options.
“I believe it is never a good practice to force a patient into a procedure or surgery,” he says. “Risks can include kidney failure, which may necessitate temporary dialysis. There can be internal bleeding or allergic reactions to the contrast used, or, in rare cases, to the metal in the stent. We have reduced some of these potential risks by inserting the catheter through the patient’s wrist instead of the groin. It’s less stressful and uncomfortable for the patient as well.”
Physician experience is another important factor, Caceres adds.
“There’s a risk of stroke, but it’s less than 1 percent when the stenting procedure is performed by a competent, fully trained and experienced cardiologist,” he says.

Da Vinci Robotic Surgery

For Dr. David G. Cable, a board-certified cardiac surgeon at OSF Saint Anthony Medical Center, the most innovative methodology available today involves the use of the da Vinci robotics system to do heart surgeries.
OSF is one of only three cardiac surgery departments in the Upper Midwest (including Illinois, Wisconsin, Minnesota, Iowa, Missouri and northwest Indiana) to offer minimally invasive bypass surgery. The University of Chicago and Mayo Clinics also provide da Vinci services but Mayo does only mitral valve replacement and single-vessel coronary artery bypass graphs.
“Da Vinci was first developed specifically for heart surgery but it proved so much more complex,” Cable explains. “Many surgeries are mostly about taking things out of the body such as a tumor, but cardiac surgery involves reconstructive procedures which can be more difficult.”
Because heart surgery still involves risk, Cable focuses on using the da Vinci for procedures that will attempt to minimize these risks but allow for the benefits of minimally invasive approaches to the heart.
“For example, I concentrate on the left internal mammary artery to address blockage of the most important coronary artery and bring this down to the heart to perform bypass surgeries,” Cable explains. “Minimally invasive robotics are also successfully used to treat atrial fibrillation (A-fib) by preventing the short circuiting in this arrhythmia.”
Another way the da Vinci has proven its worth is by treating chronic angina, in which the patient experiences constant chest pain.
“These patients have had stents implanted or had bypass surgery but are still having chest pain,” Cable says. “Basically, they have no further options. We’ve had patients that can’t walk across a room because of chest pain. With the da Vinci robot, we can use a laser to drill holes and this immediately numbs the heart but also stimulates the growth of new blood vessels. This stops the pain.”
Cable says remarkable benefits of da Vinci include smaller incisions, lower risk of infection, greater flexibility in treating each patient and swifter recovery time.
“Patients bounce back so much more quickly,” he adds. “A recent patient coded during a stress test on a Friday, had the bypass procedure using robotics on Monday, and was out of the hospital by Wednesday. This was primarily because da Vinci is substantially less invasive.”
The patient takes the lead on all cardiology decisions and treatments, says Cable.
“My job is to help them know the options available, but patients need to decide which option are best for them. We don’t do anything a patient doesn’t want. Still, it’s a tremendous advantage to have the da Vinci program available here at OSF. Not many medical centers have the money or the trained cardiac surgeon to offer it. It’s just one of the benefits of OSF Saint Anthony’s program. We have a three-star rating for cardiac surgery, which is only for the top 10 percent of heart surgery programs, a transcatheter valve replacement option which in only in 400 hospitals in the country, and we were just ranked in the top 50 hospitals in the country.”

TAVR for Elderly Hearts

The challenge in treating patients with malfunctioning valves is that the majority are older than 80, says Dr. Jan Skowronski, a board-certified interventional cardiologist at OSF. This is why a relatively new procedure called transcatherater aortic valve replacement (TAVR) is proving to be a lifesaver.
“The heart has four valves, two of which are the most important: the aortic and mitral valves,” Skowronski explains. “In the past, it was necessary to perform open-heart surgery, breaking ribs and cutting into the heart muscle to replace valves that no longer functioned properly because of calcification (aortic stenosis) or leakage. With older patients, that was extremely risky. At the same time, if the valve is not replaced, the patient will suffer heart failure and increasing shortness of breath, and will die horribly.”
By contrast, TAVR is a process similar to stenting. A pig’s valve is encased inside a stent and fed through an artery in the groin until it reaches the diseased valve. The stent snaps open, smashing the old valve out of the way while the new valve takes its place.
“This procedure causes far less stress on the heart and the patient,” Skowronski says. “I’ve performed TAVRs on patients as old as 97 and one of them is now a few months shy from her 100th birthday.”
In the past, patients who survived open-heart valve surgery stayed in the hospital for a long time and needed three to nine months of recovery time. In TAVR patients, recovery time is substantially reduced and the patient is better able to resume a full, active lifestyle.
“We had a 92-year-old TAVR patient who attended our OSF reception less than two weeks after the procedure,” Skowronski adds. “When I was first in practice, I would have never dreamed of or anticipated this incredible advancement and such great patient outcomes.”
Earl Lutzow, a patient of Skowronski, sums up the amazing advances being made in the field of cardiology this way: “I had a pacemaker installed in 2004 and open-heart bypass surgery in 2013. Since then, I’ve been in and out of the hospital. But it wasn’t until earlier this year that I learned I also had a bad valve.”
Because of dangerously low sodium and potassium levels plus also being treated for cancer, he entered OSF on July 3 and was stable enough for TAVR surgery on July 14.
“My heart was working at 21 percent,” Lutzow recalls. “I couldn’t walk and was constantly out of breath. I had no energy and could barely talk. Even with the stabilization, I was so sick that I coded twice on the operating table. Dr. Skowronski, Dr. Hart and their coordinator, Emily Dempsey, saved my life. I’m on the road back. I can walk now and talk.”
Lutzow credits the team effort for his recovery, including the cessation of chemotherapy treatment during the time he was being prepared for TAVR surgery.
“I had no fears,” he concludes. “The OSF team is just like family. I have nothing but hope for the future now.”
Skowronski adds that OSF is the only medical center in northern Illinois that offers TAVR.
“One of the added privileges of working so successfully with patients who have reached the ages of 80 and beyond is listening to their life stories,” Skowronski concludes. “It is justifiably called The Greatest Generation, those who were born in the 1920s, and the stories they share of The Great Depression and World War II and the values with which they grew up are so inspiring and frankly humbling. They are America’s best. It’s such an incredible lesson for us and our children.”