Expanding the Footprint: VCU in Your Neighborhood

Although she just moved here last fall from the West Coast, Dr. Phoebe Ashley quickly learned something about her patients at MCV Physicians at Ridgefield: They really like the office’s convenience.

“Many of our patients are quite elderly, and being able to travel to a nearby location, with easy parking, is very appealing to them,” says Dr. Ashley, a cardiologist and former medical director of the Oregon Heart and Vascular Institute’s Cardiovascular Wellness and Rehabilitation Center and the St. Peter’s Rehabilitation Center in the state of Washington.

Located in an attractive brick building in Richmond’s West End, MCV Physicians at Ridgefield is close to many neighborhoods and assisted living communities. The suburban cardiology practice, which opened in August 2014, is the latest venture by the VCU Pauley Heart Center to expand its physical presence beyond the parameters of downtown to areas where many of its patients live.

Story-1_Dr_Phoebe_AshleyIn addition to Ridgefield, the heart center offers outreach cardiology services at Stony Point, Williamsburg and South Hill, says Jalana McCasland, vice president of Ambulatory Services for VCU Medical Center. The first standalone facility, Stony Point, opened in October 1993. “We have about 4,546 adult cardiology patient visits each year at our outreach centers—and that number is growing,” she says.

At these facilities, “We can do some diagnostic testing; we can see them as outpatients. Of course, when they need a more advanced diagnostic or therapeutic procedure, downtown is the place to come,” says Dr. Kenneth Ellenbogen, chair of the Cardiology Division at VCU. “But we can at least make being seen by a VCU physician easier.”

At Ridgefield, Dr. Ashley and cardiologist Dr. Roshanak Markley provide consultations to their adult patients as well as testing with 3-D-capable echocardiograms and Holter monitoring. (Four highly regarded pediatric cardiologists, Dr. Doug Allen, Dr. Kerri Carter, Dr. Scott Gullquist and Dr. William Moskowitz, of Children’s Hospital of Richmond at VCU, also offer office hours at the practice.)

In addition to convenience, “The number one thing that patients love about this practice is that we spend a lot of time with them,” says Dr. Markley. “I think a lot of the time heart disease can be a complex problem. And if you really want to help your patients change their behavior to prevent heart disease you have to spend time with them and get to know them at a personal level.”

Originally from Tehran, Dr. Markley received her medical degree at the Medical College of Georgia, served her internship and residency in internal medicine at VCU and completed her fellowship in cardiovascular medicine at Vanderbilt University.

Dr. Ashley, a Eureka, California, native, received her M.D. from the Medical College of Wisconsin, where she also conducted her internal medicine residency. She completed her cardiovascular fellowship at University of New Mexico Health Sciences Center.

“Dr. Ashley is an exceptionally good cardiologist, whose interests include women and cardiology, prevention of heart disease, and exercise. She is a very holistic cardiologist,” says Dr. Ellenbogen. “Dr. Markley is an excellent clinical cardiologist, with special interests in imaging and prevention of heart disease.” He adds, “Patients love both of them; they’re just wonderful doctors.”

Lori Edwards sits on an examining room table at the Ridgefield office, dressed in stylish athletic clothing and tennis shoes. At 44, the school clinic assistant is the picture of health. But then she pulls out her iPhone and, gliding her finger over the screen, reveals another picture of herself from last December, in a hospital bed.

“It happened the Saturday before Christmas,” she says. “I was just driving down the interstate with my 9-year-old and two dogs in the car.” Then, without warning, “I went into cardiac arrest and wrecked the car.” Edwards had a blood clot in her heart artery that led to an ST-elevation myocardial infarction—a dangerous heart attack known as a STEMI. “Because of the clot, my heart was beating about 200 beats per minute and that’s what caused me to pass out.”

She adds, “I had a little bit of high cholesterol, not terrible, my total cholesterol was 190. I had never smoked. But my father passed away at 59 from cardiac arrest, a heart attack, and my brother passed away at 41 from a heart attack.”

Fortunately, her family was not injured in the wreck, and Edwards received CPR and AED treatment from several people who stopped to help. After receiving initial treatment at Sentara Williamsburg Regional Medical Center, she was flown by helicopter to VCU Medical Center, where she remained for 18 days.

Dr. Markley, who was assigned to her case, visited or called to check in on her every day, says Edwards. “I felt very confident with her. She took great care of me.”

Story-1_Dr_Roshanak_MarkleyThe doctor helped Edwards make necessary changes in her life, following her discharge—including cardiac rehabilitation, stress reduction and the movement toward a low-sodium, more plant-based diet. The mother of two also takes medication and wears an external defibrillator known as a Life Vest. When she first came home from the hospital, she could barely walk to the mailbox. Now, she can walk 1 ½ miles.

“Since December, she has been making great progress,” says Dr. Markley. “She has had a remarkable attitude and has been a source of inspiration to people who know her.”

Today, at Edwards’ three-month check-up, her echo shows significant improvement, particularly with her ejection fraction—the amount of blood pumped out by the heart. “I left the hospital at 30 percent and today’s echo showed close to a 45% ejection fraction,” she says. “I feel great.”

Dr. Markley’s commitment to her patients is no surprise to Dr. Antonio Abbate, vice-chairman, Division of Cardiology at VCU, who served as her mentor during her residency. “I have known Roshi for many years. She was one of the brightest trainees I have ever had. Her enthusiasm for medicine is exceptional— and contagious,” he says. “She is the doctor that everyone would want to have: knowledgeable, caring and passionate.”

Downtown, the phones ring nearly nonstop in the reception area for the Noninvasive Cardiology Laboratories. The chairs are filled with patients awaiting appointments. It’s a big change from the calm at Ridgefield—but Dr. Ashley enjoys coming down here. Like Dr. Markley, she visits the main campus at least once a week to read studies, see inpatients and, as she puts it, “to stay on top of things.”

“It’s important to not be an isolated outpatient cardiologist. I have a whole group of colleagues who I can call upon to say, ‘You know, what about this? What would you do for this?’ It’s really nice to have that,” she says.

Dr. Ashley is sitting in an office with several other cardiologists. On her computer screen is a moving black-and-white image of a beating heart. This full-study echo—involving about 80-120 images—was taken during a patient’s stress test. With her computer mouse, she clicks through the images, occasionally freezing the screen to take a measurement. With the echo’s 3-D capability, she is able to move around the heart, to see it from many angles.

With the study, “We’re looking at the overall function of the heart, the ejection fraction, the thickness of the ventricular wall, all of the chamber sizes, all the valves—their structure and function, the great vessels and the pericardium, the sac that holds the heart. And we’re also getting an estimate of the pressure within the lungs.”

On busy days, she and another cardiologist may read 50-60 of these studies, involving a great variety of cases.

At Ridgefield, Dr. Ashley enjoys getting referrals for complicated cases—patients with atypical chest pain, for instance. “I like diagnostic dilemmas, so I think I get some of the patients who are a little more challenging sometimes.”

Although she is new to VCU, she has already gained the respect of her co-workers. “Dr. Ashley is a wonderful colleague. She is eager to help, approachable and consistently pleasant,” says Dr. Hem Bhardwaj, director of Cardiology Consultation Services for VCU. “She is an outstanding physician who is thorough, detail-oriented and dedicated to achieving optimal outcomes for her patients. She is a charismatic educator and role model—a terrific addition to our cardiology team.”

Dr. Ashley, a dedicated volunteer with the American Heart Association out west, plans to get more involved with community education here. “I really think education is critical to the success of what we do,” she says. “People are not just a heart and blood vessels—they are a whole being. And each of the different organ systems impacts the cardiovascular system. I think you have to look at an individual holistically and try to optimize each of those things.”

More expansions are in the works for Ridgefield and other neighborhood clinics, says McClasland, VCU’s vice president of Ambulatory Services. VCU hopes to add an evening clinic at Ridgefield, and possibly add new services such as stress tests, electrophysiology testing and device management.

The Pauley Heart Center is also looking to expand its offerings in South Hill and Stony Point, and open a new office in Emporia. “We are currently looking at sites there now,” she says. The office will specialize in the care of heart failure patients. As with all the clinics, “We are trying to work as a partner with local physicians to supplement the services that are already in the communities.”

The notion of a hospital being in one location is changing, says Dr. Ellenbogen. “The best places in the world, places like [Johns] Hopkins, realized that you can’t just have one hospital in downtown Baltimore, you have to be able to branch out, and that’s what we’re doing. We’re bringing world-class medicine, world-class cardiovascular specialists to your neighborhood.”

 

TOP: DR. ROSHANAK MARKLEY AND DR. PHOEBE ASHLEY / ABOVE RIGHT: DR. ASHLEY IN THE NEW RIDGEFIELD OFFICE. / ABOVE LEFT: DR. MARKLEY’S PATIENT LORI EDWARDS RECEIVES GOOD NEWS ON HER ECHO; LAST DECEMBER, SHE WENT INTO CARDIAC ARREST WHILE DRIVING.

 

 


Researchers Target Heart Failure

Researchers Target Heart Failure

The odds are daunting. According to the Centers for Disease Control and Prevention, about 5.1 million people in the U.S. suffer from heart failure, a condition in which the heart loses its ability to pump effectively. Sadly, about half of those diagnosed with the condition will lose their battle within five years.

In this issue, meet two rising stars of research who are striking back at th is deadly disease with innovative therapies.

Hardworking, intelligent, creative—these are words that colleagues use to describe Antonio Abbate, M.D., Ph.D., and Fadi Salloum, Ph.D. Both are devoted to translational research, conducting basic science experiments with the goal of developing clinical therapies to improve the odds for patients with cardiovascular disease. The two doctors are friends—both have young families and grew up in Mediterranean countries (Abbate in Italy, Salloum in Lebanon). They collaborate on numerous research projects. Both have received American Heart Association (AHA) Young Investigator awards and other national recognitions and are principal investigators for several important research projects funded by entities including the National Institutes of Health (NIH) and the AHA.

Salloum-colleagueIt is a Thursday morning in August and Dr. Abbate, the James C. Roberts, Esquire, Professor of Cardiology, is making his rounds on VCU Medical Center’s 10th floor Coronary Intensive Care Unit (ICU). Most of the patients in this ICU have experienced an acute cardiac incident or are in the later stages of heart failure. One patient who suffered cardiac arrest breathes with the support of a ventilator’s pale blue tubing. At the nurses’ station in the center of it all, monitors continuously beep.

Abbate stops by the room of a longtime patient, who he notices has missed several appointments over the past few months. “I should be upset with you,” he says, teasing. The 53-year-old man has a critical blockage that will require a bypass and a pacemaker. Standing at the man’s bedside, Abbate says gently, “Well, it seems like it’s time for that surgery.”

“Dr. Abbate is like a spoonful of sugar. He can take care of the sickest of patients in the intensive care unit that you can imagine,” said Alpha “Berry” Fowler III, M.D., chair of VCU’s Department of Internal Medicine. “He is an amazing clinician.”

In addition to his work with patients, Abbate conducts research with Fowler and others as part of a multidisciplinary team focused on pulmonary and critical care at the Victoria Johnson Research Laboratories. He is the lead investigator in several preclinical (“basic science”) studies and the principal investigator or co-investigator in numerous clinical studies, in which he is examining the role of inflammation in heart disease. He has also published over 200 articles in scientific journals.

“He does everything. He’s the paradigm of a clinical researcher—from bench to bedside. His research takes him from the lab bench and molecules all the way to patient care and making it better,” said Kenneth Ellenbogen, M.D., chair of the Division of Cardiology.

Abbate grew up in the small town of Fondi, Italy (where his wife, Vera, is also from). As a young child, he lost his mother to cancer, which he believes drew him to medicine. “I realized how many people were ill and sick and required care. I thought [medicine] was something important to do. … I thought it would be a way to have my passion for science and doing something useful merge,” he said.

He received his medical degree from the University Campus Bio-Medico in Rome, graduating magna cum laude in 2000, and later obtained his Ph.D. in cellular and molecular cardiology from Catholic University, also in Rome. He completed his specialty training at Catholic University and VCU. He joined the VCU faculty in 2007, after one of his mentors, George Vetrovec, M.D., director of the Adult Cardiac Catheterization Lab, helped recruit him.

“I first met Dr. Abbate [in the summer of 1998] when he was a medical student in Italy, and he was just one of the most enthusiastic, intelligent folks that I’ve had the opportunity to be around. He just had huge energy and enthusiasm, and I thought, `This is the sort of person that we really want to have as a part of our faculty,’” said Vetrovec. “He’s been remarkable.”

“Dr. Vetrovec has given me so much guidance, opportunities, support and encouragement,” said Abbate. Once, after his grants were initially declined a few years ago, “Dr. Vetrovec told me, `Don’t worry—keep trying. You will succeed. They will come.’”

They did. Over the past six years, Abbate has collaborated with Benjamin Van Tassell, Pharm.D., an assistant and research professor with the VCU School of Pharmacy. Together, they have received over $3 million in NIH and other funding to develop a successful therapy using the drug anakinra to prevent or improve heart failure in patients who either have heart failure or have suffered a heart attack.

Their research involves Interleukin-1 (IL-1), a harmful pro-inflammatory agent that kicks into action following a heart attack. “Inflammation is a complex response to injury or infection,” explained Abbate. While initially IL-1 may contribute to healing, it also causes molecular and cellular changes to the myocardium “that may be compensatory at first but ultimately lead to heart failure,” he said. Anakinra is an IL-1 blocker that can prevent this further damage.

Following their initial animal model and early clinical trials, which received early support from VCU Pauley Heart Center and other sources, the pair is currently engaged in three larger NIH-funded trials in which they are providing anakinra therapy to three distinct groups of patients: 1) heart failure, 2) large heart attacks (STEMI) and 3) diastolic heart failure. These are Phase II clinical trials, which will hopefully guide the final Phase III studies for FDA approval.

His patients inspire his research. “They make it valuable. Knowing the patients, knowing the unmet needs in clinical practice, makes me approach research in a way to address those needs,” he said. “I realize how little we understand of disease and how much better we could be doing if we had more tools to treat patients.”

Hydrogen sulfide (H2S) is often associated with the rotten egg smell of swamps. Surprisingly, the noxious gas has healing properties too—and may prove a critical link to preventing heart failure, says Salloum, VCU assistant professor of medicine and physiology and biophysics.

“Hydrogen sulfide is toxic in certain concentrations—one whiff of it, and you’re dead. But it’s also something that enzymes naturally produce in our bodies,” Salloum says. After a person experiences a heart attack, his or her level of H2S drops. Of his research, Salloum says “I started looking at the physiological levels of hydrogen sulfide. … If the levels are too high, that will be bad. However, there’s a certain level we need to maintain, and if we go below that, it’s also bad.”

Salloum, a dedicated researcher who regularly puts in 10- to 12-hour days, stands in the bright, open lab room in the newly renovated Pauley Heart Center research laboratories in Sanger Hall. A long, white lab bench divides the room. Set on it are bottles of chemicals, test tubes and other tools that he uses to prepare doses of hydrogen sulfide for his preclinical studies.

Abbate-patientFor the past four years, he’s studied—with the support of a prestigious AHA National Scientist Development Grant—what happens to the body when hydrogen sulfide is given on a daily basis to animal subjects following a heart attack. He specifically traces inflammation and programmed cell death, two conditions that occur following a heart attack and can contribute to heart failure. “Both are significantly attenuated with hydrogen sulfide therapy,” he says.

Ranking his research proposal in the top 1%, the AHA recently provided Salloum with additional funding to further his work. He currently has two active grants as principal investigator to study heart failure prevention from the AHA and Novartis Pharmaceuticals and is co-investigator on three NIH grants. In addition to his AHA Young Investigator Award, he’s also received the American Association for the Advancement of Science’s Excellence in Science Award.

“His work is high impact. He’s looking at critical cellular and molecular mechanisms that address the transition from cardiac stress into heart failure, which really is still a challenging and difficult area,” said Edward Lesnefsky Jr., M.D., VCU professor of and chief of cardiology at McGuire V.A. Medical Center.

A native of Beirut, Salloum says his interest comes naturally. Growing up in a Mediterranean country, he has long heard about the sulfur-based hot springs in Europe and North Africa known for their healing properties. Interestingly, recent studies have shown the springs can alleviate edema and other symptoms of heart failure, he says. Additionally, garlic, a heart-healthy staple of the Mediterranean diet, also releases H2S.

He earned his B.S. in biology from the American University of Beirut in 1996. After graduation, he served in the Lebanese Army Medical Brigade and then emigrated to the U.S. in 1998 and moved to Richmond (where his wife, Lusene, is from) to pursue his doctorate in physiology from VCU School of Medicine. He completed his postdoctoral training in 2008 under the mentorship of Rakesh Kukreja, Ph.D., director of the VCU Molecular Cardiology Research Laboratories, and then joined the VCU staff in 2009.

As a young scientist, he has appreciated the creative and encouraging environment fostered by Kukreja. “There’s so much room to explore and advance the field in the vibrant research setting that we have here at Pauley Heart Center,” says Salloum.

Together, the two have been co-investigators on multiple NIH grants over the past 10 years and have jointly authored over 50 research papers. “Dr. Salloum’s extraordinary research productivity and work ethic impressed me the most when I recruited him as a faculty member. In fact, he is one of the most talented colleagues I have worked with during my 30 years at VCU,” Kukreja said. “He is very passionate about science and is very pleasant to work with. He thinks beyond his own work to support others.”

Another colleague, Fowler shares this perception. “Fadi Salloum, is first of all, a very good human being. He’s very polite. And most of all, he is a very intense scientist. When he goes into a research topic, he dives deep into the problem,” he said.

About 10 years ago, Fowler and Salloum joined efforts to create the very first mouse cardiac ischemia model at VCU—a blueprint on how to induce and treat the condition in mice, as a precursor to human studies. Salloum has taught the surgical skill to various research groups, including one in Rome.

Basic research is at the front end of a long process. After the animal studies come many years of clinical trials before FDA approval is possible. For instance, Salloum says it may be at least 10 years before his H2S therapy is available by prescription to humans.

“Dr. Salloum’s strength has been real dedication. He’s going to keep after it until he’s successful. … He’s also a very creative individual. And I think he’s just really getting started and that there’s much more that he will achieve,” said Vetrovec.

Kukreja added, “His research is going to have huge impact on the treatment of patients with myocardial infarction and heart failure in the future.”


VCU Pauley Heart Center Renowned for Care of Afib Patients

Although every case of atrial fibrillation is different, many begin the same way.

“My patients will tell me, `I feel washed out. I don’t have any energy,’” said Dr. Jay Koneru, assistant professor of medicine, Division of Cardiology and Electrophysiology at the VCU Pauley Heart Center.

In addition to fatigue, patients may feel a fluttering or pounding in the chest, dizziness, lightheadedness, or shortness of breath.

According to the American Heart Association, about 2.7 million people in the U.S. suffer from atrial fibrillation. The condition can lead to heart failure and is one of the leading causes of stroke. It’s marked by an irregular and rapid heartbeat in the atria, the upper chambers of the heart. The condition affects the organ’s ability to pump blood efficiently, leading to pooling in the atria. At the root of the problem are abnormal electrical signals in the heart.

Dr. Kenneth Ellenbogen and Dr. Jay Koneru

Up to 10% of individuals over the age of 75 will develop the condition. In addition to age, the following are considered risk factors: previous heart attack; congestive heart failure; leaky valves; coronary artery disease, or inflammation near the heart; high blood pressure or diabetes; thyroid, lung or other illnesses; high levels of caffeine or alcohol use; sleep apnea. Afib may occur sporadically or be a chronic condition.

VCU Pauley Heart Center’s Atrial Fibrillation Program offers innovative treatments and cutting-edge research to patients under the direction of renowned physicians Dr. Kenneth Ellenbogen, Chair of Cardiology and Dr. Vigneshwar Kasirajan, Interim Chair of the Department of Surgery and Chair of Cardiothoracic Surgery.

Following appropriate treatment, afib rarely causes serious or life-threatening problems. The comprehensive, interdisciplinary program at VCU begins with diagnosis and extends to a full range of treatments, including medication management; implantation of cardiac assist devices such as pacemakers; cardioversions to shock the heart back into a normal rhythm; catheter-based ablations to disable the areas causing the fibrillation; and surgery, including minimally invasive options.

“We probably have one of the largest centers in the U.S. in terms of both the EP [electrophysiology] component and the surgical treatment of afib. The departments have a unique collaborative relationship,” said Dr. Kasirajan.

VCU’s afib program has gained widespread recognition for its expertise and innovation with ablative techniques. “We are one of the preeminent institutions in the world for atrial fibrillation ablation,” said Dr. Ellenbogen. “We have a track record of over 15 years in ablation and have pioneered—and continue to pioneer—the use of new tools and techniques.”

Dr. Jay KoneruThe center has, for instance, performed over 8,000 radiofrequency catheter-based ablations, which involves applying a burst of heat to destroy the tissues that cause the abnormal electrical signals. Pauley’s specialists can also freeze the problematic tissue areas through a newer procedure, cryoablation. They are also exploring cryoballoon ablation in clinical trials.

Other new advances at Pauley include the LARIAT procedure (see sidebar) and, soon, Topera’s FIRMap™ 3D, multipolar catheter which places an expandable wire “basket” over the heart. The structure conforms to the shape of the heart’s contours and contains 64 evenly spaced electrodes that record its electrical activity. The images are analyzed through Topera’s RhythmView™ 3D Electrophysiological Mapping System. Pauley will also be one of the few centers to begin using the WATCHMAN®, a device that is implanted in the opening of the left atrial appendage to help prevent strokes.

According to Dr. Koneru, “While there is currently no cure for atrial fibrillation, there are effective treatments.”


VCU Pauley Heart Center Receives $5 Million Gift from Pauley Family

Mrs_Pauley_award

The Pauley Heart Center at the Virginia Commonwealth University Medical Center recently received a $5 million gift from the Pauley Family Foundation to support research and recruitment for its worldclass Cardiology program.

“VCU’s progress as one of the nation’s Top 50 public research universities has been accelerated by a series of game-changers, and the Pauley Family Foundation’s latest generous gift is another example,” said Michael Rao, Ph.D., president of VCU and the VCU Health System.

According to Dr. Jerome F. Strauss III, dean of the School of Medicine, “we are very fortunate to have philanthropists in our community like Stanley and Dorothy Pauley, who are instrumental in helping us bring innovation and excellence to the care of patients with cardiovascular disease.”

The Pauley Heart Center ConsortiumThe Pauley gift, announced February 26 at the Pauley Heart Center Consortium dinner, will be paid out over four years. VCU received the first installment of $1.25 million in December 2012.

“This is a project that is near and dear to my heart,” said Stanley Pauley, who oversees the Pauley Family Foundation along with his wife, Dorothy, and daughters, Katharine Pauley Hickok and Lorna Pauley Jordan. Pauley, a former heart center patient, was so impressed with the staff that, in 2006, his foundation gave its first $5 million gift to the VCU heart center, which was later renamed the Pauley Heart Center. “The care these health care professionals provide is so genuine and moving that it is an honor to contribute to research that will enable them to learn even more about heart disease.”

The Pauley Heart Center ConsortiumAt the Consortium, guests learned that the Pauleys’ $5 million gift will be matched by the Glasgow Endowment— resulting in a total of $10 million for the heart program. The Pauley donation is also the lead gift in a new campaign that will provide additional opportunities for matching funds (see sidebar).

Dr. Rao presented Stan and Dorothy Pauley with white coats with their names embroidered in appreciation for their longtime commitment to the heart center.

“The Pauleys’ generosity through the years will have a lasting impact on the region and nation for the remarkable breakthroughs made possible for their support,” said Dr. Sheldon M. Retchin, senior vice president for VCU Health Sciences and CEO of the VCU Health System. “Thanks to their marvelous gift, we will be able to recruit even more talented faculty to the Pauley Heart Center.”

The Pauley Heart Center Consortium

The Pauleys’ first gift has already brought about significant improvements to the center, said Dr. Kenneth Ellenbogen, chairman of Pauley’s division of cardiology. “The Pauleys’ gift has transformed our facility into a first-tier heart center by allowing us to devote resources towards renovating and improving our research laboratories. It has also resulted in our attracting some new faculty in cardiology and particularly in structural heart disease and heart failure that has been substantial in improving our ability to take care of the sickest and most complex patients from all over the region.”

Originally from Canada, the Pauleys were married in 1949 and moved to the U.S. in 1954. Mr. Pauley is an engineer and the owner, chairman, and CEO of Carpenter Company in Richmond, the largest manufacturer of comfort cushioning in the world.


Female Clinical Cardiologists Thrive at VCU

Dr. Denlinger attended the VCU School of Medicine for both her residency and fellowship. Today, she is an outreach cardiologist for the Pauley Heart Center. She spends three days each week in South Hill, Va., assessing patients with a wide variety of cardiovascular diseases and performing non-invasive cardiac imaging.

In addition, two days a week she teaches medical students and fellows and sees patients at the Hunter Holmes McGuire V.A. Hospital in Richmond.

“She really is the ultimate clinical and academic modern physician,” said Dr. George Vetrovec, Director of VCU’s Adult Cardiac Catheterization Lab and Associate Chair for Clinical Affairs. “She teaches at the V.A. Hospital and is very accomplished in that regard. But she also has made a very critical contribution by bringing our traditional academic center into the South Hill community and creating a partnership there.”

The busy cardiologist stands among an increasing number of women who are thriving in a field historically dominated by men.

“Having more women in cardiology can bring different perspectives and different priorities in care. For instance, one of my interests is heart disease in women. Women have atypical presentations of heart disease, sometimes ignore their symptoms, and can be more difficult to diagnose,” she said. “I think if more women are in the field of cardiology, then there will be more awareness of these issues.”

Among medical students, a significantly higher percentage of men choose to go into the cardiology field than women. According to the American College of Cardiology, women make up only 20% of the total number of heart doctors.

The Pauley Heart Center has a successful record of recruiting female cardiologists. Like their male colleagues, Pauley’s female cardiologists are drawn to the university’s vibrant clinical and academic setting. Many of them, in fact, served their residency or fellowship at VCU.

“For instance, one of my interests is heart disease in women. Women have atypical presentations of heart disease, sometimes ignore their symptoms, and can be more difficult to diagnose.”

“VCU is world-renowned in cardiovascular medicine. We draw smart, hardworking doctors who want to be at the forefront of cardiac clinical research and advanced patient care,” said Dr. Kenneth Ellenbogen, Chief of the Cardiology Division, Pauley Heart Center.

Dr. Mary Ann Peberdy serves as Director of the VCU’s Advanced Resuscitation, Cooling Therapeutics, and Intensive Care (ARCTIC) program—featured last year on PBS’s NOVA series—and Medical Director of the hospital’s code and rapid response teams.

“Dr. Peberdy has helped build one of the best cardiac resuscitation programs in the world,” said Dr. Ellenbogen.

The patients seen by the ARCTIC team have suffered sudden cardiac arrest. Often confused with a heart attack, cardiac arrest occurs when the heart suddenly and unexpectedly stops beating. The result is that blood stops flowing to the brain and other vital organs.

Dr. Mary Ann Peberdy

ARCTIC’s strategy calls for paramedics to start the cooling efforts in the field, often before the heart can be restarted. Nationally, survival from cardiac arrest that occurs outside of the hospital is around 11%; ARCTIC has a consistent survival rate for these patients of about 50%.

In recent years, “there is a much deeper understanding of what causes the brain and heart injury after cardiac arrest, and new therapies, such as hypothermia and goal-directed care, can now significantly improve outcomes,” said Dr. Peberdy.

She joined the VCU faculty in 1993, after completing her residency and cardiology training at the Medical College of Pennsylvania. In addition to treating patients, she undertakes clinical and translational research in the fields of resuscitation and heart failure and is the author of over 140 research papers. She also maintains an active cardiology practice, specializing in patient care for advanced heart failure and critical care cardiology.

“The last 10 to 15 years have brought dramatic changes in the therapies available to treat patients with both heart failure and cardiac arrest,” she said. “They are probably two areas in cardiology that have seen a rapid advancement in the science that has translated into improved outcomes for both populations.”

Dr. Peberdy enjoys the challenge of caring for acutely and critically ill patients. “The greatest reward is being able to send someone home and back to their family after suffering a cardiac arrest.”

According to the American College of Cardiology, women make up only 20% of the total number of heart doctors. The Pauley Heart Center has a successful record of recruiting female cardiologists.

Originally from Canada, Dr. Evelyne Goudreau completed her medical training, residency, and cardiology fellowship at University of Montreal Faculty of Medicine. She attended VCU for a fellowship in interventional cardiology and then accepted a position on the faculty in 1988. She works as an attending physician in both the Cardiac Catheterization Lab and the Coronary Care Unit (CCU).

“Dr. Goudreau is a critical component of our faculty—a very hardworking, highly talented clinician,” said Dr. Vetrovec.

Dr. Evelyne Goudreau

Her work involves cardiac catheterization and percutaneous interventions. Since she began, one major change in the cath lab has been the implementation of primary angioplasty for patients presenting with acute myocardial infarctions, which has significantly improved their clinical outcome. This has been possible by reducing “time to balloon”—that is, the time it takes for a heart attack victim to receive angioplasty or other revascularization procedures.

“We have been at the frontier of interventional cardiology innovations,” she said. “We have pioneered many new technologies over the years, and the introduction of coronary stenting was truly a revolution in the cath lab, allowing performance of more complex angioplasties with significant improvement in short-term and longterm outcomes.”

Recently, “we have been involved in the clinical evaluation of robotics,” she said.

“Structural heart disease in the adult patient population is a field that will bring new technologies to the cath lab. We also anticipate increasing our involvement in hybrid procedures as we team with the CT surgeons.”

In the CCU, she has noticed a shift in patient population, with a substantial increase in heart failure patients. As a result, she said, “we are offering more aggressive mechanical support with the expansion of the heart failure and transplant program.”

Clinical electrophysiologist Dr. Jordana Kron found her calling while working shifts as a resident in the cardiac ICU of Johns Hopkins Hospital.

“It’s a very intense rotation, and we were on call there every third night. I think what I loved about it most was that the patients would come in so sick but there was such opportunity to help them,” she said.

Dr. Jordana Kron

One patient arrived with complete heart block and a pulse of 20. “The patient was critically ill and couldn’t stand up. The electrophysiology team came in and put a pacemaker in, and the patient went home the next day.”

Dr. Kron went on to receive her cardiology and electrophysiology training at the University of Florida in Gainesville, Fla. She now works at both VCU’s downtown campus and its outreach clinic at Stony Point.

“She is an outstanding clinician, with wide-ranging interests,” said Dr. Ellenbogen.

Her areas of focus include an extensive list of atrial and ventricular arrhythmias as well as device management in patients with heart failure. She has a special interest in cardiac sarcoidosis, a rare form of inflammatory heart disease that can cause both fast and slow rhythms in patients and can lead to sudden death.

“So little is known about cardiac sarcoidosis. It is hard to study these patients because it is so rare,” she said.

To further research, she organized a group of colleagues from 13 medical institutions in the United States, Canada, and India. The physicians studied the data collected in the defibrillators of 235 patients with the disease— the largest sample ever—and presented their findings at the Heart Rhythm Society in May 2012. Dr. Kron also helped to create the Cardiac Sarcoidosis Consortium, a registry to track the patients worldwide.

“The last 10 to 15 years have brought dramatic changes in the therapies available to treat patients with both heart failure and cardiac arrest,” she said.

She enjoys the intellectual, collaborative environment at VCU. “If we have an interesting case going on, we will pull in our partners so that we can work together,” she said. “I think that leads to really good patient care and also to ongoing education, where you continually learn from your partners.”

Dr. Hem Bhardwaj served her residency at University of Virginia Medical Center, and then attended VCU for her fellowship in cardiology. Upon completion of her fellowship, VCU offered her a faculty position.

“I jumped at the chance,” she said. “Working at VCU provides me the opportunity to teach cardiology fellows and interact with physicians who are on the leading edge of not only cardiovascular medicine but other specialties as well.”

Dr. Hem Bhardwa

“Hem Bhardwaj is a general cardiologist— something of a rarity in the field of academic cardiology, where the majority of cardiologists are subspecialized in some fashion. She has a better global view of the patients because of this,” said Dr. Richard Cooke, Interim Medical Director of VCU’s Heart Transplant and Advanced Heart Failure programs.

Dr. Bhardwaj’s special interests include echocardiographic imaging, especially related to heart failure. Most of her time is spent in clinical work, she said, “but I am now starting to participate in research. I am starting to look at the role of echocardiography in patients with heart failure who have mechanical assist devices.”

Additionally, she said, transcatheter aortic valve replacement (TAVR) is being introduced this year to VCU. The TAVR procedure involves replacing the aortic valve with a less invasive approach, as an alternative to openheart surgery.

“I am very excited to have been offered the chance to be involved in the echocardio- graphic portion of this new venture at VCU,” she said. “Having opportunities like this is instrumental to why I chose to work here.”


A Cut Above

At many hospitals, cardiac transplants are a rare and dramatic event; at Vcu’s Pauley heart center, “they’re a routine thing for us,” said dr. Vigneshwar Kasirajan, Pauley’s chairman of cardiothoracic surgery and director of heart transplantation and mechanical circulatory support.

The routine begins like this: When a good donor match is identified for a patient, the surgeon on call contacts the transplant coordinator. The coordinator works out the logistics with the organ procurement agency and the hospital’s staff, and then assembles the operating, critical care, and ICU teams. Two surgeons and their assistants scrub in for every transplant, along with a team that comprises cardiac anesthesiologists, operating room nurses, and perfusionists to operate the heartlung machine. One surgeon travels to the donor hospital to procure the heart. After returning to VCU, the surgeon makes any needed repairs to the heart before surgery. When the heart is ready, the surgeons can begin the transplant.

Once a heart is removed from a donor, the transplant team has only a four-hour window of time in which to work.

“That time frame is very critical. If you cross four hours, the outcomes are definitely worse,” said Dr. Kasirajan.

But with their experience, and their routines and procedures already in place, the VCU transplant team swings easily into action.

“Everybody knows exactly what their roles and responsibilities are, and there’s not a lot of hand wringing,” he said. “And I think that’s important, because if it’s not routine, and everything is a big production, there’s more room for error.”

Donor hearts can become available at any time; the hospital has even performed two cardiac transplants in a single day. A transplant surgeon’s life is composed of late–night phone calls, long and unpredictable hours—and unimaginable rewards.

“I did a transplant on Sunday on a woman who had been in the hospital for a long time,” he said. “It was very gratifying to see her get a heart, get well, and go home.”

“Vig,” as he is often called, grew up in india, the son of a cardiologist and a homemaker.

“My dad was a cardiology fellow in the United states in the 1960s, and he was at Maimonides [Medical Center in Brooklyn] when the first human heart transplant in the United States was performed by Dr. Adrian Kantrowitz,” said Dr. Kasirajan.

He grew up listening to his father’s stories of heart surgery and transplantation. “It was a big thing,” he said. “The ’60s and ’70s were when heart surgery was rapidly exploding, and it was very exciting.”

Inspired by his father, Dr. Kasirajan attended Madras Medical College in India. As a young medical student, he watched his first open heart surgery. That’s when he decided to become a cardiac surgeon.

“I saw the heart and it was kind of bouncing in and out,” he said, his eyes lighting up. “It was beating—it was actually beating. It was a dynamic organ.”

He went on to serve his fellowship in cardiothoracic transplantation and mechanical assist devices at the Cleveland Clinic Foundation and remained there for his residency in thoracic and cardiovascular surgery.

He has helped to create a vibrant environment at VCU, where he has been since 2003.

“Vig has been very instrumental in the resurrection of the heart transplantation program here,” said Dr. Keyur B. Shah, Medical Director of the Mechanical Circulatory Support Program.

In addition to his work with transplant patients, Dr. Kasirajan is at the forefront of a new frontier in cardiac surgery that includes artificial hearts and mechanical assist devices.

In 2006, he led the first surgical team on the East Coast to implant the SynCardia Total Artificial Heart, the only device of its kind approved by the FDA Since that time, he has implanted a total of 50 of the devices, and his work has helped establish VCU as one of the leaders in the realm of artificial hearts.

Data presented to VCU by SynCardia last fall establishes Dr. Kasirajan’s reputation as “one of the best total artificial heart surgeons in the world,” said Dr. Michael Hess, Director of Pauley’s Heart Failure Program. “He now has the largest and best experience with the SynCardia total artificial heart.”

Artificial hearts enable patients to improve their health, and even prolong their lives, as they await cardiac transplantation. The current wait time for a donor heart is six months to two years or more, depending upon the patient’s priority status.

Patient care plays a critical role in recovery. After receiving an artificial heart, the patient is transported first to the ICU and then to Pauley’s special device-dedicated, stepdown floor. Working in the unit are biomedical engineers and nurses specially trained to take care of patients with artificial hearts, left ventricular artificial devices (LVADs), and other heart–assist technologies.

As patients recover on the step-down floor, they begin to get stronger almost immediately. “The artificial heart has dramatically improved patient outcomes,” said Dr. Kasirajan. “We went from taking really sick patients who might have had only a 20 to 30 percent chance of survival to over 85 percent survival to transplant,” he said.

Based upon his experience and success with artificial hearts, Dr. Kasirajan was selected to be the lead investigator of a national clinical trial for the freedom driver, a small, portable air compressor that keeps artificial hearts pumping.

“With the Freedom Driver, the goal is to take selective patients who meet the criteria and ultimately let them go home to wait for a transplant,” he said. “Until now, when a patient went on an artificial heart and was waiting for a transplant, they couldn’t go home because they were attached to a large driver.”

VCU’s large driver, “Big Blue,” weighs more than 400 pounds. The Freedom Driver, by contrast, weighs about 14 pounds and can fit in a backpack.

Six patients at VCU have received the device, and “the ones that have been able to go home have been very happy, because a lot of them have spent months in the hospital,” he said.

“The device could lead to tremendous savings in health care costs,” he said. For instance, before the Freedom Driver, “we had one patient who was in the hospital for over 400 days, waiting for a transplant.”

Not everyone can receive an artificial heart; only those who are candidates for donor hearts. The devices are approved only as a “bridge-to-transplant.”

LVADs, on the other hand, can be either a “bridge-to-transplant” or a “destination therapy.” That means patients can live with the implanted device instead of continuing on to a transplant. LVADs are small, batteryoperated pumps that patients can recharge off their car lighters.

“We have a number of patients living at home with LVADs who don’t want a transplant because they’re doing really well on them,” he said. To qualify for an LVAD, the right side of the patient’s heart must function well. As its name implies, the left ventricular assist device supports primarily the left side of the heart.

The movement from large, pulsating pumps like the HeartMate XVE to smaller, quieter, continuous flow machines like the HeartMate II “is perhaps the single most important surgical advance [in treating advanced heart failure],” he said.

Dr. Kasirajan is part of a seven-surgeon cardiothoracic team that treats patients at both VCU and the Hunter Holmes McGuire Veteran’s Hospital. Their busy practice performs about 1,000 cardiac procedures each year, from valve repairs and coronary bypasses to minimally invasive surgeries for atrial fibrillation. They implant about 60-80 mechanical assist devices like LVADs, artificial hearts, and other temporary devices each year.

“We offer a comprehensive list of options for patients requiring heart surgery,” he said.

With its Medical College of Virginia campus, VCU operates the longest-running cardiac transplant program on the East Coast and the second–oldest in the nation. The program began with the hiring in 1965 of Dr. Richard Lower, an early pioneer in cardiac transplantation, who performed Virginia’s first human heart transplant in 1968. The university was also the site of the state’s first heart-lung transplant in 1986.

“VCU is very rich in the history of transplantation. I’m very fortunate to be here,” said Dr. Kasirajan.

He hopes to see donor heart transplantation move further along the continuum. “Candidly, transplantation has not changed a lot since Dr. Lower started doing it,” he said. For instance, “we’re still limited to four hours of time, from the time we take out the heart to the time we put it in. It limits us to donors who are within 800 miles.”

He would like to see devices developed that can prolong the time a heart can be safely preserved. Additionally, he is interested in testing donor hearts prior to transplantation and an organ donor waiting list that considers antigen matching.

“Heart transplantation is still evolving compared to liver and kidneys and other organs because we match hearts based only on blood type,” he said. “But that is probably going to change very dramatically in the future as we learn more about organ preservation and matching.”

He also believes that, ultimately, artificial hearts will be approved as destination therapies for many patients who are not optimal candidates for transplantation.

He is impatient for these changes, and that’s why he enjoys working at VCU. “In additional to doing clinical work, being here gives us an opportunity to participate in some cutting edge research with people in other specialties,” he said. “We have a lot of opportunities to collaborate with them and come up with new ideas.”