Page 36 – Englewood Health

TAVR Expands Treatment of Aortic Stenosis to More Patients

Posted on September 18, 2017January 24, 2024 by John Williams

TAVR Team doctors — Members of the Englewood Hospital and Medical Center TAVR Team, from left to right: Joseph De Gregorio, MD, Lance Kovar, MD, Ramin Hastings, MD, Richard Goldweit, MD, Adam Arnofsky, MD.

High-risk cardiology patients in northern New Jersey now have the opportunity to undergo transcatheter aortic valve replacement (TAVR) at Englewood Hospital and Medical Center, one of the first hospitals in the country to offer the procedure since the FDA approved it in 2011.

Thanks to the efforts of Englewood Hospital’s staff of cardiology experts and its reputable surgical infrastructure, it was able to become a major center to offer TAVR to high-risk patients who have severe aortic stenosis or who are not considered ideal candidates for open-heart procedures. Since then, Englewood Hospital has performed the procedure on 250 of these patients.

“We’re operating on patients in their 70s, 80s, and well into their 90s. Formerly, referring physicians and cardiologists would never have thought of sending patients that old for a procedure, and they would just be stuck at home feeling unwell,” said Adam Arnofsky, MD, a cardiothoracic surgeon at Englewood Hospital and Medical Center. “Now we have a procedure we can offer them with a very quick, easy recovery that can get them symptom-free and really turn their lives around.”

Initially, the manufacturer of the TAVR device was very conservative in identifying centers with which it wanted to be involved. “They were rolling the device out in a very particular way, where they wanted the proper operators and a specific surgical setup. We fit the bill,” said Joseph De Gregorio, MD, section chief, invasive cardiology at Englewood Hospital and Medical Center.

Since TAVR was introduced at Englewood Hospital, the program has grown dramatically each year. The heart team performed more than 100 TAVR cases in 2016 and expects substantial growth in 2017, especially since the FDA has approved the device for intermediate-risk patients in addition to the high-risk patients for whom it was already approved. “That expanded the procedure tremendously,” Dr. De Gregorio said.

Englewood Hospital’s cardiac surgeons and cardiologists have observed a high success rate in TAVR patients, with outcomes better than the national average. Dr. De Gregorio attributes this success to the multidisciplinary approach.

“This takes a real team approach, and we have an excellent team in place, which is not common in most centers,” he said. “That’s really why we’ve done so well.”

With their TAVR program well underway, the team is now set to embark on their next project: the MitraClip. “That’s expanding the transcatheter structural heart therapeutics to the next level,” Dr. Arnofsky said. “This is the first procedure that’s been FDA approved to correct mitral valve abnormalities in high-risk patients who are not candidates for an open procedure. We have performed several MitraClip procedures so far.

“Englewood Hospital has been a great place to work,” said Dr. Arnofsky, who has been with the hospital for eight years. “The collegial relationships we have among the departments allow us to be involved with some of the highest, newest technological advances out there to treat patients with cardiovascular disease.”

Another technological development is an absorbable coronary stent. Dr. De Gregorio was one of the investigators involved in a three-year-long clinical trial of the stent, which was approved by the FDA last year.

“When people have blockages in their coronary arteries, we’ve historically used metal stents that act as scaffolding to open up the area blockage. But those stents stay in forever. The artery grows around it, and the stent becomes embedded, a permanent part of the arterial wall,” he said.

These new stents, which are made of polylactic acid, start to be resorbed by the body at six months. By the end of three years, they are often completely resorbed. “The basis of this is that by six months you wouldn’t need a stent anymore because the artery has healed in an open position,” Dr. De Gregorio said.

“Englewood was one of the few centers involved in the trial, and we can now offer that procedure. If we can make a resorbable stent that’s as easy as the metal stent in terms of usability, we’d be better off using the resorbable stent. We don’t like to leave things behind; we like arteries to return to their normal state.” It is possible that future generations of the resorbable stent could replace metal stents in most situations, he added.

Dr. De Gregorio, now in his 11th year as co-director of the annual Complex Interventional Cardiovascular Therapy (CICT) meeting, an educational conference dedicated to discussions of structural and interventional therapies, gave a presentation on the absorbable stent at the meeting, which took place at the end of July in San Francisco.

Combined TAVR and EVAR Procedures

Although open-heart surgeries are common, Englewood Hospital and Medical Center is committed to providing less invasive options. One such option, transcatheter aortic valve replacement (TAVR), allows physicians to repair an old or damaged valve without actually removing it. Another, endovascular aneurysm repair (EVAR), involves making a small incision in one or two arteries in the groin and inserting a catheter to guide a graft into the aneurysm. The benefit of this procedure is that there is no need for abdominal surgery, and it has fewer associated risks and a short recovery time.

A TAVR procedure may become more complicated if a patient has an aneurysm that requires intervention from a vascular surgeon. This is where Englewood Hospital’s multidisciplinary approach comes into play.

The seamless coordination between Englewood Hospital’s cardiac and vascular surgeons allows for smooth handoffs of those patients who require additional interventions. An advanced and minimally invasive technology that has come out of this process is fenestrated EVAR grafts, which give vascular surgeons the ability to navigate and fix aneurysms while maintaining the integrity and structure of the valves and veins. This is an advanced technique, and with fenestrated grafts, more patients with different anatomies can be treated, as the devices can fit almost all patients.

“Fenestrated devices can now be used to treat more and more patients because 30% of patients had anatomies that didn’t fit a standard,” said Michael Wilderman, MD, a vascular surgeon at Englewood Hospital. “As the devices get better, we’ll be able to treat almost all patients with minimally invasive procedures as opposed to open surgery.”

Fortunately, the cardiac and vascular surgeons at Englewood Hospital can decide the best course for individual patients with abdominal aortic aneurysms and which of the two types of EVAR procedures (standard and complex) they should receive.

Posted September 2017

World-Class Cardiovascular Care Close to Home

Posted on September 18, 2017May 17, 2023 by John Williams

Vascular Surgery — Vascular surgery at the Heart and Vascular Institute is designed around a multidisciplinary approach.

“Even before I came here, Englewood Hospital had in place high-end technology for vascular surgeons to perform advanced procedures,” said Thomas R. Bernik, MD, chief, vascular surgery at Englewood Hospital. “A lot of our physicians are New York City transplants, including myself. We have the technology here, the medical teams and the administrative support that I really didn’t have in New York City. It was one of the attractions for me to come here.”

Dr. Bernik came to Englewood Hospital in January 2016 from Mount Sinai Beth Israel, in New York City, where he was an associate professor of surgery and chief of vascular surgery. Prior tothat, he was chief of endovascular surgery at St. Vincent’s Hospital and Medical Center, also in New York City. As a vascular and endovascular surgeon, Dr. Bernik specializes in complex open surgery and minimally invasive surgery for aortic aneurysms, carotid disease, peripheral vascular disease, dialysis access and complex venous thrombosis.

Dr. Bernik is continuing to expand the hospital’s vascular surgery services and oversees the leadership of the Wound Care/Limb Salvage Center.

Englewood Hospital’s programs are multidisciplinary, which foster and individualize patient care. Doctors, even those at major big-city academic hospitals, tend to work in silos, Dr. Bernik said, and operate within their specific disciplines.

“The uniqueness of what we have here is the multispecialty design of the programs,” Dr. Bernik said. “We start with a very good vascular surgery base of physicians, but we also have support from all the different disciplines that we bring into our programs, helping us give the quality of care that is needed.”

For example, the Wound Care Center brings in specialists from infectious diseases, vascular surgery, cardiology and endocrinology to provide comprehensive, whole-body care. “These are some of the sickest patients that you are going to have in the hospital from a cardiovascular standpoint,” Dr. Bernik said. “They have multisystem organ issues.” These include coronary artery disease, lung disease or kidney disease, he noted, and all of those specialties should have a say in the treatment of that patient.

Because vascular issues can affect the entire body, “we have multispecialist practices that participate in the care of the one patient,” Dr. Bernik said. “The biggest thing we do for the care of patients who are really sick is maintain our focus on quality, quality, quality.” That focus on quality has been consistently recognized by external rating agencies, including CareChex, a division of Quantros, Inc., which recognized Englewood Hospital’s vascular surgery division as being among the top 10% in New Jersey and the nation for both medical excellence and patient safety in 2016.

Posted September 2017

Englewood Hospital: Dedicated to Continuous Improvement

Posted on September 18, 2017May 17, 2023 by John Williams

Now more than ever, it is an exciting time to be caring for patients with heart and vascular disease. New developments in technology, rapidly expanding expertise in surgical and catheter-based treatments, and new treatment options derived from national clinical trials in which Englewood Hospital and Medical Center has participated have greatly expanded the options available for treating patients, including the critically ill and elderly.

At the Heart and Vascular Institute at Englewood Hospital, we are dedicated to patient- and family-centered care for those with heart and vascular conditions through a full range of treatment options that match those provided by the most highly regarded academic medical centers in the region. We have a proud history of service: Our team has performed more than 4,000 open-heart surgeries since we began this program in 2000, and it has one of the lowest mortality rates in the state for coronary bypass surgery. Last year alone, we performed more than 100 transcatheter aortic valve replacements (TAVRs) for treating severe aortic stenosis; and for more than two decades, we have been an international leader in patient blood management and bloodless surgery, which has been shown to significantly reduce the incidence of serious and life-threatening postoperative complications, including for open-heart surgery.

Heart and Vascular Institute centers of excellence — The Heart and Vascular Institute’s four centers of excellence.

As ever, we are engaged in continuous improvement to drive forward quality and outcomes. With new energy, we are enhancing the Heart and Vascular Institute by aligning our efforts under four centers of excellence: structural heart disease, coronary artery disease, aortic disease and arrhythmia management. Together our surgeons, interventional and noninvasive cardiologists, cardiac electrophysiologists and vascular surgeons are working toward improving access, expanding treatment programs, pushing quality even higher, and aligning ourselves with efficient partners as we prepare for and participate in new payment models that demand the highest quality.

Among our resources for referring cardiologists and primary care physicians are recent innovations: an Impella program to support patients in cardiogenic shock or severe heart failure and complex coronary interventions; the TAVR program for treating severe aortic stenosis; the WATCHMAN device for left appendage closure to reduce the risk for stroke in people with atrial fibrillation; MitraClip procedures for managing inoperable mitral valve disease; transcatheter interventions for chronic total coronary artery occlusions; and thoracic endovascular aortic repair, a minimally invasive procedure to address aortic aneurysms. Many of these new procedures are alternatives to major surgery, giving critically ill or elderly patients a previously unavailable option.

Our expertise in these areas makes Englewood Hospital and Medical Center a leader in advanced cardiovascular care. Our goal is to work closely with cardiologists, and other referring physicians, throughout the region to ensure that all adults with heart and vascular disease can be treated close to home, with the highly personalized care for which Englewood Hospital is known.

Posted September 2017

Collaboration and Communication Define the Electrophysiology Team

Posted on September 18, 2017May 17, 2023 by John Williams

WATCHMAN implant — The hospital was the first in northern New Jersey to implant the WATCHMAN device, a safer alternative to blood thinners.

“We are a high-quality, high-volume center,” said Grant Simons, MD, section chief, heart rhythm services at Englewood Hospital and Medical Center’s Heart and Vascular Institute. “We have the most advanced mapping and ablation technologies available. For example, we’re able to use 3-D mapping of atrial fibrillation to pinpoint problems in time and space with the clearest possible computer-rendered images.”

In fact, the reputation, experience and expertise of Dr. Simons and Englewood Hospital’s electrophysiology team were why the hospital was chosen as northern New Jersey’s first hospital to implant the WATCHMAN Left Atrial Appendage Device (Boston Scientific) for nonvalvular atrial fibrillation. The WATCHMAN device, which the FDA approved in 2015, is implanted into the heart’s left atrial appendage via a delivery catheter in the femoral vein to prevent blood clots from entering the bloodstream and causing ischemic stroke.

“While blood thinners can be effective, they have the potential for some dangerous side effects,” Dr. Simons said. “The WATCHMAN implant is actually a safer alternative to blood thinners, and it is more effective at reducing stroke risk among patients with atrial fibrillation. It also means a patient no longer needs to take blood thinners for the rest of his or her life.”

Although the relatively new procedure is only covered by insurance if a patient is considered an unsuitable candidate for long-term blood thinners, it is gaining traction. The procedure is relatively quick, taking anywhere from 45 minutes to 1.5 hours, and patients go home the next day requiring only a short-term course of anticoagulants.

Low Complications, High Innovations

“As awareness of the WATCHMAN increases, we’ve become a destination for this procedure and the LARIAT procedure, as well as cryoablation and mapping of atrial fibrillation,” Dr. Simons said. The LARIAT procedure is a minimally invasive alternative for patients with atrial fibrillation who are unable to take blood thinning medications. “We’re recommended because we have a very low complication rate, innovative technologies, a dedicated nurse practitioner program and a patient-centered system that quickly connects patients with physicians. We’ve eliminated that waiting-around, lost-in-the-system feeling,” Dr. Simons added.

Asad Cheema, MD, Medical Director, Cardiac Electrophysiology Laboratory

In addition to the patient-oriented approach, the electrophysiology team works collaboratively, relying on decades of experience. “The team at Englewood is extremely experienced and that makes a huge difference when you’re working in such a complicated field,” said Asad Cheema, MD, medical director, electrophysiology laboratory who performs ablations for correcting arrhythmias at Englewood Hospital. “When you have a team of nurses and doctors that have been together for two decades, everything moves smoothly, everyone knows their roles, and everything runs like a well-oiled machine.”

Catheter ablation cures arrhythmias such as those seen in Wolff-Parkinson-White syndrome or atrioventricular nodal reentrant tachycardia, a type of supraventricular tachycardia. Dr. Cheema and the other physicians in the department often use radiofrequency energy to heat the catheter tip for precise ablation of live heart tissue. The procedure, which has a nearly 100% success rate, is quick and patients leave the same day, only needing to take a short course of aspirin.

Dr. Cheema explained that the laboratories at Englewood Hospital use the most advanced satellite sensors to pinpoint the exact location of catheters and the diseased tissue in the heart, allowing for cure of arrhythmias without risking side effects, such as esophageal damage. “All the latest technology and all the bells and whistles improve outcomes, recovery time and the patient’s prognosis,” he said. “It’s really a great way to treat patients.”

While heat cures arrhythmias, the electrophysiology team—which includes David Feigenblum, MD, PhD, Dmitry Nemirovsky, MD, and Satish Tiyyagura, MD—often also uses cryoablation to freeze heart tissue that causes paroxysmal atrial fibrillation. The surgeons use 3-D mapping to tailor the cryoballoon to variations in left atrial size and pulmonary vein anatomy.

The variety of expertise and experience creates a collaborative atmosphere at Englewood Hospital. “While we have our own teams, we often communicate and share thoughts on tough cases,” Dr. Cheema said. “We’re competing for excellence. We’re not competing against each other.”

Dr. Cheema sees something unique at Englewood Hospital. “We develop wonderful relationships because the hospital environment is friendly and patient oriented. Patients get directed to the right person very quickly.”

Posted September 2017

New Program Targets Coronary Artery Chronic Total Occlusions

Posted on September 18, 2017May 17, 2023 by John Williams

CTO procedure — The success rate using standard PCI techniques was historically only about 40% to 50%. With newer technologies and techniques, the success rate at Englewood Hospital now exceeds 90%.

The use of novel technology in the newly established coronary artery chronic total occlusion (CTO) program at Englewood Hospital and Medical Center is giving many patients a new lease on life.

CTOs are arteries that are 100% blocked for three or more months. They are responsible for clinically significant decreases in blood flow, and they can affect the survival and quality of life of hundreds of thousands of people who have artery blockages. CTOs also are identified in up to 31% of patients referred for coronary angiography.

Now, a procedure called percutaneous coronary intervention (PCI) can successfully treat over 90% of patients with CTOs and improve their quality of life.

While some patients with CTOs are treated with bypass surgery, 60% of them are treated with only prescription drugs. Many of these patients also are told that nothing can be done to open their CTOs using standard angioplasty and that they may end up living with chronic angina. Historically, fewer than 5% of CTOs in the United States have been treated by traditional PCI, but now with novel techniques in use at selected medical centers, including Englewood Hospital, many patients can be effectively treated with PCI.

“Historically, using standard PCI techniques, the success rate was only about 40% to 50%,” said Aron Schwarcz, MD, an interventional cardiologist at Englewood Hospital. “With newer technologies and newer techniques, the success rate at Englewood Hospital exceeds 90%.”

Dr. Schwarcz, along with Richard Goldweit, MD, developed the CTO program at Englewood Hospital in 2015. The program uses a hybrid algorithm to determine which methods would be most effective to achieve a successful PCI outcome. There are three techniques to cross the CTO stenosis: using wires to enter the lesion, using the subintimal space to go around the lesion and reenter the vessel on the other side, or going retrograde past the lesion. Clinicians at Englewood Hospital have treated more than 60 patients since the program began, with nearly all experiencing a lower angina burden and an improved quality of life.

Dr. Schwarcz said clinicians should keep a few things in mind when managing coronary CTOs. First, not all patients have typical angina symptoms. “Patients don’t necessarily get chest pain or chest pressure. Some of our most symptomatic patients had chronic dyspnea on exertion and atypical chest discomfort as their angina,” he said. “You need a detailed history and workup to determine if the dyspnea or other symptoms are an anginal equivalent or from a different cause.”

Second, failing past treatments for CTOs doesn’t preclude an individual from receiving effective treatment with the new procedure.

In May 2015, one of the first patients to enter the CTO program at Englewood Hospital was a 57-year-old, small-business owner who was unable to work or travel due to crippling angina. He had a CTO of the left circumflex artery and had two previous failed attempts to fix the blockage. Physicians at Englewood Hospital treated the patient by opening the CTO using the novel PCI procedure.

“His case really stuck out in my mind. About a week after the procedure, we saw him for follow-up in the office, and he was ecstatic. He was feeling 100% better, and he was able to work at the level that he used to. He had no angina and no limitations,” Dr. Schwarcz said. “This case illustrates the types of patients that we can help and the benefit that we can give them.”

Posted September 2017

Bloodless Medicine Options for Cardiac Surgery Patients

Posted on September 18, 2017January 24, 2024 by John Williams

Patients for whom blood transfusion is not an option can still receive comprehensive care at Englewood Hospital and Medical Center, thanks to its pioneering Institute for Patient Blood Management & Bloodless Medicine and Surgery.

The bloodless medicine and surgery program dates to the 1990s, when the institution was approached by Jehovah’s Witnesses who were often denied medical care due to their religious objections to blood transfusions.

Jehovah's Witness blood table — Jehovah’s Witnesses make personal decisions on what they can accept in good conscience. It is important to discuss in advance what products or procedures are acceptable to each patient.

Richard Goldweit, MD — Richard S. Goldweit, MD, Section Chief of Interventional Cardiology and Medical Director of Cardiac Catheterization Laboratory

“Because we felt that this was such a compelling issue, we assembled key medical and administrative leaders to clearly define clinical, ethical and legal fundamentals for structuring such a program,” said Richard S. Goldweit, MD, section chief of interventional cardiology and medical director of cardiac catheterization laboratory at Englewood Hospital and Medical Center. “We’ve now developed an entire multidisciplinary science to support that effort and manage patients without transfusion.”

Although blood transfusion remains a common part of medical practice in many institutions, it carries a host of clinical and infection-related risks. In addition, transfusions can have negative costs and outcome implications.

“If you look back historically at the literature, the data on blood transfusion are not very good. Transfusions are overused, and there is only a relatively small number of cases where it is actually clinically indicated; most transfusions could be avoided,” Dr. Goldweit said.

In 2000, after observing the early benefits of reducing transfusions, the state of New Jersey partnered with Englewood Hospital to launch an innovative project designed to demonstrate the clinical and public health benefits of bloodless medicine and surgery in patients needing cardiac surgery. Within a few years, Dr. Goldweit and his colleagues published research showing that lowering the transfusion rate in open-heart surgery to 10% improved outcomes by reducing complications and improving survival.

“That 10% transfusion rate is sort of a landmark,” Dr. Goldweit said. “Year after year for more than a decade, Englewood Hospital had a zero mortality rate in cardiac bypass surgery.”

According to evidence documented in the surgical literature, excessive bleeding and vascular complications contribute to poorer outcomes and mortality. Because of this, Dr. Goldweit and his colleagues made the best use of all available technology and developed innovative techniques to avoid transfusions and minimize bleeding whenever possible.

For instance, Dr. Goldweit has developed a bloodless puncture, which consists of routinely working through the radial artery instead of the femoral artery. “Even in patients with myocardial infarction, I can perform a diagnostic angiogram and appropriate stenting procedure through the wrist, which has less bleeding risk.”

He also uses smaller devices to minimize bleeding and is judicious with the use of blood-thinning agents. “We use an intravenous agent that is like Plavix [clopidogrel] but that can be turned off during a procedure if you run into a problem,” Dr. Goldweit explained.

The ongoing success at Englewood Hospital in treating even the most challenging cardiac patients, such as those undergoing high-risk interventional procedures or chronic total occlusion, hinges on the dedication of everyone involved: a collaborative heart team approach.

“The patient blood management program at Englewood is very multidisciplinary. Interventional cardiology is only a small part of it,” Dr. Goldweit said. “We have everybody on the same page, whether they are vascular surgeons or hematologists or gastroenterologists, all trying to limit bleeding, and aggressively treat anemia. Thanks to this approach, we’ve seen many benefits, including improved patient outcomes, shorter hospital stays, less postoperative infections and greater patient satisfaction.”

In addition to publishing research on blood management in cardiac surgery, Englewood Hospital has been extensively involved in the investigation of various devices and therapeutic approaches for treating cardiac patients.

Englewood Hospital is now a participating site in the national ISCHEMIA trial, which is investigating how to best manage people with stable coronary disease, to determine whether medication or more invasive approaches would offer an advantage. “For a community hospital, we’ve enrolled quite a few patients into that trial,” Dr. Goldweit said.

The medical center has also been involved in trials investigating the use of antiplatelet agents in certain stenting platforms. “We’re very much engaged in research, and are now collating our data on TAVR [transcatheter aortic valve replacement] to compare our experience with other sites in New Jersey and nationally,” Dr. Goldweit said.

“Being engaged in research keeps you on the cutting edge,” he added. “It allows you to answer questions you may not have previously had the answers to, especially in situations where you have equipoise and you don’t know which way to go. However, with patient blood management, the benefits are clear.”

Posted September 2017

Prolonged Ambulatory Electrocardiography Monitoring Advances Stroke Care

Posted on September 18, 2017May 17, 2023 by John Williams

Medtronic Reveal size comparison — Insertable cardiac monitors enable physicians to continuously and wirelessly monitor a patient’s heartbeat for up to three years.

Long-term monitoring for atrial fibrillation with implantable cardiac monitors is a cutting-edge tactic for managing patients who have suffered a stroke, and it is an approach that neurologists and cardiologists at Englewood Hospital and Medical Center now regularly employ.

“We have been on the front line of advocating prolonged ambulatory electrocardiography [ECG] monitoring after stroke,” said Dennis Katechis, DO, a cardiologist at Englewood Hospital.

Patients admitted with an ischemic stroke are routinely placed on a heart monitor for the first 24 to 48 hours. In many cases, atrial fibrillation is difficult to detect within this short time period and the patient is discharged with a diagnosis of cryptogenic stroke (i.e., no cause is identified). Approximately 20% of ischemic strokes are considered cardioembolic, and atrial fibrillation is by far the most common cause of cardioembolic strokes.

Englewood Hospital was one of the first community hospitals to start using implantable cardiac monitoring after two major trials— EMBRACE (N Engl J Med 2014;370:2467-2477) and CRYSTAL AF (N Engl J Med 2014;370:2478-2486)— showed that prolonged ambulatory ECG monitoring was superior to conventional outpatient follow-up for detecting atrial fibrillation.

The EMBRACE trial demonstrated that atrial fibrillation was more readily identified in patients with cryptogenic stroke using an implantable cardiac monitor than with the conventional method of 24-hour Holter monitoring, specifically, 16.1% of patients at 30 days compared with 3.2%, respectively. In the CRYSTAL AF trial, an insertable cardiac monitor (Reveal XT, Medtronic) increased the rate of atrial fibrillation detection at six months from 1.4% to 8.9% for a control group that had received ECG monitoring.

Informed by these two studies, Englewood Hospital has taken a leadership role in the use of insertable cardiac monitors and has taken part in other trials involving implantable loop recorders.

Looped Recording

The latest monitoring technology, approved in March 2017, is the Reveal LINQ Insertable Cardiac Monitor with TruRhythm Detection (Medtronic), which enables physicians to continuously and wirelessly monitor a patient’s heartbeat for up to three years. The loop-recording device, smaller than a pen cap, can be inserted into subcutaneous tissue in the chest in a simple procedure that can be performed in an ambulatory setting. The device features a self-learning atrial fibrillation algorithm, which adapts to the patient’s heart rhythm over time. The cardiologist managing the patient is notified if a symptom is detected.

“The implant requires just a small incision and heals quickly,” said Lauren DeNiro, MD, medical director, stroke program at Englewood Hospital.

While many medical centers implant the device at a follow-up visit, Englewood Hospital does the procedure the day before a patient goes home from the hospital, so that no opportunity for early monitoring is missed. “A significant proportion of these patients—at least 15%— end up having atrial fibrillation,” Dr. DeNiro said. “This is important because it involves a different kind of treatment to prevent the next stroke. Prompt initiation of systemic anticoagulation is needed in most of these patients, as the presence of permanent or paroxysmal atrial fibrillation carries a cumulative risk of stroke that can be calculated based on a devised risk score.”

In addition to prolonged ECG monitoring, Englewood Hospital also has been on the forefront of nonpharmacologic therapy to prevent cardioembolic stroke. Grant Simons, MD, section chief, heart rhythm services, is responsible for the development and growth of the WATCHMAN program at Englewood Hospital.

The hospital participated in PROTECT AF, one of the trials that led to the approval of the WATCHMAN Left Atrial Appendage Closure Implant in 2015. This device, a self-expanding cage made of nitinol, provides an option for high-risk patients with nonvalvular atrial fibrillation who are seeking an alternative to warfarin or for those unable to take warfarin. Deploying the device in the left atrial appendage prevents a thrombus from forming and causing a stroke.

“The WATCHMAN device is truly revolutionary, a completely new standard of care in patients with atrial fibrillation to reduce their risk of stroke,” Dr. Katechis said. “It takes away the long-term risk of systemic anticoagulation for life.”

Posted September 2017

Cardiac Rehabilitation Center’s Care Is Key

Posted on September 18, 2017May 17, 2023 by John Williams

Although it’s impossible to rewrite the past, patients who have suffered from myocardial infarction, angioplasty, heart surgery or heart failure have the opportunity to improve the future. The key is cardiac rehabilitation. Medicare and all major insurance carriers cover a 12-week cardiac rehab program for patients with coronary artery disease, congestive heart disease with a low ejection fraction, or after bypass or valve surgery.

“It’s enormously beneficial and terribly underutilized,” said Samuel Suede, MD, section chief of cardiology and medical director of cardiac rehabilitation at Englewood Hospital and Medical Center. In fact, Dr. Suede cited numbers that the five-year mortality rate drops between 20% and 30% for patients who follow a prescribed cardiac rehabilitation program, yet only 20% to 30% of the eligible population enrolls in one.

“There’s a combination of factors that keeps the numbers low: from physicians who are unaware, so they don’t make a recommendation for cardiac rehabilitation, to patients who are resistant to starting an exercise regimen,” Dr. Suede said.

The Englewood Hospital cardiac rehabilitation center addresses patient apathy and maintains long working hours that can accommodate most patients’ schedules. The center’s staff works with patients one-on-one and coaches patients on every aspect of their well-being, including nutrition, stress management, and physical activity. The center also offers a comprehensive program with state-of-the-art exercise equipment.

“We really want to get a patient in as soon as they’re discharged,” Dr. Suede said. “So we’ve set up a comfortable and inviting atmosphere. We have experienced nurses and exercise physiologists who work closely with the patients. The staff is there for them and keeps them motivated and focused.”

The one-on-one setting allows the staff to educate patients in an intimate setting about their disease, risk factors, and lifestyle. “The program is customized for every single patient,” Dr. Suede said. “We customize the exercise program for anyone who has a neurological or orthopedic limitation.”

The care the staff puts into each patient leads to a very low dropout rate, Dr. Suede said. In fact, the program that the cardiac rehabilitation center created is so effective at stabilizing and reversing risk factors for heart disease and improving endurance and mobility that many patients choose to continue participating in the maintenance program after their insurance coverage lapses.

Dr. Suede reiterates the benefits of cardiac rehabilitation: Patients can return to their normal activity level sooner; their disease state is managed better; and with continuous exercise, their sense of wellness and mortality is improved.

Dr. Suede said he wishes more physicians referred their patients to cardiac rehab programs and more patients found the time and discipline to participate in cardiac rehab programs, given all of the benefits seen with Englewood Hospital’s cardiac rehabilitation center. “What could be better than a fully covered program that improves wellness and mortality?” he asked.

Posted September 2017

Cardio-Oncology Monitors the Challenges of Chemotherapy That Is Toxic to the Heart

Posted on September 18, 2017February 12, 2019 by John Williams

Echocardiology Lab — Cancer patients receiving potentially cardiotoxic drugs are seen in the echocardiology laboratory, which uses echo machines to ensure consistent results.

Expertise in cardio-oncology can be a decisive factor for patients challenged by the cardiotoxicity of cancer treatment who nonetheless need the therapeutic benefit of the medications.

Jay Erlebacher, MD, FACC, medical director, echocardiology laboratory at Englewood Hospital and Medical Center, has set up a cardio-oncology subsection in his lab and serves as the resident expert. “We have developed methodology to train our technical staff to do specialized heart function testing in patients who are getting chemotherapy, so we can follow their response to chemotherapeutic agents that are toxic to the heart,” he said.

Many cancer treatments can damage the heart, and patients with cardiac conditions treated with chemotherapy often have plans of care that differ from those who don’t. The top two cardiotoxic cancer drugs, doxorubicin (Adriamycin; others) and trastuzumab (Herceptin, Genentech), which typically are used in breast cancer patients, can cause chemotherapy-related cardiac dysfunction or weakening of the heart. Clinicians evaluate the heart function of patients receiving these drugs primarily by measuring left ventricular ejection fraction—the horsepower of the heart. A normal ejection fraction ranges from 55% to 65%, according to Dr. Erlebacher.

“The definition of chemotherapy-related heart dysfunction is when the ejection fraction drops by more than 10% and the final ejection fraction is under 50%. This happens in an unpredictable way in patients receiving Adriamycin and Herceptin,” Dr. Erlebacher said. “It is more common in people who have a history of heart attacks, valvular heart disease or other kinds of cardiomyopathy, as well as individuals with hypertension or diabetes, but this heart dysfunction can happen to young, healthy people, too. If clinicians keep pushing these drugs in someone whose heart has already become weak, they almost guarantee their heart function will be impaired and it can lead to congestive heart failure.”

Women treated for breast cancer with chemotherapeutic agents are at increased risk for developing congestive heart failure over the following five years, according to Dr. Erlebacher. Most doxorubicin toxicity occurs within six months of completing therapy and is dose-related, which is why patients taking doxorubicin receive an echocardiogram at baseline, at the end of chemotherapy, and then again six months later. Trastuzumab toxicity is not dose-related and can occur at any time, and thus, patients on this HER2-targeted therapy are evaluated every three months with an echocardiogram. Whereas damage from doxorubicin is often permanent, much of the damage from trastuzumab is reversible by holding or stopping use.

All cancer patients receiving potentially cardiotoxic drugs at Englewood Hospital are seen in the special subsection of the echo lab, which uses echo machines and employs two highly trained technicians to ensure consistent results. In addition to doxorubicin and trastuzumab, other drugs used routinely in oncology cause other problems, including clotting, atherosclerosis and severe hypertension. Tyrosine kinase inhibitors have adverse effects in a small percentage of patients and some new immunotherapies have been linked to rare lethal arrhythmias and reduced heart function.

Left Ventricular Global Longitudinal Strain

Recently, Englewood Hospital has started evaluating cancer patients for earlier signs of heart dysfunction using a newer measurement called left ventricular global longitudinal strain (GLS). GLS is assessed using automated speckle-tracking echocardiography to detect and quantify subtle disturbances in left ventricular systolic function. “The echocardiogram strain function looks at the relative motion of tiny speckles in the heart muscle,” Dr. Erlebacher explained. “In doing that, you can evaluate individual small segments of the heart in multiple planes.”

Alterations in GLS often precede any change in ejection fraction. If clinicians can detect subtle changes in heart function before they affect the overall ejection fraction, clinicians can provide standard treatments, such as ACE inhibitors or beta blockers, and reverse the course of many patients who would have developed heart dysfunction from chemotherapy. “The earlier you detect left ventricular dysfunction, the more successful you will be at reversing it,” Dr. Erlebacher said.

Dr. Erlebacher believes every center should have at least one or two cardiologists who are willing to take the time to specialize in cardio-oncology. “If you have a doctor who is not well versed and sees some of these changes, his first reaction may be to tell the oncologist to stop lifesaving chemotherapy,” he said. “The role of the cardio-oncologist is to watch the patient closely, treat if necessary, and permit the oncologist to give the patient as much chemotherapy as is safe, not stopping prematurely.” Thus, a trusting relationship between the cardiologist and oncologist is critical for the optimal care of cancer patients.

Posted September 2017

Taking the Stress Out of Going for a Stress Test

Posted on September 18, 2017February 12, 2019 by John Williams

Nuclear Stress Test: Cardiovascular Imaging — Cardiovascular imaging machines may be used to support a diagnosis of a heart condition or cardiovascular disease.

Driving in heavily populated northern New Jersey can be demanding even at the best of times.

Add the worry that your patient, who might have cardiovascular disease, is driving in this stressful environment to obtain cardiovascular imaging recommended by you, and you have a prescription for additional stress.

To address this patient need, Englewood Hospital and Medical Center is working to make cardiovascular testing more convenient. The hospital system is bringing its high-quality imaging centers closer to patients’ own communities, nearer to their primary care physicians. The procedures are done as an outpatient service to save them the trip to the hospital.

Englewood Hospital’s three new outpatient locations offer nuclear cardiology, stress testing, echocardiography, vascular testing, and Holter monitoring. The practices are located at several sites in Fair Lawn, which is in Bergen County, and in Pompton Plains and Woodland Park, which are both in Passaic County.

The Cardiac Imaging Centers of Englewood Hospital and Medical Center join two Englewood Hospital satellite imaging facilities: Advanced Medical Imaging of Englewood Hospital and Medical Center in Emerson, Bergen County; and Magnus Imaging of Englewood Hospital and Medical Center in Glen Ridge, Essex County.

“The main issue is the convenience and the ease of access and the ease of booking testing for patients in their own communities,” said Mahesh Bikkina, MD, a cardiologist at Heart & Vascular Associates of Northern New Jersey, P.A. “Englewood Hospital is providing this hospital-quality outpatient service so the patient doesn’t need to go to the hospital for this testing.” The imaging centers maintain the same rigorous quality standards in their testing as those established by the hospital for testing performed at Englewood Hospital.

Dr. Bikkina acknowledged that patients tend to worry when they have to go for any test, but being able to travel within their own community and being close to home might eliminate some of that anxiety. “You pull into our parking lot and we are right there,” he said.

“Patients are much more comfortable having their tests done in a smaller, easier to navigate and comfortable outpatient setting,” Dr. Bikkina said.“Sometimes patients have multiple tests being done and our centers work very hard to schedule them all around the same time, which patients are very happy with.”

To further facilitate the care of patients, imaging results are added to patients’ electronic medical records, which are available to patients’ primary care physicians and doctors at Englewood Hospital if further referrals are needed. This creates a seamless flow of patients’ medical data among their physicians, which could substantially reduce the incidence of medical errors while serving to avoid inconvenient and costly duplications of testing.

Physicians can take advantage of the considerable expertise that Englewood Hospital, a leading cardiovascular center, has. The care that it provides goes beyond hospital-quality diagnostic testing and the comprehensive interchange of medical data.

Posted September 2017