The best in cardiac surgery - King's Daughters Medical Center

INSIDE It
Update
C A R D I O V A S C U L A R
VOLUME 1, ISSUE 4 Winter 2006
Complex
CV surgery
case study
Page 2
KDMC
introduces
64-slice CT
imaging
Page 3
IV pumps
donated to
area medics
Page 3
CDC says
diabetes
on the rise
Page 4
The best in
cardiac surgery
at King’s Daughters Medical Center
is well documented that higher volumes mean
superior outcomes. The Cardiothoracic Surgery
program at King’s Daughters ranks among the
region’s top programs for volumes and reports
significantly lower mortality, morbidity and complication
rates than the national average (KDMC overall mortality
= 1.9 percent; Society of Thoracic Surgery overall
mortality = 2.6 percent). Our program has a reputation
for early adoption of new and innovative techniques that
improve patient outcomes, even as we perform the most
complex procedures on the highest
risk patients. And while high
volumes are good for outcomes,
we also maintain a patient-centered
focus. Each patient is carefully
evaluated and treated according
to an individualized plan.
Cardiac surgery innovations
at King’s Daughters include:
■ For a consult
or to refer a
patient to one of
our cardiothoracic
surgeons, please
call toll free,
1-866-HEART-KY
(432-7859).
Off-pump or “beating heart” bypass surgery
This type of coronary artery bypass surgery
(CABG) is especially beneficial for patients who
are at increased risk for stroke and other
complications from clamping the aorta.
Performing CABG surgery without the bypass
pump has been associated with improved survival, and
lower rates of strokes and blood transfusions, without a
decrease in the number of grafts. In 2005 we performed
about 25 percent of isolated CABG cases without the
bypass pump. The Society of Thoracic Surgeons reports
a national off-pump CABG rate of 18 percent.
Valve surgery
Surgeons now are treating valve disorders earlier,
reducing mortality and morbidity rates. Repair is
preferable to replacement whenever possible, leading
to long-lasting results without anticoagulation therapy.
The latest proven innovations, such as the GeoForm
KDMC cardiothoracic surgeons, from left, Robert Fried, M.D.;
Marcos Nores, M.D.; and Richard Heuer, M.D.
annuloplasty ring, are utilized when appropriate. The
most common valve procedures at King’s Daughters
involve the mitral and aortic valves, and we have the
expertise to repair the tricuspid and pulmonary valves,
as well. Valve repair or replacement often is indicated
in patients who experience:
• Fatigue, especially during times of increased activity
• Shortness of breath, especially with exertion or when
lying down
See cardiac surgery, page 2
1-866-HEART-KY | kdmc.com 2201 Lexington Ave., Ashland, KY 41101

2 CARDIOVASCULAR UPDATE KING’S DAUGHTERS HEART AND VASCULAR CENTER
LEADERSHIP TEAM
Richard Paulus, M.D.
medical director
of the Heart and Vascular Center
(606) 324-4745
Kristie Estep, R.N., MSN
vice president of the
Heart and Vascular Center
(606) 327-4691
Richard Heuer, M.D.
medical director of
Cardiothoracic Surgery
(606) 326-9847
Zane Darnell, M.D.
medical director
of the Chest Pain Unit
(606) 324-4745
John Van Deren III, M.D.
medical director of Electrophysiology
(606) 324-4745
Heart Transfer Number
1-866-HEART KY (1-866-432-7859)
Physician Courtesy Number to access
KDMC operator (606) 327-7100
KDMC Emergency Department
(606) 327-4565
Newsletter Questions/Comments
Julie Marsh (606) 327-4436
julie.marsh@kdmc.net
Newsletter
Editor
Chris Epling, D.O.
(606) 327-4745
Heart and Vascular Outreach
Coordinator Jamie Mills can
provide your office with additional
information about our services and
can arrange meetings with our
physicians. She can be reached at
(606) 922-3818.
2201 Lexington Ave.
Ashland, KY 41101
cardiac surgery
• Swollen feet or ankles
• Heart palpitations
• Frequent respiratory infections, such as
bronchitis
• Heavy coughing, sometimes with blood-tinged
sputum
• Rarely, chest discomfort or chest pain
Atrial fibrillation surgery
The cardiothoracic surgeons at King’s
Daughters are experienced with microwave,
radiofrequency or cryoblation energy for
treatment of atrial fibrillation. Patients with atrial
fibrillation who have advanced coronary artery
disease, mitral or aortic valve disease and need
surgery can also receive accompanying “maze”
procedures to redirect electrical impulses through
the heart. Patients with severe coronary artery
disease, mitral stenosis and/or regurgitation,
aortic stenosis or regurgitation who have atrial
fibrillation are candidates to have a maze
procedure while the open-heart surgery is
performed. Also, stand-alone surgery for atrial
fibrillation can be performed through very small
incisions on the chest without the use of the
heart-lung machine or dividing the sternum.
Thoracic aortic aneurysm surgery
Surgeons at King’s Daughters routinely
perform aortic aneurysm surgery for dissecting or
atherosclerotic aneurysms, and repair aneurysms
that affect the function of the aortic valve.
Other cardiothoracic surgeries
Our surgeons also perform uncommon and
complex surgeries such as minimally invasive
lobectomies for lung cancer; “elephant trunk”
aortic arch repair utilizing tubular aortic graft
prosthesis to repair the ascending aorta and aortic
arch; esophageal repair; and tracheal resections.
External heart assist device
King’s Daughters recently purchased the
AbioMed AB5000 ventricle pump and console.
This system is used to keep a patient’s blood
flowing and help the heart rest and recover, in
a process called “unloading,” following a heart
attack and cardiogenic shock. Once hooked up
to the device, the patient’s heart still beats, but
the muscle doesn’t have to pump the three to
six liters of blood per minute that it normally
would. The system can sustain a patient for
several months until the heart recovers, or
can bridge the time until a transplant can be
arranged.
continued from front page
CASE STUDY
KDMC was recently named among the nation’s 100 Top Hospitals ® by Solucient
Problem patient
A 63-year-old female presented to the
Emergency Department with chest pain and
shortness of breath. She admits to shortness
of breath with minimal exertion, including
being awakened at night with breathlessness.
Cardiac risk factors include hypertension,
hyperlipidemia, diabetes, and obesity. She had
undergone angioplasty with placement of
two stents several years previously. She said
she has had intermittent atrial fibrillation
since the age of 27. She underwent a stress
test which showed anterior wall ischemia and
an ejection fraction of 57 percent. Carotid
duplex was negative. A cardiac
catheterization performed by cardiologist
Richard Paulus, M.D., revealed 85 percent
stenosis in the left anterior descending artery,
and 75 percent lesions in the diagonal. The
patient also was found to have moderate
aortic stenosis, aortic insufficiency and mitral
regurgitation. Cardiothoracic surgeon Robert
Fried, M.D., was consulted.
Physician action plan
Dr. Fried offered multiple procedures
to treat the patient, including an aortic
valve replacement, mitral valve repair, two
vessel coronary artery bypass grafting, and
a possible microwave maze procedure to
treat her atrial fibrillation. The patient
agreed to the treatment plan.
Outcome
The patient underwent two vessel
bypass, receiving a left internal mammary
artery graft to the left anterior descending
and a vein graft to the marginal.
Endoscopic vein harvesting was used.
A #21 pericardial aortic valve was
replaced, and the mitral valve underwent
a 28 Cosgrove ring repair. A maze
procedure with microwave energy was
performed. The patient recovered well
from surgery, but experienced persistent
junctional bradycardia in the 30s with
QRS complex. Electrophysiologist Terence
Ross, M.D., implanted a pacemaker four
days post operatively. The patient was
discharged in good condition about two
weeks following the surgery.

CARDIOVASCULAR UPDATE KING’S DAUGHTERS HEART AND VASCULAR CENTER 3
Heart and Vascular Center Roundup
Quick Facts about the KDMC Heart
and Vascular Center
King’s Daughters Medical Center now
ranks fourth in the state of Kentucky in
terms of admissions, and experienced
another record year in 2005. Our heart
and vascular services performed 11,000
catheterization procedures in the past year,
including:
• 5,600 heart caths
• 2,000 angioplasty/stent procedures
• 1,300 diagnostic and non-invasive
procedures
• 1,300 peripheral vascular catheterizations
and interventions
Our team also performed 850 openheart
surgeries in the past year.
To receive a 2006 physician directory
listing the more than 230 medical specalists
at King’s Daughters, please call
1-888-377-KDMC (5362).
KDMC now performing 64-slice
CT imaging
King’s Daughters Medical Center now is
performing 64-slice CT imaging, with the
ability to perform cardiac CT, including
coronary CT angiography
(CTA). CT angiograms help
determine, with up to 90
percent accuracy, whether
obstructions have built
up in the coronary
arteries.
Coronary catheterization
remains the
“gold standard” for
detecting coronary
artery stenosis.
However, this new CT
technology has
consistently shown the
ability to rule out significant
narrowing of the major
coronary arteries and can
non-invasively detect soft
plaque or fatty matter that has not yet
A 64-slice CT image
of the heart.
hardened but may lead to future problems
without lifestyle changes or medical
treatment.
Editor’s Comment: King’s Daughters
currently supports the selective use of
Coronary CTA for patients who have:
• Intermediate to high-risk profiles for
coronary artery disease, but who do not
have typical symptoms (especially chest
pain, shortness of breath, or fatigue
during heavy physical activity).
• Unusual symptoms for coronary artery
disease (chest pain unrelated to physical
exertion), but low to intermediate risk
profiles for coronary artery disease.
• Unclear or inconclusive stress-test
(treadmill test) results.
The patient’s initial consultation with
their primary physician is key for patients
seeking to determine the appropriateness
of coronary CTA. For more details about
Coronary CTA, call the King’s Daughters
Radiology Dept. at (606) 327-4724.
KDMC one of top 50 enrollers in
international ACUITY trial
Patient enrollment in the 13,800 patient
global Phase III ACUITY trial (Acute
Catheterization and Urgent
Revascularization Triage Strategy) was
completed in December, and King’s
Daughters was ranked among the top 50
enrollers. This randomized clinical trial,
which enrolled patients over a two-year
period, is evaluating the direct thrombin
inhibitor Angiomax ® (bivalirudin) replacing
heparins in patients with acute
coronary syndromes presenting to
the emergency department.
ACUITY is being conducted at
450 clinical trail sites in 17
countries worldwide.
ACUITY is evaluating the use
of Angiomax, starting in the
emergency department and
continued through the cardiac
catheterization laboratory.
Investigators are anticipating that
the trial will support the use of
Angiomax in acute coronary
syndrome patients, whether or not
patients undergo angioplasty, and will
provide patients with a safe and effective
treatment option to unfractionated
heparin or enoxaparin.
Editor’s Comment: Several cardiologists
at King’s Daughters participated in
enrolling appropriate patients in the study.
The first announcement of ACUITY results
is expected at the American College of
Cardiology Annual Scientific Session in
March, and to be published in leading
peer-reviewed journals.
To request a free 2006 Physician Directory, call 1-888-377-KDMC or visit kdmc.com
Alex Hou opens new vascular practice
Vascular/endovascular
surgeon Alex Hou,
M.D., has opened a new
private practice in
Ashland, located at
Medical Plaza A, Suite
445, 617 23rd St.,
Ashland. He will be Alex Hou, M.D.
joined by general
surgeon William
Dunlop, M.D., whose
office was previously
located in the Medical
Arts Building. Their
office can be reached by
calling (606) 327-5628.
William Dunlop, M.D.
KDMC donates IV Pumps to
medics in eastern Kentucky
In a program called “Hearts in
Action,” King’s Daughters Medical
Center has partnered with Paul B. Hall
Regional Medical Center in Paintsville,
and medical transportation/EMS
companies in the eastern Kentucky region
in an effort to improve the care of
patients. In late 2005, Paul B. Hall hosted
an educational program where nurses
from King’s Daughters and other experts
trained about 45 EMTs and paramedics
on the topic of optimal protocols for
treating and transporting chest pain
patients. King’s Daughters then presented
participating companies with four
intravenous infusion (IV) pumps, for a
total of 20, to place in their ambulances
for administering intravenous
medications. The training and equipment
were provided at no charge by King’s
Daughters. The 20 pumps, valued at
about $40,000, were chosen for their
durability, reliability and special features.
The pumps are essential for delivering the
proper dose of medications during the
transport of patients from a community
hospital to a regional referral center for
more advanced care.
The EMS and medical transportation
companies included in this initiative are
Paintsville Fire and Rescue, DHP, Net
Care, Stat Ambulance and Trans Star.
These companies serve the southeast
region and have a high volume of patient
transports from the Johnson and Floyd
county area to larger hospitals
throughout the state.

4 CARDIOVASCULAR UPDATE KING’S DAUGHTERS HEART AND VASCULAR CENTER
New recommendations for use of
heart failure drug Nesiritide
Nesiritide (Natrecor®) is a
recombinant form of human-type
natriuretic peptide (hBNP) that occurs
naturally in the ventricles of the heart.
Approved only for the treatment of acute
decompensated heart failure (ADHF) in
patients with dyspnea at rest, it has
previously been used in patients with
varying degrees of heart failure including
those seeking treatment in outpatient
clinics. Nesiritide causes a rapid decrease
in ventricular filling pressure, thus
reversing the dyspnea that heart failure
patients experience.
Two meta-analyses recently conducted
led to the concern that nesiritide may
cause renal dysfunction as well as increase
mortality. In response to this information
Scios (manufacturer of nesiritide) hired a
panel of experts to review all data
available on the medication.
There were several final
recommendations made by the panel:
1. Nesiritide should be restricted to
patients with Class IV heart failure –
patients with dyspnea at rest.
2. Nesiritide should NOT be used to
replace diuretics, nor should the
medication be used for intermittent
outpatient infusions, for scheduled
repetitive use, to improve renal function
or to enhance diuresis.
3. The drug manufacturer should
immediately begin educating physicians
about instances where nesiritide should
not be used and all future marketing
activities should be consistent with this
new information. The educational effort
by Scios is currently underway. If you
have questions regarding nesiritide, do not
hesitate to contact one of KDMC’s
cardiologists or Jen Van Cura, Pharmacy
director, at (606) 327-4485.
Diabetes on the rise, says CDC
New figures from the Centers for
Disease Control and Prevention (CDC)
reveal that 20.8 million Americans are
now living with diabetes, a 14 percent
increase from the 18.2 million the CDC
reported in 2003. Another 41 million
have pre-diabetes, a condition that
indicates an increased risk for developing
type 2 diabetes. It is estimated that two
out of three people with diabetes die from
heart disease and stroke.
Make the Link! Diabetes, Heart
Disease and Stroke is an initiative of the
American Diabetes Association and the
American College of Cardiology aimed at
increasing awareness of the link between
diabetes and heart disease. Make the Link!
stresses that diabetes management is more
than control of blood glucose. People with
diabetes need to know their ABC targets:
• A – A1C test, which should be done at
least twice a year. The results should be
seven percent or below.
• B – Blood pressure. This should be
120/80 and checked frequently.
• C – Cholesterol (LDL) should be below
100, and needs to be checked at least
once a year.
Type 2 diabetics should have
cardiac stress test
In an article in the Jan. 3 issue of the
Journal of the American College of
Cardiology, an Italian study showed that
contrary to current guidelines, aggressive
efforts to detect coronary artery disease
are worthwhile in asymptomatic patients
with type 2 diabetes.
Current coronary artery disease
screening guidelines from the American
Diabetes Association recommend stress
testing asymptomatic patients with
diabetes if they have two or more
additional risk factors. In an attempt to
“verify the effectiveness” of these
guidelines, the researchers studied 1,899
asymptomatic type 2 diabetic patients 60
years old or younger. The patients were
divided into two groups: group A
included 1,121 patients with two or more
CAD risk factors, and group B included
778 patients with no or only one risk
factor. All the subjects underwent cardiac
stress tests, and those with abnormal
results underwent angiography. According
to the researchers, the prevalence of
abnormal stress test findings were similar
between group A and group B, as was the
prevalence of significant CAD found
during angiography. This suggests that a
substantial number of asymptomatic
diabetic patients with few risk factors
might have occult coronary artery disease
that may be missed on the basis of current
ADA guidelines.
New study finds PCI cuts AMI death
risk in half
A study published recently in the New
England Journal of Medicine found that
when clot-busting drugs fail to stop a
heart attack, angioplasty, or PCI, is the
most effective treatment. The study also
found that patients benefited even when
they had to be transferred to another
facility to undergo angioplasty. Study
results also showed that PCI reduces by
half the risk of stroke, heart failure or
later heart attack. Giving more clotbusting
drugs when the first round did
not work offered virtually no benefit.
Our Mission: To Care. To Serve. To Heal Our Vision: World-Class Care in Our Communities
2201 Lexington Ave.
Ashland, KY 41101