Heart's Ease

How the dream of non-invasive replacements for surgery is coming true at the New-York Presbyterian/Columbia University Medical Center’s Center for Interventional Vascular Therapy. By Jeffrey Moses

“The key for both physicians and also patients is knowing that this is a field that involves a lot of cognition and technical skills, and there needs to be a meeting between the two”
-Jeffrey Moses, Columbia University Medical Center

The Center for Interventional Vascular Therapy (CIVT) grew out of the New York Presbyterian/Columbia University Medical Center’s commitment to establishing a world-class center for the treatment of cardiovascular disease. We’re fulfilling this message first of all by attempting to attain excellence in clinical care through recruiting and retaining who we think are the leaders in the field of interventional vascular therapies in all its dimensions, as applied to cardiovascular disease. We set up care systems that are both patient-friendly and also organized efficiently, trying to incorporate the latest systems in terms of protocol-driven care as well. We work in terms of clinical research, and we’re pretty much engaged and have leadership positions in most of the major innovations in this field. 

Our group is very creative, and we interact with both researchers and other physicians around the world and the industry, testing the most promising therapies in a rigorous way and helping to bring them into the clinic from the earliest stages of development. We work on the educational front by running and being involved with our group in literally dozens of meetings, being course co-directors or having major scientific input in the program content, and speaking on and demonstrating new techniques in live cases.

Those three areas are all ingredients to help make us a world-class center in this area. They complement so many of the other services of cardiology here – we have the largest heart transplant program in America, as well as a vigorous and innovative electrophysiology program, and some of the leading cardiac surgeons. 

Non-invasive techniques
The actual techniques and technology used in the center to treat patients have advanced in many fronts. On the cardiac and coronary side we’ve had major advances in the less-invasive treatment of obstructive coronary disease. Certainly recent studies have justified this in terms of being able to substitute stenting for surgery in a very large segment of the population that previously was considered primarily a surgical province. That’s a good thing, and recent randomized trials have indicated that you can achieve the same result with fewer strokes, shorter length of stay, and a much more pleasant experience for the patient. 

We’re working on a big innovation with percutaneous valves and have a major leadership position. We’re installing aortic valves for aortic stenosis in clinical trials that are well advanced and heading toward completion. That would potentially substitute for open-heart surgery for aortic valves.

This is no longer pie in the sky; it’s being widely practiced in Europe, and we are closing in on 100 valves being done here at Columbia alone with this innovative technique, and have a leadership position in the major US trial.

On the structural side, we’re involved in trials looking at closing holes in the heart for prevention of stroke, for eventually substituting for blood thinners in patients who can’t take blood thinners, who have atrial fibrillation, by putting devices in to prevent clotting in the heart.

On the aneurysm forefront we’re expanding the reach of non-surgical treatment of diseases of the aorta and increasing treatment in the cath lab, as catheter-based treatments and in hybrid procedures. On top of that, we’re involved in many new imaging technologies to help advance our understanding of the disease process, applying the imaging so we can more effectively treat the patients as well. There’s an overall move toward more non-surgical techniques; avoiding surgery will always be a good option for the patient.

Research
The Cardiovascular Research Foundation has over 100 members and is involved in more than 40 meetings a year. The crown jewel of those meetings is the Transcatheter Cardiovascular Therapeutics conference (TCT), which has well over 10,000 attendees from all corners of the world and involves more than 900 faculty, several thousand lecturers and over 100 live cases during five days of workshops. These workshops include focused updates: extensive detailed updates on virtually every aspect of minimally invasive and non-surgical treatments of heart disease, with the most current data and innovators. 

Alternatively, we also recently ran a meeting focusing on some narrow niches, such as totally occluded arteries, which previously have not been approached in the cath lab, but were sent to surgery. We are involved in developing and exploring and teaching new techniques in opening those, which again expands the venue for these catheter-based treatments as a substitute for surgery. These are smaller meetings, where just a few physicians will come for a day or two on a focused didactic and technical training for specific techniques in the cath lab, whether it’s training to the study percutaneous valves or learning how to do complex coronary interventions. So we go from 10,000 down to very small meetings for teaching. 

In the move toward non-surgical techniques, we’ve had some major triumphs in the field of interventional vascular therapy, but we’ve also been confronted with some setbacks regarding the thrombosis issue in stents. Although not as large as it was thought to be by the headlines, and not an overwhelming problem, it’s still enough of a problem that it limits broader applicability. We’re moving toward the technological responses to that, which will make the current treatments with stenting much safer, and thereby much more effective.

The valve area is potentially transforming: in five years the whole landscape of how patients with heart valve disease are treated is going to be radically changed, if the clinical trials outcomes are what we expect. That’s a big deal. In the endovascular realm, with the non-cardiac vessels, we’re going to have a wealth of new evidence in the next few years, which will help us understand and broaden the applications of these non-surgical techniques with evidence; not just with assertion, but with good randomized data.

Advances
We will also have some potential advances in stroke prevention with certain devices we’re using, as certain other trials emerge in the next year or two to support their use in certain individuals and help prevent stroke. This is done in several ways, by actually installing devices into the heart.

The key for both physicians and patients is knowing that this is a field that involves a lot of cognition and technical skills, and there needs to be a meeting between the two. Just the ability to do something; say you do a certain thing and it doesn’t necessarily translate into the optimum use of the technologies.

The spread of understanding what the capabilities are, even among the interventional community, is very wide. It’s important if you’re going to get an opinion in this field that you’re dealing with people who have a true understanding of both the capabilities and the limitations of the technique. My adage is that sometimes patients’ needs are dictated by the capabilities of the individual or groups you’re working with, and that shouldn’t be the case. Adopting the broadest potential application of the technology to meet those needs should be the standard.

Jeffrey W. Moses is Professor of Medicine at Columbia University College of Physicians and Surgeons, and Director of the Center for Interventional Vascular Therapy at New York Presbyterian Hospital/Columbia University Medical Center. He is also Director of the Cardiac Catheterization Lab at New York Presbyterian/Columbia. Moses previously held a professorship in Clinical Medicine at New York University School of Medicine, and served in various positions at The New York Hospital, where he became Associate Director of the Adult Cardiac Catheterization Laboratory and Director of Clinical Electrophysiology.

New York Presbyterian Hospital

The New York Presbyterian, based in New York, is the nation’s largest not-for-profit hospital. It accommodates 2,224 beds and provides state-of-the-art inpatient, ambulatory and preventative care in all areas of medicine.

These divisions combined allow New York Presbyterian to provide acute care, long-term care facilities and ambulatory services to its patients; the hospital serves one in four patients in the New York metropolitan area.

Columbia University Medical Center

Vital statistics 2008
Academic Schools... 4
Budget (FY 2007)... $1.56 billion
Endowment (1 June 2008)... $1.67 billion
Philanthropic gifts... $200.032 million
Endowed chairs... 198
Total enrollment, Fall 2007... 3,4651
Degrees Granted, 2007... 1,422
Full-time faculty... 2,4162
Total faculty... 5,4622
Research expenditures, 2007... $584.8 million
Nobel Prizes... 16 in Medicine or Physiology (2 current)

Center for Interventional Vascular Therapy

The center was created by the New York Presbyterian/Columbia University Medical Center, and provides patients with a team of physicians operating in almost every field of cardiovascular medicine.

The center is also affiliated with one of the country’s most esteemed academic institutions, providing patients with access to one of the most notable clinical research programs available in the country. The Cardiovascular Research Foundation (CRF) provides a platform for physicians to learn about the most innovative techniques and technologies in the area of cardiovascular intervention.

The CRF hosts the annual Transcatheter Cardiovascular Therapeutics conference, which attracts more than 11,000 physicians, making it the world’s largest cardiovascular interventional meeting.

Definitions

Atrial fibrillation
An abnormal heart rhythm involving the two upper chambers of the heart. Can often be identified by taking a pulse and observing that the heartbeats don't occur at regular intervals. Conclusive indication is the absence of P waves on an electrocardiogram.

Non-invasive
A medical procedure in which there is no break in the skin and no contact with the mucosa, or skin break or internal body cavity beyond a natural or artificial body orifice.

Percutaneous
Any medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an approach where inner organs or tissue are exposed.

Stenosis
Abnormal narrowing in a blood vessel or other tubular organ.

Stent
A tube inserted into a natural passage/conduit in the body to prevent, or counteract, a disease-induced, localized flow constriction. The term may also refer to a tube used to hold such a natural conduit open to allow access for surgery.