The Heart of Collaboration:
University of Maryland Heart Center Leaders Create Innovations in Patient care and Research

It was Saturday, December 8, 2001, a day that signaled the start of major advances in cardiac care at the University of Maryland. For Bartley P. Griffith, MD, professor and head of cardiac surgery at Maryland, it was the end of his first week on the job. Late the night before, he had received an urgent call from doctors at Baltimore Washington Medical Center that led to unprecedented preparations for emergency surgery.

Advanced cardiac care was needed, STAT, to save a man with a heart so weak that if he had waited just two more hours to come to the emergency room, he would have died.

Dr. Griffith, chief of cardiac surgery and director of heart and lung transplantation at the University of Maryland Medical Center, immediately put in a rush order for two heart pumps, then quickly assembled and briefed a team on the procedure they would perform—a first for the medical center.

At the end of the day, both devices were stabilizing the pumping action on the left and right sides of the man’s heart. This dual-pump surgery saved the man’s life and kept him healthy long enough for a successful heart transplant two months later. The patient, Robert Bothe, continues to do well today.

"Without the pumps, Mr. Bothe would have died from the effects of shock. One of the key things we’ve learned is that if you institute these pumps early enough, you can prevent irreversible damage to the brain, the lungs and the kidneys,” Dr. Griffith said shortly after the procedure.

Mr. Bothe and other heart patients are benefiting from an explosion in new patient care innovations and research initiatives at the University of Maryland Heart Center, driven by two internationally renowned cardiac care specialists, both recognized clinical and research leaders.
Mandeep R. Mehra, MD, professor of medicine and head of cardiology, joined the medical center in 2005. He came from the Ochsner Clinic Foundation in New Orleans, La., where he was vice chair for clinical and academic affairs in cardiovascular medicine and chief of cardiomyopathy and heart transplantation at the Ochsner Multi-Organ Transplant Center.

Dr. Griffith came to the University of Maryland from the University of Pittsburgh, where he had established a worldwide reputation as a pioneer in heart and lung transplantation, with vast experience in the implantation and development of heart pumps for a wide range of patients with end-stage heart failure.

Dr. Griffith’s creative action in that early case set the stage for his approach to patient care at the Maryland Heart Center. His leadership has inspired the center’s multidisciplinary team to develop innovative treatments and become nationally known for advanced treatment of most heart problems.

The dual-pump therapy was soon followed by a first for the nation. Dr. Griffith implanted a new, experimental heart pump, the Jarvik 2000, in two people who became the first in the United States to go home from the hospital with the pump to await a heart transplant. Until then, FDA regulations required Jarvik 2000 patients to remain in the hospital to await a donor heart.

The “firsts” continued with another dramatic heart surgery to save the life of a woman with a rare recurring heart tumor. In a first-of-its-kind solution for her vexing problem, Dr. Griffith completely removed both of her heart’s upper chambers (the left and right atria), then reconstructed them with animal and human donor tissue. To make this possible, the woman’s heart was removed from her chest for about five hours before being re-implanted.

Personalized Care
Similarly, Dr. Mehra’s arrival at Maryland heralded a new era of personalized care and compassion on the cardiology side of the heart center. He has fostered a special emphasis on cardiac care for the whole person through simple measures such as a mid-afternoon quiet hour in the cardiac care unit and the use of yogic breathing exercises for heart failure patients. He has also galvanized all levels of the heart center to provide rapid, high quality cardiac care.

He had moved from New Orleans to Baltimore just a few months before Hurricane Katrina hit. Shortly after the devastating storm, Dr. Mehra received a call for help from one of his former heart failure patients in New Orleans. She had lost her home to the storm, and flooded hospitals in New Orleans were unable to treat her rapidly worsening heart failure. Dr. Mehra arranged for the woman to come to the University of Maryland Medical Center for treatment. The patient, who calls Dr. Mehra her lifesaver, received a heart pump soon after she arrived in Baltimore, just in time to prevent further cardiac damage.

In another case, in the fall of 2006, Dr. Mehra’s prompt action prevented what could have been a life-threatening heart attack for Sandy Unitas, widow of football great Johnny Unitas. She had no history of heart disease, but came to Dr. Mehra for a routine cardiac checkup as she prepared to address an organization that promotes heart disease prevention in women. Dr. Mehra suspected she had a problem based on a potential symptom that can presage a heart attack in some women—depression. He ordered tests that confirmed she had a large blockage in her main coronary artery. Within hours, she was in the cardiac catheterization suite where Dr. Mehra opened the blocked vessel.

“This could have been like a ticking time bomb in her heart,” says Dr. Mehra. “But we got it before her heart was damaged." Dr. Mehra is well known for his clinical and research expertise in heart failure.

He is the lead author of new heart transplantation guidelines from the International Society for Heart and Lung Trans-plantation, published in September 2006. As chair of the expert panel that developed the guidelines, he says they represent the first truly international consensus in an effort to standardize care of patients with heart failure.

He is also a principal investigator in a multi-center study of a new blood test that may predict early organ rejection in heart transplant patients, without the traditional heart biopsy.

Unique Collaboration
Some of the most interesting advances at Maryland in recent years have evolved from collaborations among cardiologists and cardiac surgeons that both leaders say are unique. According to Dr. Mehra, “Heart centers in general try to bring together the cardiologists and cardiac surgeons, but we have gone beyond what many have been able to do. We are integrating surgical and medical treatments to provide the best care for individual patients.” This integration contributed to a 25 percent growth in cardiac admissions from 2004 to 2006.

A new hybrid procedure to treat multi-vessel coronary blockages exemplifies this collaboration. The University of Maryland Medical Center is one of the first hospitals in the United States where cardiac surgeons and cardiologists work together to restore normal blood flow to all of a person’s blocked coronary arteries while also improving patient recovery and convenience.

A surgeon uses robotic assistance to perform multiple-vessel bypass surgery without opening the chest. In the same operating room, which is both a fully-equipped surgical suite and a state-of-the-art cardiac catheterization laboratory, an interventional cardiologist uses stented angioplasty to open other blocked heart vessels.

The hybrid approach began in 2005; robotic assistance with the da Vinci S Surgical System was added to the mix in 2007.

Another collaboration links a cardiac surgeon who has expertise in the surgical treatment of atrial fibrillation with cardiologists who specialize in the medical management of the condition. The result is a multidisciplinary clinic in which the team will assess whether drugs, non-surgical ablations or surgical procedures are best for a patient.

On another front, cardiologists in the heart rhythm service have joined their colleagues in nuclear medicine and radiology to bring real-time imaging into the electrophysiology laboratory. They have coupled highly detailed PET/CT and MRI images with traditional catheter-based mapping to determine where to apply radiofrequency ablation.

This type of therapy destroys scar tissue on the underside of the heart that may cause the electrical abnormalities in ventricular tachycardia, often associated with sudden cardiac death. The task of locating these multiple points of heart attack-related scar tissue has traditionally been time-consuming and risky: healthy tissue or blood vessels could inadvertently be destroyed; abnormal tissue could be overlooked.

The addition of imaging speeds up the process, enhances accuracy and improves success rates. “Things we thought were not possible before are being done now, thanks to the power of more sophisticated imaging and advanced percutaneous techniques,” says Dr. Mehra. He adds that treatment success for ventricular tachycardia using conventional electrical methods hovers at about 50 percent nationally. At the University of Maryland, the imaging component has helped boost the success rate to 80 percent.

Another strong heart center program focuses on pulmonary hypertension, a lung disorder in which blood pressure in the pulmonary artery rises far above normal levels. This collaborative effort, led by Myung H. Park, MD, assistant professor of medicine, was started shortly after Dr. Mehra arrived and is now the region’s largest pulmonary hypertension program. It offers comprehensive diagnostic and treatment services to patients with all forms and stages of pulmonary hypertension.

While collaboration has become a distinguishing characteristic of the Maryland Heart Center, the strength of that collaboration pivots around the expertise of individual team members.

Early on, Dr. Griffith decided to focus on making each surgeon a regional and/or national expert in one area in which he or she was particularly gifted and interested in pursuing. “We began to see how we might be able to deliver all the patients with the same problem to one surgeon, so that individual’s experience would grow,” says Dr. Griffith.

A heart valve program soon began to emerge. James S. Gammie, MD, associate professor of surgery, began specializing in mitral valves while Jamie M. Brown, MD, associate professor of surgery, concentrated on aortic valves.

In another example of specialization, Robert S. Poston Jr., MD, assistant professor of surgery, concentrated on coronary artery bypass grafting (CABG). That specialization led to his novel notion to configure a surgical robot, often used in pro-state surgery, to assist in bypass surgery. In September 2006, the University of Maryland Medical Center became the first hospital in Maryland, Delaware, Washington D.C., and Northern Virginia to perform minimally invasive, beating heart, multiple-vessel coronary artery bypass surgery with the assistance of a surgical robot.

“We’ve seen patients now contact us from out of town for coronary artery bypass surgery because they’ve read about our robot-assisted procedure, and that’s basically the bet paying off,” says Dr. Griffith.

The heart center’s heart failure service is a major endeavor that illustrates the continuum of medical and surgical treatments available at Maryland. Stephen S. Gottlieb, MD, heart failure service director and professor of medicine, leads the program, which draws on the talents of a large team of nurses, cardiologists, surgeons and other caregivers who provide therapies that either block or slow the progression of the disease.

On the heart failure research front, a recent landmark genetic study at Maryland’s cardiopulmonary genomics laboratory is opening the door for person-alized medical treatment. Lab director Stephen B. Liggett, MD, professor of medicine and physiology, has identified a common genetic variation that predicts a patient’s response to beta-blockers, frequently used to treat chronic heart failure. A simple genetic test guides physicians as they develop the best treatment for individual patients with heart failure.

Many patients with end-stage heart failure benefit from the heart center’s mechanical circulatory support program. Heart pumps, also known as ventricular assist devices (VAD), are the main tools of this program. The use of VADs at Maryland has accelerated during the five years since Dr. Griffith’s arrival. “We have 11 VADs of all sizes and shapes, some FDA-approved, some experimental,” Dr. Griffith says. He is principal investigator on a National Institutes of Health (NIH)-funded project to develop a tiny heart pump for infants.

For many patients, heart transplantation is the next step after a VAD. The heart transplant program at Maryland now leads the region and is another example of effective collaboration among cardiologists and cardiac surgeons.

Research Vision
Heart center surgeons are exploring new frontiers, such as biosurgery or regenerative surgery, in the school of medicine’s research laboratories. With seven NIH awards, the surgeons have robust portfolios of new research designed to translate to patient care.
In one study, heart patches that contain human fibroblast cells are sewn to the heart to stimulate heart muscle revascularization. Stem cell studies are also in the works. “I predict that within a year we’ll have at least one protocol where we’ll be putting patients’ own bone marrow-derived stem cells into their hearts,” says Dr. Griffith.

He adds that Maryland has a foremost investigator in another area of research, xenotransplantation. This is the transplantation of animal cells, tissues or whole organs into people. In describing the work of Richard N. Pierson III, MD, clinical director, heart and lung transplantation and professor of surgery, Dr. Griffith says, “If they’re able to unlock the challenge of pig hearts and lungs into humans, we’ll be there, because there’s no more accomplished leader in heart xenotransplantation than Dr. Pierson. When the time comes for renewed clinical evaluation of this challenging work, our center will be at the forefront.”

In cardiology, Dr. Mehra has brought about shifts in staffing, research and programming to further personalize cardiac care. “We’ve become a lot more patient-friendly,” he says. “Our inherent focus is on improving outcomes for patients using the least invasive techniques. Improving the patient experience is one of the key areas that has evolved since I’ve been here.”

The catheterization laboratory is an example of this. For the best outcome, the goal is to have most patients with a certain type of heart attack in the lab within 90 minutes. An American College of Cardiology database ranks the University of Maryland Medical Center in the 97th percentile of hospitals nationwide that met the goal.

Another example is the preventive cardiology program, where cardiologists strive to intervene early to reduce risk factors. Researchers in the program have produced significant studies on lipids and dietary interventions.

The new emphasis on personalized cardiology includes a unique program: behavioral cardiology, which embraces a holistic view of the patient with heart disease. Willem J. Kop, PhD, associate professor of medicine whose background is in psychology, says this new program will attempt to account for all the factors not strictly related to the biomedical model that may drive heart disease.

Behavioral cardiology involves the study and application of health behaviors and psychosocial factors in the assessment and reduction of cardiovascular risk. Health behaviors are exercise, smoking, eating habits, alcohol consumption. Psychosocial factors, such as stress, anger and depression are relatively new areas of research. “We know a lot about cholesterol and blood pressure, and we have started to increase our knowledge of genetic factors. But most of these risk factors reflect an interplay between genetics and environmental factors such as diet, stress and exercise,” says Dr. Kop.

One of his studies looks at depression. Another study examines the role of acute stress in heart disease, focusing on inflammatory markers of heart disease, such as C-reactive protein and interleukin 6, and the activity of blood particles. Dr. Kop plans to incorporate behavioral cardiology into the teaching curriculum because it could become an important tool for the next generation of physicians.

Dr. Mehra says heart center cardiologists and surgeons practice a form of medicine that mirrors the vision of the future as articulated by the NIH. It is cardiac care that is predictive, personalized, preemptive and participatory. “You cannot be in your physician silo,” he says. “You have to participate with the patient. You have to participate with the community.”

As for the future of the University of Maryland Heart Center, both Dr. Griffith and Dr. Mehra foresee growth in existing programs, the development of even more innovations, and continuing improvements in patient care delivery.

For Dr. Griffith, innovation is the key. “I think the only way we can expect to have a viable, healthy, growing heart center is if we’re bringing innovations to health care. We have the core people here necessary to make this all happen, and I think the core people will be able to bring the next generation of bright stars here to take us to the next step,” he says.

Dr. Mehra predicts a gradual merging of cardiovascular medicine and cardiovascular surgery. “The surgeons will be less surgical and the cardiologists will become more surgical. Minimally invasive procedures will move into the entire realm,” he says.

Further, he says genomic medicine will become a clinical reality. Simple blood tests will enable the development of a risk profile based on a person’s genes. “From genetic profiling, we’re going to learn your risk of obesity, what kind of obesity you will have. Will it be more responsive to running, to aerobic exercise, or more responsive to stretching exercises like yoga? So we’re going to develop a personalized profile and then we’ll tackle it preemptively and in a predictive way,” he says.

Says Dr. Mehra, “The future, as I see it, is the elimination of crisis intervention. Heart attacks will be only for the very few.”