1. Welcome Dear Colleague, Welcome to the first letter of the New Year from the Heart and Cardiovascular Service Line. The MedicalCollege of Georgia has a 50-year tradition of taking care of children with heart problems. Therefore, it should not come as a surprise to anyone that these children, now productive young adults, look to us for continuity of their care. The cardiovascular service line has a highly specialized team consisting of a dedicated cadre of physicians, nurses, perfusionists and a parents' group to take care of these complex patients. Sheldon Litwin, M.D., Professor and Chief of Cardiology at Georgia Regents University, has special expertise and interest in the subject and has written an overview in this edition of the newsletter. I know you will find it interesting and informative. Mary Arthur, M.D., Associate Professor of Anesthesiology, shares with us the benefits of using bloodless medicine as an alternative to donor blood. Almost every week, we discover new complications and side effects of blood transfusions. As such,it behooves us to use all possible means to minimize use of blood and blood products without comprom ising patient outcomes. I a m pleased to report that, owing to our evidenced­ based guidelines and a team of driven individuals,blood utilization rates in our cardiac surgery patients are one of the lowest in the country. As we encounter an increasing number of aged patients w ith concomitant advanced diseases, we find ourselves performing staged procedures to allow these patients time to recover from their multiple problems. Paul Poommipanit, M.D. writes about one such temporizing measure, balloon aortic valvulop lasty, in patients with severe aortic stenosis too ill t·o undergo definitive surgery. A close coordination between various specialists is essential for optimaloutcomes. II.II. As always, we are proud of our fellows in training and some of their activities are outlined inside. I am sure you will agree that they are all multifaceted and talented individuals wit h considerable promise. We have a busy year of CME activities ahead of us (schedu le attached). If you have suggestions for new topics or a different format please let us know. Wishing you and yours the best for the New Year, In This Issue Welcome Balloon Aortic Valvuloplasty Bloodless Medicine Adult Congenital Heart Disease Fellowship Highlights Conferences,_,_ M.Vinayak Kamath, M.D. Director, Heart and Cardiovascular Services and Chief, Cardiothoracic Surgery Georgia Regents University 1120 15th Street BA-4300 Augusta, GA 30912 706-721-3226 kamath@gru.edu G Health GEORGIA REGENTS HEART & CARDIOVASCULAR SERVICES M.Vinayak Kamath, M.D. Director, Heart and Ca rdiovascular Services and Chief, Cardiothoracic Surgery

2. Assistant Professor of For patients with severe aortic stenosis,the option of a less-invas ive procedure is becoming more common at Georgia Regents Medical Center's Heart and Cardiovascular Center.Subsequently, we learned that restenosis within six months is common. Today, balloon aortic valv uloplasty is increasingly used as a"bridge" to more definitive therapy. Balloon aortic valvuloplasty (BAV) increases the aortic valve area by inflating a balloon within a severely stenotic aortic valve.Historically,this procedure was done in hopes of providing a durable, less-invas ive solution for aortic stenosis. With the advent of TAVR, BAV is being performed more frequently. Since surgicalaortic valve replacement (AVR) provides a durable, long-last ing solution for aortic stenos is, BAV has infrequently been performed. But, with the advent of transcatheter aortic valve replacement (TAVR), in w hich an aortic valve can be implanted percutaneously, BAV is being performed more freque ntly, providing an alternative treatment for seve re aortic stenos is. At the Georgia Regents Medical Hea rt and Cardiovascular Center, an 84'-year-old man with end-stage renaldisease recent ly underwent BAV. This patient has cardiomyopat hy with an ejection fraction of 30 percent and moderate aort ic stenosis. He presented with a non-ST elevation myocardial infarction, class IV heart failu re and hypotens ion. A ca rdiac catheterization revea led s ignificant coronary artery disease of the right coronary a rtery and left anterior descending artery. Surgery was deemed too risky since his EF was now 20-25 percent with severe aortic stenosis and severe mitraland tricuspid regurgitation. The patient underwent high-risk stenting of his RCA and LAD and the previously placed intra-aortic balloon pump was removed the fo llowing day. Weeks later, the patient improved, but was still having class III-IV hea rt fai lure and receiving daily hemodialysis wh ile havirig episodes of hypotension.This patient was too decondition ed to tolerate open-heart surgery and the decision was made to perform BAV as a bridge to futu re AVR orTAVR. The patient was brought to the cardiac catheter ization lab, gracio usly provided by the pediatric ca rdiovascular service. Cardiac anesthesia and hemodynamic support were provided. Transesoph ageal echocard iography demonstrated a valve area of 0.8-0.9cm2 (severe aortic stenos is). One balloon inflation was done and repeat echocardiography demonstrated a va lve area of 1.2cm2 (moderate aortic stenosis).The patient then had a SO percent decrease in the pressure gradient across the va lve. Given his other critical illnesses, the team decided to terminate the procedure.The patient has slow ly recovered and is wor king with physical therapy to improve his conditioning. BAV for severe aortic stenosis is used to temporize prior to surgica l AVR,assess for response and as an alternative in severely symptomatic patients who are not candidates for other procedures such as AVR orTAVR. A multidisciplinary approac h at Georgia Regents University involving cardiac a nesthes iologists, cardiac surgeons, interventiona I cardiologists and cardiovasc ular imaging specia lists improved the patient's quality of life. -2--2-

3. Mary E. Arthur, M.D. Associate Professor, Anesthesiology and Perioperative Medicine Blood Enhances Oxygen Blood enhances oxygen-carrying capacity, improves wound-clotting and provides volume support for cardiac output. Nevertheless, more and more patients are seeking safe and effective alternatives to blood transfusions during surgery- even cardiac surgery- because of religious convictions, medical concerns or personal preference. Religious objections tend to be limited to primary components (packed red blood cells, platelets and fresh frozen plasma) while secondary compo nents such as albumin and factor concentrates are generally acceptable. Physicians are increasingly accommodating patients' preferences for bloodless surgery because of mounting evidence that blood transfusions portend worse outcomes. Minimizing bleeding and limiting blood transfusions have become important elements of quality improvement programs. Bloodless cardiac surgical procedures require special expertise, precise monitoring, state-of-the-art equipment and innovative techniques. The GRU Bloodless Medicine and Surgery Program was designed expressly for these reasons. How big is the problem? Almost 15 million units of packed red blood cells are transfused annually in the United States during surgery, with cardiac operations consuming as much as 15 percent of the nation's blood supply. This percentage is growing, largely because of the increasing complexity of cardiac surgical procedures. 1) Patient's blood collected 2) Blood volume restored using plasma expa nders (Albumin, Hetastarch or Crystallods). Why do we care? Concerns regarding the safety and efficacy of allogeneic blood transfusion s, the impact on patient outcomes and the astounding costs and challenges associated with maintaining an adequate supply of blood products has renewed an interest in alternatives to transfusion. In addition to transfusion-related risks such as infections I respiratory failure and thromboembolic complications, red blood cell transfusions may alter immune function, impacting long-term survival. What do we know? Most cardiopulmonary bypass patients have sufficient wound-clotting after reversal of heparin and do not require transfusion.Evidence suggests that transfusions might not improve the outcomes of stable non-bleeding patients in nearly 90 percent of the common transfusion scenarios reviewed. Transfusions are only deemed appropriate for patients 65 and older with comorbidities and a hemoglobin of <8 g/dl. Several tools are available to accommodate the need or preference for bloodless surgery, covering all phases of the procedure: preoperative, intraoperative and postoperative. ANH Acute Normovolemic Hemodilution 1 blood is returned, 3) Off CPB, the patient's connedion maintains closed circut. One important strategy is acute normovolemic hemodilution, a process increasing the volume of the patient's own stored blood using expanders such as albumin, hetastarch and crystalloids. The tubing remains connected to the patient at all times, maintaining a closed circuit. The patient's stored blood, which has all the major clotting factors as well as platelets, is returned to the patient after weaning from cardiopulmonary bypass. - 3 -

4. How do we involve the patient? Before surgery, a member of the blood conservatio nteam gives the patient a form listing all the facto r concentrates. The patient then decides which concentrates can be used during the procedure. Our multidisc iplinary blood management team works toget her to limit blood transfus ions and decrease perioperat ive bleeding while still mainta ining safe outcomes. At GRU, about 25 inpatient and outpatient cases per month utilize bloodless medicine tec hniques across all specia lty areas. Four successful bloodless cardiac surgery procedures have been done inthe last few months. More than 180 community members attended a Bloodless Medicine and Surgery Program seminar last fall highlighting techniques that enable medical and surgical treatment w ithout blood tra nsfusions, attesting to the acute interest and growing awareness ofthis burgeoning field of medicine. GRUis happy to fill this vital niche in the community. Cardiovascu lar disease is the leading cause of death wor ldwide. In addition to acquired diseases associated wit h aging, heart disease can be present from birth. Because of steady advances in medicine, most patients with congenitalheart disease today survive into adulthood and many have normallifespa ns. Patients with congenital heart problems are likely to benefit from consultat ion or ongoing care from a cardiovascu lar clinician or team with specia l interest or training in this area. The most common congenital heart condition is the bicuspid aortic valve. The most common congenital heart condition is the bicuspid aortic valve. About 1 in 100 people have a bicuspid aortic valve. The aortic va lve normally has three distinct leaflets (Figure 1A). Each leaflet, or cusp, is associated wit h a s inus of Va lsalva (Figure 1C) in the aortic root.The right and left coronary arteries arise from the respective right and left sinuses ofValsalva.The noncoronary sinus does not give rise to a coronary artery. The three leaflets of the aortic valve open to produce a triangle-shaped orifice (Figure 1A) and whe n closed, appear like a "Mercedes" sign (Figure 1B). Patients with bicuspid aort ic valves have -4--4- A c Ollrl" U.-\II U">#Aol D..., ": _ '"N" 90o --- Boo. - - ---- - ""' ·- -..., B D

5. only two leaflets (Figure 2A valve open, Figure 28 valve closed). In some cases, this results from fusion of the commissure between two leaflets producing a raphe (Figure 28). In normal individuals, the cellophane-thin valve leaflets perform admirably over the course of 80-plus years. However, bicuspid va lves produce turbulent flow patterns that likely contr ibute to early damage of the leaflets. Degenerative changes of the leaflets, including prolapse or calcification (Figure 20), may cause regurgitation or leakage (Figure 2E) or stenosis (Figure 2A). These conditions typically do not become evident until adulthood. Echoca rdiogra phy is generally performed on adult patients with bicuspid valves every one to two years to look for regurgitation or stenosis. Once these abnormalities become clinically significant, surgical valve replacement is usually recommended (Figure 3C). Bicuspid aortic valve is also linked to abnormalities of the aorta. Bicuspid aortic valve also is also linked to abnormalities of the aorta. Coarctation of the aorta, a narrowing of the descending thoracic aorta just after the take-off of the left subclavian artery (Figure 3D) occurs in up to 40 percent of patients with bicuspid valves. Such narrowings have a number of adverse effects, particularly hypertension of the upper body.In addition to aortic coarctation, the wall of the entire aorta may be abnormal. This may lead to enlargement and/or dissection of the ascending aorta. For this reason, aortic imaging with MRI or CT is often done periodically in patients with bicuspid valves (Figure 3A ang B).The natural history of patients w ith bicuspid valves and aortic enlargement is similar to that of patients with Marfan's syndrome. Aortic root replacement may be recommended at the time of valve replacement surgery in those with bicuspid valves, or sometimes even before the valve itself requires surgica lintervention. Angiotens in receptor blocking agents are increasingly being used to protect the aorta from expansion in patients with various aortopathies, including those with bicuspid aortic valves. Being born with 2 rather than 3 leaflets of the aortic va lve requires lifelong monitoring. To effectively diagnose and treat the significant valvular and vascular complications that can arise in patients with bicuspid aortic valve, referral to centers with specia lized interest in medical care, imaging and surg ical therapy for patients with adult congenital heart disease is appropriate. A B c D A B Figure 3. A and B. Two views of aortic root aneurysm (arrow with dissection of descending aorta (arrowheads). C. CT image of mechanical aortic valve in open position. D. Image of repaired aortic coarctation with native aorta (arrow) and graft going around coarct (arrowhead). -5 -

6. Alberto Morales-Pabon, M.D. 3rd Year Chief Adult Cardiology Fellow -6 - lauren Holliday, M.D. 1st Year Adult Cardiology Fellow Michele Murphy, M.D. 1st Yea r Adult Cardiology Fellow I '('( " Jose Cuellar, M.D. 3rd Year Adult Cardiology Fellow Rod Evan Pellenberg, M.D. 2nd Year Pediatric Cardiology Fellow Syed S. Zaidi, M.D. 2nd Year Adult Cardiology Fellow Amin Yehya, M.D. 3rd Year Adult Cardiology Fellow Pediatric Cardiology Fellowship Highlights November 2012 ·Rod Evan Pellenberg, M.D., submitted the manuscript, "Papillary Fibroelastoma ofTricuspid Valve in a Pediatric Patient"and was accepted to Annals ofThoracic Surgery. ·Rod Evan Pellenberg, M.D., lectured for first-year medical students' embryology course. ·Justin Mackenzie Vining, M.D.,was selected a GRU Fellow Representative Nonvoting member of the Georgia Chapter of the ACC. December 2012 ·Justin Mackenzie Vining, M.D., was board certified in general pediatrics by the American Academy of Pediatrics. 201.3 Pediatric Fellowship Program Match The Pediatric Fellowship Program is happy to announce the match for a new fellow who will start July 1,2013. Stefani M.Samples, M.D.- Medical College of Georgia at GRU. 2013 Adult Fellowship Program Match The CV Disease Fellowship Program had a highly successful match for new fellows who will start July 1,2013. Rebecca Napier, M.D. - GRU Residency Program Pratik Choksy, M.D.,M.B.B.S.- GRU Residency Program Amudhan Jyothidasan,M.D.- University of Massachusetts Loren Morgan, M.D.- University of South Carolina Fethi Benraouane, M.D. 3rd Year Adult Cardiology Fellow Justin Mackenzie Vining, M.D. 2nd Year Pediatric Cardiology Fellow Adu lt Cardiology Fellowship Highlights August 2012 ·Amin Yehya, M.D., was elected President of the Housestaff Organization for 2012-13. October 2012 Amin Yehya, M.D., Alberto Morales-Pabon, M.D. and Fethi Benraouane, M.D. passed the Echocardiography Boards on their first attempt in July. This 100 percent pass rate for our fellows was also associated with some fellows scoring in the 90 1 h percentile. ·The 12 adult cardiology fellows completed their first nationwide American College of Cardiology In-Service Exam. Overall program score was significant ly above the national average. The final year trainees scored 100 points above the national average for all other third year cardiology fellowship trainees nationally. November 2012 ·Four of our cardiology fellows presented their research posters at the Annual Georgia Chapter of the American College of Cardiology. ·Lauren Holliday,M.D. was selected to be the Fellow Representative Nonvoting member of the Georgia Chapter of the ACC. :"'::oo!! -· · Amin Yehya, M.D., orga nized the collection of toys fortheJames BrownToy Drive for local needy children at the James Brown Arena on December 20. report.gru.edu/archives/13424

7. 'I'I...... '",, - CME -- L e Ct ures '.·, February 22 Speaker: Michael Luc, M.D., 2nd Year GRU Cardiology Fellow Topic: "Stress Testing" March8 Spea ker: Simi Kumar, M.D., 1st Year GRU Card iology Fellow Topic: "Cardiac CT/Ca rdiac MRI" March 15 Speaker: Ashkan Attara n, M.D., /nd Yea r GRU Card iology Fellow Please contact us for more information 106-72 -2136 '. !1!1 -.. Topic: March22 Speaker: "Chronic Heart Failure" Lauren Holliday, M.D., 1st Year GRU Cardiology Fellow "Intra-aortic Balloon Pumps" Topic: March 29 Speaker: Alber to Morales, M.D., 3rd Year GRU Cardiology Fellow Topic: "Diastolic Heart Failure" April12 Speaker: Michele Murphy,M.D., 1st Year GR U Cardiology Fellow "Women and Heart Disease" Topic: April19 Spea ker: Reza Amini, M.D., 2nd Year, GRU Cardiology Fellow Topic: "Novel Anticoagulation Therapy" April26 Speaker: Jose Cuellar, M.D., 3rd Year GRU Cardiology Fellow Topic: "Comprehensive Approach to Syncope" May3 Speaker: Vincent Robinson, M.D., Program Director, CV Disease Topic: "The New ACGME" May24 Speaker: Fet hi Benraoua ne, M.D., 3rd Year GRU Cardiology Fellow Topic: "Recanalizat ion of Chronically Occluded Graft: Is it a Paradigm Shift? Cardiovascular Conferences ' 7 GRU Coronary Revascularization Symposium June 6-9, 2013 Kiawah Island, SC GRU Cardiac Conference October 9-13, 2013 Chateau Elan Braselton, GA Cardiovascular Update for Primary Care Providers October 26-27, 2013 · Marriott Riverfront Augusta, GA Please contact us for more information 706-721-2736