New technologies, from the heart-lung bypass machine in the 1950s to the miniaturized echocardiogram transducers of today, has changed the delivery of cardiac care. These advances in imaging tools and technologies, as well as in the size and capabilities of catheters, are improving cardiac treatment options and quality of life for patients in Hampton Roads and across the globe.
Percutaneous Treatment of Valvular Heart Disease
Thousands of patients have now benefited from rapidly developing percutaneous treatments for valvular heart disease. These treatments are made possible by the development of specially designed stents that expand and contain an artificial valve.
“Recent developments in structural intervention are exciting, namely the transcatheter valvular therapies for valvular heart disease,” says Dr. David Adler, an interventional cardiologist who practices at Cardiovascular Associates, a Bayview Physicians Group practice, and is on staff at Sentara and Chesapeake Regional Healthcare.
“In my world, these advances are exciting and welcomed,” Dr. Adler says.
Percutaneous approaches primarily benefit older, high-risk patients with multiple co-morbidities. As Baby Boomers age, this patient population is expected to increase and raise the demand for catheter-based approaches.
Many of these novel therapies are already seeing success, lowering the rates of morbidity and mortality in high-risk patients. Current effective treatments include:
• Transcatheter aortic valve replacement (TAVR) for aortic stenosis
• Transcatheter pulmonary valve replacement for pulmonary stenosis
• Transcatheter mitral valve repair for degenerative mitral regurgitation
“To date, [transcatheter aortic valve replacement] is very impressive for those who are at a high risk for open heart surgery. This has shown to be a better option. It has moderate risk and the benefit is that the patient has an easier recovery. Most can leave the hospital in 24 to 48 hours after it is done,” Dr. Adler says.
Percutaneous approaches for valvular heart disease still need further study and refinement. Research is underway to develop transcatheter mitral valve replacements as well as improve the efficacy of existing valve replacements. As these procedures improve, physicians are likely to utilize them more and more often while serving a wider range of patient populations.
Catheter Ablation for Abnormal Heart Rhythms
Dr. Edward Chu, interventional cardiologist with Riverside Cardiology Specialists, says there have been great advances in the treatment of abnormal heart rhythms in the form of catheter ablation.
Cardiac electrophysiologists utilize catheter ablation to treat a variety of arrhythmias, from atrial fibrillation to ventricular tachycardia. While radiofrequency catheter ablation is still the most commonly used procedure, current research is examining the benefits and efficacy of cryotherapy and laser energy ablations. Some electrophysiologists consider cryotherapy to be a safer approach; however, studies have shown that patients are more likely to experience recurrence of arrhythmias after cryoablation than radiofrequency ablation.
New devices and imaging approaches are improving the effectiveness and safety of ablation procedures. Advanced catheters can offer vital information about contact force between the catheter and heart tissues, helping physicians use the right force to create appropriate lesions without risk of perforation. Multi-array ablation catheters allow physicians to create lesions in multiple parts of the heart at once. However, these catheters have mixed success and need further study.
Electrophysiologists are also finding intracardiac echocardiography (ICE) provides more accurate guidance of ablation procedures. The catheter-tipped miniaturized echo transducer offers real-time images of the heart as well as evaluation of tissues. The use of this device may lead to a reduced risk of damage to healthy tissues as well as improve precision of lesions. ICE is not currently used widely for ablation procedures, but may become more common as catheter ablation procedures become more targeted.
Radial artery catheterization
Radial artery catheterization for interventional procedures became possible in the early 1990s thanks to new, more delicate catheters that could move through the smaller arteries in the wrist. This approach continues to grow in popularity for both diagnostic and interventional procedures. The procedure is becoming safer as physicians gain more experience with this delicate approach to catheterization.
Dr. Chu states that at Riverside Regional Medical Center, catheterization is now commonly accessed by the radial artery. The procedure is more comfortable and the patient is released from the hospital sooner than with the femoral access site. Patients are also at a lower risk for bleeding with the same high success rates achieved with femoral artery catheterization.
Treatment for the Smallest Heart Patients
Children’s Hospital of The King’s Daughters (CHKD) has the only accredited fetal echocardiography lab in the region. Fetal echocardiography uses ultrasound technology to create a more detailed picture of the fetus’s heart than is obtained from a standard ultrasound, says Dr. Jonathan Fleenor, director of cardiology at CHKD.
Fetal echocardiography shows the fetus’s heart structure, blood flow and heart rhythm, allowing the accurate diagnosis of many, but not all, heart problems.
A special prenatal team consisting of a pediatric cardiologist, pediatric sonographers and a social worker works closely with the families. They also work with referring physicians, neonatologists, geneticists and others as needed to create prenatal and postnatal management plans, Dr. Fleenor says.
Many of the mothers who undergo fetal echocardiography are patients of the Maternal Fetal Medicine Department at Eastern Virginia Medical School, the region’s referral center for high-risk pregnancies.
Most mothers usually deliver their baby at Sentara Norfolk General Hospital, which operates a perinatal intensive care unit for high-risk patients and complicated births.
CHKD’s neonatal unit is connected to Sentara Norfolk General by an interior hallway, allowing neonatologists to easily attend births and begin care in the delivery room.
Collaboration between CHKD and University of Virginia
Hampton Roads children with heart conditions will receive the most up-to-date treatment with the recent collaboration between CHKD and University of Virginia Children’s Hospital in Charlottesville.
The partnership between the two cardiac programs, led by Dr. Jay Gangemi, combines the medical efforts of pediatric cardiologists, cardiac surgeons, cardiac anesthesiologists, intensive care physicians and cardiac support professionals.
The University of Virginia’s pediatric cardiac surgery program is ranked among the best in the nation according to, U.S. News and World Report, while CHKD has the highest volume pediatric surgical program in the Commonwealth, according to Jim Dahling, president and CEO of CHKD Health System.
Dr. Fleenor says that prenatal diagnosis of babies with heart conditions through technology like fetal echocardiography is a major benefit to successful treatment. If a fetus is found to have a heart condition, physicians can immediately begin preparations for proper medical intervention.
“Together with UVA, we can come up with the best plan. In cases like this, it is always good to have an extra set of eyes,” Dr. Fleenor says.
Heart problems occur in 1 percent of babies born in the area, and about a quarter of these problems are critical. While the percentage may seem low, Dr. Fleenor says it is the most common birth defect overall. Physicians perform about 150 heart surgeries each year at CHKD.
As imaging becomes clearer, catheters become smaller and devices become more effective, cardiac patients of all ages will have the treatment options they need for a higher quality of life.
