YOURHEART our commitment HEARTANDVASCULAROUTCOMESREPORT Heart and Vascular Outcomes T hecardiologistscardiothoracicsurgeonsandvascularsurgeonsatRogueValleyMedicalCenter arepleasedtopresentthissecondbiennialeditionoftheHeartandVascularOutcomesReport Thereportreviewstheactualvolumesandpatientoutcomesforeachcardiovascularprocedurecovers newtechnologiesandprovidesanoverviewoftheentireheartandvascularprogramThedatareflects ourdedicationtotreatingawiderangeofcardiovasculardiseases AsphysiciansweallstrivetoprovidethebestpossiblecareforourpatientsSincetheinceptionofthe cardiacprogramyearsagoatRogueValleyMedicalCenterwehavealwaysbelievedthatteamwork amongphysiciansisessentialfordeterminingthebesttreatmentoptionforeachpatientWealsoaimfor excellenceinallareasandtechniquessothatwecanachievethebestpossibleresultsOurperformance improvementprogramprovidestimelyfeedbacksothatwecanmakecontinuousimprovements Wehopeyoufindthisinformationinterestingandusefulandwelookforwardtoacontinuedcollaboration withyousothattogetherwecanprovideyourpatientswiththebestpossibleoutcomes —ThephysiciansandsurgeonsoftheHeartandVascularCenteratRogueValleyMedicalCenter TheHeartofRogueValleyMedicalCenter OurMission Asanteexiststoprovide qualityhealthcareservicesina compassionatemannervaluedby thecommunitiesweserve OurVision Asantewillberecognizedfor medicalexcellenceforoutstanding customerserviceandasa greatplacetowork TheValuesin WhichWeBelieve Excellenceineverythingwedo Respectforall Cardiac disease is the leading cause of death in Oregon and California. Fortunately, effective therapy is available. Rogue Valley Medical Center, a part of the Asante family, is a tax-exempt 378-licensed-bed facility created by and for the people of Southern Oregon and Northern California over 50 years ago. It is a nationally recognized program providing highly specialized heart and vascular care. RogueValley MedicalCenter Opens Cardiac FirstCardiac FirstOpen IntensiveCare Catheterization HeartSurgery UnitOpens LaboratoryOpens CardiacFacilitiesatRVMC t Cardiac Intensive Care Unit (16 beds) t Heart Center (52 telemetry beds) t Cardiac Catheterization Laboratories · 2 outpatient labs · 5 inpatient labs t Cardiovascular Recovery Unit t 3 Operating Rooms for cardiovascular procedures · 2 dedicated to open heart procedures · The region’s only endovascular angiographic suite t Imaging Department · Echocardiography · Stress Nuclear · Cardiac CT Honestyinallourrelationships Servicetothecommunity physiciansandeachother Teamworkalways Physiciansallboardcertified t 16 Cardiologists t 4 Cardiothoracic Surgeons t 5 Vascular Surgeons t 6 Cardiac Anesthesiologists t 4 Intensivists t 17 Hospitalists FirstCoronary Balloon Angioplasty ASSET Program Established PatientTower Constructed OtherTeamMembers includingphysicianassistants nursestechniciansandclinicians The first number represents the total number of people working in that department. Numbers in parenthesis represent people with 10 or more years’ experience in that particular field. t Operating Room 13 (9) t Cardiac Perfusionists 4 (4) t Cardiac Catheterization Laboratory · RVMC 21 (20) · RVMC Lab at the Cardiovascular Institute 11 (4) t Cardiovascular Recovery 12 (3) t Cardiac Intensive Care Unit 47 (16) t Heart Center 145 (38) t Cardiac Clinical Case Managers 6 (3) t Cardiac Rehabilitation 8 (5) t Echocardiographers 8 (6) t Vascular Ultrasound 3 (2) t Stress Testing 6 (2) t Cardiopulmonary 7 (3) t Clinical Quality Analysts 4 (3) Heart and Vascular Outcomes Table of Contents CoronaryArteryDisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – VascularSurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – CardiacCatheterizationandCoronaryIntervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RVMCCardiovascularLabattheCardiovascularInstitute. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MyocardialInfarctionTheASSETProgram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HypothermiaforCardiacArrestPatients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EnhancedExternalCounterpulsation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ComprehensiveVascularCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AorticAneurysmRepair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CarotidEndarterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CarotidStenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .– Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - NoninvasiveDiagnosticTesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CardiacCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CoronaryCalciumScore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ElectrophysiologyProgram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DiagnosticElectrophysiologyStudies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TiltTableTesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IntracardiacAblation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PulmonaryVeinAntralIsolation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DeviceImplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LeadExtractions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PreventiveCardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - HeartTransplantCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TherapiesontheHorizon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CongenitalHeartDisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . QualityOurApproach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - AdultCongenitalHeartDisease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CardiovascularScreeningforYoungCompetitiveAthletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PhysicianBiographies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - CardiacSurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – CardiacRehabilitationProgram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SecondaryPrevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CardiacEducators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ContactInformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CardiothoracicSurgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CoronaryArteryBypassGra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ValveProcedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MinimallyInvasiveValveProcedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STSRiskAdjustment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EndovascularTreatmentofThoracicAorticAneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TransmyocardialRevascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AtrialFibrillation/MazeProcedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CORONARYARTERYDISEASE Coronary Artery Disease CardiacCatheterizationandCoronaryIntervention Coronary interventionalprogram startedatRVMC Cardiac catheterization facilities at Rogue Valley Medical Center were established in 1973. Five catheterization and angiographic laboratories are dedicated to state-of-the-art diagnostic coronary angiography, coronary interventions, peripheral angiography and interventions, electrophysiologic procedures, and device implants. Board certification in cardiology is required of all cardiologists. Cardiologists who perform coronary interventions are board certified in interventional cardiology. Expertise is maintained by focusing procedural experience within a small group of high-volume, experienced interventionalists whose complication rates and outcomes exceed national benchmarks. Coronary interventional volume for the institution and for each interventionalist exceeds volume recommendations established by the Leapfrog Group, Thomson Healthcare, and the American College of Cardiology. A proven record of satisfactory outcomes and active participation in quality improvement programs is mandatory for all physicians. RVMC continues to adhere to the percutaneous coronary intervention (PCI) guidelines written and recommended by the American Heart Association, the American College of Cardiology, and the Society of Cardiac Angiography and Interventions. These guidelines are as follows:* t Operators perform at least 75 procedures at high-volume hospitals (more than 400 procedures per year) with on-site cardiac surgery. t Operators and institutions should have outcomes comparable to those reported in contemporary national data registries. t For ST-segment elevation myocardial infarction (STEMI), emergent PCI should be performed by experienced operators who do more than 75 elective PCI procedures per year and, ideally, at least 11 PCI procedures for STEMI each year. Ideally, these procedures should be conducted in institutions that perform more than 400 elective PCIs per year and more than 36 primary PCI procedures for STEMI per year. RVMCcathlabteam *SmithSCJrFeldmanTEHirshfeldJWJrJacobsAKKernMJKing SBIIIMorrisonDAO’NeillWWSchaffHVWhitlowPLWilliamsDO ACC/AHA/SCAIguidelineupdateforpercutaneouscoronary interventionAreportoftheAmericanCollegeofCardiology/American HeartAssociationTaskForceonPracticeGuidelinesACC/AHA/SCAI WritingCommieetoUpdatetheGuidelinesforPercutaneous CoronaryInterventionCirculation– Heart and Vascular Outcomes AnnualVolumeofDiagnosticCoronaryAngiograms RVMC RVMCLabatCardiovascularInstitute coronary interventionshavebeen performedsince CombinedVolume Thefiveinterventional cardiologistsareboardcertifiedin bothcardiovasculardiseaseand interventionalcardiologyandprovide around-the-clockcoverage AnnualVolumeofCoronaryInterventionalProcedures atRogueValleyMedicalCenter CurrentUseofBareMetalStents andDrug-ElutingStents TypeofStentUsed Year BareMetalStent Drug-ElutingStent RVMCcardiovascularrecoverystaff cardiacprocedures havebeenperformedat RVMCsince CORONARYARTERYDISEASE Coronary Artery Disease Stentbetweenfingers CourtesyofCordis Pressurewiremeasurementofahemodynamically significantcoronaryarteryblockage CourtesyofVolcano Pressurewireandintravascular ultrasonographyprovideadditional physiologicandanatomicinformation regardingcoronaryarteryplaques Drug-elutingstent Stent CourtesyofFairmanStudios Intravascularultrasoundimagecross-sectionalviewofa coronaryarterywithaneccentricatheromatousplaque Workhorseballoonforangioplasty CourtesyofBostonScientific CourtesyofCordis Cuingballoonwithsurgicalblades mountedontheballoon CourtesyofBostonScientific CourtesyofVolcano Diamond-coatedburrthatspinsat revolutionsperminutetodrill throughheavilycalcifiedlesions CourtesyofBostonScientific Heart and Vascular Outcomes GilGilbertson GrantsPassOregon Chronictotalocclusioninmid-rightcoronaryartery Simultaneousleandrightcoronaryinjectionsto visualizetheentirerightcoronaryarteryandlengthof occlusionNotetheinchcoronarywirehalfway throughtheocclusion Stentdeployedwithballooninflation Twostentsrequirednoremainingblockage Sheriff Gilbertson had noted debilitating angina for two months. Coronary angiography showed a long occlusion in the mid-right coronary artery with faint collaterals to the distal vessel. Fortunately, he had normal left ventricular systolic function. At the time of percutaneous coronary intervention, simultaneous left and right coronary angiography was performed to determine the full length of the blockage and to visualize the destination of the coronary wire. A special coronary wire was utilized to cross the hard blockage, and two coronary stents were deployed with good result. Gil is now symptom-free and has no physical limitation. CORONARYARTERYDISEASE Coronary Artery Disease RVMCCardiovascularLabattheCardiovascularInstitute Each year 16 cardiologists and five vascular surgeons perform a high volume of diagnostic cardiac catheterizations, peripheral angiograms, and peripheral vascular interventions at the RVMC Cardiovascular Lab. Located in a comfortable, state-of-the-art facility within the outpatient facilities of the Cardiovascular Institute (CVI) on the RVMC campus, the RVMC Cardiovascular Lab allows elective studies to be performed conveniently; total stays average just four hours. PeripheralInterventionVolume CathlabstaffatCVI Awiderangeofdiagnostic andinterventionalprocedures areperformedinseven state-of-the-artcatheterization laboratoriesfiveatRVMC andtwoatCVI PeripheralAngiographyVolume Includesupper-andlower-extremityangiographyrenalangiography mesentericangiographyandiliacangiography Includescarotidangiographyrenalangiographymesenteric angiographyupper-andlower-extremityangiography andabdominalangiography CardiacCatheterization/CoronaryAngiographyVolume PeripheralAngiographyComplications Stroke MyocardialInfarction Death Nostrokemyocardialinfarction ordeathfromto Heart and Vascular Outcomes MyocardialInfarctionTheASSETProgram ASSETProgram MissionStatement ASSET (Acute ST-Segment Elevation Task Force) is a regional heart attack response team that coordinates the simultaneous activation of paramedics, emergency departments, and the cardiac catheterization laboratory at RVMC for rapid identification, triage, and treatment of ST elevation myocardial infarction patients (severe heart attacks) throughout Southern Oregon and Northern California. The ASSET program has received national recognition for its dramatic reduction in death rates from heart attacks and is serving as a model for other programs in development across the country. The program represents the integration of care supported by the efforts of hospitals within the direct ASSET service area, hospitals within the regional support services area whose initial management may include thrombolytic therapy followed by emergent transfer for possible rescue PCI, and those hopitals having PCI capability supported by the cardiothoracic surgical program at RVMC. ASSETRegionalSTEMIreceiving hospitalforPrimaryPCI tRogue Valley Medical Center ASSETServiceAreaSTEMIreferring hospitalsforPrimaryPCI t Ashland Community Hospital t Fairchild Medical Center t Providence Medford Medical Center t Three Rivers Community Hospital ASSET RegionalSupportServiceArea hospitalsprovidingthrombolytictherapy withemergenttransfertoRVMC tCurry General HospitaltLake District Hospital tSutter Coast Hospital ASSETServiceArea O R E G O N Coos Bay Coquille Bandon ASSETServiceArea ASSETRegional SupportServicesArea Roseburg Myrtle Point Myrtle Creek Port Orford Paisley Chiloquin Gold Beach Redwood Grants Pass Rogue River Cave Junction CardiothoracicSurgerySupport tMercy Medical CentertSky Lakes Medical Center Tofacilitatetheaccurateandrapid diagnosistreatmentandtransport ofpatientswithacuteST-Segment ElevationMyocardialInfarction STEMIfromthroughouttheregion totheRogueValleyMedicalCenter cathlabforemergentPercutaneous CoronaryInterventionPCI Brookings RVMC Medford Klamath Falls Ashland Harbor Dorris ParticipatingHeartSpecialists t"TBOUF$BSEJPWBTDVMBSBOEɨPSBDJD4VSHFPOT t4PVUIFSO0SFHPO$BSEJPMPHZ--$ Happy Camp Crescent City Yreka Montague C A L I F O R N I A cardiologistsandfourcardiothoracic surgeonsworktogethertoprovide carearound-the-clock Malin Tulelake 5 CorePartnership—EmergencyServices t"NFSJDBO.FEJDBM3FTQPOTF".3 t"TIMBOE'JSF3FTDVFt+BDLTPO$PVOUZ'JSF%JTUSJDUǢ t.FEGPSE'JSF%FQBSUNFOUt.FSDZ'MJHIUT t/PSUIFSO4JTLJZPV"NCVMBODF t3PHVF3JWFS'JSF%JTUSJDU Altamont Lakeview CORONARYARTERYDISEASE Coronary Artery Disease DonAckley MyocardialInfarctionTimeIsMuscle KenoOregon Cross-sectionalimageoftheleventricle duringaninferiormyocardialinfarction Don developed severe indigestion while playing Yahtzee with his wife at Fish Lake. Butte Falls Mercy Flights paramedics promptly responded, and the patient was emergently transported to Rogue Valley Medical Center by helicopter in minutes. He was taken directly to the cardiac catheterization laboratory, where emergent coronary angiography revealed a thrombotic occlusion in his proximal right coronary artery. Mechanical thrombectomy restored coronary blood flow. Balloon angioplasty was performed followed by stent deployment to ensure vessel patency. Hospital arrival-to-balloon time was 18 minutes. The patient did well and was discharged home three days later. Don is currently asymptomatic with normal left ventricular systolic function. hours hours hours Healthyheartmuscle Deadheartmuscle iemyocardialinfarctionheartaack Bloodwithintheheart CoronaryArteryStenting Coronaryarteryatheroscleroticplaque Thromboticocclusionin proximalrightcoronaryartery Ballooninflation Bloodflowrestoredbut severeblockageremains Low-profilestentandballoonadvancedacrossblockage Ballooninflationresultsinstentdeployment Stentdeployedwith ballooninflation Widelypatentstentwith excellentbloodflow Balloonremovedstentmaintainsanopenartery Heart and Vascular Outcomes –ASSETPatientsAverageMedianTimetoTreatmentforSTEMI TimeatReferringHospital ParamedicTransportTime TimefromEmergencyDepartmentDoortoCardiacCathLabDoor CardiacCathLabArrivaltoOpenArtery minutes RVMCdoor–to–wiretime AllASSETPatientsJun–Decn minutes RVMCdoor–to–wiretime minutes RVMCdoor–to–balloontime AllASSETPatientsJun–Augn AllASSETPatientsJan–Decn minutes RVMCdoor–to–balloontime AllASSETPatientsJan–Dec n minutes RVMCdoor–to–balloontime AllASSETPatientsJan–Decn minutes* RVMCdoor–to–balloontime AllASSETPatientsJan–Decn TimeinMinutes ArrivalatRVMC *Door-to-balloontimeof ASSETPatientsAverageMedianTimetoTreatmentforSTEMI Timeat ReferringHospital Paramedic TimeonScene Paramedic TransportTime TimefromEmergencyDepartment DoortoCardiacCathLabDoor Patientsoenbroughtdirectly tothecardiaccatheterization laboratorybyparamedics TransferfromReferringHospitaln minutesplacesRVMC amongthetopperformers inthenation CardiacCathLabArrival toOpenArtery Paramedicn Patientarrivesunnannouncedto theRVMCEmergencyDepartment ASSETTeamemergentlyactivated RVMCn minutes*RVMCdoor–to–balloontime AllASSETPatientsn TimeinMinutes ArrivalatRVMC CORONARYARTERYDISEASE Coronary Artery Disease PatientswithDoor-to-BalloonTimewithinMinutes – TotalnumberofSTEMIpatientsfromto RVMCEmergencyDepartmentstaff STEMIMortality ASSETSTEMIPatients TransferfromReferringHospital Paramedic RVMC Total – Heart and Vascular Outcomes HistoricalMyocardialInfarctionMortalityRates HistoricalNationalHospitalMortalityRatesforSTElevationMyocardialInfarctionHeartA!ack Apercentmortality rateisamongthelowest reportedinthenation s s s ASSETProgramatRVMC –n SourceClinicalPracticeGuidelinesAHCPRPublicationNo- percentofpatientshad hospitaldoor–to–balloontimes withinminutesin makingASSEToneofthe elitemyocardialinfarction programsinthecountry STElevationMyocardialInfarctionIn-HospitalMortalityComparisonRVMCVersusOtherHospitals NationalRegistryof MyocardialInfarction “SimilarHospitals” RVMC ASSET ServiceArea patientstreatedatRVMCforSTEMI fromJunethroughDecember CORONARYARTERYDISEASE Coronary Artery Disease NationalRecognition Primarypercutaneous coronaryinterventionisthe mostcomplexmultidisciplinary andtime-sensitivetherapeutic interventionintheworldof medicinetoday “An Approach to Shorten Time to Infarct Artery Patency in Patients with ST-Segment Elevation Myocardial Infarction” American Journal of Cardiology 2007;99:1360–63. Theprocess ismeasuredinminutes Theoutcomes aremeasuredinmortality Teamworkandsmooth transitionsareessential —IvanRokosMD STEMISystemsMay “Integration of Pre-Hospital Electrocardiograms and ST-Elevation Myocardial Infarction Receiving Center (SRC) Networks: Impact on Door-to-Balloon Times Across 10 Independent Regions” Journal of the American College of Cardiology: Cardiovascular Interventions 2009;2(4):339-46. Heart and Vascular Outcomes Cardiac arrest (ventricular fibrillation) results in impaired blood flow to the brain. A prolonged cardiac arrest (more than five minutes) can cause brain damage (anoxic encephalopathy). On occasion the heart can be stabilized, but the patient remains unresponsive due to inadequate cerebral perfusion. Inducing mild hypothermia to a core body temperature of 33 degrees C via an external cooling blanket reduces cerebral metabolism and edema and increases the likelihood of making a meaningful neurologic recovery. This treatment has been proven to save one additional life for every seven patients treated and is currently recommended by the American Heart Association. At Rogue Valley Medical Center, 40 patients were treated from November 2006 through December 2009. Eighteen patients survived, and seven required rehabilitation care. CumulativeSurvivalinthe HypothermiaandNormothermiaGroups Hypothermia C Normothermia NoTemperatureAdjustment Survival HypothermiaforCardiacArrestPatients SteveFredricksen Days SourceTheHypothermiaaerCardiacArrestStudyGroup NewEnglandJournalofMedicine– HypothermiaPatientSurvivors Nov throughDec n n n Averageage years Averagelengthofstay days CourtesyofAbboNorthwesternHospital MedfordOregon Steve is a radiologic technologist and former cardiac catheterization lab manager at Rogue Valley Medical Center who suddenly collapsed at an auto body shop. The owner promptly provided cardiopulmonary resuscitation (CPR), and paramedics found Steve in ventricular fibrillation. He was successfully electrically cardioverted to sinus rhythm. Subsequent coronary angiography showed severe left main and three-vessel coronary artery disease. An intra-aortic balloon pump was placed. He was initially unresponsive due to anoxic encephalopathy, and hypothermia was induced. He fortunately made a full neurologic recovery and underwent six-vessel coronary artery bypass graft surgery. He made a complete recovery and has returned to work without limitation. Steve remains a valued and important member of the cath lab team. CORONARYARTERYDISEASE Coronary Artery Disease EnhancedExternalCounterpulsation For patients with debilitating chronic angina not amenable to coronary revascularization (stent or bypass surgery), Enhanced External Counterpulsation (EECP) is a well-tolerated, atraumatic, noninvasive procedure that can reduce the symptoms of angina pectoris, presumably by increasing coronary blood flow to ischemic areas of the heart. DuringanEECPtreatmentthepatient’s calvesandthighsarewrappedwithcompressive cuffsthatareinflatedanddeflatedaccording tothecardiaccycleThisresultsinimproved diastoliccentralaorticpressureand increasedcoronaryperfusionpressure The EECP device uses a series of compressive cuffs wrapped around the patient’s calves, thighs, and buttocks and synchronizes their inflation and deflation to the cardiac cycle. During diastole the cuffs inflate sequentially from the calves proximally, resulting in augmented diastolic central aortic pressure and increased coronary perfusion pressure (when coronary artery flow is maximal). Rapid and simultaneous decompression of the cuffs at the onset of systole reduces the systolic pressure and the cardiac workload. Patients typically undergo 35 one-hour sessions over a seven-week period and should first be evaluated by a cardiologist. There have been 170 patients since the program was established in 2003. percentofpatientsnoted animprovementindistancethat canbewalkedinsixminutes ApprovedbythefederalFoodandDrug AdministrationFDAandMedicare ChangeinNitroglycerinUsen" ChangeinChestPainn" TwoWeeksAer CompletionofTherapy AtCompletionofTherapy OneYearLater Good Slight Unchanged Improvement Improvement OneYearLater RVMCcardiopulmonaryandEECPstaff Although the mechanism at work is unclear (possibly improved collateral flow), studies have repeatedly shown that 60 to 80 percent of patients experience the following results: t Reduced frequency and intensity of chest pain t Increased exercise tolerance t Reduced need for anti-anginal medications (such as nitroglycerin) t Improved sense of well-being and quality of life Worse Large Reduction inUse Slight Reduction inUse Unchanged Worse ARRHYTHMIAS Arrhythmias Heart and Vascular Outcomes ElectrophysiologyProgram TiltTableTesting Rogue Valley Medical Center’s electrophysiology (EP) program provides comprehensive diagnostic and therapeutic management of simple and complex heart rhythm disorders, device management for heart failure, evaluation and management of syncope, and sudden-death risk assessment and management. Our large procedure volumes, well-equipped electrophysiology laboratories, and highly experienced electrophysiologists and staff account for the excellent patient outcomes and are comparable to the nation’s highest-rated programs. Both electrophysiologists at RVMC are certified by the American Board of Internal Medicine in cardiovascular disease and electrophysiology. This simple, noninvasive test is used to evaluate for neurocardiogenic (vasovagal) physiology as a part of the evaluation of patients with syncope. The test is often used to evaluate patients with recurrent syncope of unknown cause unlikely to be related to pathologic arrhythmia, such as those with structurally normal hearts. Diagnostic EP studies are routine heart catheterization procedures used to identify and guide the treatment of heart rhythm disorders. Sophisticated, state-of-the-art three-dimensional (3D) electroanatomical mapping systems are used (like a global positioning system for the heart) to guide the clinician’s understanding and treatment of complex arrhythmia mechanisms. Often these diagnostic procedures are done in the same setting as therapeutic intracardiac ablations, pacemaker insertions, or defibrillator implants as indicated. These tests have a complication rate well below 1 percent. ElectrophysiologyStudies LoopRecorderImplants NumberofDiagnostic ElectrophysiologyStudies Numberof TiltTableStudies DiagnosticElectrophysiologyStudies ARRHYTHMIAS Arrhythmias JamesWatson IntracardiacAblation LasVegasNevada Ablations are catheter-based procedures performed to treat a variety of arrhythmias, including many forms of supraventricular tachycardia, atrial flutter, atrial fibrillation, and some types of ventricular tachycardia. Radiofrequency energy is used to ablate arrhythmia foci and reentrant circuits to manage tachyarrhythmias. Cure rates for many arrhythmias exceed 95 percent, with complication rates usually less than 1 percent. +BNFTJOJUJBMMZQSFTFOUFEXJUIOPOJTDIFNJDDBSEJPNZPQBUIZDISPOJDBUSJBMëCSJMMBUJPOBOEWFOUSJDVMBS tachycardia (VT) originating from the right ventricular outflow tract. His atrial fibrillation was initially controlled with dofetilide and carvedilol, but his ventricular tachycardia remained refractory to medical therapy. He underwent radiofrequency ablation of two separate VT foci, utilizing a 3D basket catheter in the right ventricular outflow tract (figure 1). This allowed simultaneous recording from 64 locations and permitted single-beat mapping and ablation of his abnormal foci (figure 2). Fourteen months later he presented with recurrent atrial fibrillation and congestive heart failure, with left ventricular ejection fraction 30 percent refractory to dofetilide and dronedarone. He underwent radiofrequency ablation for his atrial fibrillation, utilizing antral isolation supplemented by targeting of complex atrial electrograms and including them in our lesion set. Three-dimensional mapping software reconstructed the left atrium and guided our lesion set (figure 3). +BNFTJTOPXGSFFPGBUSJBMëCSJMMBUJPOBOEWFOUSJDVMBS tachycardia. His left ventricular function has returned to normal, and he is off all anti-arrhythmics. Patientswithhighly symptomaticatrialfibrillation whofailedanti-arrhythmic therapyoenbenefitfrom intracardiacablationtherapy NumberofAblationProcedures figure 2— Electrogramsofright ventricularoutflowtractablation figure 1— Biplaneimageofbasketcatheterin rightventricularoutflowtract figure 3— AtrialfibrillationDmapping Fromtotherehasbeenonlyoneprocedure-related deathpatientwithsevereischemiccardiomyopathyandelectrical stormierefractoryventriculartachycardia Heart and Vascular Outcomes IntracardiacAblationComplications Death MyocardialInfarction Stroke Tamponade figure 1— Dvoltagesubstratemapoftheleventricle PulmonaryVeinAntralIsolation Pulmonary vein antral isolation, also known as atrial fibrillation ablation, is used to treat problematic atrial fibrillation when anti-arrhythmic medications fail. The procedure isolates nests of atrial fibrillation–generating tissue in the posterior part of the left atrium and sometimes the superior vena cava. Mapping systems are used to generate atrial geometry that is then merged with computerized axial tomography (CT) scans of the posterior atria and the pulmonary veins to guide ablation and electrical isolation of areas of the heart that trigger and sustain atrial fibrillation. Cure rates vary with the extent of cardiac pathology and range from 50 to 80 percent. NinaKiskadden JacksonvilleOregon Nina is an active volunteer firefighter who was walking up a steep hill when she collapsed due to ventricular tachycardia. Coronary angiography showed an occlusion in her distal obtuse marginal artery. Left ventriculography showed evidence of a prior small posterolateral myocardial infarction. The patient’s ventricular tachycardia was not hemodynamically tolerated for routine mapping and ablation. A three-dimensional voltage substrate map of the left ventricle was constructed, which demonstrated the posterolateral scar and arrhythmogenic corridor bordered by the mitral annulus (figure 1). Substrate mapping is a relatively new way of approaching ventricular tachycardias that cannot be mapped due to hemodynamic collapse. Radiofrequency ablation between the posterolateral scar and the mitral annulus obliterated the clinical ventricular tachycardia. The patient has had no recurrence and has led a very active lifestyle, including horseback riding. We use 3D mapping systems that provide electroanatomic information defining scar tissue, normal tissue, and transitional tissue. The abnormal circuits are ablated, providing an option to a previously “impossible” situation. ARRHYTHMIAS Arrhythmias DeviceImplantation RVMC’s electrophysiology laboratory implants the full range of cardiac rhythm management devices, including pacemakers, implantable cardioverter defibrillators (ICDs), implantable loop recorders, and cardiac resynchronization (biventricular, or Bi-V) devices for the management of heart failure. ICDs have dramatically reduced arrhythmic and all-cause mortality in at-risk individuals. Biventricular pacing (with and without an ICD) has become a routine part of managing patients with advanced heart failure. Pacing leads are used to synchronize activation of the right and left ventricles to improve contractile dynamics, left ventricular ejection fraction, exercise capacity, and survival. PacemakerandImplantableCardioverterDefibrillatorVolumes LakeviewOregon Kathy is a retired waitress who presented with progressive and severely debilitating heart failure, left ventricular ejection fraction (LVEF) 30 percent, 3+ mitral regurgitation, and 4+ tricuspid regurgitation (0–4 scale) despite good medical therapy, including high-dose diuretics. Coronary and bypass graft angiography revealed a severe stenosis at the origin of the posterior descending artery. A coronary stent was deployed with good result. She also had a left bundle branch block with dyssynchronous contractility of her septal wall. She underwent implantation of a biventricular pacemaker/intracardiac defibrillator. Four months later Kathy was asymptomatic with LVEF 60 percent, 1+ mitral regurgitation, and 1+ tricuspid regurgitation. DeviceImplantationComplicationRates PercentageofPatients EKathyOverton PopulationTotalCombined ProcedureRelated Deaths Infections Hematoma Requiring Re-Exploration Pneumothorax Lead Dislodgement Chamber Perforation ComplicationratesareforpacerbiventricularpacerandICDimplantsFordeviceimplantscomplicationratesaredefinedasprocedure-relatedmortality infectionhematomarequiringre-explorationpneumothoraxleaddislodgmentandperforation Heart and Vascular Outcomes LeadExtractions DistributionofDeviceImplantation ICDs Bi-VDevices Pacemakers The effectiveness and the dramatic increase in the use of implanted cardiac devices have resulted in the need for complex device management and, at times, the removal of implanted pacing and ICD systems, including leads that have been in place for an extended time. Laser lead extraction is used to remove highly fibrosed lead systems from the heart and the vascular system after extended use. Although serious intrathoracic bleeding can occur during lead removal, careful planning, monitoring, and technique by experienced physicians have led to a high success rate. RVMCparticipates intheAmericanCollegeof Cardiology’sICDRegistry Biventricularpacing/ICDleadsinheart CourtesyofBostonScientific Pacemakersanddefibrillatorsare implantedandmanagedonlyby physicianswhoarecertifiedby theHeartRhythmSociety ARRHYTHMIAS Arrhythmias IndicationsforICDTherapy CardiacarrestduetoventricularfibrillationVF orventriculartachycardiaVTunrelatedtoa reversiblecause SustainedVTassociatedwithstructural heartdisease Syncopeofundeterminedoriginwithinducible VTattimeofelectrophysiologicstudiesEPS NonsustainedVTinpatientswithischemic cardiomyopathyejectionfractionEF≤ percentandinduciblesustainedVTatEPS “Cardiacsyncope”inpatientswith cardiomyopathyandnoexplanationof mechanismofsyncopeaerEPS a Syncopeinseingofcardiomyopathy warrantshospitalizationandreferralto arrhythmiaspecialist Patientswithpotentiallylethalgeneticdisorders andhigh-riskcharacteristics a ProlongedQTsyndrome i Recurrentsyncopedespitetreatment withbeta-blockers ii Significantfamilyhistoryofunexplained suddencardiacdeathSCDespecially ifpatienthassyncope iii VF b Brugadasyndrome i SyncopewithspontaneousBrugadaEKG ii VF c Hypertrophiccardiomyopathy i Hypertrophy≥ mm ii Significantfamilyhistory iii NonsustainedVT iv Syncope v Abnormalbloodpressureresponsetoexercise vi VT/VF d Rightventriculardysplasia i Syncope ii SignificantfamilyhistoryofSCD iii VT/VF Heart Transplant Care PrimarypreventionofSCDinpatientswith ischemiccardiomyopathyandEF≤ percent a Receivingoptimalmedicaltherapy b Atleastdaysaermyocardialinfarction c Lifeexpectancyofatleastoneyearwithgood functionalstatus d ClassI–IIIcongestiveheartfailureCHF e ClassIVCHFifcandidateforbiventricularpacing PrimarypreventionofSCDinpatientswith nonischemiccardiomyopathyandEF≤ percent a Receiptofoptimalmedicaltherapyfor pastthreetoninemonths b ClassII–IIICHF c ClassIVCHFifcandidateforbiventricularpacing BasedontheDeviceImplantationGuidelinesandtheSeptember PreventionofSuddenCardiacDeathGuidelines IndicationsforBiventricularPacing ClassI–IVheartfailuresymptomswithle bundlebranchblockLBBBorintraventricular conductiondefectIVCDwithQRSms a Receiptofoptimalmedicaltherapyfor pastthreetoninemonths b EF≤ percent Anypatientwithsignificantcardiomyopathythat requiressustainedventricularpacingsupport a Rightventricularapicalpacingisknown tobedetrimentalinthispatientsubset b Itisreasonabletoupgradeapatientfroma dual-chamberpacingdeviceifEF≤ percent andClassIII–IVCHFsymptomsarepresent Patientswithatrialfibrillationwhorequire atrioventricularnodalablation a Heartfailuresymptoms b Leventriculardysfunction Mark Huth, MD, PhD, FACC, specializes in the care of patients who have had heart transplants. He earned both his doctor of philosophy and his medical degree and served as an assistant professor of medicine at the University of Washington in Seattle. Myocardial biopsies are performed to monitor for rejection. Coronary angiography and intravascular ultrasonography are available to monitor coronary allograft vasculopathy. CONGENITALHEARTDISEASE Congenital Heart Disease Heart and Vascular Outcomes AdultCongenitalHeartDisease Care of the adult congenital heart disease (ACHD) patient is a rapidly growing subspecialty of cardiology. These patients are survivors of childhood congenital heart operations and interventional procedures and include those adults who have undiagnosed cardiac disease of a congenital origin. Based on conservative estimates of 800,000 such patients in the United States, it is estimated that there are 12,000 Oregonians with ACHD. Care of these patients is highly complex and can often involve multiple specialties. Unique issues during non-cardiac surgery, general medical care, and high-risk obstetrical care are some of the concerns addressed by ACHD specialists. Therearetwo echosonographers whoareboardcertified inpediatricecho At RVMC, and in conjunction with the Pediatric and Adult Congenital Cardiac Units at Oregon Health Sciences University (OHSU), we are able to deliver state-of-the-art care with multimodality imaging, electrophysiological (EP) evaluation and treatment, outpatient follow-up, and cardiac surgical care. Other issues addressed by the ACHD section include preparticipation screening for young athletes, patients with Marfan syndrome, and other inherited diseases of the cardiovascular system. Brian Morrison, MD, FACC, specializes in the care of ACHD patients. He trained at the internationally known UCLA Adult Congenital Heart Disease Center—the first and one of the largest of its kind in the United States. He has served as an assistant clinical professor at the OHSU Division of Pediatric Cardiology for the past 12 years and has spoken at national meetings. Cardiovascularcausesofsudden deathassociatedwithsports Agegreaterthanorequaltoyears s "UIFSPTDMFSPUJDŐDPSPOBSZŐ arterydisease Agelessthatyears s )ZQFSUSPQIJDŐDBSEJPNZPQBUIZ s "SSIZUINPHFOJDŐSJHIUŐWFOUSJDVMBSŐ cardiomyopathyordysplasia s 1SFNBUVSFŐDPSPOBSZŐBUIFSPTDMFSPTJT s $POHFOJUBMŐBOPNBMJFTŐPGŐ coronaryarteries s .ZPDBSEJUJT s "PSUJDŐSVQUVSF s 7BMWVMBSŐEJTFBTF s 1SFȬFYDJUBUJPOŐTZOESPNFTŐBOEŐ conductiondiseases s *POŐDIBOOFMŐEJTFBTFT s $POHFOJUBMŐIFBSUŐEJTFBTFŗŐ operatedorunoperated CardiovascularScreeningforYoungCompetitiveAthletes toyears Familyandpersonalhistoryphysicalexamination-leadEKG PediatricEchocardiographyVolumes—RVMC PositiveFindings NegativeFindings Eligibility forCompetition FutherExaminations Nonivasiveechocardiographystresstest-HHolterCardiacMR Invasiveangiographyendomyocardialbiopsyelectrophysiologicstudy NoEvidenceof CardiovascularDisease Modified from: Corrado D, Pelliccia A, BjØrnstad HH, et al. Cardiovascular preparticipation screening of young competitive athletes for prevention of sudden death; proposal for a common european protocol. Consensus statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. European Heart Journal. 2005;26:516-24. Diagnosisof CardiovascularDisease ManagementAccordingto EstablishedProtocols CARDIACSURGERY Cardiac Surgery CardiothoracicSurgery The cardiothoracic program at Rogue Valley Medical Center has been in existence for more than 33 years, during which time our surgeons have performed more than 15,000 cardiac operations. Excellence in cardiothoracic surgery requires an integrated team effort. It represents the collective experience gained over the many years of the program as well as a continuing commitment to innovation and expertise provided by physicians, operating-room staff, Coronary Care Unit (CCU) nurses, and support staff. A team of four cardiothoracic surgeons, each of whom individually performs more than 100 operations per year, along with their cardiac anesthesia colleagues perform more than 600 cardiac operations each year. Excellence in postoperative care is achieved by a team of highly experienced CCU nurses, who along with intensivists and cardiologists have cared for thousands of cardiac patients. Cardiacsurgicalprogram establishedyearsago NumberofSurgeriesPerformed CardiacSurgeriesPerformed·–YearTotal" DistributionofCardiacProcedures Nosternalwound infectionsiemediastinitis inand CoronaryArtery BypassGra CABGTotal Isolated CABG AorticValve Replacement AVRTotal MitralValve Replacement MVRTotal Isolated AVR MitralValve RepairTotal Isolated MVR SurgicalAtrial Fibrillation AblationMaze Transmyocardial Revascularization Heart and Vascular Outcomes CoronaryArteryBypassGra# STSoverallsurgicalbenchmark STSnationaldatabasecombined resultspersurgicalcategoryfrom overparticipants CABGMortalityRateforFirstOperation RVMC SocietyofThoracicSurgerySTSComparableHospitalBenchmark n n n n n n n n n n Forand therewerenodeathsinpatients whorequiredasecondthird orfourthcoronaryartery bypassgrasurgery MortalityRateforSecondThirdorFourthCABGSurgeryReoperation RVMC STSBenchmark n n n n n n n n percentoffirst-time CABGsurgerypatients/ receivedaninternalmammary arterygrainand MortalityRatebyAgeforOpenHeartSurgery- - n - n - n - n - n - n - n - n - n CARDIACSURGERY Cardiac Surgery ValveProcedures ValveProcedureVolume TracyHanson TrailOregon Tracy was born with mitral valve prolapse (2 to 3 percent of the population) and a pectus excavatum (a chest wall deformity). As an adult, she developed severe mitral regurgitation which began to cause her left ventricle to enlarge. She had borderline normal left ventricular systolic function and noted more dyspnea than was expected during strenuous exertion. She underwent simultaneous bileaflet repair of her mitral valve and reconstruction of her chest wall deformity. Tracy made a full recovery and has excellent left ventricular function and no residual mitral regurgitation. Her chest wall deformity has been corrected and she is enjoying an active lifestyle. Severeregurgitantjet Flailmitralvalveleaflet Le#atrium Valveleaflettipsdonotcoapt Transesophagealecho Le#ventricle Dopplersignalshowingtheseverelyleakyvalve Transesophagealecho Heart and Vascular Outcomes MinimallyInvasiveValveProcedures MinimallyInvasiveValveProcedureVolume The minimally invasive thoracoscopic video-assisted mitral/tricuspid valve procedure allows valve repair or replacement to be performed without sternotomy. Rogue Valley Medical Center cardiac surgeons use this technique primarily for patients who require mitral valve replacement, mitral valve repair for degenerative prolapse, or tricuspid valve repair. Minimally invasive surgery offers a better cosmetic outcome and can reduce pain, likelihood of infection, and length of hospital stay. Standardsternotomy Cardiacanesthesiologists SteveCannonMDLindyDeatherageMD JamesFaraoniMDBrianHallMD ThomasHammondMDRobertTrujilloMD Smallthoracicincision Therearesixboard-certified cardiacanesthesiologiststrainedin transesophagealechocardiography Repairedvalve$noregurgitation Vascularaccess Standardsternotomyonleminimallyinvasive approachformitralvalverepaironright CourtesyofEdwardsLifesciences Valveaerrepairleafletstouchnomitralregurgitation Transesophagealecho CARDIACSURGERY Cardiac Surgery WilliamBickers GrantsPassOregon #JMMJTB+PTFQIJOF$PVOUZ1VCMJD8PSLTFNQMPZFFXIPIBECFFOEJBHOPTFE with a heart murmur as a child. Strenuous activity such as football had not been permitted as a teenager. As an adult, he pursued a physically active lifestyle. Over the past two years, he developed progressive exertional angina and was cut from a sports team. He was subsequently diagnosed with critical aortic stenosis. Echocardiography showed a unicuspid aortic valve with peak gradient 145 mm Hg, mean gradient 98 mm Hg, and valve area 0.6 cm2 consistent with critical aortic stenosis. He underwent aortic valve replacement with implantation of a mechanical aortic valve prosthesis. Bill has resumed working out and is now running on a regular basis without any symptoms. DistributionofPrimaryValveProceduresn" ProstheticHeartValves IsolatedAorticValveRepair/Replacement IsolatedMitralValveRepair/Replacement TricuspidValveReplacement/Annuloplasty AorticValveRepair/ReplacementCABG MitralValveRepair/ReplacementCABG Aortic/MitralValveRepair/ReplacementCABG OtherValveProcedures Pericardialtissuevalvebioprosthetic Implantedmechanicalaorticandmitralvalves CourtesyofEdwardsLifesciences CourtesyofCarboMedics Porcinetissuevalve bioprosthetic CourtesyofMedtronic StJudeMedicalmechanicalvalve CourtesyofStJudeMedical Intraoperativetransesophageal echocardiographyisperformed routinelyonpatientsundergoing valvesurgeryatRVMC Heart and Vascular Outcomes IsolatedMitralValveRepairMortalityRate RVMC STSRiskAdjustment The purpose of the risk adjustment is to allow STS database participants to compare their performance with other participants (e.g., overall STS, like participants, region or state). By accounting for and controlling patient risk factors that are present prior to surgery, risk adjustment “levels the playing field” as best as possible. Comparing unadjusted event rates would unfairly penalize participants that perform operations on higher-risk patients. Risk adjustment more accurately represents a participant’s performance relative to that of a reference group presented with the same patient population. STSBenchmarkRisk-AdjustedRate* n n n n n n n *NoteSTSdidnotcalculateriskadjustmentonthispopulationuntil IsolatedMitralValveReplacementMortalityRate STSBenchmarkRisk-AdjustedRate RVMC n n n n n n n n n n n IsolatedAorticValveReplacementMortalityRate STSBenchmarkRisk-AdjustedRate RVMC n n n CARDIACSURGERY Cardiac Surgery EndovascularTreatment ofThoracicAorticAneurysm Until recently, treatment of a descending thoracic aortic aneurysm required an open and morbid surgical procedure associated with a significant risk of paraplegia. A new endovascular approach is safer and less invasive and involves accessing the femoral artery, advancing a stent graft to the descending thoracic aorta, and deploying the stent graft across the aneurysm to seal it off. Patients often go home in one to two days. MarjorieMcBeth AshlandOregon Marjorie suffered from a ruptured thoracic aortic aneurysm. In the past this would have been a mortal event for a woman of her age. Using the minimally invasive endograft stent technology available at RVMC, surgeons repaired Marjorie’s ruptured aneurysm. RVMC’s hybrid operating room was developed with the technology to complete such complex procedures. Three years after surgery, Marjorie is alive and healthy. She continues to enjoy her family and relish her retirement life. ThoracicAortaProcedureVolumes OpenSurgeryofAscendingAortaAorticArch and/orDescendingThoracicAorta EndovascularStentGraof DescendingThoracicAorta Leventricularassistdevice CourtesyofAbiomed AnAbiomedleventricular assistdeviceisavailablefor patientswithsevereleventricular dysfunctionandassociated congestiveheartfailure Heart and Vascular Outcomes TransmyocardialRevascularization Transmyocardial revascularization (TMR) is an option for patients with stable angina refractory to medical treatment and not amenable to standard coronary revascularization. A carbon dioxide laser is used to fire single high-energy pulses to create smooth, straight microchannels in the wall of the left ventricle. TMR is occasionally used in conjunction with standard CABG to treat an area of myocardium that cannot be revascularized with bypass grafts or stents. Clinical trials have demonstrated TMR to be a safe and effective means of obtaining long-term relief of angina, improved heart muscle perfusion, and improved quality of life. This technology was introduced at Rogue Valley Medical Center in 2001. TransmyocardialRevascularizationProcedureVolume RVMCCardiacIntensiveCareUnitstaff AtrialFibrillation RVMCopenheartsurgicalteam MazeProcedureVolume MazeProcedure The Maze procedure uses a cryoablation technique to create lines of nonconducting scar tissue at the pulmonary vein orifices and within the walls of the atria to prevent the propagation of electrical excitation originating in the pulmonary veins into the atria and the sustained disorganized electrical activity within the atria which lead to initiation of sustained atrial fibrillation. The procedure is appropriate for individuals with highly symptomatic atrial fibrillation who have failed conventional therapy. RVMCHeartCenterstaff VASCULARSURGERY Vascular Surgery ComprehensiveVascularCare Five board-certified vascular surgeons provide around-the-clock elective and emergent care for a wide spectrum of peripheral vascular disorders. Outpatient angiography and peripheral vascular interventions are performed in the outpatient angiography suite within CVI. Complex surgical reconstructive procedures, including a high-volume endovascular program for the management of abdominal aortic aneurysms, are performed within our region’s only state-of-the-art dedicated endovascular angiographic operating room located at Rogue Valley Medical Center. Vascular surgeons, cardiothoracic surgeons, and cardiologists provide an integrated approach to the management of complex thoracic and abdominal aortic disease, combining thoracotomy and endovascular approaches to the management of thoracoabdominal aortic aneurysms and acute aortic dissections. Vascular surgeons, interventional cardiologists, and neurologists work together to provide a comprehensive management of carotid artery disease, using either surgical endarterectomy or percutaneous stent procedures. PeripheralAngiographyVolume InpatientandOutpatient Includescarotidangiographyrenalangiographymesenteric angiographyupper-andlower-extremityangiography andabdominalangiography Iliacarteries Aneurysm Aorta Fiveboard-certified vascularsurgeonsprovide around-the-clockcoverage Stentgra# Stentgraplacedacrossaneurysmeffectivelysealingitoff CourtesyofMedtronic Theperipheralvasculature CourtesyofAbboVascular Heart and Vascular Outcomes Femoralarteryaccess Abdominal aorticaneurysm Opensurgicalrepairofabdominalaorticaneurysm CourtesyofMedtronic Endovascularapproachvia thefemoralarterieslessinvasive CourtesyofMedtronic ElectiveEndovascularStentGra#RepairIn-HospitalMortalityRate Abdominalaorticaneurysm CourtesyofMedtronic n n n n n n n ElectiveAbdominalAorticAneurysmSurgicalVolume TotalRepairs OpenSurgicalRepair EndovascularStentGraRepair Leapfrogrecommendsthat AnnualHospitalVolumesfor abdominalaorticaneurysmrepair bemorethanperyear VASCULARSURGERY Vascular Surgery CarotidEndarterectomy NaturalHistoryofCarotidDisease RiskofIpsilateralStroke While the patient is under general anesthesia, an incision is made in the skin over the carotid artery. The carotid artery is clamped and incised, and the atherosclerotic plaque is removed (endarterectomy). This is similar to removing the inner layers of an onion. The artery and the skin are then surgically closed. Symptomatic patients: transient ischemic attack (TIA)/stroke: t 70 to 99 percent stenosis: 13.0 percent per year t 50 to 69 percent stenosis: 4.4 percent per year Asymptomatic patients t >60 percent stenosis: 2 to 3 percent per year SourceNASCETNASCETIIACASandACSTtrials IsolatedCarotidEndarterectomyIn-HospitalDeath/StrokeRate Death Stroke n n n n n n n TotalCarotidArteryRevascularizationProcedures IsolatedCarotidEndarterectomy SimultaneousCarotidEndarterectomyandCardiacSurgery CarotidStent Carotidstentprogrambeganin Heart and Vascular Outcomes WhoShouldBeConsidered forCarotidStenting? Stentacross carotidartery plaque Bloodflow tobrain High surgical risk patient: t Symptomatic patient with ≥50 percent stenosis t Asymptomatic patient with ≥80 percent stenosis CriteriaforIncreasedSurgicalRisk t Congestive heart failure Class III/IV and/or left ventricular ejection fraction <30 percent t Open heart surgery indicated t Recent myocardial infarction t Unstable angina t Severe pulmonary disease t Contralateral carotid occlusion t Contralateral laryngeal nerve palsy t Irradiated neck t Previous carotid endarterectomy with recurrent stenosis t High cervical internal carotid artery lesions t Common carotid lesions below the clavicle t Severe tandem lesions Filtertraps particlesfrom plaquebut permits bloodflow Equipment placedvia femoralartery inleg Internal carotidartery Carotidstentdeployedfilternotyetretrieved CourtesyofAbboVascular HighSurgicalRiskPatients Stenting Endarterectomy FreedomfromMajor AdverseEvent Normal surgical risk patient: t Standard of care is carotid endarterectomy t National Institutes of Health (NIH)–sponsored CREST study randomly assigns patients to either carotid stenting or surgical endarterectomy P DaysA#erInitialProcedure SourceGurmHSYadavJSFayadPetalLong-termresultsofcarotidstentingversusendarterectomyinhigh-riskpatientstheSAPPHIREStudy NewEnglandJournalofMedicine - VASCULARSURGERY Vascular Surgery CarotidStentVolume carotidstentprocedures havebeenperformedat RVMCsince Sept RVMChasreceivedtheAmerican HeartAssociationGetWithThe Guidelines®–Strokeaward CarotidStentinginHigh-RiskSurgicalPatients ComparisonwithMAVERICIICarotidStentRegistry -DayOutcomes MAVERICII RVMC Theregion’sonlystate-of-the-art dedicatedendovascularangiographic operatingroomislocatedatRVMC DeathStroke Myocardial Infarction Death Stroke Major Stroke Minor NIHstrokescaleperformedbeforeandaereachprocedure MAVERICIIhadthebestoutcomesofanyreportedcarotidstentregistry Myocardial Infarction PatientsatNormalSurgicalRisk NIH–SponsoredCRESTTrial Rogue Valley Medical Center was one of 110 centers in North America chosen to participate in the National Institutes of Health–sponsored CREST trial. This study randomized normal surgical risk patients with carotid artery disease to carotid endarterectomy versus carotid stenting with distal emboli protection. The screening process for treating physicians is rigorous; only experienced physicians with an excellent track record are chosen. Eleven patients participated in the study, and nine received carotid stents. All patients did well, with no death, stroke, or myocardial infarction. Heart and Vascular Outcomes LlynPayne BrookingsOregon Llyn, an avid knitter, attended a yarn workshop in central Oregon and had a myocardial infarction. Coronary angiography revealed severe blockages in the left main and proximal left anterior descending arteries, occluded proximal right coronary artery, and left ventricular ejection fraction 30 percent. She was not felt to be a candidate for coronary artery bypass graft surgery. She returned to her home city, where she subsequently had a stroke with right hemiparesis and expressive aphasia. She was subsequently transferred to Rogue Valley Medical Center for further care. Carotid studies revealed an occluded left carotid and left subclavian arteries and severe stenosis of the right internal carotid artery. She was also in cardiogenic shock, requiring dopamine for blood pressure support. Coronary stenting of the left main and proximal left anterior descending arteries with femoral artery–femoral venous bypass backup was performed in the hybrid surgical suite. The patient had severe bilateral iliac artery disease that required bilateral iliac artery stent deployment prior to placement of the large bypass cannulae (figure 1). Intravascular ultrasound–guided coronary stent deployment was performed in both the left main and left anterior descending coronary arteries (figure 2). Her blood pressure immediately improved, the dopamine was stopped, and beta-blockers and angiotensin converting enzyme (ACE) inhibitors were eventually started. She subsequently underwent carotid stenting with distal emboli protection, with good result (figure 3). Llyn has made a good neurologic recovery, has no further angina, and has resumed knitting. Severestenosisat originoflemain andinproximalle anteriordescending coronaryarteries figure 1— Severeblockagesin bothcommoniliacarteries Stentsdeployedinbothcommon iliacarterieswithballooninflation Stentsdeployedwithwidely patentiliacarteries figure 3— Cerebral angiographyaer stentdeployment withexcellent collateralstothe leanteriorand middlecerebral arteries figure 2— Stentsdeployedinlemain andproximalleanteriordescending coronaryarterieswithgoodresult Severestenosisinproximalright internalcarotidarterylecarotid arteryoccluded Successfulrightcarotidarterystent IMAGING Imaging NoninvasiveDiagnosticTesting Rogue Valley Medical Center offers a full spectrum of noninvasive diagnostic testing for cardiovascular diseases: t Echocardiography (transthoracic, transesophageal, pediatric) t Treadmill stress testing t Nuclear stress testing t MUGA scans Echocardiography is a noninvasive ultrasonographic assessment of cardiac structure and function, including evaluation of ischemic and nonischemic ventricular dysfunction, cardiomyopathy, valvular heart disease, and congenital malformations. Invasive transesophageal assessment is also performed in the inpatient and outpatient settings, as well as intraoperative assessment of cardiothoracic surgical procedures. t Holter/event monitors t Tilt table testing t Vascular imaging Transesophagealechois availablearound-the-clock atRVMC t Cardiac CT angiography, coronary calcium scoring Echocardiogram EchocardiographyVolumes—RVMCandTRCH Echo TransesophagealEcho PediatricEcho RVMCechocardiographyimagingstaff Heart and Vascular Outcomes Treadmill stress testing provides electrocardiogram (EKG) assessment for exercise-induced ischemia or arrhythmias, including chronotropic competence. Treadmill testing is used predominantly in patients who are able to exercise and have a normal baseline EKG. TotalStressTests—RVMCandTRCH RVMCnuclearimagingstaff Nuclearstresstesting RVMCvascularimagingstaff Treadmillstresstesting IMAGING Imaging Nuclear stress testing allows a noninvasive assessment of coronary blood flow and cardiac function; it is performed with exercise or pharmacologic stress protocols. It is useful in assessment of ischemia with a baseline abnormal EKG, a nonspecific or possibly false-positive treadmill result, moderate probability for coronary artery disease, localization of ischemia in known coronary artery disease, or risk stratification after a cardiac event. Cardiologiststrainedin Multiple gated acquisition scans are used for evaluation of right and left ventricular systolic performance. Transesophageal echocardiography Nuclearstresstests CardiacCT A Holter monitor continuously records a patient’s heart rhythm for 24 hours. The patient notes any symptoms, which allows correlation of the heart rhythm to any concerning symptoms. An event monitor is worn for approximately one month. When a patient has symptoms (such as palpitations, light-headedness, or dizziness), the patient pushes a button to record the heart rhythm. This information is then transmitted over the telephone to the physician for review. Tilt table testing is a noninvasive assessment for vasovagal (neurocardiogenic) syncope. Vascular imaging consists of ultrasonographic assessment of carotid and peripheral vascular disease, including atherosclerotic blockage, aneurysm formation, and deep venous thrombosis. Cardiac magnetic resonance imaging (MRI) is used to evaluate for arrhythmogenic right ventricular dysplasia, constrictive pericarditis, and myocardial viability following infarction. PeripheralVascularImagingVolumes—RVMCandTRCH ArterialUltrasoundofArmsandLegs CarotidArteryUltrasound VenousUltrasoundofLegs Holter/LoopEventMonitor—RVMCandTRCH Heart and Vascular Outcomes CardiacCT CoronaryCalciumScore Coronary calcium score is a screening heart scan used to detect calcium deposits found in atherosclerotic plaque in the coronary arteries. The calcium score is then used to evaluate risk of future coronary heart disease and events. Coronary arterial calcification is part of the development of atherosclerosis (hardening of the arteries), occurs almost exclusively in atherosclerotic arteries, and is absent in the normal vessel wall. A score of 0 implies a low likelihood of coronary obstruction but cannot totally exclude the presence of atherosclerosis. A high score indicates a significant plaque burden and an increased relative risk of future heart and vascular events. It should be understood that calcification does not imply significant obstruction, nor is it site specific for a stenotic lesion; rather, it indicates the extent of atherosclerosis throughout the coronary arteries. Coronary CT angiography consists of high-resolution three-dimensional 3D pictures of the moving heart and great vessels that are used to determine whether a patient has significant coronary atherosclerosis or any structural abnormality of the heart and the surrounding structures. LightspeedVCT CoronaryArteryCalciumScore MedicareCoveragefor CoronaryCTAngiography t Patients with acute chest pain presenting in an emergency room (or equivalent) when necessary to rapidly differentiate among reasonably probable aortic, pulmonary, and/or coronary etiologies t First-line testing for coronary artery disease in nondiabetic patients with intermediate risk factors presenting in an emergency room (or equivalent) with chest pain syndrome or other symptoms strongly suggestive of coronary disease, and who have normal or borderline enzymes and EKGs, when negative findings will result in avoiding invasive coronary angiography t Equivocal or suspected inaccurate stress (or stress imaging) test in patients with low to intermediate risk factors when a negative CTCA will result in avoiding invasive coronary angiography t Clinical findings strongly suggestive of a congenital anomaly of the coronary vessels or great vessels DcardiacCTimage CourtesyofGEHealthcare CumulativeIncidenceofCoronaryEvents -sliceCTscannersareavailable atRogueValleyMedicalCenterand ThreeRiversCommunityHospital CourtesyofGEHealthcare – > – YearstoEvent SourceDetranoRGuerciADCarrJJetalCoronarycalcium asapredictorofcoronaryeventsinfourracialorethnicgroups NewEnglandJournalofMedicine- PREVENTIVECARDIOLOGY Preventive Cardiology Cardiacrehabilitationis recommendedbytheAmerican HeartAssociationandtheAmerican CollegeofCardiology RVMCandTRCHareboth certifiedbytheAmerican AssociationofCardiovascular andPulmonaryRehabilitation percentofpatients notedimprovementin strengthandendurance CardiacRehabilitationProgram SecondaryPrevention Cardiac rehabilitation is a program of monitored exercise and education that provides an essential service to patients with heart disease. It is recommended for those who have had a cardiac event such as a myocardial infarction, heart surgery, coronary artery stenting, or angina within the past year. Research continues to show that participation in cardiac rehab reduces mortality by about 25 percent. Physical strength and endurance are improved by an average of 50 percent. After a heart attack, stent, or open heart surgery, patients have many questions about what happened and what to expect in the future. The Cardiac Rehabilitation program is designed to address these concerns, providing information and support to improve patient health and reduce the risk of future cardiac issues. The RVMC Cardiac Rehabilitation program has been in place since 1998; it and the program at Three Rivers Community Hospital (TRCH) are two of the 11 certified programs in the state of Oregon. They are the only QSPWJEFSTPGDBSEJBDSFIBCJMJUBUJPOQSPHSBNTJO+BDLTPO +PTFQIJOF,MBNBUI%FM/PSUF$VSSZ-BLFBOE Siskiyou Counties. The programs are directed by cardiologists, and the multidisciplinary team is trained in Advanced Cardiac Life Support. percentofpatientshavegood bloodpressurecontrolatthe completionoftheprogram Goals: t Educate patients and families regarding cardiac disease and treatment t Build healthy habits of diet, exercise, and tobacco cessation t Optimize a sense of well-being and function for patient and family t Determine the level at which a patient can safely exercise t Increase endurance Recent international research shows that positive changes in diet, exercise, and tobacco use reduce patient risk within six months after an acute coronary syndrome. Patients who adhere to a good diet and exercise reduce their risk of myocardial infarction (MI) by nearly half compared with those who did not comply with lifestyle improvement regimens. Patients who continue to smoke and ignore advice to improve diet and exercise are 3.8 times more likely to suffer an MI, stroke, or death within six months than nonsmokers who modify their diet and exercise. To boost post–MI survival rates, study authors recommended programs such as cardiac rehabilitation that teach and support lifestyle changes. percentofpatients reportcontinuedhome exercisecompliance Coverage RVMCcardiacrehabstaff Medicare and most other insurers cover patients who in the previous year have had angina, myocardial infarction, coronary artery stenting, bypass surgery, valve surgery, or heart transplantation. Heart and Vascular Outcomes patientsatRVMCsince patientsatRVMCin patientsatTRCHin percentofpatientswerevery satisfiedwiththeirexperience percentofourprevioussmokers weresmoke-freeattheconclusion oftheircardiacrehabprogram CardiacEducators RVMC Cardiac Clinical Case Managers, who are all registered nurses, visit with patients who have had heart failure, angina, or a heart attack. They teach patients about the nature of their illnesses and the steps they can take to avoid future problems. These nurses also work with patients who have cardiac procedures, such as open heart surgery, placement of a coronary or carotid stent, insertion of a pacemaker, or implantation of a defibrillator. Cardiac Clinical Case Managers provide an additional level of care and answer patients’ questions. They review important instructions, discuss the procedure, and show patients actual balloons, stents, pacemakers, and defibrillators. The purpose of their visits is to ensure that patients understand their medical condition and upcoming outpatient care plan. Patientsexperiencedanaveragewaist circumferencereductionofinches RogueValleyMedicalCenter CardiacRehabilitation Third Floor Northwest 2825 East Barnett Road Medford, OR 97504 (541) 789-4466 SomeCommentsfromPatients “Fantastic staff and program…professional and friendly…I owe them everything.” ThreeRiversCommunityHospital CardiacRehabilitation “Felt like part of the family…” 520 SW Ramsey Avenue Grants Pass, OR 97527 (541) 472-7474 “Not only good for one’s health but also for your emotional well-being…don’t change a thing” RVMCCardiacClinicalCaseManagers “A sincere and unequivocal thank-you for all you did for me during the past three months…You helped me physically, emotionally, and intellectually…you created an environment of hope and optimism. Your work is deeply appreciated.” THERAPIESONTHEHORIZON Therapies on the Horizon DabigatranAReplacementforWarfarin? Dabigatran (Pradaxa®) is an oral thrombin inhibitor that may replace warfarin. In the RE-LY trial, 18,000 patients with atrial fibrillation were randomized to dabigatran and warfarin. The dabigatran 150 mg bid group had a significantly lower risk of stroke/systemic embolization and intracranial hemorrhage than the warfarin group did. The FDA approved this medication on October 19, 2010. This medication does not require INR testing or any dietary restriction. There are also fewer drug interactions. Dabigatran is not yet approved for deep venous thrombosis, pulmonary embolism, or mechanical heart valves. The cost is unknown but will almost certainly be more expensive than generic warfarin. Source: Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. New England Journal of Medicine. 2009;361:2342-52. CarotidStentinginNormal SurgicalRiskPatients TandemHeartPercutaneous VentricularAssistDevice Carotid artery disease accounts for approximately 30 percent of all strokes. For a normal surgical risk patient with a severe atherosclerotic blockage in the carotid artery, the standard of care has historically been surgical carotid endarterectomy. In the NIHsponsored CREST trial, 2,502 normal surgical risk patients were randomized to surgical carotid endarterectomy and carotid stenting with distal emboli protection with a filter. At 2.5 years the combined endpoint of death, stroke, and myocardial infarction showed no statistically significant difference between the treatments (6.8 percent versus 7.2 percent). The carotid endarterectomy group had a slightly lower risk of stroke (2.3 percent versus 4.1 percent), whereas the carotid stent group had a slightly lower risk of myocardial infarction (2.3 percent versus 1.1 percent). This percutaneously placed device is designed for critically ill patients in cardiogenic shock who are refractory to intra-aortic balloon pumping, inotropes, and vasopressors. These patients may be having a myocardial infarction, having difficulty coming off the bypass pump at the time of open heart surgery, or undergoing a high-risk percutaneous coronary intervention (e.g., left main). This technology provides both cardiac (pumps blood) and pulmonary (oxygenates blood) support for a failing heart, hopefully long enough to give the heart a chance to recover. This device can be placed in either the operating room or the cardiac catheterization laboratory. Source: Brott TG, Hobson RW, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine. 2010;363:11-23. TranscatheterAorticValveImplantation TreatingHigh-RiskAorticStenosisPatientswithaPercutaneousApproach For patients with severe symptomatic aortic stenosis who are poor candidates for open heart surgery and standard aortic valve replacement, transcatheter aortic valve implantation (TAVI) via a percutaneous approach was recently found to be superior to medical therapy. In fact, the PARTNERS trial showed an absolute risk reduction of 20 percent at one year (50.7 percent mortality rate at one year in the medical therapy group, 30.7 percent mortality rate at one year in the TAVI group). This technology typically requires access via the femoral or axillary artery. A large balloon is advanced across the stenotic valve and inflated (balloon valvuloplasty) to split apart the valve commissures. A valve within a stent is then mounted on a balloon, advanced across the diseased valve, and inflated at high pressure to deploy the stent valve. The balloon is then removed, and the patient has a bioprosthetic valve in place—all while the heart is beating. The native valve is crushed to the side and is under the stent valve structure. The second part of the PARTNERS trial is comparing high surgical risk patients who were randomized to TAVI versus open heart surgery with aortic valve replacement. These results should be available in spring 2011. This technology is currently being reviewed by the FDA. Source: Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. New England Journal of Medicine. 2010;363:1597-1607. TheTandemHeartdevice CourtesyofCardiacAssists Heart and Vascular Outcomes Le#AtrialAppendageOccluderPreventing StrokesinAtrialFibrillationPatients The feared outcome of atrial fibrillation is embolic stroke. The left atrial appendage is typically the site for thrombus formation. A left atrial appendage occluder (plug) has been developed and can be delivered from the inferior vena cava through the atrial septum via a transseptal puncture. In the PROTECT-AF study, patients with atrial fibrillation were randomized to warfarin versus a left atrial appendage occluder. For patients who received the left atrial appendage occluder, warfarin was stopped after 30 days and both groups were followed for an average of three years. The left atrial appendage occluder had a higher risk of adverse safety events at the time of implantation, such as pericardial effusion (4.8 percent), device embolization (0.6 percent), and stroke (1.1 percent). Despite these risks at the time of implantation, the left atrial appendage occluder group had a lower risk of stroke (“non-inferior by trial design”). As mandated by the FDA, a second clinical trial will soon be under way to better clarify whether the benefits of this left atrial appendage occluder outweigh the risks. If approved, it is unclear if the left atrial appendage occluder will be available only for patients who are unable to take anticoagulation therapy (e.g. warfarin) or for all atrial fibrillation patients at increased risk of stroke. Fourteenhospitalists providecareformanycardiac patientsAllhospitalists areboardcertified RVMChospitalists ArthurAungMDTinoBauerMDErinBrenderMD AgnieszkaDobieckaMDChristinaFordMDJonathan GellMDGregoryGrunwaldDOStevenHerschMD ElizabethHirniDOAhsanJaffarMDJoseMondesiMD KennethSanfordMDDonnaTribelhornMD EeLinWanMD FourintensivistsatRVMCare boardcertifiedincriticalcare medicinewithonewhois additionallyboardcertifiedin pulmonarymedicine Source: Holmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009;374:534-41. DEchocardiography Echocardiography is a powerful cardiac imaging modality that typically uses two-dimensional ultrasonography and color Doppler with a transthoracic window. Three-dimensional echo technology coupled with a transesophageal approach is now available and can be particularly helpful when assessing heart valves, septal defects, and other forms of structural heart disease, especially at the time of open heart surgery. RVMCintensivists PeteyLaohaburanakitMDFCCPFranciscoPazMD IlanaPorzecanskiMDKrishnamurthyUmapathyMD TamaraDixonNPJamesStubenrauchPA Anintensivistispresentinthe hospitalaround-the-clockHospitals withanintensivistprogramare associatedwithbeeroutcomes andlowermortalityrates QUALITYOURAPPROACH Quality: Our Approach The divisions of cardiology and cardiothoracic surgery believe in the importance and the value of a robust quality improvement approach to the delivery of healthcare. With the assistance of the performance improvement staff, clinical outcomes are compared with external benchmarks to continuously identify areas of potential improvement and to provide patients with information useful in their own healthcare decisions. RVMC has participated in the development of $FOUFSTGPS.FEJDBSF.FEJDBJE4FSWJDFT$.4 projects and strives to achieve high levels of compliance with the current CMS Core Measures for Best Practice. Guidelines and best practices from a wide range of resources, including the Leapfrog Group, the Institute for Healthcare Improvement 100K Lives Best Practices campaign, the American College of Cardiology, and the Society of Thoracic Surgery, are used to define standards of care and goals for improvement. LeapfrogGuidelines CoronaryArteryBypassGra#ing PercutaneousCoronaryIntervention t Favorable hospital volume (450 or more procedures per year) t Participation in Society of Thoracic Surgeons data collection t STS score better than national average for risk-adjusted mortality t Minimum surgeon volume per year for CABG (100 cases per year) LeapfrogEvidence-Based HospitalReferralSafetyStandard t Favorable hospital volume (400 or more procedures per year) t Participation in the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or > 80 percent adherence to the Leapfrog Expert Panel t Endorsed Process Measures for Quality Score better than the national average for risk-adjusted mortality t Minimum surgeon volume per year for PCI (100 cases per year) RecommendedAnnualVolume AmericanHeartAssociation “GetWithTheGuidelines®”Award Recipient·CoronaryArteryDisease GoldStatusand RVMCVolume Volume Itisourbeliefthat… Experiencedboard-certifiedphysicians % patientvolume % well-designedhospitalsystem % regularoutcomesreviewwith appropriatefeedback " Qualitygoodoutcomes Through participation in national initiatives, we support transparent public reporting of healthcare quality data and participate in the following initiatives: t $FOUFSTGPS.FEJDBSF.FEJDBJE4FSWJDFT Hospital Compare (www.hospitalcompare.hhs.gov) t Consumer Reports (www.consumerreports.org/health) Percutaneous Coronary Intervention CoronaryArtery BypassGraing AorticValve Replacement AbdominalAortic AneurysmRepair RVMCperformanceimprovementstaff Heart and Vascular Outcomes AcuteMyocardialInfarctionCMSQualityMeasure CongestiveHeartFailureCMSQualityMeasure Compliance Compliance Aspirin atDischarge Aspirin atArrival Smoking Cessation ACEInhibitor/Angiotensin ReceptorBlockerforLVSystolic DysfunctionatDischarge PrimaryPercutaneous CoronaryIntervention WithinMinutes LeVentricularLV Assessment Smoking Cessation ClearDischarge ACEInhibitor/Angiotensin Instructions ReceptorBlockerforLV SystolicDysfunction Beta-Blocker atDischarge CoronaryArteryBypassGra#SurgeryCMSQualityMeasure Compliance RVMCistheonlyOregonhospital tohavereceivedrecognitionfromthe DepartmentofHealthandHuman Servicesforhavingalowerthan nationalaverageinallthreeareas Prophylactic AntibioticsWithin Hour Aspirin atDischarge Prophylactic AntibioticsDiscontinued WithinHours Prophylactic Antibiotics Selection Beta-BlockerWithin Peri-Operative Period ControlledAM Post-Operative SerumGlucose UrinaryCatheter Removedby Post-Operative Day Appropriate HairRemoval MortalityFollowing AcuteMyocardialInfarction ReadmissionFollowing AcuteMyocardialInfarction ReadmissionFollowing CongestiveHeartFailure GoldAwardtobepresented inNovemberbythe AmericanCollegeofCardiology’s ACTIONRegistry ThomsonSolucientTop Hospitals®Cardiovascular BenchmarksforSuccessAward ···· PHYSICIANBIOGRAPHIES Physician Biographies Asante Cardiovascular and Thoracic Surgeons CharlesCarmeciMDFACS DavidLFolsomMDFACS RogerVHallMDFACS CardiovascularandThoracicSurgery CardiovascularandThoracicSurgery CardiovascularandThoracicSurgery Specialties Coronary artery bypass graft surgery, valve surgery, thoracic aortic aneurysm repair, minimally invasive valve surgery, thoracic oncology, minimally invasive thoracic surgery, thoracic aortic aneurysm surgery, and stent grafts Specialties Coronary artery bypass graft surgery, valve surgery, thoracic aortic aneurysm repair, minimally invasive valve surgery, thoracic oncology, minimally invasive thoracic surgery Specialties Coronary artery bypass surgery with extensive experience in thoracic aortic aneurysm repair, re-do surgery, valve surgery, thoracic oncology MedicalDegree University of Utah MedicalDegree Medical College of Virginia Internship/Residency General Surgery at Case Western Reserve University Internship/Residency General Surgery at Madigan Army Medical Center Internship/Residency General Surgery at Stanford University Medical Center CardiothoracicSurgeryFellowship University of Wisconsin BoardCertification American Board of Surgery, American Board of Thoracic Surgery Honors/Awards Graduated with honors from George Washington University (undergraduate degree) and Medical College of Virginia CardiothoracicSurgeryFellowshipCase Western Reserve University BoardCertification American Board of Surgery, American Board of Thoracic Surgery MedicalDegree University of Utah CardiothoracicSurgeryFellowshipLetterman Army Medical Center BoardCertification American Board of Surgery, American Board of Thoracic Surgery (recertified 2006) Honors/Awards Chairman, Department of Surgery at Rogue Valley Medical Center 2002–2005; Allen Research Fellow at Wade Park VA Medical Center Honors/Awards Past President, Medical Staff at Rogue Valley Medical Center; Past Chairman, Department of Surgery at Rogue Valley Medical Center OfficeMedford OfficeMedford OfficeMedford Heart and Vascular Outcomes Southern Oregon Cardiology, LLC GeorgeRWilkinsonMDFACS JonRBrowerMDFACC DouglasTBurwellMDFACC CardiovascularandThoracicSurgery Cardiology Cardiology Specialties Cardiovascular and thoracic surgery, valve repair, off-pump surgery, complete aortic reconstruction Specialties Consultative cardiology, echocardiography, transesophageal echocardiography, nuclear cardiology, coronary angiography Specialties Consultative and preventive cardiology, echocardiography, nuclear cardiology, coronary angiography MedicalDegree University of Iowa MedicalDegree University of Arizona Internship/ResidencyGeneral Surgery at Tripler Army Medical Center Internship/Residency Neurology and Internal Medicine at University of Arizona MedicalDegree University of California, Los Angeles CardiothoracicSurgeryFellowshipLetterman Army Medical Center CardiologyFellowship University of Arizona Internship/Residency Internal Medicine at University of California, Irvine BoardCertification Internal Medicine, Cardiovascular Disease CardiologyFellowship University of California, Irvine Honors/Awards Residency Excellence in Teaching (three years) BoardCertification Internal Medicine, Cardiology BoardCertification American Board of Thoracic Surgery Honors/Awards Clinical Associate Professor of Surgery, Uniformed Services Medical School Dr. Burwell received his undergraduate degree from Stanford University. OfficeMedford OfficeMedford OfficeGrants Pass PHYSICIANBIOGRAPHIES Physician Biographies Southern Oregon Cardiology, LLC KentWDautermanMDFACCFSCAI NicholasHDienelMDFACC BrianWGrossMDFACC Cardiology Cardiology Cardiology Specialties Consultative and interventional cardiology including peripheral vascular disease (e.g., carotid stenting) Specialties Consultative and preventive cardiology, complex lipid disorders, congestive heart failure, echocardiography, nuclear cardiology Specialties Consultative and interventional cardiology, heart catheterization, echocardiography, nuclear imaging MedicalDegree University of Pennsylvania MedicalDegree University of Rochester School of Medicine and Dentistry, New York MedicalDegree+PIOT)PQLJOT4DIPPMPG.FEJDJOF Internship/ResidencyandChiefResidency University of California, San Francisco CardiologyFellowship University of California, San Francisco InterventionalCardiovascularFellowship Cleveland Clinic BoardCertification Cardiovascular Medicine, Interventional Cardiology Honors/Awards Valedictorian, College of Arts and Sciences, University of Toledo; Top Three (SBEVBUF+PIOT)PQLJOT4DIPPMPG.FEJDJOF Internship/Residency Internal Medicine at University of Michigan CardiologyFellowshipUniversity of Pennsylvania Internship/Residency Dartmouth Medical School, New Hampshire BoardCertification Internal Medicine, Cardiology CardiologyFellowship University of Washington Honors/Awards Graduated with highest honors from Pennsylvania State University (undergraduate); Alpha Omega Alpha Medical Honor Society BoardCertification Internal Medicine, Cardiovascular Medicine, Interventional Cardiology OfficeMedford Dr. Dauterman served as a Peace Corps public health volunteer in Zaïre. Honors/Awards Oregon American College of Cardiology Leadership Award, May 2009; Washington Research Award (American Heart Association), Intern and Resident of the Year; Oregon Fire Chief’s Award–Meritorious Service Award; All American Selection to the All New England Soccer Team Dr. Gross served as an assistant professor at the University of Washington, Division of Cardiology. Research Serves as the local principal investigator for the NIH-sponsored CREST trial and CAPTURE I and II, and CHOICE carotid stent registries OfficeMedford OfficesMedford, Grants Pass Heart and Vascular Outcomes MarkMHuthMDPhDFACC ToddSKotlerMDFACC KennethMLightheartMDFACC Cardiology Cardiology Cardiology Specialties General cardiology, heart failure, heart transplant, echocardiography, nuclear cardiology, coronary angiography Specialties Consultative cardiology, interventional cardiology, general cardiology, nuclear cardiology Specialties Consultative cardiology, transesophageal echocardiography, nuclear cardiology, coronary angiography, cardiac CT MedicalandDoctoralDegrees Louisiana State University MedicalDegree Stanford University School of Medicine MedicalDegree Oregon Health Sciences University Internship/Residency Internal Medicine at University of California, Los Angeles InternshipInternal Medicine at Legacy Portland Hospitals CardiologyFellowshipCedars-Sinai Medical Center, UCLA Residency Internal Medicine at David Grant Medical Center, Travis Air Force Base, California BoardCertification Internal Medicine, Cardiology, Interventional Cardiology CardiologyFellowshipWilford Hall Medical Center, Lackland Air Force Base, Texas Honors/Awards Highest honors from University of California, Santa Cruz (undergraduate) BoardCertification Internal Medicine, Cardiology, Nuclear Cardiology OfficesMedford, Grants Pass Dr. Huth served as an assistant professor at the University of Washington, Division of Cardiology. Honors/Awards Summa cum laude from Brigham Young University, cum laude from Oregon Health Sciences University, Alpha Omega Alpha Honor Society in medical school, Housestaff Scientific Research Second Place Award OfficesMedford, Grants Pass OfficesMedford, Grants Pass Internship/Residency Louisiana State University CardiologyFellowshipUniversity of Washington PostdoctoralFellowshipPhysiology at University of Washington BoardCertification Internal Medicine, Cardiology Honors/Awards Honors in physiology from Rutgers University (undergraduate); Outstanding Intern and Resident of the Year; Chairman of the American College of Cardiology’s Oregon GAP Project in Congestive Heart Failure PHYSICIANBIOGRAPHIES Physician Biographies Southern Oregon Cardiology, LLC KristinMLinzmeyerMDFACC DavidJMartinMDFACC MarkGMoranMDFACCFSCAI Cardiology Cardiology Cardiology Specialties General and invasive cardiology, heart disease in women MedicalDegree Oregon Health Sciences University Specialties Electrophysiology, intracardiac ablation, pacemakers, defibrillators, invasive and noninvasive cardiology Specialties Interventional cardiology, pacemaker and defibrillator implantation and follow-up, invasive and noninvasive cardiology, nuclear cardiology Internship Internal Medicine at University of Utah MedicalDegree Dartmouth Medical School ResidencyInternal Medicine at Oregon Health Sciences University Internship/Residency Internal Medicine at Cedars-Sinai Medical Center, UCLA MedicalDegree University of California, Los Angeles CardiologyFellowshipUniversity of New Mexico CardiologyFellowshipCedars-Sinai Medical Center CardiologyFellowship UCLA Medical Center BoardCertification Internal Medicine, Cardiovascular Disease BoardCertification Clinical Cardiac Electrophysiology, Cardiovascular Disease OfficesMedford, Grants Pass Honors/Awards Alpha Omega Alpha Honor Society in medical school, Phi Beta Kappa BoardCertification Internal Medicine, Cardiology, Interventional Cardiology; Testamur NASPExAM; Certified Cardiac Device Specialist IBHRE OfficeMedford Internship/Residency UCLA Medical Center Honors/Awards California Heart Association Research Fellow; bachelor’s degree in biology with highest honors from University of California, Santa Cruz; Department of Medicine Intern of the Year, UCLA Medical Center; Fellow Society for Cardiac Angiography and Interventions OfficesMedford, Grants Pass Heart and Vascular Outcomes BrianJMorrisonMDFACC BrucePa!ersonMDFACC EricAPenaMDFACC Cardiology Cardiology Cardiology Specialties Consultative cardiology, pediatric and adult congenital heart disease Specialties Consultative and preventative cardiology, echocardiography, transesophageal echocardiography, nuclear cardiology, coronary angiography Specialties Cardiology, electrophysiology MedicalDegree University of Illinois, Chicago Internship/ResidencyInternal Medicine at University of Colorado Health Sciences Center, Denver CardiologyFellowshipMassachusetts General Hospital, Harvard Medical School BoardCertificationCardiology Honors/Awards Grove Outstanding Senior Award Finalist, University of Illinois College of Medicine; Outstanding Resident Teaching Award, University of Colorado Health Sciences Center Dr. Morrison’s training included a senior clinical research fellowship at Boston Children’s Hospital. He also spent one year as an instructor and a staff physician at the Adult Congenital Heart Disease Center at the University of California, Los Angeles. MedicalDegree University of South Florida MedicalDegree University of Pennsylvania Internship/Residency Emory University, Atlanta, Georgia Internship/Residency Internal Medicine at Brigham and Women’s Hospital, Harvard Medical School CardiologyFellowship Emory University CardiologyFellowship Boston University Medical Center Honors/Awards Chief Medical Resident BoardCertification Internal Medicine, Cardiology Honors/Awards Cook Memorial Prize in Economics at Pomona College, California; President, Alpha Omega Alpha Honor Society, University of Pennsylvania School of Medicine Dr. Patterson earned his master’s degree from the 1SJODFUPOɨFPMPHJDBM4FNJOBSZJO/FX+FSTFZ OfficeMedford OfficesMedford, Grants Pass BoardCertification Cardiology, Electrophysiology Dr. Pena has served on the faculty of the Heart Rhythm Society’s International Meeting for the past three years. Research Primary investigator or co-investigator in many PIVOTAL clinical trials, Miracle ICD, Companion trial, PAVE trial, and MADIT CRT trial OfficeMedford PHYSICIANBIOGRAPHIES Physician Biographies Oregon Surgical Specialists, PC BradleyEPersoniusMDFACC StephenJSchnuggMDFACC JuanMCastilloMDFACS Cardiology Cardiology VascularGeneralandBariatricSurgery Specialties Consultative and preventative cardiology, transesophageal echocardiography, pacemakers, complex lipid disorders, cardiac CT, nuclear cardiology, cardiac catheterization Specialties Consultative cardiology, interventional cardiology, cardiac catheterization, echocardiography Specialties Vascular, endovascular, bariatric, and general surgery, including laparoscopic surgery MedicalDegree University of California, Los Angeles MedicalDegree New York University Medical Center MedicalDegree Loma Linda University School of Medicine Internship/Residency Internal Medicine at Wadsworth VA Medical Center Internship/Residency Internal Medicine at Wilford Hall Medical Center, Lackland Air Force Base, Texas CardiologyFellowship Wadsworth VA Medical Center Internship/Residency General Surgery at University of Texas Southwestern Medical Center and Parkland Memorial Hospital CardiologyFellowshipWilford Hall Medical Center BoardCertification Internal Medicine, Cardiology, Interventional Cardiology BoardCertification Internal Medicine, Cardiology, Cardiac Device Specialist OfficesMedford, Grants Pass VascularSurgeryFellowshipNew York University Medical Center BoardCertification General Surgery, Vascular Surgery Honors/Awards Honors program at New York University Medical Center; Chairman, Committee on Cancer by American College of Surgeons for Rogue Valley Medical Center and Providence Medford Medical Center OfficeGrants Pass Research Subinvestigator in PIVOTAL small aneurysm study, Endologix large neck aneurysm study, and CREST carotid stent studies OfficeMedford Heart and Vascular Outcomes MarkAEatonMDFACS WilliamEFaughtMDFACS NancyO’NealMDFACS VascularGeneralandBariatricSurgery VascularandGeneralSurgery GeneralSurgery Specialties Vascular, endovascular, bariatric, and general surgery, including laparoscopic surgery Specialties General, vascular, and endovascular surgery, including laparoscopic surgery Specialties General surgery, including laparoscopic, breast, and oncologic surgery MedicalDegree University of New Mexico MedicalDegree Southern Illinois University Internship/Residency General Surgery at University of Texas Southwestern Medical Center and Parkland Memorial Hospital Internship/Residency General Surgery at University of Utah MedicalDegree University of Texas Southwestern Medical School, Dallas Internship/Residency General Surgery at University of Texas Southwestern Medical Center and Parkland Memorial Hospital VascularSurgeryFellowship University of Tennessee VascularSurgeryFellowship Southern Illinois University BoardCertification General Surgery, Vascular Surgery BoardCertification General Surgery, Vascular Surgery Honors/Awards Alpha Omega Alpha Honor Society in medical school Honors/Awards Alpha Omega Alpha Honor Society in medical school Research Subinvestigator in PIVOTAL small aneurysm study, Endologix large neck aneurysm study, and CREST carotid stent studies Research Subinvestigator in PIVOTAL small aneurysm study, Endologix large neck aneurysm study, and CREST carotid stent studies OfficeMedford OfficeMedford BoardCertification General Surgery OfficeMedford PHYSICIANBIOGRAPHIES Physician Biographies Oregon Surgical Specialists, PC DavidLStreetMDFACS DavidKTraulMDFACS VascularGeneralandBariatricSurgery VascularGeneralandBariatricSurgery Specialties Vascular, endovascular, bariatric, and general surgery, including laparoscopic surgery Specialties Vascular, endovascular, bariatric, and general surgery, including laparoscopic surgery MedicalDegree University of California, Davis MedicalDegree Medical College of Wisconsin Internship/Residency General Surgery at University of California, Davis Internship/Residency General Surgery at Medical College of Wisconsin VascularSurgeryFellowship University of Rochester School of Medicine and Dentistry VascularSurgeryFellowship Cleveland Clinic BoardCertification General Surgery, Vascular Surgery Honors/Awards Graduation with distinction, Point Loma College Research Primary investigator in Endologix large neck aneurysm study and CAPTURE II carotid stent study; subinvestigator in PIVOTAL small aneurysm study and CREST carotid stent study; and subinvestigator in CHOICE, CAPTURE I and II, and CREST carotid stent studies OregonSurgicalSpecialistsPCstaff BoardCertification General Surgery, Vascular Surgery Honors/Awards#FTU+VOJPS4VSHJDBM3FTJEFOU Research Primary investigator in PIVOTAL small aneurysm study; and subinvestigator in CHOICE, CAPTURE I and II, and CREST carotid stent studies OfficeMedford AsanteCardiovascularand ThoracicSurgeonsstaff OfficeMedford Heart and Vascular Outcomes Contact Information Rogue'Valley'Medical'Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .()+-0'123-1444 RVMCCardiovascularLab Admissions Hotline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(541) 951-0097 Cardiac Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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(541) 789-4440 attheCardiovascularInstitute. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ()+-0'626-7774 Asante'Cardiovascular'and'Thoracic'Surgeons . . . . . . . . . . . . . ()+-0'123-)1-4 Charles Carmeci, MD, FACS David L. Folsom, MD, FACS Roger V. Hall, MD George R. Wilkinson, MD, FACS 2954 Siskiyou Blvd. Medford, OR 97504 Fax: (541) 789-5711 Oregon'Surgical'Specialists5'PC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ()+-0'626-7724 +VBO.$BTUJMMP.%'"$4 Mark A. Eaton, MD, FACS William E. Faught, MD, FACS Nancy O’Neal, MD, FACS David L. Street, MD, FACS David K. Traul, MD, FACS Website: www.oregonsurgical.com 520 Medical Center Drive, Suite 300 Medford, OR 97504 Fax: (541) 282-6681 E-mail: surgery@oregonsurgical.com 520 Medical Center Drive, Suite 150 Medford, OR 97504 Fax: (541) 282-6660 Southern'Oregon'Cardiology5'LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ()+-0'626-7747 +PO3#SPXFS.%'"$$ Douglas T. Burwell, MD, FACC Kent W. Dauterman, MD, FACC, FSCAI Nicholas H. Dienel, MD, FACC Brian W. Gross, MD, FACC Mark M. Huth, MD, PhD, FACC Todd S. Kotler, MD, FACC Kenneth M. Lightheart, MD, FACC Kristin M. Linzmeyer, MD, FACC %BWJE+.BSUJO.%'"$$ Mark G. Moran, MD, FACC, FSCAI #SJBO+.PSSJTPO.%'"$$ Bruce Patterson, MD, FACC Eric A. Pena, MD, FACC Bradley E. Personius, MD, FACC 4UFQIFO+4DIOVHH.%'"$$ SouthernOregonCardiologyLLCstaff Toll-free: (800) 283-0423 Website: www.socardiology.com Medford Office 520 Medical Center Drive, Suite 200 Medford, OR 97504 Phone: (541) 282-6606 Fax: (541) 282-6601 Grants Pass Office 520 SW Ramsey Avenue, Suite 101 Grants Pass, OR 97527 Phone: (541) 472-7800 Fax: (541) 472-7801 EastBarneRoadMedfordOR · - Copyright©–AsanteHealthSystemAllrightsreservedNopartofthispublicationmaybereproduced inanyformexceptbypriorwrienpermissionPrintedwithsoyinkonrecycledpaper AHS
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