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COvEr+ FEaTurE able to go home in a day or two. The apical incision is associated with modestly more postoperative pain and morbidity, and a longer recovery time. For this reason, apical access is used only for patients whose vascular disease is so severe that transfemoral access isn't possible. "Apical access is reserved for our vasculopathic patients — those whose arteries are filled with plaque and calcium," explains Dr. Kroshus. "These are sicker patients by definition. They have more limited long-term survival and higher risk of stroke and embolic complications." "We are working with first-generation technology," adds Johannes Brechtken, MD, an interventional cardiologist with Regions Hospital Heart Center. "The catheter is almost a centimeter in circumference and usually requires a surgical cutdown to access the artery." Dr. Brechtken anticipates that cutdowns will decrease by half in the next three to four years as subsequent generations of equipment become smaller, making the procedure more accessible for patients with smaller arteries. Cardiac imaging guides the placement of the new valve and is a critical component of the procedure. Regions offers 3-D transesophageal echo imaging for appropriate valve cases. This imaging allows physicians to view the heart as a three-dimensional structure in real time, affording a better appreciation for the anatomy structure than traditional echo imaging. "Imaging guidance is critical to achieving the best result," explains Dr. Smalley. "It accurately identifies the amount of valve leakage and shows whether the new valve is completely sealed." 8 | Twin Cities MD News ■ mDnews.com For m ore inf or m at i on a b out Regions Hospital Heart Center, visit w w w.reg ion shospital.com /hear t or call 651-254-4887. ■ Johannes brechtken, MD Timothy Kroshus, MD PhoTos CouRTesy of ReGioNs hosPiTAl comprehensive taVR program offers new Hope As awareness of this procedure increases, Regions anticipates that it will be performing approximately 30 to 40 TAVR procedures each year. The heart team emphasizes that both its comprehensive care model and the expertise of team members are critical for maximizing patient outcomes. "We have the most comprehensive surgical program in the Twin Cities in terms of our interactions and collaborations with cardiology, our surgical program, our dedicated cardiac surgical intensive care units, and our dedicated endocrine service for heart surgery patients with postoperative diabetes," says Dr. Kroshus. Hospitalists at Regions Hospital manage the medical issues of each heart surgery patient through discharge planning, social work and clinic follow-up. Hospital administration has made it a priority to integrate all program services from the patient's initial evaluation through postoperative recovery and follow-up. Regions Hospital Heart Center conducts monthly evaluations for markers of care and mortality. Physicians gather to present and evaluate the complications of each case. "Our evaluations show us what we need to tweak to maintain the highest level of care," says Dr. Kroshus. "We want to take good performance and make it great performance. That requires constant feedback and learning. Our open discussions are vital to maximize outcomes." "The TAVR procedure enables us to give our patients an option they didn't have three years ago," says Dr. Smalley. "It is really miraculous to see the old valve pushed out of the way by a new, functioning valve." Without treatment, the projected outcomes for high-risk and inoperable patients with aortic stenosis are grim. For patients such as Alice, the TAVR procedure offers a new option and new hope. Alice recently sent her cardiologists a photo of herself walking her dogs. "She looks so happy," says Dr. Brechtken with a smile. "Today, Alice is enjoying a quality of life that would have been unimaginable without this procedure. It is exciting to be able to help these patients. For me, outcomes like Alice's are what make our work so worthwhile." stephen smalley, MD

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