Cutting-Edge Cardiology: Bringing the latest tools and technologies to Saint John's
December 25, 2014
Nancy Beacham, 71, a retired publishing professional in Playa Vista, has had her share of health worries. She succeeded in dropping more than 100 unhealthy pounds through a 12-step program and survived a bout with breast cancer. But it was her time on the blood thinner warfarin—treatment for her atrial fibrillation—that nearly got the best of her.
A variety of foods can interfere with warfarin and render the medication ineffective. “I was frightened of bleeding,” says Beacham, who is a volunteer counselor in the field of addictions and also an elementary school volunteer. “I was frightened of gaining weight because of the restrictions on my diet. I felt powerless.”
So Beacham jumped at the chance to get an alternative to the blood thinner: a surgically implanted device called the Watchman, which she received at Saint John’s Health Center.
“To get off the blood thinner seemed like the impossible dream,” she says. “What the Watchman represents to me is to live a life with purpose. It made me healthy so I could help others who are trying to be healthy. My happiest moments are in my volunteer work with children.”
Atrial fibrillation, or A-fib—a heart rhythm abnormality affecting 6 million Americans—occurs when the heart beats erratically, causing blood to clot in the heart’s left atrial appendage. This can cause life-threatening strokes. Warfarin lowers stroke risk; however, blood levels of the drug must be frequently monitored because they can be easily thrown off by foods and other medications.
Blood thinners also have another more obvious disadvantage: they increase the risk of bleeding, posing a particular problem as people age and the risk of falls increases. “We’re stuck in a difficult position with older patients,” says Shephal K. Doshi, MD, director of cardiac electrophysiology and pacing at Saint John’s. “It’s a catch-22.”
The Watchman device, an expandable metal cage that looks like a parachute, is guided through a catheter inserted into a vein in the leg. It is placed in the atrium to block the left atrial appendage so blood can’t collect and clot. The left atrial appendage is a pouch-like structure that is believed to be the source of most of the blood clots that occur in non-valvar atrial fibrillation patients.
“It offers a way to seal off this pouch in people at risk for stroke from atrial fibrillation as an alternative to taking blood thinners,” says Dr. Doshi.
Older patients with A-fib and on blood thinners who are poor candidates for long-term use of blood thinners are the ideal candidates for the Watchman device. “The average age is 72, but I’ve treated patients as old as 94,” he says.
Beacham was part of a five-year, multicenter clinical trial designed to compare the device to warfarin. “The data show that the Watchman was as good as warfarin in reducing stroke and has less bleeding and improved cardiovascular survival. Patients get the benefit of blood thinners with a lower risk of bleeding,” says Dr. Doshi, a pioneer in using the device.
Dr. Doshi spearheaded the trial at Saint John’s and has performed more than 300 Watchman procedures. He has helped train many physicians in the United States and worldwide, launched the procedure in Europe and conducted the first cases in Asia.
“He’s done more than anyone else in the country and performed the procedure in more than 14 countries. He was also a key presenter at the recent Food and Drug Administration approval meeting in Washington,” says John M. Robertson, MD, chairman of the Saint John’s Health Center Foundation board of trustees and director of thoracic and cardiovascular surgery at the Health Center.
Although the Watchman does not have the FDA’s approval yet, there is optimism that approval could come soon; an advisory committee has already voted in its favor.
“We look forward to the FDA’s final review,” says Dr. Doshi. “Our expectation is that if it’s approved, it will be covered by Medicare.” Coverage by Medicare would make the device available to many more individuals.
Saint John’s physicians are also at the forefront of other treatments for stroke prevention in A-fib, including performing, in 2009, the first non-surgical procedure that use sutures to tie off the left atrial appendage. Using the LARIAT Suture Delivery Device, physicians guide two catheters into the patient’s heart to seal the appendage with a pre-tied suture loop.
While the search for alternative therapies to anticoagulation has been paramount, Dr. Doshi has developed a world-class center for the actual correction of A-fib itself with catheter ablation. This progress stems from groundbreaking research and a high volume of cases.
“As A-fib has become an epidemic for our aging population, we will continue to seek innovative approaches to correct it." – Dr. Shephal K. Doshi
For example, the first endoscopic laser balloon ablation for atrial fibrillation in the United States was performed at Saint John’s. For the first time, physicians could see into the heart through a catheter equipped with a tiny camera and use laser energy to destroy unhealthy heart tissue where abnormal heartbeats may cause an arrhythmia to start.
“We boast some of the most advanced technology, certainly in Los Angeles but also in the United States,” says Dr. Doshi. This includes the most up-to-date, three-dimensional mapping systems. The Health Center’s electrophysiology lab is a Technical Expertise Center for A-fib ablation and hosts physicians from all over the world to observe and learn advanced techniques.
“We have some of the highest success rates with ablation and a complication rate that is much, much lower than that reported elsewhere,” Dr. Doshi explains. “One of our specialties is minimizing a patient’s exposure to X-ray radiation during the procedure.” While most centers use anywhere from 20 to 40 minutes of X-ray during the ablation, Dr. Doshi averages less than 30 seconds per case.
Recently a team of physicians from China visited Saint John’s Health Center to observe this technique. Another first at the Health Center was a live transmission of an A-fib ablation to the Asia Pacific Heart Rhythm Society meeting in New Delhi, India, a gathering of arrhythmia specialists from all over the world.
“As A-fib has become an epidemic for our aging population, we will continue to seek innovative approaches to correct it,” Dr. Doshi says.
Minimally invasive heart valve replacement
Equally groundbreaking advances are coming to the Health Center’s valve clinic, which is introducing a new type of valve replacement. Called transvascular aortic valve replacement (TAVR), the minimally invasive procedure involves repairing a damaged valve without removing it.
To perform TAVR, surgeons place a collapsible replacement valve through a catheter into the old valve, similar to placing a stent in an artery. Once the new valve is expanded, the old valve is moved out of the way and the new valve takes over the job of regulating blood flow.
Traditional surgery requires opening the sternum and putting the patient on a heart-lung machine, and thus completely stopping the heart while surgeons replace the faulty valve with an artificial one.
“TAVR is far less stressful for the patient,” says Peter C.D. Pelikan, MD, medical director of Saint John’s cardiac catheterization laboratory. “Valves are put in either through an artery in the groin or a small incision in the chest. The heart keeps beating, and the patient avoids all the trauma of opening the chest and cardiopulmonary bypass.”
In addition to suffering less pain, patients typically experience a quicker and easier recovery. “The average patient goes home two to three days later feeling pretty well,” says Dr. Pelikan. Candidates for the procedure are people for whom open-heart surgery is too risky—generally older patients.
“There are a variety of technical requirements, such as assessing the size of the arteries and determining the right size valve to put through the catheter,” Dr. Pelikan says. “All the ducks have to be lined up before doing TAVR. We want to be sure the patient is right for the procedure and the procedure is right for the patient.”
To properly assess prospective patients, the hospital is laying the groundwork for a multi-specialty valve clinic. The clinic will offer “one-stop shopping,” Dr. Pelikan says.
Patients will be evaluated by different practitioners—cardiologists, surgeons, nurse practitioners—and receive needed tests, including ultrasounds of the heart and CT scans. Importantly, the clinic will allow patients with valve disease to be assessed over time and treated appropriately.
“Patients with valve disease need to be followed,” Dr. Robertson says. “With the passage of time, valves get narrower and narrower, leading to stenosis.”
The plan for a multi-specialty valve clinic also calls for a hybrid operating room, which combines the functions of a catheterization lab and an operating room and is equipped with the advanced medical imaging devices required to perform minimally invasive cardiac procedures. “If circumstances warrant, you need to be able to perform open surgery,” Dr. Robertson explains.
Superior cardiac care
Being on cardiology’s cutting edge is par for the course at the Health Center, which has been named a Healthgrades™ America’s 100 Best Hospitals for Cardiac Care for the past three years and a Healthgrades 100 Best Hospitals for Cardiac Surgery in 2014. Saint John’s has had many firsts in cardiac care, including performing one of the world’s first open-heart surgeries called coronary artery bypass grafting.
“Since the beginning of the hospital, cardiovascular care has been one of our primary service lines,” says Dr. Robertson. “We have always provided state-of-the-art cardiovascular care, and our clinical results over the years have been outstanding.”
Saint John’s boasts four separate catheterization laboratories located adjacent to the operating room and a short distance from the emergency room. The facilities are equipped with advanced imaging equipment and electronic communications technologies, allowing images to be uploaded to cath lab monitors in seconds—improving outcomes for patients with heart attack and other cardiac conditions.
Thanks to technological capabilities like these, the Health Center was also invited to be part of a national initiative designed to improve the treatment of patients with heart attack symptoms. Saint John’s is one of 30 hospitals in Los Angeles County designated to receive patients having the most severe kinds of heart attacks. The Health Center was named one of the top 14 hospitals in California for outstanding heart attack outcomes by the Office of Statewide Health Planning and Development (OSHPD).
Says Dr. Robertson, “The latest and most innovative technology and techniques plus our reputation for
excellent patient care provides for an outstanding program overall.”
Nancy Beacham agrees. She has been free from the restrictions of blood thinners and stroke fears since her surgery 10 years ago.
“Dr. Doshi’s whole team was so compassionate and caring,” she says. “I felt like I could place my health in their hands.”
A campaign to raise $5 million is underway to build a new cardiac valve clinic specializing in transvascular aortic valve replacement (TAVR), a minimally invasive procedure that repairs a damaged valve without removing it.
To learn more about supporting the TAVR program, please call Irene Bristol at 310-829-8348.