Archive for January, 2019

Second Hybrid Operating Room Opens

The New Hybrid Room Accommodates Growing Needs of the Heart and Vascular Program A second hybrid operating room opened Nov. 30 and has already been put to good use with more than 50 procedures being done so far. “The opening of a second hybrid operating room allows us to expand our capabilities for performing the most advanced endovascular and structural heart interventions including transcatheter aortic valve replacement, MitraClip and aortic endograft placement for complex aneurysms,” says Mike Moulton, MD, triad-physician leader, Heart and Vascular Network, and chief of Cardiothoracic Surgery. For those unfamiliar, a hybrid operating room is equipped with advanced medical imaging devices and combines several departments to provide the best care for our patients. Heart and Vascular, Radiology, and Surgery staff all work together to have the ability to provide a wide range of procedures, which increases the overall flexibility, and efficiency of the department. One of the main benefits to providing care in a hybrid room is the ability to quickly and efficiently transition from a minimally invasive procedure to an open surgery case as needed.

The hybrid OR suite opened for business on Nov. 30 and has already been used many times. The technology inside the room allows doctors to perform a wide range of heart and vascular procedures.

“With the growing need for advanced structural heart and vascular interventions, this additional procedural capacity allows us to effectively perform complex cardiovascular procedures for our patients,” says Dan Anderson, MD, PhD, triad-physician leader, Heart and Vascular Network and chief of Cardiovascular Medicine. The types of procedures performed in the hybrid rooms are primarily complex cardiac and vascular cases such as transcatheter aortic valve replacements (TAVR), angiograms, electrophysiology (EP) Lead Extractions, MitraClips, and fistulograms. “All members of the vascular surgery and cardiac teams have been eager for this second hybrid suite,” says Matthew Longo, MD, Vascular Surgery. “It allows the Heart and Vascular Services team to see and treat an increased number of patients both in the community and region. Furthermore, it increases efficiency, decreases patient wait times for treatment and increases collaboration between the vascular surgery, cardiac surgery and cardiology.” It took a little more than a year to complete the creation of this second hybrid operating room, which is located next to the existing one in the southwest corner of level two at Clarkson Tower. “This was a fast moving complex project which required a lot of hard work and dedication from multiple teams,” says Michaela Newman, director, Heart and Vascular Network. “Thank you to all those involved in making this happen. As our Heart and Vascular Program continues to grow, this second hybrid operating room will help us accommodate those needs to continue to provide the expertise care our patients expect.”

UNMC Announces Most Advanced MRI Scanner in Nebraska

From left, UNMC Chancellor Jeffrey P. Gold, MD, Jennifer Larsen, MD, Matthew Rizzo, MD, and Tony Wilson, PhD, spoke at the news conference Jan. 9.

A new arrival has joined UNMC, and it will allow the school to compete with the elite research institutions in the country to better understand the complexities of the brain. The new arrival comes in the form of the most advanced magnetic resonance imaging (MRI) scanner in Nebraska — a state-of-the-art, 28,000-pound unit that will provide the highest resolution imaging available while cutting the time the subject has to be in the MRI in half. “This is truly a game changer,” says UNMC Chancellor Jeffrey P. Gold, MD. “Having an MRI dedicated to research is the missing piece of the puzzle that we needed to take our research enterprise to the next level.

“It will not only have a huge impact on research, but it also will enhance our education and clinical care. Ultimately, it will help us unlock the mysteries of the brain and hopefully provide some answers to complex neurological problems such as Alzheimer’s disease and Parkinson’s disease, which presently don’t have any real solutions.” The unit — the Siemens Prisma MRI scanner — cost $2.5 million with an additional expense of about $1.5 million to install it. It is conveniently located in the heart of the UNMC/Nebraska Medical Center campus on level one of the Hixson-Lied Center, which connects Clarkson and University towers. Primary funding — about $3 million — was provided by the UNMC College of Medicine under the leadership of Dean Bradley Britigan, MD, with the remaining $1 million coming from a National Institutes of Health research grant. In 2016, UNMC landed the largest research grant in its history, the Great Plains IDeA-Clinical and Translational Research award — a five-year, nearly $20 million grant through the Institutional Development Award (IDeA) program and the NIH’s National Institute of General Medical Studies

UNMC and Nebraska Medicine leaders — as well as a young research participant — cut the ribbon to mark the acquisition of the new MRI.

Matthew Rizzo, MD, professor and chair of the UNMC Department of Neurological Sciences, is the principal investigator on the grant, which supports clinical and translational research (CTR) among a collaboration of nine institutions in four states — Nebraska, North Dakota, South Dakota and Kansas. Initially, the research-dedicated MRI will be used by UNMC researchers in neurological sciences, psychiatry, cardiology and neurosurgery, he says. But, it also will be available for investigators who are part of the four-state collaborative grant as well as any other researchers who can benefit from it. Installation of the MRI was completed on Dec. 3, and research studies are already underway. “This is a key addition to UNMC’s research toolbox,” Dr. Rizzo says. “It greatly enhances our already outstanding research environment, raises our national profile in the neurosciences, and improves our ability to win extramural research awards. It further distinguishes UNMC as the regional leader in brain imaging, while rallying our strong local neuroscience community around an essential core resource.” In fiscal year 2018, UNMC researchers brought in $135.6 million in research funding, an increase of 15.8 percent from the $117 million garnered the previous year. Thanks to the research-dedicated MRI, those numbers should continue to grow, says Jennifer Larsen, MD, UNMC vice chancellor for research. “Having this instrument will not only speed up our ability to conduct this type of research, but it also will allow us to participate in national multicenter trials focused on brain research,” she says. “Neuroimaging is critical to understanding how the brain works or is impacted. This MRI will allow us to explore brain development and brain deterioration. It will help us understand how cancers develop or move to the brain and determine which medications are most effective in treating certain neurological conditions.” Dr. Larsen praised the College of Medicine for providing the majority of funding needed to purchase the MRI. She also noted that obtaining the research-dedicated MRI was a collaborative effort bringing together the College of Medicine, the IDeA-CTR, Nebraska Medicine, the office of the vice chancellor for research, the assistant vice chancellor for business and finance, as well as Tony Wilson, PhD, the scientific director for the project. She specifically cited Dr. Rizzo and Howard Fox, MD, PhD, associate dean for research in the College of Medicine, for their work with the IDeA-CTR grant and others who were instrumental in the collaboration including – Dr. Wilson; William Lawlor, UNMC’s assistant vice chancellor for business and finance; Cory Shaw, executive vice president/chief operating officer for Nebraska Medicine; and Pamela Flax-Laws, chief scientific administrator, Neurological Sciences. Dr. Wilson, director of the Magnetoencephalography Laboratory at UNMC/Nebraska Medicine, will oversee the MRI. As one of UNMC’s top funded researchers, Dr. Wilson’s team currently has five active NIH awards, a National Science Foundation grant and an American Heart Association grant totaling more than $23 million in federal funding. “This advanced imaging tool will allow investigators from around the region to examine the precise structure, function, and chemical composition of all parts of the body, but especially the brain,” Dr. Wilson says. “The brain is considered the final frontier in research – we know far less about the brain compared to the heart and other organs. This scanner will enable investigators to begin to unravel how diseases such as Alzheimer’s disease, Parkinson’s disease and multiple sclerosis cause aberrations in the brain that severely affect behavior and quality of life. “The MRI also will enable us to identify how brain activity changes when people perform mental tasks that require our attention, decision-making, and memory capacities. These and other critical abilities make us human, and understanding how these are implemented in the brain will have a major impact on future health care. I think it is fair to say that we are entering a new era for brain research in Nebraska.”

Pancreatic Cancer Team Provides Patients Best Fighting Chance

Pancreatic cancer is expected to become the No. 2 cause of cancer death in the United States within the next few years. It’s a cancer that’s been difficult to beat. In most cases, it has no symptoms until it has reached advanced stages. The multi-disciplinary team of specialists at the Nebraska Medicine Pancreatic Cancer Program combines the expertise of doctors who specialize in diagnosing and treating pancreatic cancer and a variety of other pancreas-related disorders to provide patients with a comprehensive plan to give them the best fighting chance. This team includes medical oncologists, surgical oncologists, radiation oncologists and pathologists. Pancreatic Care from the Experts To learn more about our Pancreatic Cancer Program, visit NebraskaMed.com/Cancer/Pancreatic. To participate or learn more about the clinical trial, please call 402.559.5600 or visit NebraskaMed.com/Clinical-trials. These doctors meet every week to discuss and collaborate on treatment for challenging pancreatic cancer patient issues, and then meet with the patient as a team to provide a well-researched, coordinated and comprehensive plan.

Kelsey Klute, MD, hematologist and medical oncologist

“Because we specialize in these cancers, we have more experience and are current on the newest surgical techniques and treatment approaches,” says Kelsey Klute, MD, Nebraska Medicine hematologist and medical oncologist. “When treating pancreatic cancers, you want to put your best foot forward in every step of the treatment process, and you want your doctors to be as aggressive as possible. That’s where our highly experienced physicians and surgeons can make a difference.” Advancements in radiation oncology is one area that has helped improve the prognoses for pancreatic cancer patients. “While surgery is the primary treatment for pancreatic cancer, less than 20 percent of patients are diagnosed early enough to be candidates for surgery,” says Chi Lin, MD, PhD, a radiation oncologist who specializes in pancreatic cancer. “Studies show that the use of chemotherapy and radiation therapy can convert a tumor that initially cannot be removed surgically to a tumor that can be surgically removed in up to 30 percent of patients,” she says. “Radiation therapy after surgery also can help reduce the chance of recurrence in the original tumor and help with symptom control.” Nebraska Medicine uses one of the most advanced radiation technologies to treat pancreatic cancer called stereotactic body radiation therapy (SBRT). SBRT can deliver treatments up to four times faster than other techniques at higher doses per treatment with more precision resulting in minimal toxicity to other tissues.

Chi Lin, MD, radiation oncologist, meets with other members of the pancreatic research team.

Dr. Lin is also collaborating with other researchers in the investigation of new agents that may make pancreatic tumors more responsive to chemotherapy and radiation. “If we can make radiation more effective, we will be able to improve disease control and quality of life for many of these patients,” says Dr. Lin. Advanced radiation techniques like these are allowing doctors to perform surgery more effectively on patients with locally advanced tumors who might not have been candidates for surgery five years ago, notes Bradley Reames, MD, Nebraska Medicine surgical oncologist who specializes in pancreatic cancer. “Surgery is the only treatment that can offer a chance for cure,” he says. “While we have known that chemotherapy is an essential treatment for every patient, emerging data suggests that patients that receive chemotherapy, and potentially radiation therapy, before surgery, tolerate it better and may live longer.” Nebraska Medicine also treats some of the most complex pancreatic cancer cases in the region. “Because of our experience and the volume of patients we see here, we are comfortable performing surgery on some of the most difficult and complex patient cases that might not be offered surgery by other hospitals or surgeons,” says Dr. Reames.

Bradley Reames, MD, surgical oncologist

Some patients may also be candidates for a minimally invasive robotic approach, which allows surgeons to perform the same surgery through smaller incisions, potentially resulting in less pain to the patient and a shorter hospital stay. “While we have made substantial improvements in pancreatic cancer treatment in the last five years, many promising therapies are currently being studied that have the potential for exciting advancements in the future” he says. Another factor that differentiates the Nebraska Medicine Pancreatic Cancer Program is our comprehensive research program. Researchers at the University of Nebraska Medical Center (UNMC) have played a key role in basic science and translational pancreatic research over the years and continue to work toward finding early detection methods and improved treatment techniques. Basic science refers to laboratory research that uncovers the background knowledge necessary for technological and drug development. Translational research involves applying the discoveries found in the laboratory to the development of clinical trials that can be used in humans to determine the effectiveness of a medical strategy, treatment or device. Nebraska Medicine and UNMC are part of the Early Detection Research Network (EDRN), an initiative of the National Cancer Institute (NCI). This network includes dozens of institutions from across the country who collaborate on research and the development of biomarkers and technologies for the clinical application of early cancer detection strategies. One of the medical center’s largest grants is the SPORE (Specialized Programs of Research Excellence) pancreatic cancer project with funding of $11 million from the National Cancer Institute over five years. This is the third time UNMC and Nebraska Medicine have been granted pancreatic SPORE funding. Three of its previous SPORE research projects are on their way to clinical trials. SPORE research projects are unique in that they must follow a model that involves translational research with collaboration between teams led by basic science researchers and clinicians. “We are involved in fighting pancreatic cancer from every angle – basic science research, diagnostics and therapeutics,” says Dr. Klute. “While there is only an 8 percent 5-year survival rate with pancreatic cancer, we believe we are going to start seeing an increase in survival because of a better understanding of the disease and discoveries that are happening right here in our labs.”

Sentinel Device Reduces Stroke Risk for TAVR Patients

Andrew, Goldsweig, MD

At Nebraska Medicine, we are serious about heart health. With state-of-the art cardiovascular care, we lead the state with outstanding results and the latest in minimally-invasive surgical techniques. For patients undergoing Transcatheter Aortic Valve Replacement (TAVR), we are the first and only hospital in the region to offer the Sentinel Cerebral Protection System to reduce the risk of stroke during the TAVR procedure. Improving Quality of Life with TAVR

For patients with severe aortic stenosis, TAVR offers a minimally-invasive way to replace the diseased aortic valve through a pencil-sized tube inserted into a blood vessel in the leg, avoiding open-heart surgery. TAVR improves quality of life by making people both feel better and live longer. Patients who have aortic stenosis may have shortness of breath, chest pain, lightheadedness, and leg swelling. Replacing the valve alleviates these symptoms and improves cardiac function. In addition, patients with severe, symptomatic aortic stenosis have a life expectancy of only 2-5 years, but valve replacement returns their life expectancy to normal.

TAVR is currently approved for patients with severe aortic stenosis who are at intermediate or high risk for surgical aortic valve replacement (SAVR) due to their age or other medical issues. However, the indications are rapidly expanding. In March 2019, two major national trials of TAVR in patients at low risk for SAVR will present results, and these trials are expected to result in expansion of TAVR to low-risk patients. Also, Nebraska Medicine is participating in a major national trial called TAVR UNLOAD for patients with moderate aortic stenosis and heart failure who remain symptomatic despite maximal medical therapy. Through this trial, we are currently the only hospital in the region able to offer TAVR to such patients. When the trial results are published in 2-3 years, TAVR may become generally available for such patients at other hospitals.

TAVR is performed under conscious sedation with local anesthesia, similar to a colonoscopy. Patients are sleepy but do not require breathing tubes or machines. The prosthetic valve is crimped onto a catheter and delivered through a 0.2 inch (5 mm) tube inserted into a leg artery. The procedure usually takes less than 2 hours. Patients are up walking the next morning and typically spend between 24 and 72 hours in the hospital.

Risk of Brain Injury or Stroke During TAVR
Patients with severe aortic stenosis have aortic valve leaflets that are thickened and calcified. Most patients also have significant atherosclerotic plaque on the walls of the aorta. During TAVR, as a prosthetic valve is advanced through the aorta and into the calcified native valve, debris from the aorta and native valve leaflets may break off and travel with the blood stream up the arteries that feed the brain. When debris blocks blood flow to the brain, this causes a stroke.

The rate of any stroke during TAVR is less than 2%, and the rate of severe or disabling stroke is far less than 1%. However, these events are devastating when they occur, so we want to do everything we can to prevent them.

How the Sentinel Device Reduces Stroke Risk
The Sentinel Cerebral Protection System filters the blood passing through the arteries that supply the brain. It captures any debris that may otherwise make their way to branches of the brain arteries, preventing a stroke. The device is delivered at the beginning of the TAVR procedure with a small tube inserted through into a blood vessel in the right wrist. Using a tiny catheter, two filters are placed in the two main arteries feeding the brain. After the procedure, the filters are recaptured into the catheter and removed from the patient.

Adopting the use of the Sentinel for TAVR in October 2018, we were the first and remain the only hospital in the state offering cerebral embolic protection for TAVR. To date, we have performed approximately 25 Sentinel-protected TAVR procedures.

Patient Eligibility and Effectiveness of Sentinel Device

All patients undergoing TAVR are candidates for protection with the Sentinel device. In practice however, Sentinel can be used in approximately 90% of patients. In the remaining 10% of candidates, diseased and tortuous carotid arteries prevent its use. In randomized trials, TAVR patients with the Sentinel device experienced a 63% lower stroke rate than patients without Sentinel as well as a reduction in severe or fatal stroke.

The Benefits
When Sentinel is removed at the conclusion of each TAVR procedure, there is significant debris caught in the filters 99% of the time. This debris could have caused a stroke had it not been captured by the Sentinel device. Patients and families are particularly impressed when they see a photograph of the captured debris after the procedure.

Here is a photograph of the debris captured in our very first use of the Sentinel device:

Here is a photograph of the debris captured in our very first use of the Sentinel device: Potential Risks It’s important to remember that any medical procedure caries some risk of bleeding or infection. However, Sentinel is a very small device at insertion (0.08 inches or 2 mm in diameter), so the risks are very low. In theory, the Sentinel could scrape plaque from the carotid arteries and cause a stroke with deployment; therefore, we are very careful to image the carotid arteries with both a CT scan and an angiogram prior to deploying the device. At Nebraska Medicine, we care about your heart health. Learn more about TAVR and heart care highlights at Nebraska Medicine, as well as news coverage of our use of the Sentinel device. Also, see our video interview that offers new hope for patients with valve disease.

UNMC Joins Network to Combat Viral Diseases

Chris Kratochvil, MD

The University of Nebraska Medical Center have joined the Global Virus Network (GVN), a worldwide network of members from 29 countries combating major threats posed by various human viruses. The network represents experts at 45 Centers of Excellence and seven affiliates in 29 countries recognized for expertise in infectious diseases in every class of virus causing disease in humans. Work includes drug development, research, training and education in the areas of biocontainment and antiviral therapeutics preparedness, defense and first research response to emerging, exiting and unidentified viruses that pose a clear and present threat to public health. Criteria for a GVN Center of Excellence includes a productivity and expertise in two to three viral areas, a commitment to capacity building, particularly in resource-poor nations and a commitment to support the GVN central operation through inclusion on grant and contract applications, fundraising events, direct donations or other means. UNMC is one of three of GVN’s newest Centers of Excellence invited to join the network. UNMC was selected because of its long history of significant viral research activities and for leading a unique array of initiatives that include innovative basic and translational research, a special pathogens clinical trials network and multiple global public health initiatives. The two other centers are the West African Centre for Cell Biology of Infectious Pathogens at the University of Ghana and Colombia-Wisconsin One-Health Consortium in Madison, Wisconsin. Howard Gendelman, MD The UNMC center will be led by Christopher Kratochvil, MD, UNMC associate vice chancellor for clinical research and vice president for research at Nebraska Medicine and Howard Gendelman, MD, Margaret R. Larson professor of Internal Medicine and chair of the UNMC Department of Pharmacology and Experimental Neuroscience. Among other things, UNMC will deepen the network’s expertise in improved therapies against HIV and biosecurity. “This opportunity and recognition as a Center of Excellence would not have been possible without our incredible partnership with Nebraska Medicine and our many University of Nebraska collaborations,” says Dr. Kratochvil. Dr. Gendelman says UNMC is looking forward to working with the GVN to establish and foster further collaboration domestically and abroad, to include drug development, research, training and education in the areas of biocontainment and antiviral therapeutics. “The breadth of activities from both of our organizations is significant, and significantly overlapping. We also look forward to working to develop medicines for the treatment, prevention and elimination of viral diseases through UNMC’s antiviral production facilities and other research resources,” he said. GVN President Christian Bréchot, MD, PhD, says adding the new centers to the network is an important step for GVN’s development. “Indeed, the GVN is reinforcing its expertise in biosecurity by bringing together centers such as the UNMC and those working in the most basic aspects of research on human viruses,” says Dr. Bréchot, who also is the Homer & Martha Gudelsky Distinguished Professor in Medicine and director of the Institute of Human Virology at the University of Maryland School of Medicine.

Howard Gendelman, MD