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Combining a Forward Focus and Committed Care

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LEXINGTON When interviewing four of the physicians from the heart and vascular care department of Saint Joseph Hospital (SJH), the word commitment became the central theme — commitment to integrity, commitment to technology, commitment to continuing education, and commitment to patient care. With cardiovascular disease being the second leading cause of death in Kentucky, the focus must be on providing superior heart healthcare to our population.

Keeping His Mentors in Mind

Since joining SJH and the KentuckyOne Health network six months ago, vascular surgeon, Igor Voskresensky, MD has been able to put into practice the principles he learned from the mentors who shaped his surgical career.

In 1996, Voskresensky and his parents moved to the United States from Krasnodar, Russia. After attending Henry Clay High School and graduating from the University of Kentucky, he went on to complete medical school and his residency at Vanderbilt University. This was followed by a vascular surgery fellowship at the University of Florida (UF).

While at UF, Voskresensky met three vascular surgeons, who he describes as “true gentlemen.” These mentors greatly influenced his path. “I saw how calm they were in difficult situations. How they would get up at two in the morning to take care of a patient. And, this selfless approach to medicine was hugely formative to me as a vascular fellow.”

Upon fulfilling his fellowship, Voskresensky realized Kentucky was the perfect place to practice. His parents still live in Lexington and vascular disease is centered in this area of the southeastern United States. “For a vascular surgeon, this is the place to be if you want to impact a lot of people. And, there are not enough vascular specialists out there.”

Some of the most common conditions Voskresensky treats are peripheral arterial disease (PAD), aneurysms, dialysis access and maintenance, and carotid artery disease. He notes, with vascular surgery, “the procedures range from minimally-invasive repairs to major surgical reconstructions, but each can have an incredible impact on the patients’ life.”

Most of these procedures rely on state-of-art imaging, ultrasound, and computed tomography (CT) scanning for diagnosis and planning. “That is one of the most important aspects of vascular surgery. You have to have a plan. You have to visualize the anatomy and have a plan each step of the procedure. And if plan one fails, you have to have plan two. Imaging greatly helps because that’s how you plan. That’s how you plan for success.”

When faced with a difficult situation, Voskresensky always comes back to the words of one of his fellowship mentors, “The right thing to do is usually the hard thing to do.”

Taking on Technology

“Electrophysiology is one of the most advancing fields,” says Firas El Sabbagh, MD, a cardiac electrophysiologist. Electrophysiology is the biomedical field dealing with the study of electric activity in the body, which encompasses heart rhythms. El Sabbagh continues, “There is a great deal of research and new technology coming out.” El Sabbagh attended medical school at the American University of Beirut and did his residency in internal medicine at Cleveland Clinic. Fellowships in cardiology at the University of Missouri and electrophysiology at Case Western Reserve followed.

El Sabbagh sees a wide range of heart rhythm disorders in individuals of all ages. The treatments for rhythm disorders range from medicine to ablations to implantable devices. Variety is one of the reasons El Sabbagh chose the field of cardiac electrophysiology. “It is a challenging specialty It needs a lot of systematic thinking and approach,” El Sabbagh says, “This field is very quickly advancing. And, for us in this field, it’s not only just continuing practice and waiting until things land on your plate. I personally go to conferences on a regular basis.”

One of the most promising procedures is ablation to cure supraventricular tachycardia (SVT). In this minimally-invasive procedure, a catheter is threaded through a femoral artery or vein to the heart where it then burns the spot in that is misfiring.

In addition, improved 3-D mapping systems have allowed electrophysiologists to reduce the need for radiation. Advancement in catheters, which can now alert physicians to exact location, pressure, and the level of energy that needs to be emitted, is also leading to better results. And, implantable devices such as pacemakers that allow remote monitoring, leadless pacemakers, advanced implantable cardioverter defibrillators (ICD), which prevents clots in patients who cannot take a blood thinner, are also changing the game.

Staying in Front of the Learning Curve

Expanding his education to better serve his patients has been a lifetime goal of cardiothoracic surgeon, Ahmad Chaudhry, MD. “I have spent a very long portion of my life in school. I have grown old and grayed my hair in school,” Chaudhry says, with a laugh.

Chaudhry’s medical education began at King Edward Medical University and was followed by a residency at the University of Connecticut School of Medicine. To date, he has completed three fellowships. The first, in cardiothoracic surgery, at the University of Illinois School of Medicine-Chicago. Next, he completed a heart and lung transplantation and mechanical circulatory fellowship at the University of California in Los Angeles (UCLA). And, most recently, he fulfilled a fellowship in minimally-invasive advanced cardiac surgery and robotics at New York University.

Our State’s Greatest Challenges

Three difficult challenges are facing Kentucky at this time.

The nationwide outbreak of this year’s dangerous and deadly strain of influenza has reached epidemic levels in our state. “Flu is now becoming a very common cause for admission to the hospital,” says Chaudry. He notes that many individuals have suffered respiratory failure as a result of the flu. Some have required a ventilator, while the more serious cases have demanded extracorporeal membrane oxygenation (ECMO), which according to the Society of Critical Care Medicine, is “a temporary mechanical support system used to aid heart and lung function in patients with severe respiratory or cardiac failure.”

“With viruses becoming more virulent and less easy to treat and vaccinate against, there will be a higher rate of respiratory failure and more people will need to be put on ECMO,” says Chaudry.

The next issue, literally, hits to the heart of the opioid crisis. Kentucky’s opioid epidemic has found its way into the operating room. “One of the more prominent issues that we are seeing now that was uncommon even three or four months ago is infection in the heart and the heart valves. The majority of these infections are from the opioid crisis,” says Robert Salley, MD, a cardiothoracic surgeon with SJH.

Because of the tightened restrictions and regulatory measures taken to stop the distribution of pills, there has been a huge surge in intravenous drug use. Contaminated needles can introduce bacteria into the blood stream, which can lead to endocarditis, an infection which affects the inner lining of the heart chambers and valves of the heart. Chaudhry states, “It is unfortunate that we are seeing a lot more of it in our practice here at Saint Joseph Hospital. The number of patients coming in with endocarditis has, for lack of a better term, really skyrocketed.”

Endocarditis can require replacing or repairing the valves through open heart surgery. “The sad aspect is that most of these patients are extremely young and have no reason to develop a heart valve problem,” says Chaudhry.

The final and most prevalent threat to the health of Kentuckians is tobacco. Smoking often leads to severe arterial blockages in legs, heart, and the brain, which often precipitates a heart attack, stroke, or loss of limbs. Salley states, “The biggest contributor to heart disease in the state of Kentucky is tobacco. Unfortunately, Kentucky and West Virginia are consistently number one and two in the percentage of the state’s population that use tobacco and use cigarettes.”

As cardiothoracic surgeons in this region, Salley and Chaudhry encounter excessive rates of lung cancer, as well. “The state of Kentucky has the highest prevalence of lung cancer in the country. And, a lot of it has to do with the fact that there’s a very large number of people in Kentucky who smoke and have not just a history of smoking but a history of decades of a pack year,” says Chaudhry.

Salley feels our state government must address the smoking issue and offers a proven way to do that. “Ninety percent of the patients who have lung cancer are smokers. I think a challenge for the state of Kentucky is to figure out a way to decrease the initiation of smoking particularly in the teenage population, and most studies have shown the best way to do that is to increase the cost of a pack of cigarettes.”

Only a Call Away

Though from different specialties, all four physicians would give the same message to primary care doctors, which is essentially, don’t hesitate to call.

Chaudhry offers, “If they even have a remote suspicion that there is something a cardiothoracic surgeon could do, then instead of waiting or procrastinating, just be comfortable in contacting us. Just pick up the phone and gives us a call and let us take the burden of evaluating them and working them up.” He adds, “As with any other specialty, I can make the decision much faster than a primary care physician as to whether this person needs an operation or not.”

Voskresensky also wants first-line providers to know he is ready to assist. “The one thing I want all of the primary care physicians that we work with to know is that we’re always available. My goal is to be an expert in my field, so our interaction is extremely important. Call me, text me, we’ll make it happen.”

For El Sabbagh, not procrastinating before reaching out is essential. “It is important to refer your patient early in the disease, especially with AFIB. You do not want AFIB to get aggressive.”

When it comes to patients, the four also have a similar message.

“One message to the public is don’t ignore your symptoms. If you have any symptoms, which could include heart racing, which we call palpitations, shortness of breath, more fatigue than usual, don’t just blame it on age. You need to seek medical attention,” says El Sabbagh.

Salley, as well, would like to “encourage patients to effectively participate in their own care and allow the caregivers, as well as the families involved, to be open, allowing everyone to be a part of the process.”

In addition to being proactive, the four encourage patients to ask questions and become educated to their options. El Sabbagh states, “Our job is to educate the patient about the options and to let them know what we think the right option for them is at that time.” He goes on to say, “We really are very proud of the education we provide, with the quality of care we provide. Every patient for me, and for us, is a VIP patient, and we provide them with the best care, state-of-the-art care, and we are always available to answer their questions.”

Meet Structural Heart Team Member, Robert Salley, MD

Robert Salley, MD, a cardiothoracic surgeon at Saint Joseph Hospital (SJH), entered medicine to “be of service and give back to the community.” On entering his specialty, Salley says, “When I saw a human heart, open and beating, I was absolutely hooked and moved straight into cardiac surgery.”

Salley is part of the structural heart team at SJH. This four-person team, containing two cardiologists and two cardiothoracic surgeons, is the first of its kind in Kentucky. Salley received his medical degree from Louisiana State University School of Medicine, did his residency at the University of South Alabama, and then completed cardiac surgery fellowships at Vanderbilt University and the University of Rochester.

He most often performs cardiac and congenital heart surgery on adults and specializes in acquired valvular heart disease in patients who have complex, valve-related abnormalities. And now, thanks to new instrumentation and technology, Salley can use minimally-invasive surgery instead of sternotomy for some open heart surgical procedures. This technology is also changing the way lung disease is being treated.

The training and technology all help Salley accomplish his overriding goal of providing the best patient care. As the person to whom “patients relinquish control, in an attempt to regain their health and save their lives,” he feels a deep responsibility.

Salley states, “It is a process done with pride, but also with respect for that person’s dignity and the difficulties that both that person and their families are having.”

But, in the end, the responsibility also brings reward. “It’s so gratifying to have a patient who was in the throes of a heart attack, who gets that heart attack managed, and those heart valves fixed, and then leaves the hospital in four or five days ready to move forward and heal from that intervention. And, at the same time, be a better person from a cardiac standpoint than they were before that journey occurred.”

Voskresensky takes this one step further. “One of the things I tell patients when they come into the office and are skeptical is, ‘I would not do anything to you that I would not do to my loved ones. I will treat you like I treat my family’.”