Doctors Orders: The Heart of the Matter

ccording to the Centers for Disease Control and Prevention, heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States, accounting for one in every five deaths in 2021. Here in Baltimore, area hospitals are working hard to bring those numbers down and to improve quality of life for those living with diseases of the heart.

PREVENTION
Cardiologist Jeremy Pollock, MD, has a pragmatic view of heart disease. “Every single person gets heart disease,” says the director of heart failure and cardiac population health at University of Maryland St. Joseph’s Medical Center. Indeed, all of our hearts, one way or another, will eventually weaken, slow down and, one day, stop for good. Pollock says you can’t stop this natural process but, “I would like to teach the population how to delay [heart disease’s] development.”

The term “heart disease” is a common way of referring to several kinds of heart conditions. For patients living in the United States, the most common is atherosclerosis, or coronary arterial disease, which affects blood flow.

“Arteries are supposed to be nice and clean– they’re like water pipes,” Pollock explains. “Atherosclerosis is like crud in water pipes. It’s silent and can be a silent killer.” He continues, “It presents itself in one of two ways, unless we find it early.”

The first way, angina, presents as a tightness in the chest and breathlessness with exertion. It’s caused by a buildup of hard plaque in the arteries. It’s unpleasant but, as Pollock says, “Even a 70-percent blockage of the Widowmaker won’t kill you, it will give you angina.”

The second way atherosclerosis presents— heart attack—is caused by the accumulation of soft plaque. Unlike hard plaque, the soft form offers no warning. Unstable, it can rupture and become a clot. “If you don’t know you have it, it can go from 10 percent to 100 percent,” Pollock says, “and when no blood can flow through, that’s a heart attack.”

So how do you know if you’re a ticking bomb? Learn your CAC score, advises Pollock. The Coronary Artery Calcium test is a CT scan that measures calcium in the arteries; its score can help determine the risk of cardiovascular disease and predict the likelihood of a heart attack. The CAC test has been available for decades, but with an increased focus on disease prevention, “It’s comeback in vogue,” Pollock says. “It takes two minutes, costs less than a mammogram… we get your cardiac score and then talk about prevention.”

What’s the best course for prevention? If plaque is found, start taking a statin. “It’s the best way to stabilize plaque and delay the onset of plaquened arteries,” Pollock says. Otherwise, “The answer is holistic intervention. Maintain a healthy weight, be physically active, and eat a healthy diet.”

Pollack adds that social fitness, the mental wellness piece of holistic care, is vitally important. “Be happy… If you’re lonely, it’s as dangerous as smoking a pack of cigarettes a day. This is 95 percent of the prevention battle.”

INTERVERVENTION & DIAGNOSIS
When symptoms of a serious issue present, it’s time to see an interventional cardiologist. Specialists in catheter-based heart procedures, interventionists place stents in coronary arteries, accessing an artery through the wrist or leg. “It’s the breadand- butter procedure,” says structural interventionist John Wang, MD, MSc, director of the Cardiac Cath Lab at MedStar Union Memorial and MedStar Franklin Square hospitals.

Traditionally, a catheter has been used for diagnosis—a camera is sent through the catheter to find the root of a problem. But the field is evolving. Cardiologists at Mercy Hospital are recruiting and preparing for the development of advanced coronary angiography and cardiac MRI imaging for use in diagnosing heart disease. This technological advancement will reduce catheter use for diagnosis, allowing patients a faster and less complicated experience.

“We have strong partnerships with first-class care centers within a small [geographic] radius that excel at invasive/interventional cardiology and cardiac surgery, who are doing innovative work,” says Carlos Ince, MD, medical director for the Heart Center at Mercy. “Our goal is to become the regional leader in providing preventive and … non-invasive diagnostic services to improve the cardiovascular health of citizens across the Baltimore region.”

Diagnosis through imaging will prevent patients from having to visit major heart centers for catheterization sooner than they need to and allow interventionists to treat or focus on complex issues previously resolved only through major surgery.

“We can close congenital defects in patients’ hearts via catheter,” says MedStar’s Wang. The same can be used to treat heart valve issues.

“Heart valves fail in one of two ways,” he says. “The leaflets of the valve can thicken and not open, called stenosis; or instead of closing, they don’t close and you have leakage or ‘regurgitation,’ and the blood just leaks back.” Some patients have both.

A decade ago, the development of Transcatheter Aortic Valve Replacement (TAVR) allowed the replacement of that valve without the risk of open heart surgery. With TAVR, “We are able to deliver and place a new heart valve in approximately 30 minutes,” Wang says. “Patients are up and walking later that day and the majority of patients go home the next day … TAVR has revolutionized our whole field.”

MedStart Union Memorial Hospital (MUMH) is currently involved in a number of clinical trials in structural intervention, including studies of solutions to atrial fibrillation (“A-Fib”) for patients who do not want to go on blood thinners, advancements to the already revolutionary TAVR valves, and evaluating technologies applied to replacing a patient’s far more complicated mitral valve without open heart surgery. A repair device for severe regurgitation of the tricuspid valve is also part of a current clinical trial.

A new pulmonary artery sensor is also under trial. “This to me is just incredible,” says Wang. Many patients with congestive heart failure—a weakening of the heart that causes fluid retention that can back up into the lungs—are frequently admitted to the hospital for a Right Heart Catheterization. “This is when a catheter is inserted from the femoral vein to the heart to measure the pressures in the heart . . . and how much extra fluid they are carrying,” Wang explains. “It’s a painless procedure that takes 20 minutes,” he continues. “This sensor lasts forever and transmits the pressure in the heart wirelessly to the patient’s doctor. … The best part is the ability to make changes in a patient’s medications based on real-time data that can potentially reduce hospital admissions.”

CUTTING EDGE
A team of University of Maryland cardiologists— Diljon Chahal, Shahab Touravadkohi, and Mehrdad Ghoreishi—created global news last year by further advancing TAVR capabilities to treat patients with aortic aneurysms and aortic dissections. Until 2023, treatment was only available through open-heart surgery. “As TAVR came into the mainstream, we began to explore … a minimally invasive, totally endovascular percutaneous approach,” says Chahal.

Chahal explains the procedure, known as “Endo-Bentall,” as simply as possible: “The TAVR valve is attached on a back table in the operating room to the endograft (a large covered stent that helps seal off any dissection in the aorta or any aneurysm) in the aorta, and then the three of us are involved in the deployment using an endovascular approach by going in through the femoral artery. We create fenestrations which are a little circle or hole in the left and right side of the graft and then we can snorkel the covered stents, doing a total ascending aortic arch replacement.”

The procedure was first done successfully in Brazil in 2022. University of Maryland is the only hospital in the United States performing the Endo-Bentall.

A typical patient has severely depressed heart function, explains vascular surgeon Toursavadkohi. “Each patient we have done at Maryland was rejected for open-heart operation due to substantial risk. Their outcomes would have been dismal with a standard cardiac operation.” With this procedure, he continues, “instead of using a heart-lung machine to stop the heart and repair the structures, we can perform the endovascular operation on a native, beating heart.” To date, five such procedures have been successfully performed. All five patients have survived without complications.

“The key factor behind our ability to perform this procedure lies in the exceptional teamwork and collaboration among cardiac surgery, vascular surgery, and interventional cardiology,” says Ghoreishi. “The teams discuss the best approach … and then select the most suitable intervention.” He continues, “This close relationship has transformed the seemingly impossible into reality.”

Cardiac surgeons at Maryland have also recently performed two xenotransplantation operations—transplanting a pig’s heart into a human patient. “In my lifetime, I never thought I would see an Endo-Bentall or xenotransplantation, and in one year at Maryland we achieved the ‘Holy Grails’ of cardiovascular care,” says Maryland Director of Cardiac Surgery, Bradley Taylor, MD. “What we do here is incredibly innovative … bringing people together and using their collective intelligence, we are able to solve the most complex problems we face in cardiovascular care.”

ADVANCEMENTS FOR RECOVERY
For patients and their families, the recovery period after a cardiac event can be painful not only physically, but emotionally and psychologically. Advancements in rehabilitation, information sharing through technology, and mental-health awareness can lighten the load.

Consider an athlete suffering a cardiac event while seemingly at the top of their game. These are often caused by “channelopathy, which is an arrhythmia, or abnormality in the way the heart uses electricity to make the heart beat,” says Lifebridge cardiologist Sunal Makadia. “Unfortunately, some kids are competing without knowing they have it … and there is no pediatric screening for heart disease,” he continues. “The American College of Cardiology has come up with a registry, the ORCCA (Outcomes Registry for Cardiac Conditions in Athletes) to study these patients in detail.”

More often, it’s the young adult athlete suffering the event. “If you had a heart attack at 40, there was a time that was a sentence to never exercise again,” says Makadia. “But now we know that exercise is probably the most important way we can age well.” He continues, “Cardiac rehab is a big part of that, training the patient to know what their heart is capable of and what warning signs to look out for in a safe way.”

One way to help patients is to put the tools to recovery in their hands. Seth Martin, Johns Hopkins Hospital cardiologist and president of the American Heart Association (AHA) Maryland chapter, is leading a clinical trial at Hopkins with a grant from the AHA, testing the effectiveness of a recovery smartphone app for cardiac patients. The Corrie app (corriehealth.com) gives patients an active role in their own care. They can learn about cholesterol and blood-pressure management and use the app to communicate with their physicians.

While rehabilitation is vital to recovery, not all patients have access due to various barriers. “Seeing a doctor three times per week is challenging,” says Martin. “Patients could have issues with insurance coverage … or not be able to leave work… or not have access to transportation,” he continues. “We know a key barrier to health equity is access, so we are giving more flexibility and access to the patient.”

“This is part of the innovation ecosystem here at Hopkins,” he continues. “We are finding ways to bring [innovations] from inside the walls of our hospital and university to the outside, to help patients and their families.”

Perhaps a holistic advancement in cardiac care—focusing on the mental and emotional health of patients—will have the broadest impact. The Bridge Clinic at University of Maryland St. Joseph’s Medical Center offers a community to patients as they recover. “It can be an overwhelming time for patients,” says Sonia Baker, MD, a cardiologist at St. Joseph’s. “They can’t hear everything we are saying to them in those first few days of recovery. … The Bridge program slows down the pace.”

Doctor’s visits are an hour long (atypical for a doctor’s appointment), allowing patients time to fully discuss their concerns. Patients enter cardiac rehab, slowly re-engaging in physical activity while being monitored. The traumatic impact of a cardiac event affects not only the patient, but friends and loved ones, and that impact can be longterm. “The rates of depression are much lower among patients who go [to rehab],” continues Baker. “Rehab can be really helpful for grounding people and giving them a path forward. You’re in a community. … It’s like the show Cheers, where everybody knows your name. There’s nothing like a cardiac event to make you want to wrap a village around you.”