Archive for March, 2013

Cardiac MRI Offers Powerful Diagnostic Tool for Heart Imaging

Cardiac MRI is a very powerful diagnostic tool and one of the most valuable techniques available to image the heart, says Samer Sayyed, MD, cardiologist at The Nebraska Medical Center and assistant professor of Internal Medicine at the University of Nebraska Medical Center (UNMC).

“Cardiac MRI goes beyond just analyzing the structure of the heart, but can also provide accurate quantitative assessment of bi-ventricular and valvular function, shunt fraction, myocardial perfusion, viability and scarring, as well as angiography of the pulmonary and systemic vasculature, all while avoiding the use of ionizing radiation or contrast agents that are toxic to the kidney,” he says.

First line cardiac diagnostic studies generally involve an electrocardiogram and/or an echocardiogram. A cardiac MRI study is appropriate when other tests are inconclusive, or when additional information about a patient’s cardiac condition is required to develop a more accurate diagnosis or management plan, notes Dr. Sayyed.

To get the most value from an MRI, the exact indication for ordering the test needs to be provided so the study can be tailored to effectively answer the clinical questions at hand, says Dr. Sayyed. “The study itself can take anywhere from 30 minutes to over an hour sometimes,” he says, “therefore, time is of the essence, and it is not a test to be performed in emergency situations.”

Some of the primary indications for cardiac MRI include:

  • Assessment of cardiac structure and function when other techniques are insufficient or ineffective
  • Evaluation of valvular structure and function
  • Cardiac stress testing
  • Assessment of myocardial viability prior to revascularization
  • Ischemic and non-ischemic cardiomyopathy such as hypertrophic cardiomyopathy, sarcoidosis, amyloidosis, and hemochromatosis.
  • Cardiac masses or thrombi
  • Complex congenital heart disease
  • Aortic and pulmonary angiography for aneurysms/dissection even for those who can’t receive contrast
  • Complex intra and extra cardiac shunts
  • Arrhythmogenic right ventricular dysplasia
  • Pericardial disease such as acute pericardial inflammation and pericardial constriction

A comprehensive list of appropriate, uncertain, and inappropriate indications for cardiac MRI has been published by the Journal of the American College of Cardiology in 2006, says Dr. Sayyed.

It should also be noted that the contrast agents used for cardiac MRI are very different from those used for CT scans, says Dr. Sayyed. A CT scan uses an iodine-based agent whereas a cardiac MRI uses a gadolinium-based agent. The iodine agent can be toxic to the kidneys. The gadolinium-based agent, on the other hand, is not nephrotoxic and can be given to a larger group of patients, even those with moderate kidney disease. However, it should not be used on those patients with severe kidney disease. Even in those with a contraindication for contrast, there are ways to perform non-contrast enhanced MRI angiography with high image quality, notes Dr. Sayyed.

Because cardiac MRI uses magnetic fields, patients with implanted ferromagnetic material such as pacemakers, nerve stimulators or have a history of welding may not be eligible for this test. Obese and claustrophobic patients may also be unable to fit within the magnet, or tolerate being confined within its bore for the duration of the study. Despite these few limitations, MRI remains the gold standard noninvasive method of evaluating a wide array of cardiovascular diseases.



Early diagnosis and evaluation is key for patients with kidney disease who are candidates for hemodialysis. “Our goal is to evaluate patients well before they need dialysis so we can provide them the proper access and determine if they are candidates for transplant,” says Michael Morris, MD, who heads the Vascular Access Clinic at The Nebraska Medical Center. Dr. Morris and his team specialize in vascular access surgery, laparoscopic procedures and kidney transplantation.

“One of the leading reasons for rehospitalization for these patients is complications related to their vascular access,” he says. Common complications include strictures, infections, aneurysms, clotting and poor blood flow. “Our team has been doing this for many years. We have the experience and expertise to ensure our patients are receiving the correct type of access, the procedure is performed properly and they are cared for and managed appropriately.” Dr. Morris and his team work very closely with nephrologists in the dialysis unit to determine the best solution for each patient and to minimize complications.

“This is a long-term relationship,” says Dr. Morris. “We are committed to the long-term care and health of our patients. “We understand that the loss of vascular access can mean the difference between life and death for our patients.”

Dr. Morris specializes in placing fistulas, which is the most difficult procedure to perform but it is also the most successful with the fewest problems over the long term, he says. Patients require four to six weeks of healing time after surgery before they can begin dialysis. He also performs catheter access procedures, which are intended for short-term use and should be avoided whenever possible as they tend to injure the veins.

Because the clinic is associated with the Transplant Program at The Nebraska Medical Center, patients have the benefit of being evaluated for kidney transplant at the same time they are evaluated for vascular access. “In some cases, we can delay dialysis, and at the very least, get the transplant process started while the patient is on dialysis instead of waiting until the patient is in a dire situation,” says Dr. Morris. This is important because unless the patient has a living donor, the transplant waiting time can be up to several years. Many patients qualify as transplant candidates.

The ultimate goal, notes Dr. Morris, is to avoid dialysis whenever possible and to get a patient on the transplant list. But for this to happen, “we need to see patients well before they need dialysis,” he says. “The risks associated with dialysis tend to be far greater than the risks associated with transplant and transplant patients have longer survival rates.”

Early symptoms of kidney disease include protein in the urine, uncontrollable high blood pressure and serum creatinine.

Dr. Morris is also co-director of the Kidney/Transplant program at The Nebraska Medical Center and associate professor of Surgery at the University of Nebraska Medical Center.

High-Speed Nuclear Imaging Helps Doctors Predict Heart Attack Risk

Doctors at The Nebraska Medical Center have added a new high-speed cardiac nuclear imaging camera that can improve doctors’ ability to evaluate a patient’s risk of having a heart attack to their arsenal of cardiac diagnostic tools.

Compared to older nuclear imaging cameras, the new technology offers a solid state technology that results in images of higher quality and can reduce imaging time from approximately 15 to 20 minutes per scan to as low as two to four minutes per scan. As a result, it has the potential to significantly reduce radiation exposure for patients. Additionally, the camera allows patients to be scanned in a much more comfortable, sitting position, than the standard supine position with the arms raised above the head.

“This provides us with another important non-invasive diagnostic tool to risk stratify our patients,” says Kiran Gangahar, MD , cardiologist at The Nebraska Medical Center. “Currently, it is the only high-speed, solid-state, cardiac nuclear imaging camera available in Omaha.”

Nuclear cardiac imaging offers an alternative to patients who are unable to undergo other forms of stress imaging, such as stress echo, because of the inability to image the heart by ultrasound, intolerance to some of the pharmaceutical agents used, physical limitations or body habitus. The test can be used for assessment of ischemia, ejection fraction and myocardial viability.

It is also an effective alternative when echo images are of poor quality. “The time period allowed for echo imaging is much shorter,” says Dr. Gangahar. “With nuclear imaging we have 15 to 30 minutes to take pictures compared to just a few minutes allowed with echo. This allows us to perform multiple pictures to ensure we get the right one.”

In addition, the pharmacological agent used has a shorter half life so it is eliminated from the body much faster so patient tolerance is much better. The testing area can also accommodate obese patients up to 550 pounds as long as the patient is mobile.

Typical candidates for the procedure are those at intermediate risk for coronary artery disease. “These are patients who have risk factors for coronary artery disease, but may have atypical symptoms,” says Dr. Gangahar.

To perform the procedure, the patient is injected with a nuclear tracer fluid based on their body mass index (BMI). The patient’s chest is then imaged in a comfortable sitting position. The patient will then have either an exercise or pharmaceutical stress test, as determined by their physician. This is followed by an imaging post stress in sitting and reclining positions.

“Nuclear stress tests are strong predictors of future cardiac events,” says Dr. Gangahar. “The goal is to identify patients who are at high risk for cardiac events so that further, invasive diagnostic testing such as cardiac catheterization, appropriate medications and aggressive risk factor modification can be implemented.”


U.S. News rankings released

by John Keenan, UNMC public relations

UNMC remains the sixth-ranked primary care medical program in the United States, according to the 2014 U.S. News & World Report rankings of the nation’s top graduate schools.

“To be recognized as a leader in primary care is a testament to the tremendous work of all our faculty, staff and students at UNMC,” Chancellor Harold M. Maurer, M.D., said. “Our expertise in primary care will be particularly beneficial to our state and region in the coming years, as more emphasis is placed on wellness and preventive care, and the need increases for more primary care providers.”

U.S. News surveyed 149 institutions while compiling the rankings, which were released Tuesday.

In addition to the primary care ranking, UNMC ranked 64th in research.

“To be recognized as a leader in primary care is a testament to the tremendous work of all of our faculty, staff and students at UNMC.”

Chancellor Harold M. Maurer, M.D.

“We’re pleased to see the rankings, which reflect the exceptionally talented faculty, staff and students we have here working on behalf of Nebraska,” said Dele Davies, M.D., vice chancellor for academic affairs. “Our educational mission is vital to everything we do here at UNMC. We strive to ensure our students receive an education that gives patients the best and most innovative care possible.”

Rankings are based on two types of data: expert opinions about program excellence and statistical indicators that measure the quality of a school’s faculty, research and students.

Primary care rankings included a series of indicators such as peer assessment, assessment by residency directors, student selectivity, mean Medical College Admission Test (MCAT) score and other factors.

Although new rankings aren’t available in all categories for 2014, UNMC continues to be rated in four other programs:

16th of 130 physician assistant programs;
32nd of 125 pharmacy programs;
34th of 201 physical therapy programs; and
36th of 467 for the master’s program in nursing.

Early Diagnosis and Treatment of MS Can Slow Disease Process

Effective treatment of multiple sclerosis (MS) begins with early and proper diagnosis. However, the episodic nature of the disease as well as the fact that no two cases are alike can make it difficult to diagnose even in the best hands, notes Mac McLaughlin, MD , an MS-trained neurologist who works at the Multiple Sclerosis Clinic at The Nebraska Medical Center and an assistant professor of Neurological Sciences at the University of Nebraska Medical Center (UNMC).

“Getting the right diagnosis and starting the right medications early in the disease is important for the overall disease outcome,” says Dr. McLaughlin. “If we can get a patient started on medications very early in the disease course, we can maximize the ability to slow down the progression of the disease.”

The use of MRI has greatly improved diagnosis of the disease and has made it possible to diagnose the disease earlier in the disease process. “An MRI image can show areas of active inflammation, which indicates active involvement of MS,” says Dr. McLaughlin.

“Because of the multiple types of medications available in addition to keeping up with the changing symptoms, the disease can be difficult to manage,” says Dr. McLaughlin. “That’s where a multi-disciplinary clinic like ours can really help patients stay on top of the disease to control symptoms and slow the progression.”

The Multiple Sclerosis Clinic is one of the most comprehensive in the region. The clinic, which follows more than 1,500 MS patients, staffs the only two MS-trained medical specialists in the area and is supported by an experienced and dedicated MS staff of physical therapists, case managers and physician assistants. Patients also benefit from the expertise of specialists in areas such as physical and occupational therapy, psychiatry, neuro-ophthalmology, pain, urology and OB/GYN.

The Multiple Sclerosis Clinic provides a comprehensive approach to MS care that addresses the physical, psycho-social and economic situation of each patient. Because MS affects each person differently, treating the whole person and their individual symptoms can make a significant difference in their quality of life, says Dr. McLaughlin. Our clinic is a partner with the patient throughout their lifetime.


New Alternative to Open-Heart Surgery

The Nebraska Medical Center is the first in the region to offer LARIAT


Marc Leger lived under the constant threat of having a stroke. His heart has atrial fibrillation, an irregular heartbeat. Because of another medical condition, the 62-year-old Plattsmouth, Neb man cannot take blood thinners, which is how doctors typically deal with the stroke risk that is present with atrial fibrillation patients.



-Dr. John Scherschel guides the Lariat into place during Marc Leger’s procedure


“It’s always in the back of your mind but you put your trust in your doctors and your prayers,” Leger said. Previously, the only way to deal with the risk was with open-heart surgery to close off the left atrial appendage; a small part of the heart where blood can pool and clots can form.


“With atrial fibrillation, blood doesn’t go in and out very well,” explained John Scherschel, MD, cardiologist at The Nebraska Medical Center. “The clots form in those nooks and crannies and can be carried out.”


Dr. Scherschel is the first physician in the region to bring a new alternative to surgery for patients like Leger. It’s called Lariat. “When I saw this technique described in scientific literature back in 2009, I said, ‘We need to be doing that,’“ Dr. Scherschel said. “That’s the right way to do this.”


The Lariat procedure involves two small incisions. It is done in a cardiac catheterization lab with the patient under general anesthetic.


Dr. Scherschel began Leger’s procedure by placing a needle and then a small tube into the pericardium, the space around the heart. Then, a catheter was placed in a vein in his leg. Guided by x-ray and ultrasound, Dr. Scherschel ran the catheter into Leger’s heart and into his left atrial appendage. That catheter is tipped with a small magnet which attached to another magnet on the probe on the outside of the heart.


“That creates a rail over which the Lariat loop can pass,” Dr. Scherschel explained.


“We place that loop over the neck of the appendage and close the loop.”

The cath lab team then uses ultrasound to make sure no more blood is flowing into the appendage. The stitch closing the appendage is then cut and the tiny instruments removed. The process typically takes less than an hour.


“I woke up afterwards and felt really good,” Leger said with a smile. “I’ve seen people have dental work that was more uncomfortable than this procedure.”

Dr. Scherschel said the biggest benefit of the Lariat procedure is the ability to provide the same outcome as open surgery without the lengthy hospital stay and risks of complication.



-Dr. John Scherschel watches x-ray and ultrasound images of Marc Leger’s heart during his Lariat procedure


“It really is an elegant solution,” Dr. Scherschel said The Nebraska Medical Center is one of a small number of hospitals in the U.S. and the only hospital in the region performing Lariat procedures.


“This is proof that the medical center is committed to bringing new cutting edge procedures here for the benefit of our patients,” said Jorge Parodi, executive director of cardiovascular services at The Nebraska Medical Center. “It also has the potential to reduce costs to the healthcare system because of the shorter hospital stay and recovery time.”


About a week after his Lariat procedure, Marc Leger was all smiles.


“I feel great; not quite ready to go out for the Olympics but I really feel good,” he said. “When you put down on your prayer request at church that you’re going to have a heart procedure done, everybody assumes they’re going to crack open your chest and you’re going to be weeks in recovery. Then they see you four days later and you’re running around a fish fry. They say, ‘Did you have your procedure?’ Oh, yeah it’s all done.”


He was one of the first Lariat patients in Nebraska, and Dr. Scherschel believes this will become the dominant way doctors deal with the condition in the future.

In his pocket, Leger carries a regular looking band aid taped to a business card as his souvenir of his Lariat procedure. It’s what covered the access point in his chest. Leger says it beats a big scar on his chest that would have resulted from open-heart surgery.


“I’ve cut my finger before and had to put bigger band aids on it than that,” he said. “They did a heart procedure and that’s it – one little band aid.”