Heart & Vascular Institute of New Jersey. Englewood Hospital and Medical Center

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1 Northern New Jersey Edition Heart & Vascular Institute of New Jersey Englewood Hospital and Medical Center Unique Approach to the Diagnosis and Treatment of Cardiovascular Disease Earns Top Heart Attack Patient Survival Rates Statewide VOL. 6, NO. 2

2 Despite significant advancements in cardiac care, heart disease remains the leading cause of death in the United States. Where a patient receives diagnosis and treatment may well determine if he or she will survive and for how long. According to recent government data released by Centers for Medicare and Medicaid Services (CMS), heart attack patients who received treatment at Englewood Hospital and Medical Center had a better chance of surviving over a 30-day period than those treated at any other hospital in New Jersey, and an almost 25 percent lower rate of mortality than the national average. In fact, Englewood Hospital was No. 3 in the nation for patient heart attack survival, according to the CMS study. This compelling piece of information prompts us to investigate how this community hospital in Northern New Jersey achieved this distinguished record and how it has become a leader in the diagnosis and treatment of all manifestations of heart disease, including: coronary artery disease, valve disease, arrhythmia, stroke, peripheral artery disease and heart failure. The Heart & Vascular Institute of New Jersey at Englewood Hospital and Medical Center opened its doors in July of Since then, data continues to show rates of success that are consistently among the highest in New Jersey and in the nation. For example, data compiled by NJ s Department of Health and Senior Services ranks the Heart & Vascular Institute s mortality rates for isolated coronary artery bypass graft surgery among the lowest in the state, with a 100 percent survival rate on three of the last four NJ DHSS Cardiac Report Cards. This has cover story Heart & Vascular Institute of New Jersey Englewood Hospital and Medical Center Unique Approach to the Diagnosis and Treatment of Cardiovascular Disease Earns Top Heart Attack Patient Survival Rates Statewide By Iris Goldberg been achieved despite its practice of accepting a high proportion of high-risk, complex cardiac cases who could not be helped at some other facilities. Also quite noteworthy and rather extraordinary, nearly 80 percent of patients undergoing cardiac surgery Richard Goldweit, M.D., F.A.C.C., is Chief of Cardiology and Director of Interventional Cardiology for Englewood Hospital and Medical Center. Photo by Ken Alswang-At Home Studios

3 at Englewood Hospital had their surgery performed without a blood transfusion. Richard Goldweit, M.D., F.A.C.C., is Chief of Cardiology and Director of Interventional Cardiology for Englewood Hospital and Medical Center. Dr. Goldweit discusses the philosophy and approach to treating cardiovascular disease that is embraced by the entire team at the Heart & Vascular Institute. At Englewood Hospital, we have a patient-driven, individualized care approach to medicine, Dr. Goldweit explains. It s all about the patients and what their needs are and their rights to have access to the best possible healthcare, he continues. We do everything we can to improve their quality of life and their length of life. That is the simplest paradigm but we try to carry that to its fullest, Dr. Goldweit emphasizes. To that end, the Heart & Vascular Institute has assembled a team of cardiac experts, including cardiologists, cardiothoracic surgeons, vascular surgeons, electrophysiologists and other specialists who take a team approach and individualize patient care to treat the entire gamut of disorders affecting the cardiovascular system. This collaborative approach allows the delivery of comprehensive care and treatment, from a wide range of specialists that addresses the patient as a whole person. Director of Cardiac Surgery Services, James Klein, M.D., who has been affiliated with the program since its inception in 2000, talks about the cohesiveness of the team of physicians, nurses and assistants who have been caring for patients. He explains that with very few exceptions, the same core group has been working together from the start. He credits this continuity with allowing for reproducible results, consistently placing Englewood Hospital at the top of the state s report card on rates of mortality. If we talk about our model of continuity and consistency and look at all of the coronary artery bypass surgeries within the last eight and a half years, the mortality rate is 0.7 percent, which is astronomically low, Dr. Klein relates. There are some recent years within that time that the rate was actually 0 percent, he adds. He feels there is a direct connection between the consistency of the nucleus of the team and the tremendously impressive data coming from Englewood Hospital s cardiac program year after year. In addition to the collaborative team approach to individualized patient care and the continuity and cohesiveness of that team, perhaps the most distinguishing feature of the model of care which has evolved at the Heart & Vascular Institute is its rate of blood transfusion, which is among the lowest in the nation. In fact, Englewood Hospital and Medical Center as a whole has embraced a commitment to bloodless medicine. Dr. Goldweit, Dr. Klein and their colleagues at the Heart & Vascular Institute are convinced it is no coincidence that the Institute Shown here, Director of Cardiac Electrophysiology at Englewood Hospital and Medical Center, Grant R. Simons, M.D., F.A.C.C., at the controls during a robotic atrial fibrillation ablation. Photo by Ken Alswang-At Home Studios

4 has one of the lowest mortality rates in the state and one of the lowest transfusion rates. The bloodless approach was originally undertaken at Englewood Hospital to serve Jehovah s Witnesses, who for religious reasons would not accept blood transfusions. In 2008, Englewood Hospital has performed more than 1,500 bloodless procedures, including 239 cardiac procedures. Some of these have been major surgeries that are usually associated with significant blood loss and would traditionally require blood transfusions. We have become a model for other centers, shares Dr. Klein, who explains that Englewood Hospital experts are constantly invited to speak all over the country and internationally, as well. Physicians from renowned, prominent institutions who want to practice blood conservation come to Englewood Hospital and Medical Center to learn the techniques that must be employed to dramatically reduce, or virtually eliminate blood loss and the need for transfusion. When speaking about Englewood Hospital s low mortality rates for cardiac patients as compared to other facilities, Dr. Goldweit explains how the bloodless approach actually results in better outcomes. He relates that by developing ways to initially treat the population of Jehovah Witnesses, a universal approach to patient care was born. What we learned is that giving blood to patients presents all sorts of problems from infections, to slow wound healing, to blood transfusion reactions, to poorer outcomes, Dr. Goldweit shares. He goes on to share that in order to minimize blood loss a host of techniques were put into use, such as the miniaturization of equipment. For example, in the cath lab Dr. Goldweit uses a catheter that is 25 percent smaller than those used elsewhere, resulting in a lower risk of bleeding. Other modalities incorporated were the development of bloodless puncture techniques which eliminate blood spurts and closure devices that seal wounds more effectively. To further limit loss of blood there is a judicious use of blood thinning agents. In addition to maintaining a more meticulous control of bleeding during surgery, advanced planning is crucial for keeping blood loss at a minimum. For example, patients who are anemic can be treated prior to surgery, with the goal of avoiding problems in the operating room that would necessitate giving blood. Dr. Goldweit points out that since these deliberate methods have been adopted blood transfusions at the Heart & Vascular Institute have become quite rare. In terms of cardiac surgeries performed at Englewood Hospital such as open heart surgery, valve cases and combined bypass and valve procedures, it was found that since using the blood conservation model, the transfusion rate could be kept at 22 percent compared to the 60 or 70 percent at some other facilities. Equally impressive is the fact that the Heart & Vascular Institute takes on complex cases such as aortic root, aortic valve and aortic dissections, and is capable of performing procedures as involved as total circulatory arrest, for example. Amazingly, these complex surgical cases are accomplished within a bloodless environment, as well. It turns out that by avoiding bleeding and transfusion, risks were lowered and outcomes improved. When you put together the fact that we don t transfuse and we have these phenomenal outcomes, it s quite extraordinary, Dr. Goldweit proudly remarks. Although he and his colleagues at the Heart & Vascular Institute learned about the unexpected correlation between rates of transfusion and rates of survival, quite by accident, through their efforts on behalf of the Jehovah s Witnesses, Dr. Goldweit shares the obvious conclusion that has to be drawn. Blood conservation really leads to practicing good medicine, he states emphatically. This happens, he explains, because physicians are forced to think more proactively and in a more preventative fashion. In terms of the CMS report on patients who suffer an acute MI and receive treatment at Englewood Hospital, Dr. Goldweit points to a variety of reasons why those patients have a better chance of surviving over a 30 day period than if they were treated anywhere else in New Jersey. One very important factor is the priority placed on treating patients who present in the ER with cardiac symptoms as quickly as possible. In fact, Englewood Hospital boasts a door to balloon time that has been 20 minutes below the national average for the last six years. This has been accomplished, in part, by the fact that there is an interventional cardiologist available 24 hours a day, seven days a week to meet a patient when he or she arrives. Often, information has been called ahead by EMS workers so that appropriate treatment can be undertaken immediately. This approach to interventional cardiology at Englewood Hospital acknowledges that the longer it takes to open an artery, the worse the outcome is The robotic mapping system allows Dr. Simons to simultaneously visualize all the catheters in the heart, shown here on the graphic display. Photo by Ken Alswang-At Home Studios

5 Photo by Ken Alswang-At Home Studios likely to be. The goal is to restore blood flow as quickly as possible and limit the damage. Patients who undergo cardiac catheterization at the Heart & Vascular Institute are evaluated thoroughly and screened for other conditions which might be affecting cardiovascular health. For example, patients are aggressively screened for obstructive sleep apnea, which increases risk of stroke, heart attack and sudden death and is present but undiagnosed in many patients who require cardiac catheterization. Also, outcomes for interventional cardiology are poorer if sleep apnea is left untreated. In addition to the screening process which, of course, addresses issues such as weight, cholesterol levels and blood pressure, patients and their family members (who might be genetically predisposed to cardiovascular disease) receive counseling on lifestyle choices such as diet, exercise, smoking, etc. In fact Englewood Hospital s Cardiac Catheterization Laboratory is unique for its ability to facilitate family cardiac counseling by providing computerized image review in a counseling room environment. Also, after an acute MI and/or cardiac surgery, cardiac rehabilitation is a must and as Dr. Goldweit points out, is crucial for nurturing medical as well as emotional healing. We re very proud of the high level of cardiac care we offer but we are never satisfied with the status quo, Dr. Goldweit emphasizes. We engage in an ongoing process of improvement that involves analyzing feedback on how we re performing, evaluating the latest research and acting on that information to continually improve and stay on the cutting edge. Our well-attended weekly cardiovascular conference is one reflection of this effort. Everyone affiliated with the Heart & Vascular Institute at Englewood Hospital is extremely gratified by the CMS report. Dr. Goldweit credits the amazing efforts of the entire team for this spectacular achievement. This 30 day statistic is really phenomenal and we are thrilled to be here, he shares. He knows exactly how Dr. Simons believes the robot enables better catheter stability and better contact than the unassisted human hand is capable of delivering. this recognition was attained. You have to reinvent yourself all the time to make sure you stay on the right track, says Dr. Goldweit. That s the idea of being patient-based and patient-focused educating our patients and our families, talking to all of the different doctors involved that s what it s all about. Besides its outstanding survival rates, the Heart & Vascular Institute of New Jersey boasts the capability of performing one of the highest numbers of complex cardiac procedures statewide. For example, Englewood Hospital s Arrhythmia Center, which has been in existence since 2001, offers patients the most technologically advanced catheter ablation for atrial fibrillation (AF). This rhythm disorder, in which the atria of the heart beat rapidly and do not adequately fill the ventricles with blood, is the most common identifiable cause of stroke in our society and it is estimated that over 10 percent of people over the age of 65 are afflicted. During AF ablation one or more catheters are guided into the blood vessels and directed via x-ray to the heart s chambers, where radiofrequency energy is applied to selectively destroy the heart cells causing abnormal rhythms. Director of Cardiac Electrophysiology at Englewood Hospital is Grant R. Simons, M.D., F.A.C.C. Dr. Simons relates that although this procedure is still relatively new and will continue to undergo refinement, the electrophysiologists at the Heart & Vascular Institute have had some remarkable technological developments that have allowed them to do a better job than was possible as recently as three or four years ago. For example, our mapping system is an incredibly useful tool that allows us to simultaneously visualize all the catheters in the heart within the virtual chamber that we create on the graphic display. It allows us to mark where we ve applied lesions and to record those spots so we have a sense of what we ve done and what needs to be done throughout the procedure, explains Dr. Simons. Another extremely important feature of this cutting edge mapping system, according to Dr. Simons, is that it has allowed him and his colleagues to develop a technique to track an esophageal marker in real time so there is constant knowledge of where the esophagus is. This tracking is crucial to make sure that the esophagus is protected from inadvertently being ablated, which could have fatal consequences and it is utilized with every patient who undergoes ablation at the Heart & Vascular Institute. This advance in technique was published in the prestigious Journal of Cardiovascular Electrophysiology in January, We think this is a really terrific system, Dr. Simons reports. It just makes us better at what we do, he says. Along with more accurate mapping, the exclusive use of open irrigated catheters which create deeper and long lasting lesions and thus lower recurrence rate has also improved the efficacy of the procedure.

6 Photos by Ken Alswang-At Home Studios On the left, Jock N. McCullough, M.D., and on the right, Director of Cardiac Surgery Services at Englewood Hospital and Medical Center James Klein, M.D., begin surgery to replace an aortic valve. Dr. Simons believes that the recent incorporation of robotics promises to further improve long-term success rates. Englewood Hospital is currently the only hospital in New Jersey using the Hansen Sensei robotic mapping system to perform AF ablation. A robotic arm directs the catheter tip to target locations. He theorizes that although this remains to be proved, the robot enables better catheter stability and better contact than the unassisted human hand can deliver and will ultimately be shown to improve technique. The Arrhythmia Center at Englewood Hospital also has a very active cardiac device program to treat cardiac rhythm disorders. Dr. Simons is eager to share another cutting edge advancement which he and his colleagues have been able to offer cardiac patients. Those who undergo procedures to place pacemakers or defibrillators and are at high-risk for developing infection are now offered increased protection through the use of a recently FDAapproved anti-bacterial envelope. This implantable pouch, which is placed around the pacemaker or defibrillator, is embedded with two antibiotic agents that provide site-specific protection with a local, concentrated dose of antibiotic, hopefully resulting in a safer post-surgical experience. The highly skilled team of cardiothoracic surgeons at the Heart & Vascular Institute has also contributed significantly to the outstanding survival rates which have secured Englewood Hospital and Medical Center s place as a leader in cardiac care. In addition to Dr. Klein, the two other members of the team are M. Arisan Ergin, M.D., Chief of Cardiothoracic Surgery and Jock N. McCullough, M.D. All three are experts in a range of cardiac surgical procedures including coronary bypass surgery, mitral valve repair, aortic valve replacement surgery and more. Recently, the surgeons have introduced minimally invasive mitral valve repair to the comprehensive list of procedures offered to cardiac patients. A leaky or narrowed mitral valve can cause the heart to work harder to pump blood through the body, causing patients to experience shortness of breath and considerable fatigue. Dr. McCullough explains that over the past few months, he and the With aortic valve replacement, as with all surgeries performed at Englewood Hospital and Medical Center, meticulous control of bleeding during surgery is a priority. other cardiothoracic surgeons at Englewood Hospital have been able to adopt and perfect a technique to successfully repair mitral valves through a port access approach. This truly minimally invasive procedure involves a five centimeter, two and a half inch incision in the right chest as opposed to a large sternotomy. We are the only program in the region that does this full port access approach to mitral valve repair, shares Dr. McCullough. In discussing the benefits of the port access approach, Dr. McCullough relates that this procedure is less traumatic to the chest wall than even a robotic mitral repair. As a result patients are out of the hospital more quickly and resuming normal activities. The appearance after mitral valve repair with the port access approach is obviously more cosmetically appealing to patients, as well. Also, Dr. McCullough emphasizes that the risk of the tragic complication of mediastinitis that can occur after sternotomy is virtually eliminated with this minimally invasive procedure. Dr. McCullough attributes the success of this newest procedure and the high rate of positive outcomes for the other surgeries performed at Englewood Hospital to the significant level of expertise possessed by the surgical team. We have an unbelievably experienced and integrated team, he says. And it is not at all unusual for difficult cases to be reviewed by the entire team, Dr. McCullough adds. Like Dr. Goldweit and Dr. Klein, Dr. McCullough also firmly believes that the meticulous approach to surgery required in order to promote blood conservation is another factor directly responsible for the consistently high marks received by the Heart & Vascular Institute. We can assume that going forward, the philosophy of a team approach to compassionate and individualized patient care and the deliberate practice of bloodless medicine will continue to earn high marks for the Heart & Vascular Institute of New Jersey. The true winners, however, will be the cardiac patients who choose to come to Englewood Hospital and Medical Center for their care and treatment. For more information or to schedule an appointment, contact the Heart & Vascular Institute of New Jersey at (201) n reprinted from new jersey m.d. news 2009 Sunshine Media, Inc. Usage Agreement Good Through: 02/27/10

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