A Local Answer for Cardiac Valve Disease at Good Samaritan Regional Medical Center

Thursday, January 3, 2013

The Rockland County Community Health Assessment of 2010-2013 reveals the county boasts a lower hospitalization rate for cardiovascular disease, yet has a higher mortality rate from coronary heart disease, than other New York counties.

To answer the need for local cardiovascular care, Good Samaritan Regional Medical Center developed a nationally recognized cardiovascular surgical center under the leadership of Edward F. Lundy, M.D., Ph.D., Chief of Cardiac Surgery, and Rawn Salenger, M.D., Director of the Center for Valve Surgery. Established in 2007, the Active International Cardiovascular Institute (AICI) at Good Samaritan Regional Medical Center offers cardiac catheterization, electrophysiology services, transesophageal echocardiogram, stress testing and cardiac surgery to comprehensively serve patients with cardiovascular disease here in the lower Hudson Valley region. Within the last year, Good Samaritan Regional Medical Center extended the reach of its cardiovascular care by formalizing the Center for Valve Surgery, a program under AICI’s umbrella, to treat valve disease.

The idea for the Center for Valve Surgery germinated in Good Samaritan Regional Medical Center’s monthly echocardiography conferences. Dr. Salenger began to put the pieces together for a multidisciplinary team focused on valve care and composed of providers with high levels of expertise in their cardiovascular discipline.

“We observed that as our cardiothoracic program at Good Samaritan Regional Medical Center grew, we were seeing progressively sicker patients who had more and more advanced cardiac disease,” says Dr. Salenger. “We realized the care of cardiac valve patients didn’t reside in the realm of one medical discipline, but required a multidisciplinary approach to produce the best possible outcomes.”

The heart valve team is comprised of cardiologists possessing a breadth of subspecialty expertise. Participants include: noninvasive cardiologists with expertise in echocardiography, magnetic resonance angiography, and computed tomography angiography; invasive cardiologists who provide cardiac catheterization and other catheterization lab interventions; cardiac anesthesiologists; cardiac surgeons; and pulmonary critical care intensivists who provide expertise in lung function and critical care.

“Before we started the cardiac surgery program here, there was a tremendous need for advanced cardiac care in this part of the state. Our goal is to impact the overall cardiovascular mortality of this region by providing advanced services, and the Center for Valve Surgery is critical to achieving that goal.”
— Rawn Salenger, M.D., cardiothoracic surgeon, Director of the Center for Valve Surgery at Good Samaritan Regional Medical Center

Dr. Salenger also notes the wide array of services available on an “as-needed” basis. These draw on the experience of medical subspecialists, such as hematologists, neurologists and others who may be called in for preoperative consultation for patients suffering from less common, associated conditions. Rounding out the team are physical therapists, who ensure patients are as strong as possible before surgery and help them achieve optimum mobility as quickly as possible after surgery.

At echocardiography conferences, members of the valve team discuss severe cases of valve disease, treatment options, surgical and nonsurgical strategies, and follow-up plans for each patient. Patients admitted to the hospital with combined heart, lung and kidney failure are a perfect example of the benefits of the multidisciplinary valve team. In cases such as these, Dr. Salenger explains, cardiologists, pulmonary critical care physicians, nephrologists and ICU nursing staff collaborate to treat patients and ultimately return them to a better quality of life.

For referring physicians who are unable to attend the conferences, either Dr. Lundy or Dr. Salenger follows up to communicate the discussion and proposed treatment plan and solicit the physicians’ input.

“We understand the importance of including the full complement of physicians in our patient assessments and surgery decisions. It allows for better patient outcomes and improvements in treatment across the continuum of their care,” says Dr. Salenger. “Our referring physicians appreciate the partnership with us in the care of their patients.”

Putting Patients at the 
Center of Care

The Center for Valve Surgery is available for patients who are referred by their doctors for possible valve surgery, as well as self-referred patients seeking a second opinion. All patients are evaluated by either Dr. Salenger or Dr. Lundy.

“A comprehensive evaluation is performed under one roof, with one visit,” says Dr. Salenger. “Other specialists are available routinely to assist in evaluation, and we provide both surgical and nonsurgical treatment options. Time is taken to explain the problem to the patient and his or her family, and the treatment plan is tailored to the individual patient. If surgery is needed, it is scheduled and carried out next door at Good Samaritan Regional Medical Center.”

Collectively, Dr. Salenger and Dr. Lundy have performed more than 2,000 valve procedures. After recovering, patients are sent back to their referring physicians for long-term follow up. For example, consider patients with mitral valve regurgitation — a condition that occurs when the mitral valve does not close correctly. This causes a backward flow of blood into the atrium from the ventricle, leading to decreased blood flow to the rest of the body. Mitral valve regurgitation may be contributed to by a heart attack, coronary artery disease, heart valve infection, fibroelastic deficiency or rheumatic heart disease. Surgical intervention is not always necessary. However, if the regurgitation becomes significant, the Center for Valve Surgery can meet with patients and evaluate the need for surgery. If Dr. Salenger or Dr. Lundy concludes the condition is severe, surgery can be scheduled and follow-up care coordinated with referring physicians.

Restoring Mitral Valve Competence and Quality of Life

Dr. Salenger notes that mitral valve repair demonstrates the benefits achieved through surgical intervention. It is common for patients with advanced degrees of mitral valve regurgitation to see huge deficits in quality of life, such as fatigue, loss of energy and shortness of breath. According to Dr. Salenger, restoring mitral valve functionality can eliminate most, if not all, of these symptoms. Additionally, patients who have had chronic mitral valve regurgitation may develop a dilated heart with decreased function, which can lead to heart failure. Dr. Salenger notes that surgical intervention may help to partially or completely reverse heart dilation, as well.

By following a philosophy of preserving as much native valve tissue as possible, surgeons at the Center for Valve Surgery aim to repair the mitral valve, not replace it. Doing so, says Dr. Salenger, restores function, which leads to an enhanced quality of life and normal life expectancy curve. Patients also benefit from retaining their own valve instead of having an artificial replacement. When artificial valve replacement proves necessary, surgeons strive to preserve as much of the valve-supporting structure as possible, maintaining as much natural continuity between the heart muscle and the new valve as possible.

In the operating room, the heart is opened while the patient’s circulation is maintained by a specialized heart-lung machine. The patient’s mitral valve is carefully analyzed. This information is synthesized together with functional data obtained by transesophageal echocardiography performed in the operating room before opening the patient’s chest. By integrating anatomic and functional information about the valve, Dr. Salenger is able to create a plan for repairing the valve and restoring proper function. Dr. Salenger states that mitral valve repair is one of the most gratifying operations he performs.

“One of the things I love about mitral valve surgery is that there is a certain amount of art that goes into restoring a valve,” he says. “When you take a leaky valve and rebuild it and see it working perfectly, it’s beautiful, and you know you have really helped that patient. By employing techniques that allow for less resection of native valvular tissue and greater surface area for valve coaptation (a zone within the valve which affects mitral valve function), we are able to produce a long-lasting repair that will ultimately lead to better heart function.”

Aortic Valve

While Dr. Salenger favors mitral valve repair over replacement, aortic valve replacements tend to last longer and function better for most patients. Although research has not pinpointed the reasons for the functional differences between mitral and aortic valve replacement, Dr. Salenger surmises it’s because of less pressure levied upon the aortic valve throughout the cardiac cycle.

The Society of Thoracic Surgeons (STS) identifies the two most common causes of aortic valve malfunction to be congenital and senile calcification. The most common congenital problem is a bicuspid aortic valve. Some of these valves will start to leak or become too tight as a person ages, usually around the sixth decade. Senile calcific aortic stenosis occurs in some elderly patients. For unknown reasons, calcium deposits on the aortic valve leaflets prevent effective opening of the valve. When this tightening of the valve occurs, patients develop aortic stenosis.

Aortic stenosis classically presents with shortness of breath, chest pain or light-headedness. The presentation can sometimes be similar to a heart attack. Other patients may complain only of being increasingly tired or lacking energy. Patients with the above constellation of symptoms should be evaluated for aortic valve disease. If assessment reveals severe aortic valve disease, surgery is most likely necessary.

Dr. Salenger and his team then take over. The patient is taken to the operating room and placed on the heart-lung machine. This machine will circulate and oxygenate the blood, keeping it away from the heart while surgeons operate. After opening the aorta, Dr. Salenger says, the malfunctioning valve is cut out and replaced with a new mechanical or biological valve. Mechanical valves, made of metal, are more durable, but have a tendency to cause blood clots, requiring patients to take anticoagulant medications for the remainder of their lives. Biological valves, made from animal or cadaveric heart tissues, reduce the risk of blood clots but are not as durable as mechanical valves. Patients and surgeons choose which valve to use based on patient preference, risks posed by age and comorbidities, and lifestyle.

Patients may have other conditions involving the aortic valve, says Dr. Salenger, including aneurysmal dilation of the ascending aorta in close proximity to the aortic valve. The STS reports that an estimated 15,000 Americans die each year from ruptured aortic aneurysms, but early detection and surgical intervention can treat the condition before it turns lethal. Depending on location, surgeons at the Center for Valve Surgery may repair the aneurysm by replacing both the valve and aorta or simply replacing the aorta, leaving the valve in place.

Since serving as a cardiac surgery instructor at The Mount Sinai Medical Center, Rawn Salenger, M.D., cardiothoracic surgeon, Director of the Center for Valve Surgery at Good Samaritan Regional Medical Center, has focused his interests on patients with complex aortic and mitral valve disorders. In addition to his expertise in the surgical repair of diseased valves, Dr. Salenger works to prevent the need for surgical intervention through his work with the American Heart Association (AHA). He serves on the board of directors for Founders Affiliate of the AHA, has acted as chairman of The Heart Walk and has lent his expertise to several “Lunch and Learns,” as part of which, he visits local businesses to talk about the importance of healthful habits.

For the surgical treatment of aortic aneurysms, Dr. Salenger’s team performs a similar open-heart procedure to standard aortic valve replacement, with an added component of reducing the patient’s body temperature. The team connects the patient to the heart-lung machine, cuts out the dilated aortic segment, cools the patient down and shuts off the heart-lung machine. Dr. Lundy and Dr. Salenger then sew a synthetic vascular graft to replace the resected aortic segment and restart the heart-lung machine, warming the patient to normal temperature. Postoperatively, specialized team members focus their expertise on restoring the patient to health.

“Postop, critical care physicians aid the patient’s recovery,” says Dr. Salenger. “Many times after valve surgery the patients feel completely renewed. They feel energy they haven’t had in years. Excellent surgery alone will not achieve that. You need excellent medicine, excellent physical therapists and an excellent nursing staff; you need everyone working together to achieve the best outcome. Our team does that every day. It’s our team approach that allows us to achieve such outstanding results for even the sickest patients.”

The Center for Valve Surgery Advantage

The role AICI’s cardiologists and the rest of the multidisciplinary team play in the foundation and perpetuation of the high levels of care provided at the Center for Valve Surgery cannot be overstated, says Dr. Salenger.

“At the Center for Valve Surgery, the medical subspecialties that contribute to our team have always provided the highest standards of care, whether contributing to patients’ pre- or postsurgical care,” Dr. Salenger says. “Whenever a service has been needed, it’s always been available at a high level. That kind of teamwork provides something that no one or two physicians can provide on their own.”

For more information about the cardiac services at Good Samaritan Regional Medical Center and the Center for Valve Surgery, please visit bschs.org and select “cardiac programs” under the “Our Services” tab.