A Publication by Baylor Scott & White HealthTexas Provider Network WINTER 2019

Baylor Dallas chosen as one of six US sites for trial of new total artificial heart

In this issue

2 Baylor Dallas names new chief of transplant pulmonology

3 BSW Center for Thoracic Surgery aims for national acclaim

6 BSW Oncology expands access, advanced treatment options

7 Innovations mark work of heart failure team

8 Endocrinologist offers prompt patient access

Todd Grazia, MD, the newest physician with Baylor Scott & White Advanced Lung Disease Specialists, has been named chief of transplant pulmonology

at Baylor University Medical Center, part of Baylor Scott & White Health.

Dr. Grazia joins HealthTexas from the faculty at the University of Colorado, which has one of the larger pulmonology programs in the United States. While there, he served as the associate medical director and acting medical director of lung transplantation.

Dr. Grazia manages patients undergoing evaluation for lung transplantation and those who are post-lung transplant. Dr. Grazia’s research interests include attenuating acute and chronic lung rejection, including the potential use of stem cell therapy. He is also interested in donor utilization, donation after cardiac death and advanced circulatory therapies to bridge extremely ill lung disease patients to transplant.

Dr. Grazia aims to work with the surgical team to grow the lung transplant program, from 42 transplants in 2018 to 60 to 65 over the next few years. Dr. Grazia aims to focus on clinically relevant research that will further improve the lung transplant procedure and the care of patients post-op.

“I hope to grow our academic prowess and leadership in the field by becoming

“ I hope to grow our academic prowess and leadership in the field by becoming more involved in clinical trials. We want to look at the newest things in the pipeline that affect how we do transplant and take care of patients in the most effective way possible.” Todd Grazia, MD

Baylor Scott & White Advanced Lung Disease Specialists Chief of transplant pulmonology, Baylor University Medical Center

Todd Grazia, MD, named chief of transplant pulmonology at Baylor Dallas

more involved in clinical trials,” he says. “We want to look at the newest things in the pipeline that affect how we do transplant and take care of patients in the most effective way possible.”

One innovation Dr. Grazia plans to bring to Baylor Dallas, in conjunction with the Department of Thoracic Surgery and Lung Transplantation, is retransplantation of patients younger than 50. These would include patients with cystic fibrosis who had their first lung transplant at an early age and are now faced with a failing transplant.

“These patients are a bigger challenge, but when the retransplants are done well, the patients generally have good outcomes. We hope to begin offering retransplantations this spring or summer,” he says.

Dr. Grazia also hopes to create an interventional pulmonology program that will focus on advanced therapies for patients with end-stage lung

disease. Procedures such as lung volume reduction surgery can give patients more quality of life and more time before needing a transplant.

Dr. Grazia plans to participate heavily in the Baylor Scott & White Specialty Care Center outreach program to increase the referral base for the advanced lung disease program. He hopes to expand outreach clinics to rural areas of Texas, as well as Arkansas, Louisiana and Oklahoma.

While in Colorado, Dr. Grazia headed a successful cardiothoracic transplantation research laboratory responsible for numerous peer-reviewed publications. He has received funding from the National Institutes of Health, the American Heart Association, the Juvenile Diabetes Research Foundation and the Gates Foundation among others.

For more information, visit LungDiseaseDFW.com or call 214.820.6856.

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BSW Center for Thoracic Surgery innovates and elevates the fieldDavid Mason, MD, Eitan Podgaetz, MD, MPH, FACS, Gary Schwartz, MD, and Leonidas Tapias, MD, of Baylor Scott & White Center for Thoracic Surgery aim to create the premier thoracic surgery program in the nation at Baylor University Medical Center. Considering their recent recognition, innovations and groundbreaking research and procedures, the surgical team seems well on the way to achieving this goal. The Department of Thoracic Surgery and Lung Transplantation at Baylor Dallas continued rapid programmatic growth in 2018 while fulfilling its fundamental mission of providing excellence in clinical care. The expanding team treated an even greater number of patients with complex thoracic disorders from around the country. While the majority treated live in Texas, there was a rapid rise in regional referrals from New Mexico, Oklahoma, Louisiana and Arkansas, as well as from more distant

states including Tennessee, Missouri, Colorado, West Virginia, Massachusetts and California.

The department continues in its mission to become the national treatment center of choice for thoracic surgical care. BSW Center for Thoracic Surgery was established in 2014 to provide focused expertise in general thoracic surgery. The surgical team performed 1,096 cases in 2018, compared to approximately 285 cases when the program first started. All patients undergo minimally invasive surgery whenever possible and are evaluated by surgeons who focus entirely on thoracic malignancies, diseases of the esophagus and complex chest disorders and lung transplantation. “Our philosophy is that non-cardiac chest diseases must be treated at high-volume centers by specialists in thoracic surgery for patients to receive the best care,” says Dr. Mason, chief of thoracic surgery

and lung transplantation. “The field has become extremely specialized, and optimal treatment requires expertise in the most up to date and advanced procedures, as well as access to robust research.” While the majority of the surgical treatment was devoted to thoracic malignancies, the department also treated a large number of complex benign esophageal disorders, central and peripheral airway disorders, life-threatening chest infections, as well as patients with advanced lung disease requiring temporary life support or lung transplantation.

Team earns impressive three-star rating

The Department of Thoracic Surgery and Lung Transplantation continues its pursuit of optimal surgical quality. The most important quality metric measured in thoracic surgery is outcomes after lung cancer surgery.

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Lobectomy is the most commonly performed surgical procedure for lung cancer and for that reason is the nationally benchmarked procedure. In 2018, Baylor Dallas earned a distinguished three-star rating from The Society of Thoracic Surgeons (STS) for its patient outcomes after lobectomy for lung cancer. The three-star rating, which denotes the highest category of quality, places Baylor Dallas among the elite for general thoracic surgery in the United States and Canada. Out of 208 thoracic programs submitting data, only Baylor Dallas and eight other programs earned this prestigious achievement. “We take a team approach to thoracic surgery. There is great complexity in terms of preoperative medical conditions a patient brings to surgery and post-op care. Patient care needs to be comprehensive and advanced to get great outcomes,” says Dr. Mason. “We have a dedicated team of thoracic anesthesiologists, nurses and respiratory therapists, as well as a fantastic operating room team specific to thoracic surgery. I am fortunate to work with a team that loves what it does and is committed to providing both excellence and compassionate care. Teamwork and these human elements have all contributed to our earning this rating.”

The STS star rating system is one of the most sophisticated and highly regarded overall measures of quality in healthcare, rating the benchmarked outcomes of cardiothoracic surgery programs in the United States and Canada. The General Thoracic Surgery Database (GTSD) star ratings are derived by testing whether the participant’s composite or domain score is significantly different from the overall STS average for lobectomy for lung cancer performed by GTSD participants. STS General Thoracic Surgery Public Reporting offers a comparison of GTSD and national outcomes, demonstrating the high performance of GTSD participants. The

latest analysis of data for lung cancer resection covers a three-year period, from January 2015 through 2017, with 167 patients undergoing lobectomy at Baylor Dallas in that time period being evaluated and on which the three-star rating was based. In addition to providing quality outcomes for lobectomy, the Department of Thoracic Surgery and Lung Transplantation also led in its use of minimally invasive surgery. Of patients with early-stage lung cancer, 79% had their lobectomies performed minimally invasively in this three-year time period, also above the national average as reported to the STS National Database.

Lung nodule clinic provides critical follow-up

To provide even more comprehensive patient care, the Department of Thoracic Surgery and Lung Transplantation officially opened its Lung Nodule Clinic to provide follow-up care and treatment guidance for patients newly diagnosed with lung nodules. This critical program was established to support the growing number of patients identified with lung nodules in the Lung Cancer Screening Program at Baylor Dallas, as well as to serve as a resource for patients and physicians with incidentally discovered lung nodules. A study conducted by the National Cancer Institute proved that screening people at high risk for lung cancer with low-dose CT scans (LDCT) reduced mortality from lung cancer by 20%. In addition to providing longitudinal follow-up for patients with nodules identified by LDCT screening, it also provides complete follow-up for any patient with a lung nodule.

This lung nodule clinic has the potential to simplify and improve upon the management of lung nodules. Previously, providers discovering a lung nodule had the options of working up or following a lung nodule themselves or determining whether the patient should be sent to a pulmonologist, oncologist

or surgeon. Now providers can refer patients directly to a clinic staffed by specialists in the management of lung nodules and receive a complete treatment and follow-up plan based on established algorithms. All patients with lung nodules are discussed amongst radiologists, pulmonologists, oncologists and surgeons in a multidisciplinary format and a treatment plan formulated. The lung nodule clinic works closely with oncology patient navigators at the Baylor Charles A. Sammons Cancer Center at Dallas. In addition to evaluating lung nodules, counseling is also provided for smoking cessation. The lung nodule clinic is open daily and provides same-day appointments.

Clinics added to outreach initiative

The department cares for an increasing number of patients from an ever-widening geographic area. To better serve these patients, BSW Center for Thoracic Surgery opened two new clinics in 2018. The newly opened Rockwall clinic will provide better access to patients in northern and eastern region of Dallas-Fort Worth. The Lubbock clinic will provide better access to patients in the northern and western Texas. While all surgery is performed at Baylor Dallas due to the complexity of thoracic surgical procedures and the necessity of utilizing Baylor Dallas’ highly specialized thoracic care team, all preoperative and postoperative care is provided at the newly established clinics. The Rockwall and Lubbock satellite clinics are the third and fourth satellite clinics opened by the department and join Fort Worth, Waxahachie and Dallas as outpatient care sites. Same-day consultation is provided at the Dallas location and selectively at the four satellite clinics.

History made with world’s smallest airway stent

The department has demonstrated leadership in utilizing new technology

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and continues to embrace advanced techniques. In 2018, surgeons in the department were the first in the world to successfully deploy the world’s smallest fully covered airway stent in the clinical setting. The stent is a 6 mm fully covered endobronchial stent designed for use in stenting small distal airways in the setting of symptomatic stenosis. Previous versions of the stent were approximately 10 mm in diameter and their applications were limited due to their larger size. Thanks to advances in technology and miniaturized stent delivery systems, distal airway stenoses can now be stented to improve breathing and prevent restenosis. The department teamed with industry leaders to become the first to trial this product in a Baylor Dallas patient with a successful result. No surgeons have any conflicts of interest in these stents. “Tremendous technological advances have been made in airway stenting, both in the quality and delivery mechanisms,” Dr. Podgaetz says. “However, most of them are large airway stents that are used in the main trachea or proximal bronchi. The very distal airways have always posed a challenge as they become narrower and narrower, and a stent small enough to use did not exist. We very much appreciate this opportunity,” Dr. Podgaetz continues. “I think this is an indication of how the industry looks at us as leaders in the field, as progressive thinkers who understand and evaluate new advances in a critical form and are at the forefront of thoracic surgery, working hard to advance the science to improve patient care and outcomes.”

Surgeons in the Department of Thoracic Surgery and Lung Transplantation have

also made use of technology in the management of air leak after chest surgery. Postoperative air leak as a complication of lung surgery can be challenging to manage and can lead to prolonged hospitalization, patient morbidity and high costs. Traditional management of prolonged leaks involves chest tube drainage and observation followed by even more invasive treatments when leaks do not resolve. A new umbrella-shaped, one-way, endobronchial valve limits airflow to damaged tissue and allows trapped air to escape. This leads to lung healing and air leak resolution.

Valve improves air leak management

Surgeons in the department successfully deployed these valves in 2018 to resolve challenging air leaks and received patients in transfer from other hospitals for this procedure. In addition to their use in air leak management, the valve has recently been approved by the Food and Drug Administration to perform endoscopic lung volume reduction (LVR). This technology can provide significant symptomatic relief for patients with dyspnea secondary to advanced emphysema. Its minimally invasive nature has the potential for better outcomes due to its avoidance of complications related to traditional surgery. Surgeons have begun evaluating patients for LVR using these valves. No surgeons in the department have any conflict of interest in these valves.

The Department of Thoracic Surgery and Lung Transplantation also has a growing research arm. Thoracic surgeons at Baylor Dallas lead multiple research studies in thoracic oncology

and lung transplantation. These studies include but are not limited to the identification of radiographic predictors of cancer recurrence after lung cancer resection, the impact of pulmonary rehabilitation prior to thoracic surgery to improve postoperative outcomes, the identification of serum markers that diagnose rejection after lung transplantation, the use of radiographic markers of nutritional state that impact survival and morbidity after lung transplantation, the value of smoking cessation prior to pulmonary resection and the use of anticoagulation in extracorporeal support.

Research to have worldwide impact

In collaboration with Baylor Scott & White Center for Esophageal Diseases and the Center for Esophageal Research at Baylor Scott & White Research Institute, a new IRB-approved protocol holds promising potential to impact research into esophageal diseases. During the time of harvest of solid organs for transplant, including lung, liver and heart, transplant surgeons will also—when families have given consent—harvest the esophagus and upper stomach, giving researchers normal esophageal tissue to use in research and to better understand the diseases that impact the esophagus. “This has never been done before in this way. Our goal is to build normal healthy esophageal cell lines to use for further research,” says Dr. Podgaetz. “Currently, normal healthy cell lines don’t exist as it is impossible to harvest in living patients. Our study has the potential to impact esophageal research worldwide.

For more information, visit CenterForThoracicSurgery.com.

“ Our philosophy is that non-cardiac chest diseases must be treated at high-volume centers by specialists in thoracic surgery for patients to receive the best care.” David Mason, MD

Chief of Thoracic Surgery and Lung Transplantation Baylor Scott & White Center for Thoracic Surgery

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Binu Nair, MD, of BSW Oncology gives patients hope with advanced cancer treatments

Binu Nair, MD, of Baylor Scott & White Oncology, is treating many types of cancers with immunotherapy, one of the most advanced forms of cancer treatment available today.

“There have been tremendous improvements in the last 10 years in our ability to treat many forms of cancer,” Dr. Nair says. Dr Nair also serves as medical director of medical oncology and hematology at

BSWMC- Waxahachie.

One form of immunotherapy consists of checkpoint inhibitors, most commonly pembrolizumab and nivolumab, which remove the brake from the patient’s immune system, allowing it to attack the cancer cells. Checkpoint inhibitors were initially used with one or two cancers, but now it is being widely tried against almost all forms of cancer, including lung cancer, melanoma, gastric cancer and others.

A second form of immunotherapy is CAR T-cell therapy. In this treatment modality, patients T-cells are removed and modified in the lab. The cells are then infused back into the patient. Currently, CAR T-cell therapy has proved to have the most significant benefit with hematological cancers.

“Many other treatments will be available in the coming years, but these two forms of immunotherapy have proven to be real game changers when it comes to how we can treat many cancers,” Dr. Nair says. “We never thought we could have these good outcomes. A cure is near for many cancers.”

Baylor Scott & White Oncology expands to Rowlett

BSW Oncology has expanded to Rowlett with the addition of radiation oncologist Jay Locke, MD, FACRO.

Baylor Scott & White Cancer Center – Rowlett is conveniently located about a mile from Baylor Scott & White Medical Center – Lake Pointe, giving patients easy access to both the hospital and outpatient facility.

Dr. Locke offers all forms of general radiation therapy, including intensity-modulated radiation therapy, image-guided radiation therapy and 3D conformational radiation.

“Radiation therapy is now available in the cancer center, saving patients travel time to outlying facilities. They can stay and have treatment near home. Additionally, we are opening an infusion center at our facility so patients can be treated on-site in a comfortable setting,” Dr. Locke says. “We hope to expand soon with additional therapies in the future. We are eager to work with physicians in the community to provide their patients with easy access to quality, advanced care.”

For new patient referrals in Epic, look for: HTPN DVCIDC HEM ONC, HTPN ROCIDC HEM ONC (Red Oak), and HTPN DVCIDC RAD ONC (Radiation).

For more information, visit CancerInstituteDallas.com.

“ We never thought we could have these good outcomes. A cure is near for many cancers.” Binu Nair, MD

Baylor Scott & White Oncology Medical Director of Medical Oncology and Hematology

Baylor Scott & White Medical Center – Waxahachie

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Baylor Dallas performs its 500th LVAD implantation

As advances in heart failure treatment continue, Baylor University Medical Center remains at the forefront and is still one of the largest programs in Texas. In 2018,

surgeons on the medical staff performed 54 heart transplants and implanted a record 78 LVADs (left ventricular assist device). Dan M. Meyer, MD, recently appointed surgical chief of heart transplant and mechanical circulatory support at Baylor Dallas, implanted the first LVAD at Baylor Dallas in 1996, and recently implanted the 500th LVAD, making Baylor Dallas the first hospital in North Texas to reach this milestone.

“The LVAD that we evaluated during the clinical trial has now been FDA approved for all patients with advanced heart failure as a bridge-to-transplant or destination therapy,” says Shelley A. Hall, MD, chief of transplant cardiology, mechanical circulatory support and advanced heart failure at Baylor Dallas. “I’m very proud of what our team has achieved.”

Baylor Dallas chosen as one of six US sites for trial of new total artificial heart

Many patients with advanced heart failure can be managed by a left ventricular assist device (LVAD). But there are some patients who are not candidates for an LVAD because they have biventricular failure. Baylor Dallas has been chosen as one of six clinical trial sites for the world’s most advanced total artificial heart.

“No major changes have occurred in the field of total artificial heart in decades, so we are very excited to be able to offer access to participation in a clinical trial for this innovative pump to our patients who qualify,” Dr. Meyer says.

Next month, Baylor Dallas will become the first implanting site in the United States for a trial of an LVAD developed by a company in Japan. This device may be able to help support patients whose heart failure is a result of the heart being stiff, and thus, not dilated, rather than the usual enlarged and weakened heart. In addition, this LVAD has the potential to decrease a major complication, which is GI bleeding.

The greatest challenge currently faced by Dr. Hall, Dr. Meyer and the rest of the heart failure/heart transplant team is the new heart allocation system, implemented by the United Network for Organ Sharing (UNOS) in October 2018, which demands that organs go to the

sickest patients no matter their location in the country. In the prior system, organs would go to the sickest patients in a particular UNOS region, and the regions were not always equitable.

“In the past, more than 50 percent of our patients would get an offer of an organ while outside of the hospital, when they were stable and therefore lower risk,” Dr. Hall says. “Now the vast majority of patients will need to be in the hospital to get a chance at a new organ, increasing risk and costs. We don’t know what the long-term implications will be since we just started with the new system.”

Dr. Meyer adds, “The new system has definitely complicated the logistics of retrieving organs. We have to travel farther distances in an attempt to optimize outcomes for our patients. Because patients are sicker at the time of transplant, it taxes our team and our resources going in, as well as post-operative management of these critical patients.”

Both Dr. Hall and Dr. Meyer had leadership roles in working with UNOS to develop the new allocation system. Dr. Meyer was the initial chair of the heart committee for UNOS, and Dr. Hall is the current chair and continues to work with the organization to optimize the new system.

For critically ill patients with advanced heart or lung failure, extracorporeal membrane oxygenation or ECMO is available at Baylor Dallas and three other Baylor Scott & White medical centers. These hospitals have formed an ECMO collaborative to work collectively as a team to provide this much-needed care.

“This is the first time the hospitals in the North Texas and Central Texas regions are working together to get these critically ill patients the care they need close to home or transported to the appropriate facility for their condition,” Dr. Meyer says. “We go all over the southwest region to put these patients on ECMO on-site and then transport back to the right facility.”

“As innovations continue to be made in the field of heart failure, we are committed to aggressively pursuing clinical trials to bring the newest technologies to our patients,” Dr. Hall says. “Whether through research into new heart failure medications, advanced monitoring of heart failure patients, and for those who qualify, heart transplantation or implantation of an LVAD, our goal is to improve the clinical outcomes for patients with advanced heart failure.”

For more information, visit CSBUMC.com or call 469.800.7760.

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8080 N. Central Expressway, Suite 1700 Dallas, TX 75206Phone: 972.860.8600 | Fax: 972.860.8601

Physicians are employees of HealthTexas Provider Network, a member of Baylor Scott & White Health. ©2019 Baylor Scott & White Health. HTPN_4624_2019 BID

Endocrinologist Emilia Popa, MD, offers prompt patient accessPatients with gestational diabetes, uncontrolled diabetes or hyperthyroidism/hypothyroidism need to be seen and treated by an endocrinologist as soon as possible to avoid complications. Emilia Popa, MD, of Baylor Scott & White Park Lane Endocrinology offers prompt access to advanced, quality care. With the addition of advanced practice provider Thao Nguyen, MPAS-PA-C, the practice’s waiting list for new patients is only two to three weeks.

“When a patient is pregnant, she doesn’t need to wait six weeks to get in when she is delivering in two months,” Dr. Popa says. “Patients with high blood sugars can end up in the hospital before they see an endocrinologist. I see at least three new patients a day, and, when needed, more than that. If a physician needs someone in sooner, we try our best to make that happen.”

Dr. Popa emphasizes the use of innovative treatments and advanced technologies to treat the full spectrum

of endocrine conditions, including diabetes, osteoporosis, thyroid disorders, and pituitary and adrenal issues. Among the new medications for diabetes are SGLT2 blockers that work on the kidneys and help with blood sugars. More recently, this class of medications has been shown to have cardiovascular benefits. Injectable GLP1 analogs help with weight loss and blood glucose control.

Thao Nguyen, who is also a certified diabetes educator, is skilled at managing challenging patients with diabetes, including patients on insulin pumps.

“As a smaller practice, we are very patient focused,” Dr. Popa says. “We can treat patients in a more personalized way. And, with the addition of Thao to the practice, we have increased access for patients with conditions where time is of the essence. “

Dr. Popa has been in practice in Dallas for almost 18 years, beginning on the campus of Baylor University

Medical Center. She later moved her practice to 9101 N. Central Expressway, conveniently located at I-75 and Park Lane. Dr. Popa has been recognized in D Magazine among the “Best Doctors in Dallas,” and her practice receives excellent Press Ganey scores.

Dr. Popa is board-certified in endocrinology, diabetes and metabolism. She received her medical degree from the Institute of Medicine and Pharmacy, School of General Medicine in Bucharest, Romania. She completed her doctoral studies at the University of Hanover, Germany, and her residency and fellowship at the University of Rochester Medical Center in Rochester, NY.

Thao Nguyen graduated from Wichita State University and then moved on to a busy endocrinology practice where she worked for 10 years before moving to Dallas.

For more information, call 469.800.7101 or visit ParkLanEendo.com.