Cardiology Updates
By Robert Merritt, M.D.

Patent Foramen Ovale and Atrial Septal Defect Percutaneous Closure Program

The year 2007 saw many updates to the Cardiology department at St. John’s. The initiation and advancement of the patent foramen ovale and atrial septal defect percutaneous closure program has helped several patients who have suffered either paradoxical embolic stroke or hypoxia-inducing intracardiac shunts. The closure device is implanted via fluoroscopic venous and transesophageal echocardiographic  guidance. Thus far, implantations have been uncomplicated with a 100 percent success rate. The percutaneous option for ASD and PFO closure is an excellent treatment for isolated PFO and ASD and replaces surgery for qualified candidates. Information and consultation can be obtained via the Cardiology  Department, Tina Terrell RN, at 417-820-3938 ext.82854.

Carotid Stenting

St. John’s enters its second year of participation in the Centers for Medicare and Medicaid services registries for carotid stenting.  In anticipation of completion of randomized controlled trials, CMS is collecting the experience of community hospitals using the device according to FDA-approved guidelines. 

Currently, carotid stenting is used for patients who would otherwise be considered high risk for surgery, that is, patients with expected excess cardiovascular risk (low ejection fraction, CHF, renal failure, complicated diabetes, recent MI or unstable angina) or anatomical comorbidities that could complicate surgery ( hostile neck, previous carotid endarterectomy with restenosis, contralateral severe carotid disease, or prior vocal chord paralysis). 

St. John’s current outcomes data is consistent with a low overall risk for stenting in this population.  Carotid stenting for low risk patients may be tied to successful implementation of carotid stenting under current CMS guidelines and thus St. John’s will be well positioned to meet demands for broadening the clinical application of carotid stenting should ongoing clinical trials verify their safety and efficacy in the general population.

Research Studies

Clinical trials in Cardiology range from device therapy for prevention of sudden cardiac death to outpatient evaluation of drugs to prevent CV mortality. The following list presents several of the clinical trials which may be of interest to referring physicians.

Acute In-hospital Studies:

•  Ascend-HF:Acute study of clinical effectiveness of nesiritide in subjects with decompensated heart failure.

•  Champion Platform:Cangrelor vs. standard therapy to achieve optimal management of platelet inhibition. Patients must be Plavix naïve.

•  Champion-PCI: Cangrelor vs. standard therapy to achieve optimal management of platelet inhibition. Plavix 75mg daily ok.

•  Tracer: Study to evaluate the safety and efficacy of SCH 530348 in addition to standard of care in subjects with acute coronary syndrome. Thrombin receptor antagonist for clinical event reduction in acute coronary syndrome. 

-40mg load of study drug/placebo 1 hour before interventional procedure. Then once daily dosing of 2.5mg.

Clinical Outreach Studies:

•  Rocket-AF: Event-driven non-inferiority study comparing the Efficacy and Safety of once-daily oral Rivaroxaban with adjusted-dose oral Warfarin for the prevention of stoke and non-central nervous system embolism in subjects with non-vavular Atrial Fibrillation.

•  Moxie: 12-week oral dose study to evaluate the effects of study drug in patients with peripheral arterial disease

•  TRA 2P: Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events. Oral tablet taken daily.

-Subjects must have evidence or a history of atherosclerosis involving the coronary, cerebral, or peripheral vascular systems.

Device Trials:

•  Insync: Registry of cardiac resynchronization therapy.

•  Freedom: A frequent optimization study using the quickOpt method.

•  Capture 2: Post market-approval study Carotid stenting trial to uncover unanticipated and rare events.

•  Choice: Carotid stenting for high surgical-risk patients; evaluating outcomes through the collecting of clinical evidence.

•  SapphireWW: Stenting and angioplasty with protective in patients at high-risk for endarterectomy. Post-market registry.

Education

The Cardiology department took a big step in 2007 toward making education a distinguishing element of the St. John’s Cardiovascular Services. 

While sponsoring medical students and nursing externs has always been supported, an extern physician training program was implemented through the Cardiac catheterization laboratory and the new PVD training program in July of 2007.

The program has successfully trained 6 physicians to perform percutaneous peripheral interventions.  The program was designed to provide hands on training to cardiologists and vascular surgeons in the rapidly evolving field of PVD intervention. The trainees, both internal to St. John’s and from regional hospitals, gain a broad experience in peripheral vascular angiography and interventional techniques that support application for privileges at their respective institutions.

Currently, the program trains Missouri licensed physicians with plans to make the program a national training site by fall 2008. 

Dr. Parvathaneni joins Cardiology

The Cardiology department welcomes Dr. Lakshmi Parvathaneni.  Lakshmi and her husband (new cardiothoracic surgeon) Sirish are a dynamic duo to cardiology and cardiothoracic surgery.  Their presence for the last half of 2007 expands clinical service in the fields of non-invasive cardiology and CT surgery. Cardiology hopes to provide an atmosphere of growth and development in women’s cardiac care with Lakshmi’s help. As the Heart Institute develops both structurally and clinically we are excited to have both Lakshmi and Sirish as young and enthusiastic supporters of  the program.  Referrals welcome.

Outpatient Facility Relocates

The St. John’s Cardiology department will relocate to Whiteside Medical building in July. The transition will provide for interim space while the Heart Institute is being constructed with planned completion in 2010. 

Some challenging times are expected as new outpatient clinical services, electronic health record, and “re-tooled” hospital services will be integrated in expectation of the transition to the Heart Institute in 2010. As always, our clinical commitment to cardiovascular consulting and delivery of premium cardiac care to regional patients will guide our transition.

St. John’s Cardiology appreciates the support of our patients and referring physicians and greets the community with best wishes for 2008 and beyond!