The Journal - Focus on Cardiac Advances - Spring 2019

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Tendoh F. Timoh, MD, FACC, cardiac imaging specialist, Cape Cod Healthcare


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And when there is coronary artery disease, cardiac MRI is used
to determine the extent of the damage done to the heart muscle (also known as viability) and the likelihood of improvement to the overall pumping function of the heart if the damaged blood vessel is repaired.
“If someone has a severe blockage in one of the major coronary vessels on top of their heart, the result of that is usually deficit in blood flow downstream,” said Dr. Timoh. “We always have that big question, ‘Is there an infarct with dead tissue?’ You have to determine that if you open up that blood vessel, will
the heart be able to recover its pumping function?”
Cardiac MRI takes more than an hour to perform and is a labor- intensive test. Consequently, it isn’t something that is done in an emergency situation. Rather, cardiologists refer their patients with chronic chest pain, cardiac masses, cardiomyopathies or
chronic valve issues for evaluation. The images can guide future treatment options by pinpointing areas of concern.
Cardiac MRI is performed in the same manner as any other MRI exam. After receiving the contrast injection, if needed, the patient
lies still inside the machine for the duration of the 60-minute session. The patient might be asked to hold his or her breath intermittently during the exam. Dr. Timoh and his staff communicate regularly with the patient to ensure comfort.
Despite its advantages, some patients are not good candidates for cardiac MRI.
“Patients with kidney disease
are often not able to receive the contrast solution, as it exacerbates their renal disease. MRI can
also be difficult for patients with claustrophobia,” said Dr. Timoh. And as is the case for most MRI exams, patients with certain metals in their body or types of pacemakers may be precluded.
“Cardiac CT is an excellent exam. It has a high negative predictive value, which means that it accurately rules out cardiac disease. If there is stenosis, the study allows you to determine to what degree it exists.”
- Tendoh Timoh, MD, FACC


CT TECHNOLOGY
While cardiac MRI provides the clearest view for differentiating variations in the soft tissue structure of the heart, cardiac CT is better for the examination of coronary blood vessels.
Diagnostic coronary cardiac CT
is used primarily in patients with chest pain and suspected coronary stenosis (blockages in cardiac blood vessels), where the pre-test suspicion is intermediate for cardiac disease.
“Cardiac CT is an excellent exam. It has a high negative predictive value, which means that it accurately
rules out cardiac disease. If there
is stenosis, the study allows you to determine to what degree it exists,” said Dr. Timoh.
Prior to the exam, patients are given small amounts of medication (nitroglycerine) to dilate the
blood vessels and a beta blocker to slow the heart rate. Using ionized radiation (X-ray), patients lie still for a short period of time. The actual image is captured in seconds.
Cardiac CT also assists interventional cardiologists with two specific procedures they do.
For the TAVR procedure (see page 8), the patient’s valve needs to be properly sized in advance and CT allows for precise measurements, as well as measurements of the diameters of the blood vessels through which the valve will be delivered, said Dr. Timoh.
“It is the best method of sizing valves that there is,” he said.
Another procedure performed at Cape Cod Hospital, known as the left atrial appendage closure done, with the WatchmanTM occluder (see page 20), decreases the risk for stroke in patients with heart arrhythmias like atrial fibrillation (AFib).
“The majority of strokes in patients with atrial fibrillation happen in the same location, the left atrial appendage. The Watchman device is implanted in this location preventively,” said Dr. Timoh. Cardiac CT is used to measure the area and properly size the device.
Cardiac CT is also used by electrophysiologists to build a model of the left atrium to assist in performing ablations on patients with AFib.
3-D TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) While MRI and CT have their utility, a clear view of certain
heart structures and functions can be impeded by the surrounding anatomy. 3-D TEE uses high frequency sound waves to investigate fast-moving structures in the heart, like the mitral valve. It provides good temporal resolution.
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The heart of a patient with a strong family history of heart disease and atypical chest pain who had an equivocal stress test. Cardiac CT 3D (left image) and 2D images of the same patient performed at CCH demonstrated a critical stenosis (red arrows) in one (left anterior descending) of the major coronary arteries. She went on to have coronary angiography and stenting and is now symptom-free.
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“You know the joke that the way to a man’s heart is through his stomach?” said Dr. Timoh. “That’s literally what we are doing here. Through a tube inserted into
the patient’s mouth, the imaging device is passed directly into the esophagus, which is directly next to your heart. There is no chest wall and there are no ribs to get in the way. We get a very good look at structures.”
Beyond diagnostics, 3-D TEE is used to assist in cardioversion, a procedure that restores normal heart rhythm in patients with arrhythmia. It is also employed during the MitraClip® procedure (see page 10) and to guide the
placement of the Watchman occluder. Performed in the Cardiac Catheterization Lab at Cape Cod Hospital, 3-D TEE is more invasive than cardiac MRI and CT. It requires moderate sedation, similar to what is administered during a colonoscopy. However, there are no medications given to slow the heart rate and there are no breath holds.
“It’s a little bit invasive, but the images that you get really change management decisions because you can tell the surgeon ‘On that valve, I know exactly where the problem is for you to go fix it,’ ” said Dr. Timoh.
The innovations in diagnostic cardiology imaging are an important part of providing
the best cardiac services to the community. Dr. Guadagnoli sums it up saying “We’re doing
a lot that is only commonly being performed in an academic setting elsewhere. But, it’s appropriate for our population. We have a very high demand
for cardiac services, and people would prefer to have those services locally.
“That’s what we are trying to provide for our patients; the same types of services provided in an academic medical center, only with the convenience of having it close to home.” | TJ
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“WOMEN TEND TO PUT THEMSELVES LAST”
Cardiologist Elissa Thompson, MD, explains why women are at particular risk of heart disease, and the reasons they tend to dismiss symptoms.
by Laurie Higgins
Even though heart disease is the number one killer of women in the United States, they are less likely than men to seek treatment, according to the American Heart Association. It’s a tendency that can have tragic consequences, warned cardiologist Elissa Thompson, MD.
“More women than men have died of heart attack every year since 1984,” she said.
One in every four deaths in women is from cardiovascular disease, and one in three women is living with the disease, according to the Centers for Disease Control (CDC). Yet only about 54 percent of women recognize that heart disease is their number one killer.
Part of the reason that heart disease in women can go undiagnosed is that women tend to receive the highest concentration of healthcare in their younger years when they are having their children, said Dr. Thompson, who is medical director of the Cape Cod Healthcare Heart Failure Clinic as well as the Cape Cod
Healthcare Cardiac Rehabilitation program in Hyannis. Afterwards, they focus on their children’s healthcare and later their husband’s care and that of aging parents, and often put aside their own health concerns.
“Women tend to put themselves last,” she said.
Another characteristic of women that can prove deadly is that they are much more likely to dismiss heart attack symptoms and therefore seek treatment later than men. For example, if
a woman notices that she is short of breath or more fatigued than normal during her daily walk, she is more apt to pass it off as just getting older than to consider cardiovascular disease. Often, even when women present in emergency departments with similar symptoms as men, they are not characterized as heart patients, Dr. Thompson said. Therefore, they are less likely to have an EKG or to see a cardiologist right away.
PEOPLE’S SYMPTOMS MAY BE DIFFERENT
“It’s not that the heart attack itself is different in women and men,” she said. “For a lot of different reasons, women’s presentations when they have heart attacks are treated differently from men’s.”
In fact, the idea that men and women have different heart attacks is a myth, according
to Dr. Thompson. Each person, regardless
of gender, will have their own version of symptoms. Things to watch for are fatigue, shortness of breath, chest pain, numbness in arms, pain radiating up to the jaw or down into the left arm, nausea, vomiting, cold sweats, or if you just don’t feel right.
The most urgent message Dr. Thompson wants to convey to women is the importance of recognizing their own risk. To improve or maintain good cardiovascular health, women should be sensitive
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HEALTHCARE IN THE FIRST PERSON
continued from intro page
and interventional radiologist Dr. Philip Dombrowski, started performing this procedure in 2015, making Cape Cod Hospital among the few community-based hospitals in the U.S. approved for this procedure.
In 2016, Dr. Zelman and cardio- electrophysiologist Dr. Peter Friedman were also at the cutting edge when they brought
the left atrial appendage closure (LAAC) procedure, using the WatchmanTM device, to some patients with atrial fibrillation. Last year, Dr. Friedman brought another new technique, the Micra Transcatheter Pacing System, to Cape Cod. The device gives some patients in need of a pacemaker a smaller, leadless option.
Dr. Loberman has perfected mini mitral valve surgery, which uses a smaller incision to repair a patient’s torn mitral valve. And our new endovascular surgeons, Dr. Lindsey Korepta and Dr. Naren Gupta, work with Dr. Dombrowski on a minimally invasive way to treat abdominal aortic aneurysms.
These are just a few of the exciting new cardiovascular advances you will hear about in this issue, and I hope, after reading more, you are as impressed as I am with the caliber of services we have at Cape Cod Healthcare.
I am inspired by the astonishing success of our cardiac services line, and encouraged
by the prospect of accomplishing the same world-renowned advances with every other service line in the Cape Cod Healthcare system. With our community’s support, Cape Cod Healthcare will continue to bring the latest and best medicine to the region, delivered by some of the most highly trained and experienced physician teams in the state.
“WOMEN TEND TO PUT THEMSELVES LAST”
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to their overall health profile, eat a healthy diet and exercise every day, she said.
It’s important to have well-controlled blood pressure, and weight and blood sugar in a normal range. Cholesterol is another risk factor, and anyone with added risk factors like diabetes and high blood pressure should have even lower cholesterol goals than the average person.
“Women should be getting yearly physicals and having that data scrutinized by a medical professional,” she said.
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Not anymore.
We’ve combined a team of top cardiac and vascular physician specialists with the full resources of Cape Cod Healthcare. This unprecedented partnership means that you and your family will get the best cardiac and vascular care right here on Cape Cod.
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