"Our cardiac catheterization laboratories are open every hour of every day," says Samin K. Sharma, MD, Director of Clinical and Interventional Cardiology, and President of Mount Sinai Heart Network. "We treat more than 14,000 cases every year” throughout Mount Sinai Heart. “We are one of the most experienced centers in the country and have one of the lowest complication rates in the New York tri-state area."
At each Mount Sinai Heart location, our goal is to establish a well-coordinated plan that includes a close partnership between you and your health care team. We consider a series of factors as we develop your treatment plan, including lifestyle changes, medications, and in more advanced cases, surgery and rehabilitation.
Factors that determine your course of treatment for heart disease include age, overall health, disease progression, risk factors, and patient preferences.
Taking advantage of the research happening every day at Mount Sinai Heart, our team can enroll patients in research trials for new and groundbreaking treatments not yet available elsewhere.
"Mount Sinai gives individual patients an unsurpassed array of options for both diagnosis and treatment of coronary disease," says Bruce Darrow, MD, PhD, Assistant Professor of Cardiology.
We often prescribe medication for our coronary artery disease patients. The most common medications include:
- Cholesterol medications such as statins
- Angiotensin converting enzyme inhibitors
- Calcium channel blockers
- Emerging therapies
Minimally Invasive Procedures
Our interventional cardiologists are highly skilled in the full spectrum of cardiac catheterization procedures, including but not limited to:
- Alcohol septal ablation (septal ablation)
- Ambulatory percutaneous coronary intervention
- Angioplasty and cutting balloon angioplasty
- Atrial septal defects closure
- Balloon valvuloplasty: Aortic and mitral
- Chronic total occlusion interventions
- Carotid stenting
- Intravascular ultrasound
- Left main coronary artery stenting
- Septal ablation (alcohol septal ablation)
- Peripheral vascular interventions
- Rotational atherectomy
- Stenting (Intracoronary and drug-eluting)
- Transcatheter aortic valve implantation
- Ventricular septal defect repair
For patients with coronary artery disease, specifically those with hypertophic obstructive cardiomyopathy (HOCM), traditional treatments have included pharmacologic agents such as beta-blockers that slow the heart rate and increase its ability to fill, pacemakers to alter the pattern of contraction to one that is more efficient (no longer a preferred treatment modality), and open heart surgery to remove overgrown heart muscle to enhance blood flow from the left ventricle. Mount Sinai Heart, and specifically The Mount Sinai Hospital’s Cardiac Cathetorization Lab is one of relatively few high-volume centers offering a fourth choice.
Alcohol septal ablation (ASA), a minimally invasive procedure, does not require general anesthesia or a lengthy recovery time, and is only rarely associated with complications sometimes found in open heart surgery. ASA is now the second treatment option for HOCM patients who are on maximum medical therapy. We also employ ASA for elderly women with hypertension who have mid-cavitary obstruction in HOCM.
Our interventional cardiologists perform ASA percutaneously to remove the overgrown heart muscle. This minimally invasive procedure involves light sedation, followed by the slow injection of 100 percent alcohol via catheter into one of the branches of the heart artery that leads to the enlarged septum. We deliver a high concentration of alcohol (1-3ml) directly to your thickened heart muscle and leave it in place for several minutes. The effect of the controlled cell death at the targeted location is immediate, as thin scar tissue starts to improve blood flow to and away from the heart. A small percentage of patients (5 to 10 percent) develop significant slowing of the heart rate (complete heart block) and, hence, a temporary pacemaker is always inserted to the heart from the neck and is left for a day or two after the ASA.
Working in a cardiac catheterization lab, our interventional cardiologists can watch the heart from all sides via X-ray fluoroscopy and echocardiography. This enables us to monitor correct catheter placement and the destruction of only the necessary cells to reduce the thickening heart mass.
Once you have undergone ASA, we monitor you closely in our Cath Lab ICU for two days following the procedure. Our team is particularly attentive to arrhythmias, heart blocks, and blood chemistry, tracking volume of creatine kinase (enzyme) leakage to indicate the extent of the controlled damage (normal leakage range is 700 to 1,500 enzyme units per liter). You will likely feel better almost immediately, and once safely stabilized, you will be able to return home on restricted activity for two to four weeks. We conduct follow-up echocardiograms three to six months later.
"The patients are happier going home the same day. The procedure is just as safe as an overnight stay," says Michael Kim, MD, Assistant Professor of Cardiology and Director of the Coronary Care Unit. "Less than 5 percent of the interventional heart centers in the United States are sending patients home the same day," says Dr. Kim. "Mount Sinai Heart is the leader in the entire country in this."
When coronary arteries become narrowed or blocked, oxygen-rich blood can’t reach the heart muscle. This can cause angina (pain) or a heart attack. Angioplasty and percutaneous coronary interventions (PCI), a minimally invasive procedure, can keep blood flowing to the heart by widening or holding arteries open. At Mount Sinai Heart, this is a same-day procedure for most patients.
To perform a PCI, our interventional cardiologists thread a catheter fitted with a device (such as a stent or balloon) from a small incision in the groin or arm to the problem site in the heart. At the problem site, the device opens the blockage and restores adequate blood flow.
When possible, at Mount Sinai, we employ the transradial approach, which uses the arm as the access site, as opposed to the groin. By using the arm, we decrease post-procedure bleeding, urination challenges, and other issues. Since there are fewer complications, you are more likely to be discharged the same day.
Once we have opened up the blocked artery, we may use a stent to keep the artery open. Stents are small, wire mesh tubes that provide support inside blocked or narrowed coronary arteries, and hold them open. Over several weeks, the artery heals around the stents, keeping them in place and the artery open.
Sometimes we use drug-eluting stents (DES), which are coated with a slow-release medication that helps inhibit scar tissue growth around the stent. This reduces the chances that the blockage will re-form (called restenosis). According to the U.S. Food and Drug Administration, DES does not increase the risk of clotting (called thrombosis) any more than use of a bare metal stent (BMS). In fact, advances in polymer stent construction and the drug elution that coats the stent makes DES more effective than BMS.
Data show that 80 percent of patients who receive stents have low recurrence of arteries closing up again, and less than 10 percent require repeat interventions. With use of drug-eluting stents, the risk of scar tissue forming in the stented area is less than 10 percent. Many of our patients receive stents in multiple vessels.
If restenosis occurs, Mount Sinai Heart physicians can treat it with intravascular brachytherapy. In this procedure, we thread a catheter to the site where it remains for a few minutes while we administer a dose of radiation that will decrease additional episodes of restenosis.
The heart's aortic and mitral valves sometimes become narrow, impeding blood flow. This narrowing, called stenosis, makes the heart work harder to maintain adequate circulation. To open the valve again, we at Mount Sinai Heart use a minimally invasive procedure called a balloon valvuloplasty.
During a balloon valvuloplasty we administer light intravenous pain medication and local anesthetic where we insert a catheter. Then we thread the catheter, tipped with a deflated balloon, from an entry point in the groin through an artery to the heart where we inflate the balloon to widen the valve. Once the valve has expanded, we deflate and remove the balloon. Stretching the valve opening generally increases blood flow and reduces symptoms.
The 30- to 60-minute procedure spares patients from having to undergo open heart surgery. Patients often stay in the hospital for at least one night following the procedure.
For the Aortic Valve
Balloon aortic valvuloplasty (BAV) is appropriate when severe aortic stenosis is causing serious symptoms (i.e. difficulty breathing, dizziness, and fatigue) and surgical replacement of the valve is not an option. Typically, patients who benefit from BAV are elderly (with an average age of 85) and suffer from co-morbid conditions, such as lung disease and prior stroke. Many have a limited life expectancy from an underlying illness making them unsuitable for more invasive procedures such as a PCI or surgical valve replacement. BAV tends to alleviate symptoms for 3 to 12 months, lasting about six months on average. We can repeat the procedure if required.
For the Mitral Valve
We use balloon mitral valvuloplasty for most cases of mitral valve stenosis. We use an echocardiogram to determine whether this approach is appropriate for the individual patient. Typically, it is appropriate for patients with are experiencing symptoms, for older patients with aortic valve stenosis who are unable to undergo surgery, and for some patients with pulmonic stenosis. Balloon mitral valvuloplasty usually lasts for five to seven years and, as with BAV, it is safe to repeat the procedure.
The left main coronary artery (LMCA) supplies blood to the heart's left ventricle. If this artery becomes blocked it impedes blood flow. Traditionally, surgeons have performed open heart surgery, often a coronary artery bypass graft (CABG), to create a detour around the blockage and restore blood flow.
However some patients with advanced coronary artery disease are candidates for a procedure called left main stenting. This procedure involves placing a metal stent coated with a time-release medication into the artery to open the blockage. Pioneered by Samin K. Sharma, MD, Director of Clinical and Interventional Cardiology, and President of Mount Sinai Heart Network, this minimally invasive technique can lower the risk of complications, shorten hospital stays, and speed recovery when compared with traditional CABG surgery.
Determining When Left Main Stenting is the Best Option
Left main coronary artery stenting is typically suitable for patients who are at high risk for surgical complications or have comorbidities. Patients with advanced aortic calcification, low life expectancy, chronic obstructive pulmonary disease, or cerebrovascular disease, for instance, may be good candidates for this procedure.
When determining the most appropriate procedure for your situation, our physicians also take into consideration your SYNTAX score, which is a grading tool for determining the complexity of coronary artery disease. If you have a lower SYNTAX score, you are more likely to be a candidate for LMCA stenting.
In a rotational atherectomy, Mount Sinai Heart interventional cardiologists use a revolving instrument to break up calcified plaque that is clogging a coronary artery. Breaking up the plaque restores blood flow to the heart.
We use rotational atherectomies for particularly tough blockages. The procedure involves navigating a catheter fitted with a Rotablator device through the site of the blockage, under a local anesthetic. The device then rotates at a speed of up to 150,000 rpm, gently pulverizing the blockage into tiny particles that can pass safely through the bloodstream. The procedure takes effect almost immediately. Within approximately five minutes, your blood flow and heart function will improve.
Our cardiologists sometimes use a rotational atherectomy with a left ventricular assist device, to give us enough time to perform the procedure as planned. We may also combine rotational atherectomies with stent placement.
Our interventional cardiologists are renowned for performing this complex procedure. Specifically, at The Mount Sinai Hospital, we manage the highest volume of rotational atherectomy in the country and are widely recognized for our success rate.
"This new technique of TAVR is a real game changer," notes Samin K. Sharma, MD, Director of Clinical and Interventional Cardiology, and President of Mount Sinai Heart Network. "It provides hope to many patients suffering from aortic stenosis who cannot undergo open heart surgery due to frailty, old age, and associated medical conditions."
Transcatheter aortic valve replacement (TAVR) and transcatheter aortic valve implantation (TAVI) are minimally invasive techniques designed to treat coronary artery disease, and particularly severe aortic stenosis. The Mount Sinai Health System, specifically The Mount Sinai Hospital, is the only hospital in the New York metropolitan area that offers both types of TAVR treatment options (Edwards Sapien Valve and Medtronic CoreValve System, which is in clinical trial) for these types of diseased aortic valves.
We use the TAVR and TAVI procedures to implant new aortic valves into the heart. The procedures take about four hours and you usually spend approximately five days in the hospital.
To perform either procedure, we make a cut on your leg to insert a sheath (a short hollow tube) that is about the size of a pencil. We use this sheath to place a balloon on your aortic valve. Then we inflate the balloon to prepare a space for the new aortic valve. After we remove the balloon, we replace it with a transcatheter delivery system containing the new aortic valve, using the sheath as a pathway and guiding it along with a type of X-ray called fluoroscopy.
Once in place, we deploy a new aortic valve into your diseased aortic valve. This new valve pushes the diseased valve to the side and the calcium build-up on the diseased valve acts like a glue to cement the new valve in place. As soon as it is in place, the new valve will start to work. We use fluoroscopy and echocardiography scanning techniques to make sure the new aortic valve is working properly. Then we remove the delivery system and close the cut in your leg.
Open Heart Surgery
In addition to minimally invasive procedures for treating coronary artery disease, at Mount Sinai Heart, we typically perform two types of open heart surgical procedures; heart bypass surgery and off-pump bypass surgery:
Heart Bypass Surgery
Heart bypass surgery, also called coronary artery bypass graft surgery, involves replacing diseased arteries with healthy ones. We use the daVinci Surgical System, a robotic device, to perform this procedure in a minimally invasive manner. This approach results in a shorter hospital stay and a quicker recovery.
"We have tremendous experience here in performing coronary bypass surgery, not only in healthier patients, but also in those with other serious medical conditions, including kidney and liver disease," says Farzan Filsoufi, MD, Professor of Cardiothoracic Surgery.
Off-Pump Bypass Surgery
Off-pump bypass, or "beating heart" surgery, does not involve the use of a heart-lung machine. This procedure reduces the need for blood transfusions, decreases risk of bleeding, stroke, and kidney failure, and lessens chance of nerve damage. In addition, hospital stays are shorter than with heart bypass surgery, and patients can make a quicker return to day-to-day activities.
"For the right patients, off-pump graft surgery is a better option than conventional surgery," says Ramachandra Reddy, MD, Assistant Professor of Cardiothoracic Surgery. For this type of surgery, the heart-lung machine is not used. Using stabilizing techniques, the surgeon grafts the bypass onto the heart while it continues to beat.