advances in cardiac: december 2011

A S U P P L E M E n t t o W E s t c h E s t E R h E a l t h & l I F E M A G A Z i n E

cardiovascularadvaNces iN

westchester medical ceNter CAREcardiovascularcardiovascular

CAREcardiovascular

CAREcardiovascular

‘i dodGEd A BULLEt!’

UGLY VEinS,BEGonE!

‘VAPoRiZinG’BLoCKAGES

GUARdinG tHEAoRtA’S WALLS

fiX foR AtoddLER’SRACinG HEARt

WMC_Cardio_1011Final_REV1.indd 1 11/23/11 11:37 AM

cardiovascular careadvances in2 westchesterheartaNdvascular.com

9

3 a passioN

for pictures

4 iNNovatioNs

in the cath lab

6 protectiNg the

largest artery

9 ‘ i dodged

a bullet!’

10 BaNishiNg

ugly veins

12 let your

blood fl ow

14 a little Boy survives

a big heart problem

Advances in Cardiovascular Care is published by

Wainscot Media, Montvale, n.J. © 2011. All rights reserved.

the information in this publication is written by professional

journalists and/or physicians. However, no publication can

replace the direct care or advice of medical professionals.

HEART & VASCULAR

coNteNts

6

12

caRdIology

hawthorNe divisioN914.909.6900imaging 914.909.6925

noninvasive cardiologyWilliam frishman, M.d.

John McClung, M.d.

Joshua Melcer, M.d.

tanya dutta, M.d.

Joseph Harburger, M.d.

nyree Sencion-Akhtar, R.n., fnP-C

Vicki Klein, P.A.-C

Invasive–Interventional cardiologyHasan Ahmad, M.d.

Martin Cohen, M.d.

Linda Cuomo, M.d.

William Gotsis, M.d.

Gary Silverman, M.d.

Robert timmermans, M.d.

Electrophysiology/devicesMartin Cohen, M.d.

Paul Eugenio, M.d.

Andrea Cronin, R.n., fnP-C

Carmela Musial, PA-C

heart Failure/vad/transplantAlan L. Gass, M.d.

Gregg Lanier, M.d.

Elizabeth Stevens, R.n., CCRn, MSn,

fnP-BC

Kathy Brown, R.n., B.S., M.S., A-nP, CCRn

North state divisioN914.762.5810

clinical & nonInvasivecardiologyArthur fass, M.d.

franklin Zimmerman, M.d.

dina Katz, M.d.

deborah okoniewski, R.n., fnP

Holly Mcnamara, R.n., AnP

New wiNdsor divisioN845.561.2773

clinical & nonInvasivecardiologyJohn tighe, M.d.Stephen Lazar, M.d.Joseph George, M.d.

Invasive–Interventional cardiologyAhmad A. Hadid, M.d.Ahmad B. Hadid, M.d.Gladys Pacenza, R.n., fnPPatricia Rainaldi, R.n., fnP

sURgERy

valhalla divisioN914.493.8793

cardiothoracic surgerySteven Lansman, M.d., Ph.d.david Spielvogel, M.d.Rocco Lafaro, M.d.Ramin Malekan, M.d.Masashi Kai, M.d.Cindy Yu, R.n., n.P.

hawthorNe divisioN914.593.1200

vascular surgerySateesh Babu, M.d.Pravin Shah, M.d.Arun Goyal, M.d.Romeo Mateo, M.d.igor Laskowski, M.d.francis Carroll, M.d.

lasER vEIn cEntERs

Hawthorne 914.593.1200Mount Kisco 914.241.3204new Windsor 845.561.2773White Plains 914.593.1234Carmel 845.278.9670

cardiovascularadvaNces iN

care

go to WEstchEstERhEaRtandvascUlaR.com

foR CoMPLEtE AddRESS LiStinGS And to SCHEdULE

An APPointMEnt onLinE.

4


This specialist knows how imaging technologies

can help treat heart disease—and prevent it

a passionthey say a p icture is worth

a thousand words, and Westchester

Heart & Vascular cardiologist Tanya

Dutta, M.D., agrees. She interprets

nuclear stress tests, echocardiograms,

cardiac CT (computed tomography)

scans, and cardiac MrI (magnetic

resonance imaging) scans. These tools

help her accurately assess patients’

hearts to assure defi nitive diagnoses—

and also provide assessments to help

others stay healthy.

“Today we have many options to treat

heart disease that can be used before we

have to refer a patient for an angioplasty or

surgery,” says Dr. Dutta. “Cardiac imaging

studies can help us detect heart disease

at an earlier, more treatable stage than

other tests. With them, we can often step

back from recommending an invasive

procedure and better guide treatment

with medications and lifestyle changes.”

For patients who require surgery, she

adds, cardiac imaging studies can fi ne-tune

the treatment needed and help surgeons

plan their procedures. A nuclear stress test

or cardiac CT can replace an

invasive angiogram for patients

who cannot tolerate those tests.

ways to view the heart

Westchester Medical Center’s

cardiac imaging technology,

unequaled in the lower Hudson

Valley, includes:

• 3-d echocardiography,

which can be used alone or

with cardiac MrI to assess heart

valves and other structures;

• a 256-slice ct scanner, which

produces detailed images of the heart

and its blood vessels in less than two

beats of a patient’s heart—so speedy that

it uses 80 percent less radiation than a

standard scanner; and

• a 3 tesla mRI imaging system that

is twice as strong as conventional MrI

machines and produces high-resolution

images that do not require radiation.

“Three-D echocardiography is par-

ticularly helpful for evaluating the heart’s

muscles and valves and determining if

WESTCHESTEr MEDICAl CENTEr

1.877.wmc.docs (1.877.962.3627) | westchesterheartaNdvascular.comto find Aphysician

tanya dutta, m.d., might have been an ace reporter. at fi rst inclined toward a career in

journalism, she edited harvard college’s daily newspaper, The Harvard Crimson, before

switching to biology and earning her B.a./m.a. degree magna cum laude.

“i realized halfway through college that i wanted to do more than interview patients—i

wanted to treat them,” says the native chicagoan.

while at cornell medical college in New york city, she fell in love with fellow student

Neville Bamji—and with cardiology. “there are many fewer women cardiologists than men,

yet almost as many american women as men with heart disease,” she

says. “i thought i could offer my women patients a fresh perspective.”

cardiology, she says, also promised her the ability to practice

medicine based on an abundance of clinical research and evidence-

based outcomes data.

after completing an internal medicine residency at New

york presbyterian hospital-cornell and a cardiology fellowship at

montefi ore medical center in the Bronx, she studied under the “guru

of cardiac imaging,” Nathaniel reichek, m.d., at st. Francis hospital

in roslyn, N.y. she completed a fellowship there in cardiac mr and

cardiac ct and did research in cardiac imaging. she and Neville have

two children, daughter tara, 2, and baby son Jayden, born June 14.

a WoUld-BE JoURnalIst gEts to thEhEaRt oF thE mattER tanya dutta, m.d.

foR PiCtURES

there are areas of scarring in the heart,”

says Dr. Dutta, who trains Westchester

Heart & Vascular’s cardiac fellows in

imaging technologies. “These tests also

help us evaluate treatment that has

already begun.”

Dr. Dutta believes heart disease,

America’s number-one killer, can someday

be tamed. “With better early

detection, medications and

lifestyle modifi cation,” she

says, “we can make great

progress in preventing heart

disease in those at risk.”

yet almost as many american women as men with heart disease,” she



in the cath labin the

InnovationsAt the region’s largest cardiovascular

center, cardiologists and surgeons make

heart-disease treatment more effective

of clinical medicine at New York Medical

College. “The heart does not beat exclusive

of the circulatory system; neither can we

afford to work without close collaboration

with our vascular-surgeon colleagues.”

Since the 1970s, the Medical

Center’s fi ve cardiac catheterization

labs have bustled with interventional

cardiologists performing diagnostic

angiograms, which let doctors watch

how blood fl ows through the heart and

coronary arteries.

While the patient is sedated with a

local anesthetic, the cardiologist threads

a thin tube, called a catheter, into the

femoral or radial artery and up to the

heart. Contrast material is injected into

the blood vessels to produce a real-time

X-ray image of the heart and its coronary

Now in late-stage

planning, westchester

medical center’s

“hybrid” operating

room will enable

cardiovascular

surgeons and

cardiologists to work

collaboratively with

vascular surgeons and

neurosurgeons on advanced interventions

for patients.

“heart and vascular problems often

go hand in hand, so we must work together

in performing both percutaneous and

surgical procedures,” says interventional

cardiologist hasan ahmad, m.d. Besides

performing cardiac interventions, dr.

ahmad also treats peripheral vascular

disease, carotid artery disease and other

circulatory problems.

a New collaBoRatIvE spacE

patieNts are the wiNNers

when different kinds of doctors work

together—and that’s what’s happening

now in the cardiac catheterization (or

“cath”) laboratory, once the exclusive

bastion of interventional cardiologists.

Today it has opened its doors to cardiac

and vascular surgeons, signaling a more

collaborative approach to treating people

with cardiovascular disease.

“research today proves that

integrating the skills and knowledge of

all members of the cardiovascular team

results in better outcomes for our patients,

and that is validated at Westchester

Medical Center daily,” says interventional

cardiologist and electrophysiologist Martin

Cohen, M.D., Acting Director of Cardiac

Catheterization and an associate professor


william gotsis, m.d.

arteries, which the cardiologist views

on a monitor. Angiograms can show

whether a coronary artery is blocked,

help assess blood pressure in the heart’s

chambers and reveal the volume of

blood pumped out of the left ventricle

during each heartbeat.

Since the late 1980s, cardiologists

have also used cardiac catheterization to

perform minimally invasive procedures

called percutaneous (through-the-

skin) coronary interventions (PCIs) to

treat blocked coronary arteries. One of

these, angioplasty—which uses a small

infl ated balloon atop a catheter to open

a blocked artery—revolutionized the

nonsurgical treatment of coronary artery

disease. By the mid-1990s, tiny metal

scaffolds called stents were added to

angioplasty to help prevent restenosis

(re-blockage), a common complication.

In 2003, stents began to be coated with

medications to make restenosis even

less likely.

Also in the cath lab, interventional

cardiologists and electrophysiologists

(cardiologists who treat heart-rhythm

abnormalities) perform:

• laser procedures to vaporize

blockages;

• coronary thrombectomies using

vacuum aspiration with a catheter to

remove a blood clot from a coronary artery;

• heart biopsies;

• implantations of pacemakers and

implantable cardioverter-defi brillators

(ICDs) to correct irregular heartbeats;

• transesophageal echocardiograms

(in which an ultrasound tool is guided down

the patient’s throat on a scope) to diagnose

structural problems of the heart, and

• radiofrequency and cryo-energy

ablations, which use heat and freezing

techniques, respectively, to vaporize tissue

that causes heart-rhythm disturbances.

what teamworK caN do

“Historically, interventionalists and cardiac

surgeons competed for patients,” says

interventional cardiologist linda Cuomo,

M.D., Director of Westchester Medical

Center’s Coronary Care Unit. “But

with exciting advances in nonsurgical

percutaneous procedures coming down the

pipeline and the hybrid room that is being

built here, we’ll all be working together.”

Among these advances is

transcatheter aortic-valve

implantation (tavI), a new

treatment for patients with

aortic stenosis—a life-

threatening narrowing

of the aortic valve—who

cannot undergo valve

replacement because

of age or other medical

conditions.

In TAVI, an interventional

cardiologist and a cardiac surgeon

replace a patient’s damaged aortic

valve with a bioprosthetic one. They

enter through a small skin puncture in

the femoral artery instead of making

the large traditional neck-to-navel

incision standard in open surgery. Once

the bioprosthetic valve is implanted, it

handles the function of allowing oxygen-

rich blood to fl ow from the ventricle to

the aorta and then out to the rest

of the body.

“We want to bring TAVI to our

patients in the lower Hudson Valley,”

says Gary Silverman, M.D., Co-Director of

Interventional Cardiology at Westchester

Medical Center and an associate clinical

professor of medicine at New York

Medical College. “Here at Westchester

Medical Center, we are putting the pieces

in place, both diagnostic and therapeutic,

to perform the TAVI procedure and other

percutaneous treatments that will save

countless lives.”

Dr. Silverman and William Gotsis,

the newest

twist on cardiac

catheterization is

to thread the catheters

and other instruments

“transradially”—up to

the heart through the

radial artery in the

patient’s wrist instead of

the femoral artery in the

groin. interventional cardiologist robert

J. timmermans, m.d., made the switch

to the transradial approach several years

ago and strives to use the technique

almost exclusively.

“the transradial approach results

in a 50-percent lower risk of major

bleeding complications at the wrist than

in the groin—and less pain too,” says

dr. timmermans. “patients can sit up

immediately following the catheterization

and can usually go home sooner than

patients who must remain lying down fl at for

several hours after the femoral approach.

“we’re working to minimize delays

and return patients home as safely and

expeditiously as possible,” adds the doctor.

USING A BETTErEntRy poInt

M.D., Co-Director of Interventional

Cardiology, were colleagues at Montefi ore

Medical Center in New York City. “We

are thrilled to be working again with

one of our mentors, Chair of Medicine

Dr. William Frishman, with whom we

conducted research at Montefi ore,” says

Dr. Gotsis, who now directs

Westchester Medical

Center’s interventional

cardiology fellowship

program.

gary silverman, m.d.linda cuomo, m.d.martin cohen, m.d.





largest the aorta, shaped liKe a caNdy

cane, is the body’s largest blood

vessel. It carries oxygenated blood

and nutrients from the heart to the

rest of the system. Originating in the

heart’s left ventricle, the

aorta rises and then

arches backward over

the left lung, descends

throughout the chest

into the abdomen, and

then ends by dividing

into the iliac arteries in

the pelvis.

In the average adult, the

aorta’s strong and fi brous walls

THEprotectiNg

arterylargest the aorta, shaped liKe a caNdy

cane, is the body’s largest blood

vessel. It carries oxygenated blood

and nutrients from the heart to the

rest of the system. Originating in the

heart’s left ventricle, the

aorta rises and then

arches backward over

the left lung, descends

throughout the chest

into the abdomen, and

then ends by dividing

into the iliac arteries in

the pelvis.

aorta’s strong and fi brous walls

protectiNg

arterylargestarterylargestA vigilant program at Westchester

Medical Center helps save the lives of

patients with thoracic aortic aneurysms


must withstand the pressure of 10 pints

of blood gushing through at all times.

An aortic aneurysm occurs when

the walls of the aorta weaken or balloon

out. Aortic aneurysms are called

thoracic if they occur in the chest above

the diaphragm and abdominal if they

appear below.

preveNtiNg disaster

Thoracic aortic aneurysms can develop

slowly or quickly. Two famous TV

comedians lost their lives to problems

in the thoracic aorta: lucille Ball

from a ruptured aorta following heart

surgery, and John ritter from an aortic

dissection.

At Westchester Medical

Center, Westchester Heart &

Vascular’s internationally recognized

cardiothoracic surgeons have

implemented a comprehensive Aortic

Aneurysm Program to prevent such

tragedies by carefully screening all

patients diagnosed with thoracic

aortic aneurysms and managing their

care. The surgeons work closely with

patients’ primary care physicians,

cardiologists and vascular surgeons to

track any changes in these aneurysms

through regular checkups, computed

tomography (CT) scans and/or

magnetic resonance imaging (MrI)

studies.

“Obviously we prefer to treat a

thoracic aortic aneurysm safely and

electively before it reaches a dangerous

stage,” says cardiothoracic surgeon

David Spielvogel, M.D., Director of the

Medical Center’s Aortic Aneurysm

Program.

moNitoriNg aortic aNeurysms

For many years, a thoracic aortic

aneurysm was considered safe until it

reached 5 centimeters in size. Today,

however, doctors at Westchester

Medical Center look beyond this simple

cutoff. To determine when to intervene,

Dr. Spielvogel and his Westchester

Heart & Vascular

colleagues,

cardiothoracic

surgeons Steven l.

lansman, M.D., Ph.D.,

and ramin Malekan,

M.D., consider

each patient’s stature, family history

and other medical conditions as well

as the aneurysm’s rate of growth and

its diameter.

Thoracic aortic aneurysms usually

do not make their presence known until

disaster is imminent. But sometimes the

condition is uncovered during a CT scan

or other radiologic study for another

medical issue.

If an aortic aneurysm is found and

is within a safe size, the patient is placed

on an individualized care schedule of

ongoing exams and imaging studies.

If a patient has experienced an aortic

dissection and has had surgery to repair

it, he or she is immediately enrolled in

the database because the patient is at

risk to develop an aortic aneurysm.

steven l. lansman, m.d., ph.d.

an aortic aneurysm

that bursts is a medical

emergency, requiring

immediate attention. call

9-1-1 if you experience:

• sudden, intense,

persistent abdominal,

chest or back pain

• pain that radiates to

your back or legs

• sweatiness

• clammy skin

• dizziness

• loss of consciousness

• shortness of breath

• signs of stroke:

weakness on one side

of the body, diffi culty

speaking, blurry vision

ramin malekan, m.d.david spielvogel, m.d.

ContinUEd on PAGE 8



WHEn AnanEURysm BURsts

“Obviously we prefer to treat a thoracic aortic aneurysm safely and effectively before it reaches a dangerous stage.”



“Since 2006, when we began this

program at Westchester Medical Center,

we have perfected our surveillance and

our surgical techniques so that we have

achieved very successful outcomes

and very low mortality rates,” says Dr.

Spielvogel, who is also a professor of

cardiothoracic surgery at New York

Medical College, Director of Heart

Transplantation, and Associate Chief of

Cardiovascular Surgery at Westchester

Medical Center.

wheN surgery is Necessary

“We look for subtle changes to time

elective surgery, rather than risk having

to repair the aorta in an emergency,” says

Dr. lansman, Chief of Cardiothoracic

Surgery at Westchester Medical Center

and a professor of cardiothoracic surgery

at New York Medical College.

The type of surgery used to

treat a thoracic aortic aneurysm

depends on the site of the weakness.

The “gold standard” of surgery to

treat an aneurysm in the aortic root

and ascending aorta is the Bentall

procedure, named for the English

surgeon who created it in the 1960s.

During a Bentall, the surgeon

removes the area of the aorta containing

the aneurysm, replaces the aortic valve

with a mechanical or bioprosthetic

one, and then re-implants the coronary

arteries into a Dacron polyester tube

graft that replaces the section of

ascending aorta that has been removed.

Drs. Spielvogel, lansman and

Malekan use a technique called valve-

sparing aortic-root reconstruction for

patients whose aortic valves are healthy.

“This saves a patient from a lifetime

of taking anticoagulant medications,

which are necessary to prevent blood

clots from forming around a mechanical

valve and putting the patient at risk for a

stroke,” says Dr. Malekan.

advaNced procedures

If a patient requires repair of the aortic

arch, a procedure called a trifurcated

graft technique will be used. This surgery

you’re at higher-than-average risk of aortic

aneurysm if you:

• are age 60 or older

• use tobacco

• have high blood pressure

• have atherosclerosis (buildup of plaque in

your arteries)

• are male (but women are at higher risk

for rupture)

• have a family history of the condition

• suffer chest trauma

• have a bicuspid aortic valve

• have marfan’s syndrome or ehlers-danlos

syndrome

KnoW YoURanEURysm RIsK

—developed by Dr. Spielvogel—is fast

becoming the standard at heart centers

around the world.

In this procedure, the surgeon

replaces the aortic arch with a Dacron

graft. A separate graft containing three

“limbs” is substituted for the area where

three arteries branch off the arch.

Sometimes when aneurysms are

in the descending aorta and the patient’s

medical condition permits, the surgeon

may use an endovascular stent-graft

procedure, avoiding “open” surgery to

treat the aneurysm. Because there is no

large chest incision, both pain and the

risk of complications are reduced, and

there is a quicker recovery.

The Westchester Heart & Vascular

cardiovascular surgery team also

performs complex surgical procedures

through incisions in the chest and

abdomen to treat thoraco-abdominal

aneurysms, which lie in both the chest

and abdomen. Few heart centers have

experience with such extensive aortic

reconstructions.

guardiNg BraiN aNd spiNal cord

Preventing a stroke during aortic surgery

is a challenge, as a stroke can occur

as the result of tiny particles of debris,

called emboli, traveling to the brain and

blocking blood fl ow there.

At Westchester Medical Center,

special protocols protect the brain during

surgery. Methods include connecting the

heart-lung bypass machine to the axillary

artery, keeping blood fl owing to the brain

while the heart is stopped, and cooling

the patient’s body temperature to slow

the metabolism while stopping blood

fl ow to vital areas.

.

protectiNg THE

largest arteryprotectiNg

largest artery

ContinUEd fRoM PAGE 7


Joseph aruilio shudders wheN

he recalls how close he came to dying.

“My doctor says I dodged a big bullet,”

says Aruilio, 52, a Carmel resident

who works as a service manager for a

medical equipment fi rm.

What almost killed Aruilio was

heart failure, caused by a virus that

enlarged his heart and compromised

its ability to pump blood. When he

was brought to Westchester Medical

alan l. gass, m.d.

Today’s heart-failure

treatments save lives

that would have been

lost a few years ago



removed when his heart is

fully recovered.

“I’m looking forward

to driving again and

returning to work,” says

Aruilio, who is grateful for

the treatment he received.

“I placed my trust in Dr. Gass,” he

adds, “and had complete confi dence in

his ability to save my heart.”

despite its name, heart failure doesn’t

mean the heart stops completely.

it’s a chronic condition in which the

heart can’t do its usual stellar job of

pumping 2,000 gallons of blood daily.

and the american heart association

says it affects 5 million people in the u.s.

many heart-failure patients are

helped by lifestyle modifications,

including smoking cessation, weight loss,

exercise, proper sleep and a low-salt

diet, and by medications that remove

remove fl uid from the body, dilate blood

vessels and calm the heart muscle.

others require more aggressive

treatments such as these, which are

provided in westchester medical

center’s comprehensive heart Failure

program:

• Electrophysiology treatments, which

utilize a pacemaker to synchronize

the beating of the heart’s two

ventricles;

• percutaneous coronary interventions

(including angioplasty and stenting),

which open up blocked or narrowed

coronary arteries;

• latest-generation mechanical assist

devices, which perform the pumping

action of the heart and serve as

bridges to transplant or as a long-

term destination therapy; and

• cardiac surgery, including heart

transplantation, coronary artery

bypass, valve repair or replacement

and aortic surgery.

HELPinG PAtiEntS WitHhEaRt FaIlURE

Today’s heart-failure

Center’s Emergency Department

on September 6, he was chronically

short of breath and his heart was

racing at an alarmingly fast rate. An

electrocardiogram was abnormal, and

he was promptly admitted.

Aruilio was hooked up to an

extracorporeal membrane

oxygenation (ECMO)

machine to help

his lungs while

a percutaneous

(through-the-

skin) CentriMag®

ventricular assist

device (VAD) was

implanted through the

groin into his heart to take

over its function temporarily

and pump oxygenated blood

through the body. Together

the two technologies gave

Aruilio’s endangered

heart the chance

it needed to

recuperate.

This

combination,

pioneered by Alan l.

Gass, M.D., Director,

Heart Transplantation

and Mechanical Circulatory Support,

and his team at Westchester Medical

Center, can be initiated within 15 minutes

in an operating room or a cardiac

catheterization lab. And it’s helping to

change heart-failure treatment today.

At an international conference

in Pennsylvania in June 2011, Dr. Gass

presented data from almost 100

ECMO procedures he and the team

at Westchester Heart & Vascular

have performed over four years. “We

rescued many of these patients from

certain death, so that we could initiate

further treatment and save their lives,”

says Dr. Gass.

Aruilio was slowly weaned off

the ECMO machine and discharged

September 26. The device will be



iF varicose veiNs have Kept

you from revealing your legs, stand up

and take notice. A minimally invasive

treatment can get you back into your

shorts and dresses without sidelining you

for days. “I was surprised by how easy

and painless it was,” reports luAnne Izzo

of Katonah, 48, who is proud of her legs

once again after years of hiding them.

Vascular surgeons at Westchester

Heart & Vascular are using the outpatient

VNUS Closure™ procedure to treat

varicose veins with little discomfort.

Patients often experience immediate relief

from burning or throbbing in the legs and

can usually go back to work and resume

their normal activities the following day.

Healthy leg veins contain one-way

valves that open and close to assist the

return of blood to the upper part of

our body. When these valves become

damaged or diseased, blood can pool

in the veins, causing a condition called

venous refl ux or venous insuffi ciency in

which leg veins may become swollen,

discolored and knotted. Symptoms—

including pain, throbbing, burning, muscle

cramps and leg fatigue—often follow. This

condition, commonly known as varicose

veins, can progress to leg ulcers and

dangerous blood clots.

It’s been estimated that nearly 60

percent of all American women and

An

outpatient

procedure

has made the

treatment

of varicose

veins simpler

and more

effective

ugly BAniSHinG


42 percent of men have varicose veins.

And though the problem sometimes

affects younger adults, its incidence

increases with age.

“Varicose veins are one of only a

few conditions that affect clinical health,

aesthetics and quality of life,” says

surgeon Arun Goyal, M.D., Director of

Vascular Imaging and the Atrium laser

Vein Center and an assistant professor

of surgery at New York Medical College.

“By the time patients come to me, many

have suffered for years and greatly

curtailed their activities.”

closiNg oFF diseased veiNs

Until about 10 years ago, doctors treated

varicose veins with an invasive procedure

called vein stripping, which Izzo recalls

her mother undergoing. The patient was

placed under general anesthesia while a

vascular surgeon made several incisions

near the knee and groin and then inserted

a medical tool into the great saphenous

vein, the major vein in the leg from which

smaller veins branch off. The saphenous

vein was tied off and then pulled from the

leg. Because smaller veins broke during

this process, blood frequently leaked

into surrounding tissues; patients had

postoperative pain, soreness and bruising,

and recovery took up to four weeks.

In the early 2000s, the surgeons

at Westchester Medical Center began

performing a procedure called radio-

frequency endovascular ablation to

treat varicose veins. As embodied in a

system known as VNUS Closure™, it has

since replaced vein stripping in all but

arun goyal, m.d.

the most severe cases.

Endovascular procedures are

performed without an incision instead of

with “open” surgical cuts. radiofrequency

ablation involves using heat energy to

remove diseased tissue, in this case the

varicose veins.

the power oF heat

Dr. Goyal performs VNUS Closure™ in

the Atrium laser Vein Center, using

local anesthesia. A Closure™ catheter

is inserted into the patient’s saphenous

vein percutaneously at the knee through

a small needle prick. Using ultrasound

imaging to guide him, Dr. Goyal delivers

quick bursts of radiofrequency energy

within the catheter to sections of the

vein’s wall. The heat shrinks the wall,

causing it to collapse and seal up. Healthy

veins take over the job of taking blood

from the legs back to the heart. The

along camE ‘spIdERs’

spider veins are varicose veins’ annoying but harmless cousins: tangled groups of tiny

blood vessels that turn blue or red from mild venous refl ux, located near the surface of

the skin. people at risk for varicose veins are also at risk for spider veins. spider veins can

be caused by ultraviolet rays of the sun, certain medications or an injury to the skin surface.

generally, spider veins are treated with one of two noninvasive or minimally

invasive methods:

• sclerotherapy, the injection of an irritant solution into the spider veins, which

causes them to seal shut. the veins are absorbed by the patient’s body.

• laser treatment, during which a device is used to deliver heat to the surface of the

skin to destroy the veins.

Because these treatments are considered cosmetic procedures, they are not

covered by health insurance. patients usually require four treatments over a period

of six months. although general practitioners, dermatologists and other healthcare

professionals offer spider-vein treatments, dr. goyal recommends consulting a board-

certifi ed vascular surgeon.

“we have extensive knowledge about the complex functioning and malfunctioning of

the entire circulatory system, so that if there are other medical issues affecting this system

we can address them too,” he says.

ugly BAniSHinG

Who’s at RIsK?you may be at risk for varicose or

spider veins if you:

• are a woman

• have been pregnant more than

once

• have a family history of the

condition

• work at a job that requires long

periods of standing

• do a lot of heavy lifting

• are overweight

Closure™ procedure takes

about an hour, and patients

go home one to two hours

later. If an ultrasound test

performed prior to the

procedure has shown

venous refl ux disease in

veins other than the saphenous, they can

be treated at the same time.

“research studies have shown that

the Closure™ procedure is about 97

percent effective,” says Dr. Goyal. “And

most patients require just one treatment.”

Patients usually go back to work

the next day. Postoperative care involves

wearing compression stockings for one to

two weeks and walking at least one mile a

day. Any bruising or scarring is minimal.

“There was no down time,” says

satisfi ed patient Izzo. “If I had known how

uncomplicated it was going to be, I would

have done it a lot sooner.”



“If I had known how uncomplicatedit was, I would have done it a lot sooner.”



Endovascular procedures

often can restore healthy

circulation without a

long hospital stay

let your

d i d yo u K N ow yo u r B lo o d

travels through roughly 60,000 miles

of arteries, veins, capillaries, organs and

cells of your body every day? When it

circulates normally, this blood (about 10

pints in the average adult) distributes

oxygen and nutrients, then picks up

waste matter and carbon dioxide

from organ and tissue cells. When

something impedes blood fl ow—either

by blocking or weakening blood vessels

or by damaging valves inside veins—a

person is said to have vascular disease.

Fortunately, today’s endovascular

(inside blood vessels) treatments can

in many cases restore good health to

people with vascular disease without

long hospitalizations.

At Westchester Heart & Vascular,

six board-certifi ed vascular surgeons

specialize in diagnosing and treating

conditions of the circulatory system.

They work closely with a team of

cardiologists and cardiothoracic

surgeons to provide comprehensive

care of the entire cardiovascular

system. Our vascular surgeons are also

an integral part of Westchester Medical

Center’s level I Trauma Center team,

which treats patients who often require

immediate emergency care.

Vascular disease can be caused by:

• atherosclerosis, a slow,

progressive disease marked by a buildup

of plaque (fat, cholesterol, calcium) in

an artery;

• infl ammation in a blood vessel

that leads to narrowing or blockage;

• blockage by an embolus (tiny mass

of debris) or thrombus (blood clot); or

• injury or trauma to blood vessels.

miNimally iNvasive procedures

“By far the most exciting advances

in the treatment of vascular disease

involve minimally invasive endovascular

procedures,” says Sateesh Babu, M.D.,

Chief of Vascular and Endovascular

Surgery at Westchester Medical Center

and professor of clinical surgery at

flowblood


New York Medical College. “These can

often spare a patient major surgery

to prevent or stop a life-threatening

vascular condition.” With Pravin Shah,

M.D., Dr. Babu cofounded the Medical

Çenter’s oldest vascular surgery

practice in 1980; it has since joined

Westchester Heart & Vascular.

preveNtiNg “triple a” disasters

In the past decade, the endovascular

treatment of a common yet potentially

deadly condition called abdominal aortic

aneurysm (AAA or “triple A”) has spared

many patients complex abdominal

surgery that would have required a

hospital stay.

An AAA is a ballooning of the aorta

in the abdominal area, most often below

the kidneys. If it ruptures, this can cause

death in up to 50 percent of patients

before they reach the hospital. By far

the greatest risk factor is cigarette

smoking. (See “When an Aneurysm

Bursts,” on page 7.)

Insidious by nature, AAAs do not

usually cause any symptoms. Often

they are discovered during a physical

exam or an imaging test for another

medical condition.

“Once we know a patient has an

AAA, we develop a surveillance plan of

checkups and ultrasounds to keep an

eye on it,” says Dr. Babu. “In men, we

may recommend treatment if it grows

above 5.5 centimeters, in women above

5 centimeters, and in both if the AAA is

growing rapidly. There is also a familial

risk, so we recommend ultrasound

screening for family members.”

During endovascular AAA repair, a

stent graft is threaded up to the site

of the aneurysm from the femoral

artery. The stent graft acts as a bridge

between the healthy parts of the aorta,

reinforcing the weakened section and

allowing blood to fl ow through the

graft and avoid the aneurysm, which

eventually shrinks.

“Because every patient’s

anatomy is different,” says Dr. Babu,

“a vascular surgeon’s decision to use

an endovascular procedure (in about

75 percent of cases) or an “open”

repair (25 percent) must take into

consideration the location of the

aneurysm, any twists and turns of the

aorta and any blockages in arteries on

the way from the femoral artery up to

the AAA.”

carotid artery disease

A major risk factor for stroke, carotid

artery disease occurs when plaque

builds up in one or both carotid arteries

located in the neck, which carry blood

to the brain and supply blood to your

face, scalp and neck. A stroke can

occur if plaque narrows the artery

or if a blood clot sitting atop plaque

breaks off and then blocks blood fl ow

to the brain.

Dr. Babu and his colleagues took

part in a major National Institutes

of Health clinical trial investigating

two treatments for carotid artery

disease. The Carotid revascularization

Endarterectomy versus Stenting Trial

(CrEST) demonstrated that carotid

endarterectomy, a traditional surgical

procedure to clear a blockage, and

the minimally invasive endovascular

angioplasty/stenting used to open

up a carotid artery had similar out-

comes (though there is a slightly higher

stroke risk with stenting in patients

over age 80).

Open surgery entails removing

plaque and diseased portions of the

artery through a small neck incision.

The stenting procedure involves

threading a balloon-tipped catheter,

metal stent and a tiny umbrella-like

“embolic protection device” (to guard

against the formation of embolisms)

up from an artery in the groin to the

carotid artery in the neck.

“A carotid artery that is less than

75 percent blocked carries only a 1

to 1.5 percent risk of stroke,” explains



Dr. Babu. “Once the blockage goes

over 75 percent, the stroke risk leaps

to 7 to 10 percent per year. Surgical

endarterectomy and stenting have

similar success rates, so the choice of

treatment is based on each patient’s

individual anatomy, medical condition,

age and overall health.”

pravin shah, m.d.sateesh Babu, m.d.

“By far the most exciting advances in the treatment of vascular disease involve minimally invasive endovascular procedures.”



iN septemer 2010, shaNNoN

Holmes of Millbrook, N.Y., thought her

three-year-old son, Hunter, was coming

down with a bug. Even the excitement of

his cousin’s birthday party didn’t get him

up and running.

On September 28, a call from

Hunter’s child care provider, also a nurse,

sent Shannon into a whirlwind of activity,

ending in Hunter’s being diagnosed in

the Pediatric Emergency Department

(ED) of Maria Fareri Children’s Hospital

at Westchester Medical Center with a

dangerous abnormal heartbeat, known as

an arrhythmia.

Upon the recommendation of

Hunter’s pediatrician—who measured

the boy’s heart rate at 194 beats per

minute instead of the normal 90 to

110—Shannon and her husband, Mark,

made the one-hour drive to Maria Fareri

Children’s Hospital.

As they reached the Emergency

Department (ED), the family was

immediately met by the hospital’s

pediatric cardiology team. By this

time, Hunter’s heart rate was up to 225

beats. An electrocardiogram revealed

supraventricular tachycardia (SVT),

a disturbance of the heart’s electrical

system that starts in the upper chambers.

When a heart beats that fast, it cannot

rest in between beats and its chambers

cannot fill with blood properly to create

the force for normal blood flow.

“Our first step was to use maximum

dosages of an intravenous medication

to try to break the SVT, but his heart

continued to beat too fast,” says Irfan

Warsy, M.D., who was called in to

supervise Hunter’s treatment. Director

of Pediatric Electrophysiology at Maria

Fareri Children’s Hospital and an assistant

professor of pediatrics at New York

Medical College, Dr. Warsy specializes in

heart arrhythmias in children.

“When a second medication also

failed, we had to consider: Was Hunter’s

enlarged heart a result of the SVT or was

it, perhaps, a reaction to something viral?”

A lITTlE BOY survives A

big heart problem

How an electrophysiology procedure

cured a rapid heart rate

hunter holmes, 4, above and with friends Noah mead, 4 (left), and isabella marie tibodeau, 2, at a summer carnival

Is my chIld havIng palpItatIons?“children,” says pediatric

electrophysiologist irfan warsy, m.d.,

“may not know how to convey that they

are experiencing heart palpitations. they

may describe their heart as ‘beeping’ or

say they are ‘having chest pains.’” if your

child does so, go first to your regular

pediatrician, who may recommend a

pediatric cardiologist; 16 of them are on

the faculty of the maria Fareri children’s

hospital at westchester medical center.


recalls Dr. Warsy. “We formulated a plan

to treat him in the hospital’s Arlene and

Arnold Goldstein Pediatric Intensive Care

Unit with another potent medication and, if

necessary, to use a ventilator to breathe for

him so his heart could rest.”

Fortunately, a third medication broke

the SVT overnight, and a ventilator was

not needed. Hunter’s heart returned to a

normal rhythm after about four days of an

incessant rapid heartbeat.

“We were allowed to stay all seven

days that Hunter was in the hospital,” says

Shannon. “By the fourth day, he started to

look like himself and wanted to play again.”

Further tests revealed to Dr. Warsy

that Hunter had a rare form of SVT called

permanent junctional reciprocating

tachycardia. The culprit was not a virus,

but a group of cells called a substrate.

“A substrate is present from birth and

acts as a kind of short circuit,” explains Dr.

Warsy. “It is patient and waits in a child

until there’s a perfect environment of

heart maturity, neurological growth and

hormones, then it acts up.”

diagNosiNg arrythmias

Dr. Warsy oversees the only pediatric

electrophysiology (EP) service in the

region. This subspecialty of cardiology

involves the diagnosis and treatment of

arrhythmias, disturbances in the heart’s

intricate electrical conduction system.

Electrophysiologists divide arrhythmias

into tachycardias, in which the heart rate

is faster than normal; and bradycardias, in

which it is slower. Noninvasive cardiac tests

used to diagnose arrhythmias include:

• electrocardiograms (EKGs);

• short- and long-term home EKG

Holter monitoring;

• event monitors and loop recordings

(which detect palpitations); and

• exercise stress tests (which

evaluate the heart’s ability to respond

appropriately to exercise and assess

medications’ effectiveness).

Dr. Warsy and his EP team also

use invasive tests to provoke rhythm

disturbances in children to discover

if a true arrhythmia exists. “Inducing an

arrhythmia is not dangerous in children,”

the doctor says. “Within the carefully

controlled environment of the EP lab, we

can provoke the heart into an arrhythmia,

study the characteristics of the substrate

and then pace the heart back to normal.

In the majority of children on whom we

perform this test, if we can’t induce a

disturbance, there is no arrhythmia.”

A “roving” catheter moved

by the electrophysiologist can

pinpoint a substrate, such as

Hunter’s, within millimeters. “The

key is to avoid the atrioventricular

(AV) node, electrically the ‘holiest’

spot in the heart,” says Dr. Warsy.

Because the medication Hunter

was taking to control his SVT can

cause significant side effects, Dr. Warsy

recommended a minimally invasive

radiofrequency ablation procedure to put

an end to the arrhythmia permanently.

While Hunter was placed under

general anesthesia, Dr. Warsy employed

catheters placed in stable predetermined

positions to provoke Hunter’s SVT with

electrical currents. Using 3-D imaging,

he determined the pathway of the SVT

and guided a roving catheter to locate

the offending substrate tissue. Within

millimeters of the substrate he used

radiofrequency energy heated to 60º

Celsius (140º Fahrenheit) to destroy the

substrate, monitoring the temperature with

special technology within the catheter.

Happily, Hunter became one of

ventricular

arrhythmia, in

which the heart’s

lower pumping

chambers beat

faster than normal,

can result from a struc-

tural abnormality of the

heart muscles, a problem

with the coronary arteries or a channelo-

pathy, a genetic aberration of the heart’s

electrical conduction system. if not treated

promptly, it may cause sudden cardiac arrest.

if such an arrest in a child is successfully

relieved, a small device called an implant-

able cardioverter-defibrillator (icd) can be

used to maintain a regular heartbeat.

“the advanced icds we now use can

differentiate between pathologic tachycar-

dia and a normal fast heart rate during a

child’s everyday activities,” says dr. warsy.

“once the icd determines via complex

algorithms that the rapid heart rate is truly

an abnormal arrhythmia, it can simply pace

the heart out of the arrhythmia or send a

small electrical current to shock it into a

normal rhythm, saving the child’s life.”

the 60 or so children each year that

Dr. Warsy treats and cures with this

procedure. After an overnight stay, he

returned home with no evidence of

the SVT. He underwent imaging tests

every couple of months until Dr. Warsy

discharged him from his care eight

months later, noting that his heart

function had normalized. There are no

restrictions on Hunter’s future activities.

“I finally exhaled when Dr. Warsy said

he was cured,” says Shannon with a laugh.

living with recurrent episodes

of SVT can be a burden for children,

notes Dr. Warsy: “They often become

withdrawn and anxious and live in fear of

recurrences that can bring an ambulance

to their school. This procedure, which

carries just a minimal one to three per-

cent risk, can turn a

child’s life around.”



irfan warsy, m.d.


Westchester Medical Center.One of America’s

100 Best Hospitals for Cardiac Surgery.

Since 1977, our team of world-class physicians has dedicated as much effort to advancing cardiac treatment methods as it has to perfecting them.

That’s why, with nearly 6,000 hospitals in the United States, HealthGrades®, the most trusted, independent source of physician information and hospital quality ratings, has placed us in the top 100 for Cardiac Surgery.

Maria Fareri Children’s Hospital • Westchester Heart & Vascular • Cancer Center • Transplant CenterNeuroscience Center • Joel A. Halpern Regional Trauma Center • Burn Center

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