Cardiac procedures become less invasive

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CEDAR RAPIDS — It’s been a busy year for the cardiology unit at UnityPoint Health-St. Luke’s Hospital. The physicians have been learning and performing new procedures, bringing less-invasive options to patients in Cedar Rapids.

In part, these new procedures are the result of an April 2015 effort between St. Luke’s and Physicians’ Clinic of Iowa, which teamed up to better treat complicated cardiac conditions through the Heart and Vascular Institute.

The goal was to offer a wider array of cardiovascular procedures to keep more patients in town rather than traveling to the Mayo Clinic in Rochester, Minn., or even the University of Iowa Hospitals and Clinics.

That designation has helped the health facilities recruit physicians and allowed physicians to subspecialize. The focus also aided in bringing two new procedures to Cedar Rapids in the past year — the transcatheter aortic valve replacement, or TAVR, and the Medtronic Micra Transcatheter Pacing System — also referred to as “the world’s smallest pacemaker.”

“There has been a real progression in advances in technology in the past 10 years,” said Dr. Richard Kettelkamp, a cardiologist at St. Luke’s Hospital. “Ten years is not that much time, so it’s a pretty remarkable change. Devices are getting smarter and smaller, and that provides a lot of opportunities to do things in a less invasive way.”

The hospital can’t adopt every new procedure or piece of technology — so it’s important to look for gaps in care and select procedures that make sense for the patient population, cardiologists said.

TAVR — a procedure the hospital began offering in October 2016 — is a less-invasive option for patients that are too high-risk or sick for surgery, especially the elderly.

Aortic stenosis — which affects three percent of people 65 and older — is a common heart problem caused by a narrowing of the heart’s aortic valve. Calcifications or fat can develop on the valve, causing it to narrow and making it harder for blood to move throughout the body.

This can cause heart failure, chest pains and increased risk for sudden cardiac death.

The surgical procedure repairs the damaged valve by inserting a replacement valve into the aortic valve. Similar to a stent placed in an artery, TAVR delivers a fully collapsible replacement valve to the valve site through a catheter.

“In a traditional valve replacement, there involves a sternum cut in addition putting the patient on heart and lung bypass, where we have a machine that breathes for them and pumps blood for them,” Kettelkamp said.

“There’s a big risk for surgical valve replacement. So when we do it with a catheter-based approach, where we go through artery with catheter, we can do it while the heart is pumping. There’s a smaller incision, no bypass, and is much easier to recover from.”

Cedar Rapids and Iowa have an older population, Kettelkamp said, so it made sense to invest the time and money into training physicians on the procedure. Patients also were traveling outside of Cedar Rapids to get this done.

And as physicians become more comfortable with the procedure — so far they’ve had about 50 TAVR cases — it will become an option for more patients, including those with a more moderate risk for surgery, said Dr. Richard Kettelkamp, a cardiologist at UnityPoint Health-St. Luke’s Hospital.

“It’ll open doors for a lot of patients,” he said.

Earlier this year, the hospital also placed its first Micra pacemaker in an Eastern Iowa patient as well as implanted the device in a second patient during an open-heart valve repair.

The pacemaker — about 93 percent smaller than conventional pacemakers — is used for patients with bradycardia, a condition characterized by a slow or irregular heart rhythm. The heart is unable to pump enough blood to the body during normal activity or exercise, causing dizziness, fatigue, shortness of breath or fainting spells.

Pacemakers are the most common way to treat bradycardia, but there are risks for infection, they can leak or create a bulge under the skin, said Dr. Mohit Chawla, an electrophysiologist at St. Luke’s.

Pacemakers usually are placed in the heart via the left shoulder — they’re slipped under the skin and over the muscle, Chawla said, and then pulled through a vein and into the heart. “You can hurt a lung going in or damage a blood vessel,” he added. “There’s a lot of issues with traditional pace makers.”

With the Micra, the device goes in through the leg, which means there’s no incision and patients are able to heal faster and without a scar, Chawla said. You can drive and shower sooner after the procedure and studies so far also show a close to zero percent infection rate, he said.

“Patients come out of the procedure, and they don’t even know they’ve had anything done — there’s no visible scar, there’s nothing to remind them every day that, ‘Oh, my gosh, I’ve had a heart procedure and how do I cover this up, what do I wear?’” he said.

The Micra procedure takes between 25 and 30 minutes, he added, compared with a traditional pacemaker that takes closer to an hour to insert.

The tiny device currently is intended for patients who need a single-chamber pacemaker, but Chawla anticipates the technology soon will allow for smaller, wireless pacemakers for multiple heart chambers.

“Things are always going to be going toward smaller incisions, smaller scars and less risk,” he said. “When it comes to technology, that’s what you want. Pacemakers, when they first started, they were open heart. There was a big incision on the abdomen, (the device) was put on the outside as opposed to the inside.

“But I suspect this will continue to be the evolution . But there’s a trade off. You use a new device and find out there’s new issues, so that’s something want to make sure you have a system in place that there is enough volume where you can pick up on these issues you may never have had before.”

l Comments: (319) 398-8331; chelsea.keenan@thegazette.com

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