The State of Cardiac Care

Cutting Edge, Less Cutting

One of the biggest advances in cardiac care has been less-invasive surgeries to fix or replace faulty heart valves, the doors between the heart’s chambers.

Each time your heart beats, the valves open and close to regulate blood flow. That keeps your blood circulating as it should, stops it from flowing backward and supports the heart’s efficient pumping action. When valves don’t open and close properly, they can impede blood flow, cause blood to leak backward or force the heart to work harder. That can cause fatigue, chest pain, shortness of breath and an increased risk of arrhythmia, blood clots, strokes or even sudden cardiac arrest.

Less Invasive Procedures: Dr. Patrick Kohtz, cardiothoracic surgeon at Atrium Health Navicent in Macon. Photo: Matt Odom

Although repairing or replacing faulty valves has been possible for decades, in the past it usually involved open-heart surgery, stopping the heart temporarily and using a heart-lung machine to keep blood flowing while the heart was being repaired. But minimally invasive procedures have now become the standard of care, says Dr. Patrick Kohtz, a cardiothoracic surgeon at Atrium Health Navicent in Macon. It’s one of about a dozen centers in the state that now do many valve replacements or repairs in a procedure called transcatheter aortic valve replacement (TAVR).

With TAVR, the surgeon makes small incisions in the patient’s wrist or groin and threads catheters through the vessels to reach the heart. The procedure was first performed at Emory Healthcare in 2007.

Since the advent of TAVR, similar technology is making it possible to repair other heart valves, such as mitral valves and tricuspid valves. “The tricuspid technology is really new, within the last few years,” says Kohtz. “And not a lot of centers do that but that something we’re working towards.”

“These and other minimally invasive procedures are really changing the lives of people who, in the past, couldn’t get procedures done because they were too sick,” says Dr. Angel Leon, professor of medicine at Emory University School of Medicine and chief of cardiology service at Emory University Hospital Midtown. “They have made procedures that were once very invasive and very complicated a lot easier to deal with, with very short stays in the hospital and quick recovery.”

Dr. Ronnie Ramadan, director of the Structural Heart Center at Georgia Heart Institute in Gainesville, concurs. “Now instead of staying in the hospital for a week after open-heart surgery and then taking about two months to recover from a sternotomy, you can literally go back to work two days later,” he says. “You don’t need anybody to kind of take care of you because you’re doing whatever you need to do. So recovery is very, very good.”

Reducing Risk

It’s not just surgery where new techniques have improved outcomes. In some cases, improvements in medical management have reduced the need for surgery altogether.

Dramatic Improvements: Dr. Ronnie Ramadan, director of the Structural Heart Center at Georgia Heart Institute in Gainesville. Photo: Contributed

“Ten years ago, every blockage that we saw we used to fix and put a stent in or send the patient to bypass. And now that’s not the case anymore,” says Ramadan. “[In 2020] data came out that was completely shocking to a lot of practicing physicians, showing that medical management for stable but significant coronary artery disease was just as good as opening the blockage in terms of death, future [heart attack] and hospitalizations,” he says. “Now we think of medicines and put the patients on medicines first and optimize them and only if they fail medicine do we bring them back and try to … open the blockage with a stent or bypass.”

Several medications approved over the past decade have been game changers in the treatment of heart disease. For example, there are new drugs to treat high cholesterol in some people. While the goal once was to lower LDL “bad” cholesterol to 160 or below, newer generations of statins have enabled many people to get their levels to 100 or lower, says Dr. Matthew Certain, a cardiologist with Southeast Georgia Health System in Brunswick. And two new medications, Repatha and Praluent, that are different from statins and are given as shots every two weeks “can make somebody’s LDL almost undetectable,” Certain says. “And what we have learned over the past 25 years is that the longer you have the lower cholesterol, specifically LDL, the lower your overall cardiovascular risk over the course of your life.”

Other drugs that have been approved to treat diabetes, a condition that puts about 1 in 9 Georgians at increased risk of heart disease, have also been found to help treat heart disease.

“…Minimally invasive procedures are really changing the lives of people who, in the past, couldn’t get procedures done because they were too sick. They have made procedures that were once very invasive and very complicated a lot easier to deal with, with very short stays in the hospital and quick recovery.” Dr. Angel Leon, professor of medicine at Emory University School of Medicine and chief of cardiology service, Emory University Hospital Midtown

In one example, researchers noticed that people who had congestive heart failure and were taking a drug for their diabetes that helps the kidneys get rid of excess blood sugar also did better with their heart failure. They decided to conduct clinical trials clinical trials specifically with people who had congestive heart failure and found “dramatic improvement” in symptoms and death rates, Ramadan says. “So, now these [drugs] are becoming standard of care for patients with diabetes or typically a very high-risk patient subset because those patients are at a very high risk of coronary disease and coronary events,” he says.

Another example involves a category of drugs that’s familiar – so-called GLP-1 agonists, the most famous of which is Ozempic (now used for weight loss as Wegovy). These drugs were originally approved to treat diabetes by mimicking the action of a hormone that helps control blood sugar and appetite.

“Now, with those classes of drugs, not only do we help obesity and diabetes – which are the two most dominant risk factors for cardiovascular disease – but you also end up having a benefit on cardiovascular health, like heart attacks and strokes,” Ramadan says. “So we often use these medicines now in our … cardiac patients, whether they have diabetes or not, to help reduce their risk factors and prevent them from having cardiovascular disease.”

“If you look at what they did in clinical trials, the clinical trial results were incredible,” says Leon. “When they are used a lot more, and outside of trials in everyday situations, that’s when you’re going to see a more widespread impact. They look like they’re going to have a tremendous impact on treating obesity [and] diabetes and the consequences of them on heart disease.”

Advances in Imaging Tests

In the past doctors relied on blood tests to treat heart disease – measuring cholesterol and triglycerides, blood glucose and hemoglobin A1c to identify diabetes or prediabetes, and C-reactive protein (CRP), which measures inflammation, a risk factor for atherosclerosis (hardening of the arteries). But increasingly, doctors are using imaging tests to identify risk for cardiovascular disease. That’s important because knowing someone has a higher risk of heart disease can help them get treatment to prevent it and encourage them to make lifestyle changes to stay healthier. Imaging tests can also help guide treatment of heart disease.

Quicker Recovery: Dr. Angel Leon, professor of medicine at Emory University School of Medicine and chief of cardiology service, Emory University Hospital Midtown. Photo: Ben Rollins

Over the past few decades, the calcium score – where a specialized CT scan measures the amount of calcium in the wall of the coronary arteries – has become a widely used tool for estimating heart disease risk. Dr. Thomas Gore, a cardiologist at the Wellstar Center for Cardiovascular Care in LaGrange, likes the test, which can be done at centers throughout the state, because it encourages people to look at their risk of heart disease more realistically and seriously. “You can talk theoretically to somebody and say, ‘you can … do this and this to lessen your risk,’ and they listen to you and think to themselves ‘That may never happen to me,’” he says. “But if they do a calcium score and see that they have plaque building in the arteries, it makes a big difference in their willingness to do these preventive measures because they know that they’ve got something going on.”

At Atrium Health Navicent locations, a noninvasive test called AngioScreen can help assess risk of heart attack and stroke. “It’s an imaging study that identifies blood flow in different parts of the body,” says Kohtz. “And [depending on the findings], you can say, ‘Well, this is abnormal here. You have a blockage or some sort of abnormal flow here. You might be at risk for heart disease or carotid disease or peripheral arterial disease.”

At hospitals in the Piedmont Health System, specialists are using a variety of advanced imaging tests, including echocardiography, coronary computed tomography (CT) angiography, cardiac magnetic resonance imaging (MRI) and positron emission tomography (PET), that provide unparalleled detailed visualizations of the heart’s structure, function and blood flow, says Dr. Venkateshwar Polsani, chief of cardiovascular imaging at Piedmont Healthcare.

New Medications: Dr. Matthew Certain, a cardiologist with Southeast Georgia Health System in Brunswick. Photo: Contributed

Advances in scanning technology such as the ability to do three-dimensional imaging in echocardiography make it particularly valuable for complex diagnoses and procedural planning. Polsani says that technology is helpful in evaluating a condition called microvascular dysfunction in which small blood vessels that branch off from coronary arteries aren’t blocked but are damaged, reducing blood flow and oxygen supply. “Using this test, we can quantitively say someone has no blockages, but they have they have a microvascular dysfunction, and blood flow is decreased quantitatively,” he says.

Other advances include improvements in CT technology that have led to the ability to detect not only calcium, but individual components within the walls of the coronary arteries, Polsani says, adding that these more precise findings could eventually replace the calcium score in predicting cardiovascular disease risk.

“Now instead of staying in the hospital for a week after open-heart surgery and then taking about two months to recover from a sternotomy, you can literally go back to work two days later.”

Dr. Ronnie Ramadan, director of the Structural Heart Center, Georgia Heart Institute in Gainesville

Restoring Heart Rhythms

Even with the advances in testing available at Georgia hospitals, doctors say one of the most important pieces of technology for one common heart problem is a fairly common device – a smart watch.

Many of the newer smart watches can sense arrhythmias, or changes in the heart’s rhythm. “That something as simple as wearing a watch that can detect heart rhythm problems, that’s a really big deal,” says Leon.

Avoiding the Knife: In some cases, newer procedures and techniques have lessened the need for the kind of open-heart surgery shown above. Photo: Contributed

The most common form of arrythmia, atrial fibrillation (A-fib), happens when the heart’s two upper chambers beat out of sync with the lower chambers. It can cause blood to pool, increasing the risk of clots and stroke.

“Some watches are pretty good at detecting atrial fibrillation and making people more aware of their heart rhythm and their rhythm disorders,” says Certain. “So they can do an EKG on their watch and take that to their physician and say, ‘Hey, my watch says I have atrial fibrillation. What are we going to do about it?’”

For many people, drugs that slow the heart rate and medications that restore a normal heart rhythm can treat A-fib, along with blood thinners to prevent blood clots and strokes. Doctors may also use a procedure called ablation, which creates tiny scars in the heart that block the signals telling it to beat erratically.

Dr. Thomas Gore, a cardiologist at the Wellstar Center for Cardiovascular Care in LaGrange, says ablation is a promising treatment for atrial fibrillation. Photo: Contributed

“Ablation is an electrical procedure where you go inside the heart, and you treat the electrical fibers to make the atrial fibrillation go away. It is not 100% effective, but it shows promise in certain situations,” says Gore, adding that some ablations can be done at local hospitals while others require going to a larger medical center.

Another procedure involves placing a device called the WATCHMAN that stops blood clots from forming in a part of the heart called the left atrial appendage, a small, pouch-like structure attached to the upper left chamber of the heart.

“This is technology that really hasn’t even entered into 10-year [or] 15-year follow-up data yet. That’s how new it is,” says Kohtz, adding that Atrium Health Navicent is one of the busiest systems in the state for the procedure, having performed over 500 of them since becoming one of the first in the region to offer them in 2018. “But it’s certainly a technology that as a cardiothoracic surgeon, I help implant and [I] help perform these procedures with our cardiologists. And it’s certainly something that is tracked by our governing agency, the Society of Thoracic Surgeons. So it’s a very important new technology that we’re still learning and implementing.”

“What we have learned over the past 25 years is that the longer you have the lower cholesterol, specifically LDL, the lower your overall cardiovascular risk over the course of your life.” Dr. Matthew Certain, cardiologist, Southeast Georgia Health System in Brunswick

Focus on Lifestyle and Prevention

Like the WATCHMAN procedure, many of the treatments used widely today either didn’t exist or were in development just 25 years ago. So what can we expect in the next 25 years? Doctors predict continued advances in:

• minimally invasive procedures
• developments in personalized treatment, including customized valves to match someone’s anatomy and medication guided by a person’s genetics
• an increased role of artificial intelligence and wearable technology (smart watches)
• the use of imaging tests for routine heart disease screening (much like mammograms for breast cancer)
• expansions in technology outside of the state’s largest hospitals, bringing care closer to home for all Georgians.
• Regardless of where technology goes, the most important factor in heart health for most people will be the same as it has always been – a healthy lifestyle.

Says Leon, “Despite all of the advances that we’re making with technology and science, something as simple as leading a healthier life can have just as much if not a greater impact.”

Certain agrees. “I think it’s important to not have every visit harping about pushing pills but also just pushing health,” he says. “So I think that’s [a] sort of shift in [the treatment of heart disease] or at least we, as cardiologists, believe this is where cardiology needs to be.”