Advances in Medicine | Penn Medicine

The Fight Against Heart and Vascular Disease Gets Personal

2012-02-15T13:00:00.000-05:00

Year after year, heart and vascular disease maintains its rank as the number one killer of Americans. Doctors at Penn Medicine are battling the epidemic through comprehensive and personalized management of cardiovascular risk factors.

There are many things people can do on their own to reduce their risk of developing heart and vascular disease, such as getting plenty of exercise and eating right. Penn Medicine’s Preventive Cardiovascular Program helps reduce that risk further using a multidisciplinary, personalized approach to treat cardiovascular risk factors. The program specializes in the treatment of complex lipid (cholesterol) and high blood pressure conditions, as well as the care of individuals with a family history of early heart attack, stroke or peripheral artery disease. The program’s expert team consists of cardiologists, vascular medicine specialists, lipid specialists, hypertension specialists, nurses and dietitians.

“We offer a wide array of preventive testing to refine cardiovascular risk assessment above and beyond traditional risk factors,” said Emil deGoma, MD, medical director of the Preventive Cardiovascular Program. “For selected individuals, advanced testing enhances our ability to personalize care for each patient; be it lifestyle changes and weight management for someone at low risk, or medication and intervention for someone at high risk.”

Advanced Risk Refinement Services

According to Dr. deGoma, the Preventive Cardiovascular Program uses innovative technologies and imaging capabilities to assess the risk of heart and vascular disease, including:

Genetic testing for heart attack risk: This blood test identifies someone’s risk for heart attack by examining variations in the sequence of their inherited genetic material, also known as DNA. Certain variations are associated with an increased risk of having a heart attack, while others can mean a decreased risk.
Vascular ultrasound screening (carotid intima-media thickness assessment): A non-invasive ultrasound evaluation examines the health of the carotid arteries, looking for warning signs such as the accumulation of plaque or thickening of the blood vessel wall.
Coronary artery calcium scanning: Another non-invasive test, this “heart scan” evaluates the coronary arteries for the buildup of calcium. Higher coronary artery calcium scores are associated with a higher risk for heart attack.
Advanced lipid laboratory testing: Testing beyond the standard fasting cholesterol panel can help diagnose lipid diseases, assess cardiovascular risk assessment, and identify the most appropriate treatment options.
Ambulatory 24-hour blood pressure monitoring. Continuous blood pressure monitoring provides a comprehensive assessment of blood pressure changes throughout the day and night. It is a valuable tool for diagnosing hypertension and ensuring the effectiveness and safety of treatment.

The wide range of risk refinement services offered by Penn Medicine’s Preventive Cardiovascular Program is located at the Ruth and Raymond Perelman Center for Advanced Medicine. For more information or to schedule an appointment, please visit PennMedicine.org/heart/prevention or call 800-789-PENN (7366).

Penn Leads in Transfusion Free Heart Surgery

2011-02-11T09:01:00.000-05:00

Penn Medicine has a long history of pioneering advanced surgical techniques. Bloodless cardiac surgery is just one of those surgical advances. The Bloodless Cardiac Surgery Program at Pennsylvania Hospital is one of the few bloodless programs in the nation to offer a full array of cardiac procedures, including complex heart surgery. Surgeons from around the world, including four cardiac surgeons recently visiting from Beijing China, have worked with Penn surgeons to observe and learn about bloodless cardiac surgery.

The complexities of performing bloodless cardiac surgery require meticulous surgical technique. From preparation through recovery, successful bloodless surgery requires the talents of a very experienced, multispecialty team. Penn cardiovascular surgeons have mastered the exact level of skill and precision necessary to perform bloodless procedures. They successfully perform the most complex and intricate surgeries using bloodless strategies, and in fact, have helped design some of these processes and techniques.

“We have to be fast and precise,” said Charles R. Bridges, MD, ScD, chief of cardiovascular surgery at Pennsylvania Hospital. “In bloodless surgery, any post-surgical bleeding is unacceptable so our radar is finely tuned to recognize and address any potential bleeding issues.”

Bloodless surgery, also known as “transfusion-free” surgery, is performed without the use of stored or donated blood products. It also involves special pre-operative and post-operative blood management techniques to minimize blood loss.

Why Bloodless?
Interest in blood conservation techniques is growing around the world. Some patients do not want blood products used during surgery because of their religious beliefs. In third-world countries, blood supplies are limited and the blood that is available has not been subjected to the same safety measures employed in the U.S. In addition, emerging research shows that blood transfusions can put patients at higher risk for complications including infection, kidney failure and death, according to Dr. Bridges. These results point to the conservation of blood during cardiac surgery when it can be done safely.

“The consensus is, blood use does impact surgical success,” Dr. Bridges said. “A blood transfusion is a type of transplant. It promotes inflammation and an immune reaction. Heart patients are already vulnerable because of the stress from surgery so a transfusion is a double hit. We now have unequivocal evidence that unnecessary blood transfusions are harmful to patients.”

Dr. Bridges said more than 90 percent of the cardiac surgeries performed at Pennsylvania Hospital can be performed without the use of blood products.

“At Pennsylvania Hospital we are doing increasingly complex procedures following blood conserving techniques including the largest series of reoperative cardiac surgery (second-time heart surgery) and complex aortic surgeries in the country. Our goal is to perform all procedures using bloodless techniques when it can be done safely,” he said.

Benefits of bloodless cardiac surgery include:
§ Fewer complications related to transfusions.
§ Faster recovery time
§ Shorter hospital stay
§ Less chance of infection
§ Faster healing time for wounds

Blood Conserving Techniques
Every member of the cardiovascular team involved with patient care follows meticulous blood conservation protocols beginning before admission and continuing throughout the patients stay in the hospital.

Before surgery, patients see a member of the bloodless medicine staff. Hemoglobin levels are checked and any anemia is managed before surgery. If catheterization is needed in addition to surgery, it is performed several days before the surgery to allow patients’ hemoglobin levels to return to normal.

During surgery, up to three units of patient blood is held, separately but still connected, and protected from the heart-lung machine. This protects the blood and its components and provides fresh blood for use following the surgery. In addition, a mini heart-lung circuit is used, reducing the amount of saline that is used. Saline dilutes the blood.

“Meticulous surgical technique also helps reduce blood loss,” Dr. Bridges said. “The less time a patient is on the heart-lung machine, the less blood that is lost.”

Post surgery, Dr. Bridges said blood is not routinely drawn from patients, but only when it is necessary for patient care. When blood is taken for testing, pediatric tubes that hold less blood are used.

For more information about bloodless cardiac surgery or to schedule an appointment, please call 800-789-PENN (7366) or visit PennMedicine.org.

Penn Physicians Place Region’s First Subcutaneous ICD

2011-01-28T09:01:00.000-05:00

In August, electrophysiologists from Penn Medicine implanted the region’s first subcutaneous implantable cardioverter defibrillator (ICD) for sudden cardiac arrest, a potentially fatal electrical malfunction of the heart. The patient, a young athletic male in his 20s, had the new system implanted during an outpatient procedure at the Hospital of the University of Pennsylvania (HUP).

“I am very glad we are able to provide this technologic breakthrough. He is an athletic young man who is now protected from life-threatening arrhythmias. It is reassuring to not have to worry about problems related to intravascular leads,” said Frank Marchlinski, MD, director of the Penn Medicine electrophysiology program.

Conventional ICDs require placement of at least one lead in or directly on the heart. Most frequently they are threaded through a vein and then placed inside the heart. The device then monitors the heart’s rhythm and delivers a life saving electric shock when a harmful arrhythmia is detected.

The new device, known as a subcutaneous implantable defibrillator or S-ICD, works much like an external defibrillator, but the entire system is implanted just under the skin on the chest. A small power unit is placed under the skin on the side of the chest and is attached to a thin sensor and shocking cable implanted under the skin near the breast bone. The new device implantation is part of an ongoing clinical trial that involves 35 sites globally. Penn’s patient is one of only 330 total patients enrolled in the trial around the world.

The trial is a prospective, multicenter, single-arm design approved in the U.S. by the FDA under an investigational device exemption (IDE). Results from four studies conducted at eight sites in Europe found that the S-ICD detected 100 percent of induced and spontaneous irregular heart rhythms with 98 percent conversion success. They confirmed that the subcutaneous defibrillator helped reduce problems associated with traditional models, including difficulty implanting the leads, risk of damage to the heart or the device, chance of infection and the need to remove a defective or damaged electrode in or on the heart. The device received European approval in 2009 and is commercially available there.

The Best of the Best in Robotics Surgery

2010-04-07T16:39:00.000-04:00

Penn Medicine has one of the most extensive and most active robotic surgical programs in the country. Over the past five years, more than 4,000 robotic-assisted procedures have been performed at Penn. It is also home to a number of surgeons whose experience and expertise in robotic-assisted surgery is known around the world. They include:

Otorhinolaryngology — Head and Neck Surgery

Bert W. O’Malley, Jr., MD, and Gregory S. Weinstein, MD
Invented and developed the transoral robotic surgery (TORS) procedure for treating tumors of the mouth and throat. The procedure was recently approved for use by the FDA and Drs. O’Malley and Weinstein are now training surgeons from around the world on the procedure.

Jason G. Newman, MD
Performs robotic-assisted thyroid removal surgery, accessing the thyroid from under the arm, avoiding neck scarring.

Erica R. Thaler, MD
Pioneering TORS for tongue, palate and tonsil surgery as a treatment for sleep apnea in a clinical trial along with Drs. O’Malley and Weinstein.

Urology

David. I. Lee, MD
Founder of the robotic urology program at Penn, Dr. Lee has performed more than 2,250 robotic-assisted prostatectomies. He is currently collaborating with the members of the Penn School of Engineering to develop enhanced surgeon sensation of the robotic surgical instruments.

Thomas J. Guzzo, MD, MPH
Performs a full range of roboticassisted urologic procedures including prostatectomy, partial nephrectomy, cystectomy and urinary diversion surgeries.

C. William Schwab II, MD
Performed Penn’s first robotic-assisted partial nephrectomy for treating kidney cancer, preserving the healthy portion of the kidney while eliminating the tumor. In addition to partial nephrectomy, performs a full range of roboticassisted urologic procedures including prostatectomy, radical nephrectomy, adrenalectomy and pyeloplasty.

Women’s Health

Sarah Adams, MD
Performs robotic-assisted gynecologic oncology surgery for the treatment of cervical, endometrial and uterine cancer.

Lily Arya, MD, MS
Chief and founder of the Urogynecology Robotic Surgery Program at Penn, Dr. Arya performed the first robotic sacrocolpopexy procedure in Pennsylvania and has extensive experience in robotic hysterectomy and sacrocolpopexy for the treatment of vaginal prolapse and incontinence.

Mathew N. Beshara, MD
A pioneer in developing Penn’s robotic gynecologic surgery program, Dr. Beshara performs robotic-assisted hysterectomy to treat uterine fibroids and abnormal or heavy menstrual bleeding.

Danielle L. Burkland, MD
Performs robotic-assisted hysterectomy, myomectomy and ovarian cystectomy to treat uterine fibroids, ovarian cysts, adenomyosis and endometriosis.

Peter J. Chen, MD
Performs robotic-assisted hysterectomy, myomectomy and ovarian cystectomy to treat uterine fibroids, ovarian cysts, adenomyosis and endometriosis.

Christina Chu, MD
Performs robotic-assisted gynecologic oncology surgery for the treatment of cervical, ovarian, endometrial and uterine cancer.

Scott E. Edwards, MD
Performs robotic-assisted hysterectomy and myomectomy as treatment for uterine fibroids, ovarian cysts, edometriosis, adenomyosis and infertility.

Samantha M. Pfeifer, MD
As a Penn Fertility Care specialist and leader in reproductive surgery, Dr. Pfeifer performs robotic-assisted procedures to treat infertility, including tubal reanastomosis to restore fertility and myomectomy to preserve fertility. She also is known for her expertise in adolescent reproductive health and surgical management of congenital malformations of the reproductive tract such as müllerian anomalies.

Thomas C. Randall, MD
A leader in robotic surgery and gynecologic cancer, Dr. Randall has performed more than 300 robotic-assisted procedures, including hysterectomy, oophorectomy, ovarian cystectomy and lymph node dissection for gynecologic cancers. His robotic surgical outcomes were recently published in the Journal of Gynecologic Oncology.

Stephen C. Rubin, MD
A national leader in gynecologic cancer, performs robotic-assisted gynecologic oncology surgery for the treatment of cervical, ovarian, endometrial and uterine cancer.

Catherine R. Salva, MD
Performs robotic-assisted hysterectomy, myomectomy and ovarian cystectomy to treat uterine fibroids, ovarian cysts, adenomyosis and endometriosis.

Megan Schimpf, MD
With extensive experience in robotic pelvic reconstructive surgery, Dr. Schimpf performs sacrocolpopexy and hysterectomy to treat urinary incontinence and vaginal prolapse.

Neurosurgery

William C. Welch, MD
Chief of neurosurgery at Pennsylvania Hospital, performs spinal fusions and disc repair using robotic-assisted access to the spine.

John Y.K. Lee, MD
Works with the manufacturer of the daVinci®surgical robot to pioneer new approaches and tools that can be used in skull-base and craniocervical junction surgery. Dr. Lee also performs spinal fusions using robotic-assisted access to the spine.

Cardiac Surgery

Y. Joseph Woo, MD
Among the first cardiovascular surgeons in the nation to perform robotic-assisted surgery for complex mitral valve repair and coronary artery bypass grafting. Dr. Woo has been performing robotic-assisted cardiac procedures since 2003.

W. Clark Hargrove III, MD
Performs robotic-assisted cardiac surgery for complex valve repair.

Juan B. Grau, MD
Performs robotic-assisted cardiac surgery for complex mitral and tricuspid valve repair and coronary revascularization procedures.

Gastrointestinal Surgery

Noel N. Williams, MD
Director of the Penn Metabolic and Bariatric Surgery Program, performs robotic-assisted bariatric surgery, and director of surgical simulation, responsible for training general surgical residents in robotic surgery.

New Hope, New Directions in Cranial-Base Surgery

2009-04-22T09:06:00.000-04:00

Cranial-base, or skull-base, tumors are traditionally among the most challenging to treat, but the Center for Cranial-Base Surgery at Penn offers new hope for patients with these complex tumors.

The skull base forms the floor of the cranial cavity and separates the brain from the facial structures. Anatomically, the region is difficult to access and poses many surgical challenges. It includes the nose and nasal passages, the pituitary gland and the frontal lobe of the brain and the brain stem.

Physicians at Penn’s Center for Cranial-Base Surgery take a targeted, comprehensive, multidisciplinary approach that focuses on minimally invasive techniques, including endoscopic surgery and radiation. It is a collaborative effort that brings together the best talents and skills from each field.

“Penn’s Center is truly integrated and interactive,” said Bert W. O’Malley, Jr, MD, chair of the department of otorhinolaryngology. “We bring together specialists in neurosurgery, otorhinolaryngology, radiation oncology, neuroradiology and oncology who meet to discuss each case. The group determines the best treatment plan based on the unique situation of each patient.”

The diagnosis of a skull-base tumor can be devastating for a patient. The need to deal with multiple specialists from many different fields can make the diagnosis overwhelming. The Center for Cranial-Base Surgery at Penn brings all of those specialists together along with a patient coordinator to guide the patient through the program. When combined with the minimally invasive treatments available at Penn, the process becomes easier, less stressful and more efficient for patients.

Penn surgeons are pioneers in minimally invasive approaches to treating tumors. Currently, state-of-the-art endoscopic endonasal resection of skull-base tumors resulting in minimal trauma to the brain is performed at Penn.

In addition, trans-oral robotic surgery (TORS)—using a robotic-assisted technique to operate on tumors of the mouth, throat and neck—was invented at Penn. Surgeons from otorhinolaryngology and neurosurgery are now collaborating on bringing those techniques to cranial-base procedures.

“We looked at the techniques developed in TORS and began to discuss ways we could use the same technology in cranial-base surgery,” said M. Sean Grady, MD, chair of the department of neurosurgery. “We are still in the study stage, but we are using what was learned in developing TORS to create the next step in minimally invasive brain surgery.”

Penn neurosurgeon John Y. K. Lee, MD, explains that cranial-base surgery poses a new challenge for the surgical robot. “Most robotic-assisted surgery is performed through soft tissue, but the brain is heavily protected by bone. This is good for us as humans, but presents special challenges to a surgeon,” said Dr. Lee. “We are working closely with Intuitive Surgical (manufacturer of the daVinci® surgical robot) to develop new tools that can be used to access the skull base.”

Dr. Lee said he is hopeful that the tools needed to perform robotic-assisted skull-base surgery will be ready for clinical trials soon.

True to Penn’s mission, the Center for Cranial-Base Surgery also has a strong research and education component. The state-of-the-art skull-base training lab was established for training residents and fellows in surgical procedures as well as how to work as part of a team.

“Along with surgery, we teach students how to build relationships. We want these new physicians to learn how to work, think and create together as a team,” said Dr. O’Malley. “There really is no other center like this in the world.”