Structural Heart Disease

A Novel Discipline in Cardiovascular Medicine

Within the past decade, we have witnessed major innovative advancements in the field of interventional cardiology for the treatment of valvular heart disease, congenital defects and stroke prevention. These novel scientific developments have led to the establishment of a new subspecialty in the world of cardiovascular medicine, known as "Structural Heart Disease”.

According to Robert J. Cubeddu, MD, Cleveland Clinic Florida interventional cardiologist and section head of the Structural Heart Disease Program, “Today, using advanced catheter technologies, skilled interventional cardiologists are able to offer many minimally invasive options to treat cardiac patients, than ever before.”

Many patients can now benefit from these innovations, without the need for open heart surgery. Dr. Cubeddu adds, “Conditions such as; closure atrial septal defects, patent foramen ovale, aortic valvular stenosis (valve narrowing), mitral stenosis/regurgitation (valve leakage), closure of the left atrial appendage, among others, are now being treated using these new approaches.”

Warning Signs
Symptoms can vary greatly depending on the type of heart condition and its severity. The following are perhaps most common, and may reflect a serious structural heart condition:

  • heart palpitations/irregular heart beat
  • chest pain/tightness
  • lower extremity swelling
  • shortness of breath
  • fainting spells
  • high blood pressure
  • leg cramping
  • fatigue
  • dizziness

If you experience any combination of these symptoms, you should consult with your doctor to be evaluated.

Medical Treatment Options
For some patients, the condition can be managed medically. There are certain medications that may be used to improve symptoms, and decrease the likelihood of long-term complications. Medical therapy; however, has its own limitations. Some patients only see minimal improvement with medical therapy, while others may simply not tolerate it at all. For example, the use of blood thinners such as warfarin carries a significant risk of bleeding, especially among older patients. Drug interactions or poor medication compliance represents other limitations of this approach. For this reason, certain patients may benefit instead from surgery or cardiac intervention.

New, Innovative Procedures
The latest structural heart interventions have become widely accepted, due to an excellent safety profile and excellent clinical outcomes, in comparison to medical therapy and open heart surgery. In most instances these catheter-based procedures are performed under local anesthesia, with minimal sedation and early recovery. “It is fascinating to see this technology evolve so rapidly, and become available to so many patients,” shares Dr. Cubeddu. Rather than doing an open sternotomy (an incision that is made along the chest wall, after which it is spread open, providing access to the heart), interventional cardiologists such as Dr. Cubeddu, are now able to replace damaged valves using catheters, through a small incision in the groin. This is done while the heart is beating, so there is no need for heart-lung bypass, and the risk of bleeding or need for transfusion is greatly reduced.

A Sophisticated Approach for Aortic Valvular Stenosis
Aortic stenosis (valve narrowing), represents one of the most common valve disorders among patients age 65 or greater. If left untreated, the condition is likely to result in progressive heart failure or even death. Until recently, the only way to cure aortic stenosis was by replacing the valve through an open-heart procedure. However, a major breakthrough occurred in 2011, when the FDA approved a new procedure commonly known as “TAVR”, or transcatheter aortic valve replacement. TAVR is a minimally invasive catheter approach to successfully replace the aortic valve under local anesthesia, without the need for open heart surgery. Originally available for high risk patients only, TAVR is now becoming the preferred treatment for patients with aortic stenosis. “For low risk patients, TAVR may be performed through the participation of the PARTNER III study,” says Dr. Cubeddu.

Reducing Stroke Risk for Patients with Atrial Fibrillation
Patients with an irregular heartbeat, or atrial fibrillation (AFib), are five times more likely to suffer a stroke. This is due to the decreased pumping capacity, which in turn causes blood to pool and clot in the left atrial appendage (LAA) sac of the heart. These blood clots can potentially break loose and travel through the bloodstream to the brain, causing a stroke. This explains why most patients with AFib take blood thinners for stroke prevention.

However, Dr. Cubeddu warns, “The use of blood thinners represents a considerable problem. They are often associated with significant bleeding, such as intracranial hemorrhage.” A new breakthrough procedure is now available to prevent stroke among AFib patients who cannot take blood thinners, providing for an alternate option.

The minimally invasive, FDA approved WATCHMAN™ procedure is being used to close the LAA for AFib patients, who are at risk for stroke. “Several important clinical trials have demonstrated the Watchman plug is safe and effective at closure of the LAA,” says Dr. Cubeddu, “and with a good seal, the odds of suffering a stroke are significantly reduced, allowing patients to safely stop their anticoagulant medications.”

Dr. Cubeddu urges that although these procedures provide new, innovative treatment options, a thorough evaluation is extremely important, to determine whether you are a candidate.

Touched by Breast Cancer

Stories from survivors

One in eight women will get breast cancer, but thanks to earlier detection, new treatments and a better understanding of the disease, the mortality rate has continued to drop over the past decade. Still, for those women who have been diagnosed, it can certainly feel like a huge emotional roller coaster ride.

According to the National Cancer Institute, there are over 3 million breast cancer survivors in the country today. Sharing survivors’ stories helps to not only spread awareness about the disease, but it can also provide comfort for women newly diagnosed. Knowing what others have gone through and overcome in their battle against breast cancer can be very reassuring.

We share the journeys of three brave breast cancer survivors, from coping with their diagnosis to making their treatment decisions, to resuming their lives after treatment, in the hope it will provide inspiration for other patients.

These amazing breast cancer survivors decided to share their impressive stories of courage and hope, to encourage others fighting against the disease.

Allie’s Story: Become a Vessel of Hope
Allie Santana found a lump while performing a self-exam, and feared the worst. Multiple mammograms and biopsies confirmed her suspicions, she had Stage II breast cancer.

“I discussed the options with my Cleveland Clinic Florida breast cancer care team, and chose an aggressive treatment of 16 rounds of chemotherapy, 28 rounds of radiation and a bilateral mastectomy,” shared Allie.

One of her main objectives was not only to get rid of the cancer in her left breast, but also make sure that it wouldn’t return in her other breast at a later time. “I felt fortunate to have world-class care in my own back yard,” said Allie, “the level of care at Cleveland Clinic is unsurpassed.”

“My breast surgeon, Elizabeth Stone, MD, was determined that we would beat this together,” added Allie.

The battle has changed her perspective on life. “Now, I take the time to say, ‘I love you,’ more often. I give longer hugs, and I no longer rush through my day without purpose,” she says.

She intends to support others facing the disease. “You can’t help but have a new outlook on life after becoming a survivor,” she states. “I believe I have an obligation to all the warriors before me and the ones that will follow to be a vessel of hope.”

Geraldine’s Story: Enjoy Every Moment
Since being diagnosed with breast cancer, Geraldine Gomez has adopted a very positive outlook on life. She urges others who are battling breast cancer not to give up the fight. “Have faith, a positive attitude, and follow your treatment plan thoroughly,” states Geraldine.

She elected to have a double mastectomy with muscle-sparing, TRAM free flap reconstruction, along with chemotherapy. “I decided to get the double mastectomy, in the hopes that I would not get breast cancer again,” shared Geraldine.

As part of her treatment and recovery, Geraldine decided to take advantage of the services offered at Cleveland Clinic Florida’s Maroone Cancer Center. “I took free yoga classes, Art and Music Therapy, and also met with a nutritionist to develop healthier eating habits,” said Geraldine.

“They have increased my positivity and will to live,” she said of the classes. “They have empowered me, helping me see life in a more positive way.”

Geraldine also has gratitude for the Cleveland Clinic Florida breast cancer team, who helped in her battle with breast cancer. “I’m so thankful to all my doctors, beginning with Cassann Blake, MD, my breast surgeon, as well as Miguel Medina, MD and Alex Earle, MD, my plastic and reconstructive surgeons, who did an amazing job, and of course my oncologist, Elizabeth Stone, MD,” said Geraldine.

“After my experience with breast cancer, I decided to enjoy every moment, laugh often, show my love for family and friends, and take care of myself,” shared Geraldine.

Teresa’s Story: Survive and Thrive
Teresa Anderson was diagnosed with breast cancer at the end of 2015. In her fight against the disease, she underwent two lumpectomies, 16 rounds of chemotherapy and 30 radiation sessions.

“During my treatment, I met an incredible young lady, Allie Santana, who was battling at the same time. We really bonded because we could share our experiences and encourage one another,” shared Teresa.

Grateful for the care she received at Cleveland Clinic Florida, Teresa states, “My doctors, nurses and support staff were not only skilled professionals, but displayed heartfelt compassion that went beyond a job description. After my experience, I know why Cleveland Clinic is highly rated and well respected.”

When Teresa Anderson was battling breast cancer, she focused on three words to help get through it all: Survive and Thrive. “Surviving was getting through treatment,” said Teresa, “but thriving is about taking on new challenges, and living a full and contented life.”

Now that she has completed treatment, she is looking forward to helping others. “I received so much support during my journey, and I want to pay it forward by supporting others who are now battling the disease,” explained Teresa.

In the war against breast cancer, Cleveland Clinic Florida offers the most comprehensive care in a compassionate environment. This approach has not only helped these three survivors fight the disease, but has also offered comfort and strength along their journey.

Epilepsy: Freezing a Moment in Time

Don’t Let Epilepsy Stop You...New Advances in Surgery Provide Relief

Approximately 3 million people in the country have epilepsy, which is defined as recurrent unprovoked seizures. When an epileptic seizure occurs, a person may experience feelings of confusion, loss of consciousness, change in sensation, uncontrollable tremors or even convulsions. These symptoms can produce the effect of having frozen a moment in time for those afflicted.

Restoring Quality of Life
Every patient is unique, which is why the development of an individualized treatment plan is the ideal method. The goal is always focused on controlling a patient’s seizures to restore quality of life. “Our epilepsy team includes epileptologists, neurosurgeons, neuroradiologists, nurses, pharmacologists, among others who collaborate to provide care in one location. This presents a tremendous advantage, allowing the entire team to be involved in patient care,” explains Badih Adada, MD, Cleveland Clinic Florida neurosurgeon.

Medical Therapy
For about two-thirds of the patients with epilepsy, one or more of the approved medical therapies will be successful. Unfortunately the remaining one-third will continue to live with uncontrollable seizures, because they have not found an effective drug therapy.

“This is often referred to as refractory epilepsy, in which the patient has not become seizure free with adequate trials of two medications,” says Dr. Adada. For those patients with refractory epilepsy, surgery is often a consideration, particularly when seizures are frequent and severe enough to interfere with their quality of life.

Epilepsy Surgery
When medical therapy is either ineffective or produces intolerable side effects, epilepsy surgery is then considered as an option. In recent years, there have been remarkable surgical advances made. The most common type of epilepsy surgery involves the removal of a seizure focus, the small area of the brain where seizures originate. This type of surgery may lead to long-term, complete freedom from seizures, for more than half of the drug-resistant patients with focal epilepsy.

Making a Well-Informed Decision
The decision to have surgery is based on a thorough medical history, physical examination and advanced diagnostic testing. “Our Epilepsy Center includes a leading-edge Epilepsy Monitoring Unit (EMU), where simultaneous computerized EEG and video are performed. Then the recorded brain waves and the physical symptoms captured on the videotape are compared and correlated,” states Dr. Adada.

Additional tests may include, magnetic resonance imaging (MRI), magnetoencephalography (MEG), positron emission tomography (PET) and single photon emission computed tomography (SPECT). “Utilizing state-of-the-art imaging modalities, our experienced epilepsy team is able to effectively diagnose the source of the seizures,” Dr. Adada adds, “the goal is to identify the affected region of the brain.”

After the necessary tests are completed, the results are presented at the Epilepsy Center’s weekly Patient Management Conference. Here, a multidisciplinary group that includes specialists from both Florida and Ohio, gather to review and discuss all the data collected for each patient. “Collaboration with our colleagues in Cleveland allows us to leverage our collective expertise to optimize patient outcomes,” shares Dr. Adada. Surgery is recommended when a localized seizure focus has been established, and when removal of that area will not create a significant risk of function loss.

Advanced Surgical Treatments
“Although traditional approaches are still being used when necessary, minimally invasive MRI-guided laser surgery is being increasingly utilized,” states Dr. Adada. This technique involves the use of a thermal laser, to ablate an epileptic area using guidance from the MRI. Other options include electrical stimulation of the brain or parts of the brain. The types of stimulation include: deep brain, intracranial cortical, and vagal nerve.

As technologies continue to advance, so do the surgical techniques that can be provided. For example, an innovative robotic system call the ROSA ® 3.0, is now expanding epilepsy surgery options. The system was designed to increase safety and reliability, without compromising established surgical protocol.

“We continue to expand the services offered to our patients. Providing them with the most progressive procedures for epilepsy treatment is a perfect example of these efforts,” says Dr. Adada. With the addition of the ROSA surgical system, the Epilepsy Center at Cleveland Clinic Florida is the only one in the region offering this advanced technology to patients.

Comparable to a "GPS" for the brain, ROSA can be used for neurological procedures requiring surgical planning with preoperative data, patient registration, precise positioning and handling of instruments. The system’s arm is designed to perform surgery with extremely small instruments, often as thin as a needle. Its range of motion and ability to assume different positions, allow for accuracy.

“Under the neurosurgeon’s control, ROSA’s computer ‘brain’ and robotic ‘arm’, facilitate a comprehensive surgical approach, offering safety, a quicker recovery and optimization of patient outcomes. Additionally, we’re able to utilize ROSA for patients previously considered inoperable,” shares Dr. Adada. Implementing the robotic system serves as a vehicle to diagnose and treat patients with epilepsy, from the very simple to the most complex, utilizing the newest minimally invasive surgery standard of care.

If medications have failed to control your epilepsy, or if they are causing intolerable side effects, you may be a candidate for epilepsy surgery. Please consult with your doctor to determine the best option for you.

Breast Cancer Survivorship

Increased Risk of Heart Disease

Breast cancer survival has improved over the years due to new and better therapies. However, some treatments may cause cardiotoxicity, or damage to your heart. This is especially true if you are at risk for heart disease.

According to Thomas Samuel, MD, Cleveland Clinic Florida breast oncologist, “A significant issue for women with breast cancer is the 'survivorship' period, which refers to what happens after they survive the cancer. It’s particularly important to be aware of the risk of heart disease." Many of the therapies used, including chemotherapy, radiation therapy and hormonal therapy, can impact a patient's long-term cardiac risk.

Dr. Samuel adds, “For example, some of the agents we use in chemotherapy increase future risk of heart failure.” Certain chemotherapy regimens that include medications called anthracyclines can cause weakness of the heart muscle and congestive heart failure. “Other commonly used drugs for treating breast cancer, like trastuzumab (Herceptin), can also contribute to cardiovascular problems down the road, so patients need to be aware of the risks,” warns Dr. Samuel.

“Thankfully, today radiation therapy techniques are very safe and localized, and are designed to spare the heart from any significant damage,” according to Dr. Samuel.

Cardiotoxicity can occur in various forms, including damage to the heart muscle itself, the heart arteries, or the heart valves. Although cardiotoxicity can be life-threatening, it can often be managed effectively with medication and minimally invasive treatments.

Diego Sadler, MD, Cleveland Clinic Florida cardiologist states, “Fortunately, the percentage of patients affected by these treatments is relatively small, and there are now sophisticated imaging modalities that allow early detection and treatment of potential cardiotoxicity, resulting from cancer treatment such as for breast cancer.”

Breast cancer patients who have undergone these types of treatments, but who are also at high risk for heart disease due to other conditions, are at an increased risk for cardiotoxicity. “Pre-existing factors such as hypertension, diabetes or genetic conditions affect breast cancer survivors similarly to how they affect the general population; however, having undergone certain cancer therapies may put them at an even higher risk for heart disease,” says Dr. Sadler.

It is also important to know that some therapies used in the treatment of breast cancer have the potential for causing cardiac disease many years, even decades after treatment. For this reason, surveillance to allow for early detection and treatment can offer improved cardio-vascular outcomes.

As a result, oncologists and cardiologists now collaborate when these types of cancer treatments are being prescribed, in a new specialty called cardio-oncology. Cleveland Clinic Florida’s multidisciplinary cardio-oncology team includes oncologists, as well as cardiologists who have a special interest in managing patients with cancer. They work together, dedicated to caring for patients in every stage of cancer treatment who are at risk for, or have developed cardiovascular disease. This allows the safe completion of potentially life-saving cancer treatments, with minimal effects to their cardiovascular health. The end goal is to balance the benefits of cancer treatment with the risk of heart damage, offering patients the best opportunity of survivorship.

Recent Advances in Treating Abdominal Cancer

Offering hope

Until recently, a diagnosis of advanced abdominal cancer typically suggested a bleak prognosis that was often measured in weeks to months. However, new developments in cancer treating methods are providing hope for more and more patients.

Thanks to the evolution of multimodality approaches, new treatment options have become available to cancer patients, including the combination of surgery and Hyperthermic (or Heated) Intraoperative Peritoneal Chemotherapy (HIPEC). According to Cleveland Clinic Florida surgeon, Conrad Simpfendorfer, MD, “HIPEC is used to treat cancers that have spread to the lining of the abdominal cavity, such as those of the appendix, colon, stomach, liver and other organs.”

As an alternative to traditional or systemic chemotherapy, which circulates throughout the body, HIPEC is an innovative method of delivering chemotherapy intravenously directly to the cancer cells in the abdomen. This makes it a good option for cancers that originated in, or have spread to the abdominal cavity. The goal of HIPEC is to prevent cancer cells from growing into new tumors, causing the cancer to return.

The Procedure
After your surgeon removes any visible tumors from the abdomen then HIPEC delivers heated chemotherapy directly inside the abdomen to help destroy any remaining cancer cells and very small tumors that cannot be seen. This occurs because the chemotherapy circulates inside the abdomen, allowing it to reach more places. The length of the procedure varies, depending on the extent of disease.

Dr. Simpfendorfer states, “The aim of surgery is to remove all visible disease, but the HIPEC portion of the surgery allows us to treat the microscopic disease that may remain in the abdominal cavity.” The ultimate goal is to “get everything out,” adds Dr. Simpfendorfer, “however, in many situations there may be small areas of disease left behind, which HIPEC provides an alternate way to treat.”

Advantages of HIPEC
Patients who are typically being considered for HIPEC are seeking an alternative to traditional chemotherapy or radiation therapy, as these options offer limited success treating advanced abdominal cancers. Patients also may have been told that no other treatment will work, but are still hoping to find a solution.

The majority of side effects patients have after this type of procedure are actually related to the surgical removal of the cancerous tumor, and not to the HIPEC that is subsequently administered,” says Dr. Simpfendorfer. There are other benefits of HIPEC, such as:

  • a higher concentration of chemotherapy can be delivered intravenously into the abdomen
  • more effective at killing cancer cells that are too small to be seen with the naked eye
  • fewer side effects than conventional chemotherapy since it does not circulate throughout the body
  • an alternative to traditional therapies that are not as successful for advanced abdominal cancers

In appropriate patients, there is an increase in survival; however, it’s highly dependent on the type of tumor and extent of the cancer. “HIPEC is very complex, intense procedure that is not for everyone, although it does offer hope for patients with specific types of cancer,” adds Dr. Simpfendorfer.

The HIPEC procedure requires extensive resources, as well as a surgeon specifically trained to safely perform the procedure. Currently not available at all cancer centers; it is however being performed at specialized centers such as Cleveland Clinic Florida.

Dr. Simpfendorfer urges talking to your physician in order to determine what the best treatment option is for you.

Comprehensive Stroke Care

A team approach

Action is the operative word when treating cerebrovascular disorders such as stroke, one of the leading causes of death and disability in the country. On average, a stroke occurs every 40 seconds with nearly 795,000 Americans suffering a new or recurrent stroke every year.

Comprehensive, timely care is required to reduce or reverse stroke damage. While much is known about how to treat both ischemic and hemorrhagic stroke swiftly and effectively, limited access to treatment often hinders the care needed for acute stroke patients.

“We perform a rapid evaluation of patients with acute stroke, offering treatments that dissolve/remove clots, reversing or limiting the damage done by the stroke,” states Efrain Salgado, MD, Cleveland Clinic Florida neurologist. “At our Comprehensive Stroke Center, patients receive the benefit of our team approach to neurological care, which includes the availability of 24/7/365 acute stroke intervention.”

Reversing the Seemingly Irreversible
The consequences of a stroke can be devastating. A stroke, or “brain attack,” occurs when the blood supply is cut off from part of the brain. When this happens, the blood-deprived brain loses its supply of oxygen and nutrients. When the brain is deprived of blood for even a few minutes, it begins to die. “For this reason, providing timely and comprehensive stroke care with all treatment modalities can reverse the possibility of permanent damage to the brain,” says Dr. Salgado.

For those experiencing an ischemic stroke, brain arteries become blocked and prevent blood from nourishing the brain. To restore nourishment, providing timely intravenous administration of the clot-busting drug known as tissue plasminogen activator (tPA) is critical. From the time an ischemic stroke patient arrives at the door, the primary directive is to provide tPA within 30 minutes.

According to Dr. Salgado, “Cleveland Clinic Florida has been acknowledged for its fast ‘door-to-needle time’ (the time from arrival at the hospital to administration of intravenous thrombolytic therapies.) This timing is recognized as crucial in stroke treatment.” Dr. Salgado adds, “We see patients come in paralyzed, unable to speak or understand, and after administering a drug or directly removing a clot, they are often left with no, or minimal residual deficit, and ready to be discharged.”

Targeted Delivery of Care
Approximately 10 percent of strokes are believed to be caused by the occlusion of the large vessels in the brain. For patients without access to endovascular therapy, approximately one-quarter will die and the remainder will be disabled. “Our goal is to get all patients presenting with stroke timely access to intravenous tPA, endovascular therapy, or both,” states Michal Obrzut, MD, Cleveland Clinic Florida interventional neuroradiologist.

Optimal stroke care is provided by state-of-the-art centers that are equipped with diagnostic tools such as, multimodal computed tomography (CT) and magnetic resonance imaging (MRI), carotid duplex ultrasonography, and biplane neuroangiography. Dr. Obrzut shares, “Our biplane neuroangiography suite is the most advanced in south Florida, allowing for the innovative treatment of stroke.”

Dr. Obrzut explains, "Although recent clinical trials have shown that, on average, patients benefit from endovascular stroke therapy when initiated within six to seven hours of symptom onset, we don’t regard that as a limited ‘treatment window’, since every patient is unique.”

Every individual presenting with a stroke has a distinctive vascular supply to the brain, and the location of their clot within the brain can vary widely. For this reason, an individualized approach must be taken. “Utilizing advanced imaging techniques such as MRI diffusion and perfusion imaging, we have been able to successfully identify and treat stroke patients as much as 12 to 24 hours from symptom onset," states Dr. Obrzut.

Stroke can be the result of multiple causes, some of which can co-exist, such as atrial fibrillation and carotid stenosis. Another factor to consider is that some patients have a variety of comorbidities, which could affect their recovery, as well as their secondary stroke prevention. This is why a multidisciplinary treatment approach for stroke patients is ideal.

“Working together, the combined efforts of an interventional neuroradiologist, cerebrovascular surgeons, stroke neurologists, among other sub-specialists, allows an individualized treatment plan to be developed, providing for the best clinical outcome,” says Dr. Obrzut.

As indicated by Cleveland Clinic Florida’s national awards and certifications, a rigorous stroke care protocol that meets or exceeds national standards and guidelines has been implemented. “For the past eight years, we have been a recipient of the American Heart Association/American Stroke Association’s Get With The Guidelines® Stroke Gold Plus and Target: Stroke Honor Roll Elite Plus Performance Achievement Award,” shares Dr. Salgado.

The continuum of stroke care delivered spans all phases of treatment, including the rehabilitative process. Offering a full spectrum of treatment options allows for excellent outcomes, returning stroke patients to the best possible quality of life.