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The Heart of the Matter: Cardiology Tips

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Duke Health News 919-660-1306

While I'm already in here . . .

It's hard enough for patients with end-stage lung disease to
wait for a chance at a life-saving lung transplant. But for
those who also have blockages in their coronary arteries, the
chances of receiving the transplant are practically nil.

While many transplant centers see coronary artery disease as
an automatic medical rule-out for lung transplantation,
surgeons at Duke University Medical Center take a different
approach. As a result, three patients have received both
procedures at the same time.

"Many transplant centers see coronary artery disease as a
reason to screen out potential candidates," says Duke's Dr.
Duane Davis, surgical director of the lung transplant program.
"At Duke, we take a case-by-case approach and see coronary
artery disease only as a relative contraindication. If
everything else about the patient looks good, we'll go ahead
and do both procedures at the same time."

Davis typically performs the bypass procedure first, usually
during the time the lungs are in transit to Duke. By the time
the donor lungs arrive in the operating room, the patient's
bypass has been completed. Davis has performed a single, a
double and a triple bypass at the time of transplant.

While a bypass operation adds complexity to an already
demanding transplant surgery, Davis feels the risk is worth it
to help this group of patients who have few options.

All three patients who received single lung transplants
tolerated the surgeries very well. "The last patient we did
went home five days after the operations, and he's doing
great," Davis says.

Hearts aflutter

Imagine having your heart begin to beat wildly, so fast you
think it will leap from your chest, and then, just as quickly,
it slows to normal pace. It happens unexpectedly, not
necessarily when you're exerting yourself, and it sometimes
fades so fast that doctors never witness it.

That's the way supraventricular tachycardia, or SVT, can
plague kids. The attacks can be frightening, so much so that
they inhibit a child from participating in normal activities.
But without being able to capture the event on standard
monitoring equipment, doctors can't recommend treatment to stop
the attacks.

Dr. Ron Kanter, a Duke pediatric cardiologist specializing
in electrophysiology, turns to a definitive diagnostic tool --
an esophageal electrophysiology study -- to help these
children. After snaking a slim catheter "like a wet spaghetti
noodle" from nose to the esophagus to a position behind the
heart, he can change the heart's pace. If the patient does
suffer from SVT, Kanter will be able to trigger an attack by
prompting premature beats. And if SVT is the problem, Kanter
can treat it with drugs or in the cath lab with radio frequency
ablation, a procedure that permanently disrupts the cardiac
short circuit causing the irregular rhythm.

Lights! Camera! Action!

What do Hollywood directors and cardiologists have in
common?

Directors can use film to tell a story that tugs at our
heart strings. Cardiologists use it to show just how our hearts
are being pulled and pushed: they want to watch the heart and
its associated arteries at work during a cardiac
catheterization.

But things have changed at Duke University Medical
Center.

While film has been the medium of choice for cardiologists
for more than 20 years, the six "cath labs" at Duke have gone
completely "cineless" and in the process have developed what
appears to be the first and only digital database of patient
catheterizations.

Duke physicians perform close to 6,000 catheterizations each
year, and over the past decade, the cath labs have moved from
recording all catheterization and angioplasty procedures on
film to displaying them digitally, which improved the quality
of the image. But because those digital files were so big - 200
megabytes for a single patient procedure - they couldn't be
stored indefinitely, so they were backed up in film, which was
an expensive hassle to store and retrieve.

Now, given computer advances, Duke has worked with industry
computer experts to create a system whereby all digital cath
records can be archived. They are now stored on optical disks
in what's being dubbed a huge "jukebox" because physicians can
instantly gain access to whatever "selection" or patient record
they want via computer workstations located throughout the
hospital. The system doesn't even blink at the 1.2 terabytes it
takes to store a year's worth of patient records, according to
Dr. Michael Sketch, director of the interventional cath lab at
Duke.

Time is an important issue, Sketch says. If a case is being
recorded on film, it must first be developed and processed
before he and his colleagues can review it. "Using the new
system, cardiologists can view images within 15 minutes of the
procedure so the ability to quickly call up the results of a
cath is a great help to us and our patients," he says.

The system also allows physicians to compare the results of
studies done at different times side-by-side on a computer
screen, Sketch says. And while enhancing patient care, it also
saves considerable money - about $40 a patient, or up to
$200,000 a year, he adds.

Stressing out blood vessels

It's pretty much medical dogma that stress is not good for
one's health. Study after study -- many performed by Duke
behavioral researchers -- have implicated stress and negative
emotions as risk factors for ischemia, potentially damaging
episodes of reduced blood flow to the heart.

Duke researchers showed last year that behavioral
modification techniques can lessen the risk of ischemia in
cardiac patients, but it is still unclear what mechanisms lie
behind the beneficial effects of stress reduction.

To answer that question, the National Heart, Lung and Blood
Institute recently awarded a $4.3 million, five-year grant to
Duke researchers James Blumenthal, Ph.D. and Andrew Sherwood,
Ph.D. Specifically, the team hopes to better understand how the
lining of blood vessels, the endothelium, responds to
stress.

Researchers will begin enrolling the first of a planned 240
heart patients on Sept. 1. They will target women and
minorities, groups who have typically been under-represented in
past heart studies.

Initially, participants will receive complete cardiac and
psychological work-ups, as well as ultrasound studies of their
arteries. Then, each patient will be randomized to one of three
interventions: exercise, stress management training, or the
standard medical care.

"At the end of four months, we will perform the same tests
and see what changes occurred, both psychologically and to the
endothelium," Blumenthal said. "We will also follow the
patients annually until the end of project to see if the
benefits are sustained over time."

Young at heart

Angioplasty continues to be a popular procedure for relief
of chest pain associated with the narrowing of arteries.
Researchers at Duke University say it is becoming safer for
even the most elderly heart patients.

Cardiologist Dr. Wayne Batchelor says a review of data sent
to Duke from 20 hospitals around the country shows the risks
involved in angioplasty are only marginally greater for those
in their 80s. "The power of this work is that it provides some
risk estimates for this procedure in this population that can
hopefully serve to allow physicians and patients to make better
decisions on an individual basis," Batchelor says.

He says angioplasty has been growing in popularity since it
was introduced in the mid-1970s, and a review of the data
covering the success and complication was necessary and
important.

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