An emphasis on team-based patient care, along with innovative hybrid technology, has opened the door at St. Luke’s University Health Network to advanced cardiac and vascular procedures that cross disciplinary boundaries.
Physicians from specialties including cardiology, cardiac surgery, vascular surgery and electrophysiology are performing procedures such as fenestrated endovascular abdominal aortic aneurysm repair (FEVAR), hybrid ablation for atrial fibrillation, extracorporeal membrane oxygenation treatment (ECMO) and implantation of ventricular assist devices (VADs). Many of these treatments are available only at limited networks in the region, and some have recently been adopted from world-renowned medical research centers.
Behind these innovations lies a strongly democratic, interdisciplinary culture in which physicians work together to provide the treatment that’s best for the patient, says Stephen Olenchock, DO, FACS, Section Chief of Cardiovascular Surgery at St. Luke’s University Health Network. The physicians have expert training and deep experience, which they continually enhance by studying with colleagues from a broad spectrum of disciplines that intersect their own.
“There are always challenges for groups of physicians of different specialties treating the same diseases,” Dr. Olenchock says. “At St. Luke’s, we see ourselves as all in the same field — we may be from different specialties, but we care for the same conditions. We have achieved this culture because our physicians have a high degree of sophistication in terms of applying and combining modalities. For cardiac and vascular patients, this means we treat them as a whole person. We hold weekly, cross-disciplinary meetings to discuss each patient’s needs.”
Stellar teamwork demands versatile technologies that allow physicians from across disciplines to practice in concert. At St. Luke’s University Hospital, the GE Healthcare Discovery IGS 730 Hybrid Operating Room (OR) fulfills this demand. The first of its kind in the nation, the hybrid OR permits electrophysiology, catheterization, laparoscopic procedures and open surgery, with the capability of transitioning from one procedure to another when circumstances dictate. This enhances patient safety while permitting surgeons to bring their skills together in innovative ways.
“Historically, cardiology, cardiac electrophysiology and vascular surgery tended to operate in their own realms, with less communication than was desirable. Our concept at St. Luke’s University Health Network has been building a heart and vascular center, opening lines of communication and taking a team approach to patient management. This stance has been espoused by the management team and made possible by the open relationships among our cardiologists, electrophysiologists and surgeons.”
— Darren Traub, DO, electrophysiologist at St. Luke’s University Health Network
Jose D. Amortegui, MD
Enhanced Flexibility, Rapid Recovery
When it comes to vascular problems, physicians have multiple approaches to choose from, including medical management, endovascular procedures and surgery. Vascular physicians at St. Luke’s University Health Network draw on the strengths of each method, providing the treatments with the best outcomes and least invasiveness for their patients, says Timothy Oskin, MD, FACS, Section Chief of Vascular Surgery at St. Luke’s. In the pursuit of these goals, advanced hybrid procedures play an important role.
“We optimize the treatment for each patient by combining modalities,” Dr. Oskin says. “For instance, a stent may not be best for a patient with a groin-level blockage because a stent is of high risk for failure over time due to fatigue caused by repetitive bending when the patient walks; however, a stent works well for a mid-thigh blockage. For the groin blockage, surgery in which the plaque is removed is generally preferred. So in treating a patient with blockages at both levels, which is a common finding, it may take a combined approach of making a small groin incision to optimally treat the blockage there then using a balloon catheter to place a stent and treat the blockage in the thigh. This minimally invasive procedure replaces a much more extensive bypass procedure that would traditionally be performed, thus reducing patient risk, shortening recovery time and optimizing long-term results.”
Raymond A. Durkin, MD
This flexibility carries over into life-or-death situations, such as the repair of aortic aneurysm. Physicians at St. Luke’s are now implanting stent grafts for aneurysms via catheters through a percutaneous approach, using 1/4-inch punctures in the groin. The stent grafts were previously inserted through more extensive incisions in both legs.
“We place a couple of stitches in the arterial wall via specialized catheters, insert catheters with the stent graft, perform the EVAR procedure and remove the catheters,” Dr. Oskin says. “We then tie the sutures down and close the puncture site. Recovery time is reduced from two to three weeks for endovascular surgery through traditional incisions, to two to three days with percutaneous EVAR. We continue to refine that evolution.”
Performed in the hybrid OR, percutaneous EVAR can be combined with high-quality imaging to obtain important information about the arterial system during stent placement and aneurysm repair to optimize patient results.
Raymond Fitzpatrick, MD
Additionally, a new device with limited exposure in the United States, the fenestrated aortic stent graft, opens the EVAR procedure to patients who were not previously candidates. In some people with aortic aneurysm, the normal segment of aorta below the aneurysm is too short to permit grafting, due to the possibility of graft migration or leakage. For these patients, fenestrated stent grafts provide the possibility of treatment. With openings or “fenestrations” for renal or mesenteric arteries, fenestrated grafts allow more range in placing stents.
“We can use a catheter through the fenestrations to bridge the kidney artery, aligning the stent graft perfectly,” Dr. Oskin says. “Now we can include some patients who would not have a stent graft otherwise, eliminating the need to perform complex open surgery in which we would need to stop the blood flow to the kidneys for a period of time, thus placing the kidneys at risk.”
Again, the vascular physicians at St. Luke’s are able to tailor the procedure to best fit the patient’s needs in order to reduce risk, shorten recovery and optimize long-term results.
Timothy C. Oskin, MD
New Approaches to Atrial Fibrillation
While medication or traditional catheter ablation alleviates symptoms in most cases of paroxysmal atrial fibrillation (episodes that start and stop on their own), catheter ablation is less effective in those with sustained atrial fibrillation (episodes lasting longer than seven days). Among patients who experience persistent (greater than seven days) or longstanding persistent (greater than one year) atrial fibrillation, approximately 50 percent or more will not be adequately helped by a single procedure involving catheter ablation. For those patients, St. Luke’s has a new solution: a technique that combines transvenous catheter ablation with thorascopic surgery to ensure accurate and complete ablation of the fibrillation’s focal points and reduces the atria’s ability to sustain atrial fibrillation.
Upon learning of this innovative procedure, Dr. Olenchock and Darren Traub, DO, electrophysiologist at St. Luke’s University Health Network, wanted to see it for themselves before bringing it to their patients. Together, they traveled to Maastricht, the Netherlands, to study alongside the surgeons who developed hybrid thorascopic surgical and transvenous catheter ablation.
Stephen A. Olenchock, DO
“This technique appears likely to offer a more successful approach for patients with persistent and longstanding persistent atrial fibrillation,” Dr. Traub says. “The surgeon inserts small ports into the chest wall and performs radiofrequency ablation from outside the heart. Immediately following, the electrophysiologist accesses the heart transvenously and completes any gaps in the surgeon’s ablation lines. The electrophysiologist also checks to see that the surgical lesions accomplished the desired electrical endpoint for ablation. The procedure represents the best of both worlds because the surgeon can truly visualize what he or she is doing; also, the surgeon is not limited by blood circulating around the ablation catheter. He or she can create more durable ablation lines, while the electrophysiologist has the tools and training to check interoperatively for electrical gaps. We are also able to exclude the left atrial appendage during the procedure, which we believe is responsible for up to 90 percent of atrial fibrillation-related strokes.”
The St. Luke’s culture encourages exactly this type of innovation, especially when the goal is bringing advanced techniques to patients in the Lehigh Valley who would not otherwise have ready access to them. With the availability of the hybrid OR, physicians and patients will benefit from increasing numbers of cross-disciplinary treatments such as the hybrid atrial fibrillation procedure.
Darren M. Traub, DO
ECMO for Acute Heart and Respiratory Failure
Long utilized for babies in respiratory distress, extracorporeal membrane oxygenation may also be used for adults in danger of acute cardiac or respiratory failure, keeping them alive while their hearts or lungs recover. At St. Luke’s, this lifesaving therapy helps patients who suffer heart failure following myocardial infarction or severe acute influenza, among other conditions. As ECMO patients typically have a very low survival rate without the intervention, this is an important new therapy offered by St. Luke’s.
“My partner, Jose Amortegui, MD, had become familiar with ECMO at the University of Maryland Medical Center,” says Raymond Fitzpatrick, MD, cardiothoracic surgeon at St. Luke’s University Health Network. “When he came here two and a half years ago, he discussed it with the leadership of the cardiac surgery division, and we have successfully implemented a program here. ECMO has the possibility to save lives among patients who otherwise have extremely limited options.”
VAD Bridges Time Gap
When heart failure is chronic rather than acute, patients may need a permanent solution to keep them alive. For some, that solution is a heart transplant. Others may not be candidates for transplants, but at St. Luke’s, they have additional options. A ventricular assist device (VAD) can help a heart transplant candidate — a “bridge” patient — survive until a donor heart becomes available. And, VADs may provide lifelong support for patients who do not go on to receive heart transplants — “destination” patients.
“When medical management is no longer enough, patients may be candidates for either heart transplant or VAD,” says Dr. Amortegui, cardiac surgeon and Director of ECMO and Mechanical Circulatory Support at St. Luke’s University Health Network. “With this technology, we place a pump in the left ventricle, which takes over most of the work of pumping the blood.”
The technology has advanced significantly during the past 30 years, Dr. Amortegui explains, with new VADs becoming an excellent option to many different patients. The devices are connected to a power supply and can run on batteries for 12–16 hours, allowing patients to work and go about their lives normally.
“Previously, patients in the Lehigh Valley had to travel to Philadelphia or further if they required a VAD,” Dr. Fitzpatrick says. “Our leadership has worked hard to attract talented physicians who are bringing advanced technologies to the area. Though some of these technologies are new to the Lehigh Valley, they are familiar to our physicians, whom we recruit from high-volume, nationally known cardiac and vascular centers.”
St. Luke’s University Health Network is continually investing resources to deliver higher standards of heart and vascular care to the Eastern Pennsylvania region. These resources bring newer technology and innovations that keep the higher standards of health care closer to home for many.
For more information, please visit www.sluhn.org/heart or call St. Luke’s Heart and Vascular Center at 484-526-3990.