Returning Her Childhood
In the four years since she was born, Juliette Valdez has endured a degree of pain and suffering that most people don’t experience in a lifetime, and yet today this bright-eyed little girl hasn’t a care in the world, thanks to the skill and experience of Dr. Alfred Gillio. As her mother, Mallelin Mendoza points out, Juliette likes to play with her Barbie and indulge her love of dancing every chance she gets. She is looking forward, above all else, to going to school next September with her older sister Crystaline.
Dr. Gillio, a pediatric hematologist-oncologist at the Joseph M. Sanzari Children's Hospital, is as certain as he can be that Mallelin can look forward to Juliette having a healthy, normal childhood. “She’s an amazing kid, who is on her way to being 100 percent cured,” he says.
It’s been a journey. When Juliette was one, she developed a rare inherited disease called hemophagocytic lymphohistiocytosis, or HLH for short. “In many ways, this is the opposite of the ‘boy-in-the-bubble’ syndrome in which the immune system is turned off,” Dr. Gillio says. “In HLH, the immune system is hypervigilant.” HLH attacks the patients’ own tissues and organs, including the bone marrow, the liver and the brain. A bone marrow transplant is the only cure.
After finding a matched donor using the National Marrow Donor Program, Dr. Gillio admitted Juliette to the Pediatric Blood and Bone Marrow Transplantation Program at HackensackUMC, the only center of its kind in New Jersey. The procedure took six weeks, and Juliette, then a year and a half old, recovered well with the exception of a mild, easily treated case of graft-versus-host disease (GVHD). “GVHD is a common side-effect of transplantation,” Gillio says.
Unfortunately, a year later Juliette developed the chronic severe form of the disease. While the acute form can cause a rash, the chronic form progressively tightens and thickens the skin. Within months, Juliette’s skin had become so taut and thick that she could hardly move. At the same time, the steroids that are the first line of treatment for chronic GVHD led to bone degeneration and, eventually, a broken leg. Central line dressing changes were torture for her—and it became clear to Dr. Gillio that despite the steroids, Juliette’s condition was worsening. “She had reached the point where she could no longer be a little girl,” Mallelin says.
Dr. Gillio decided to put Juliette on photopheresis, a technique that has recently been adapted for children. During this procedure, a portion of the child’s blood is drawn and the white blood cells are separated, treated with an activating agent, and exposed to ultraviolet light. The treated blood is returned to the patient. Initially, Juliette underwent the photopheresis several times a week.
“Juliette had a fantastic response,” Dr. Gillio says. “During the year we’ve treated her, she went from being in a wheelchair to running around the clinic. We’ve also been able to eliminate the steroids.”
Juliette’s experience served as an inspiration for the Children’s Hospital to develop an outpatient Pediatric Photopheresis Program and to reduce treatment time to just an hour and a half. “Our goal is to minimize the disruption for our patients and their families,” Dr. Gillio says. “This is especially important for children in school.”
Today, Juliette comes in twice a week every other week for treatment and in six months, Gillio expects her to be completely cured. Life in the Mendoza household is also returning to normal. “Throughout it all, Dr. Gillio and the nurses treated Juliette like a princess,” Mallelin says. “And they were very helpful to us.”
“Juliette is an adorable child who had gone through a lot and come through it really well,” Dr. Gillio says. “But photopheresis has also made a difference for me. I can remember the days when kids with chronic GVHD would become frozen into a sitting position, develop pulmonary problems and die. It’s wonderful not having to go through that anymore.”
Juliette is an adorable child who had gone through a lot and come through it really well.
Mobilizing the Trauma Team After a Car Accident
Without even realizing it, the driver of the car taking Amber Fernandez home closed his eyes for a few seconds. The next thing they knew, his Range Rover collided with a utility pole. The driver emerged with only minor injuries, but the force of the impact broke both of Amber’s ankles and two vertebrae in her back. Amber, Cliffside Park High School’s starting goalie, had just taken her final exams and attended her prom and was looking forward to her graduation ceremony. Now she was heading to the Emergency and Trauma Center at HackensackUMC.
Doris Fernandez, Amber’s mother, received a call no parent ever wants to get. There was a message from the police. "My heart dropped," she said.
On the line with the precinct, she received a call from a number she didn’t recognize. She clicked over. It was a nurse from HackensackUMC’s Trauma Center telling her that her daughter was stable, conscious and wanted to speak with her.
"I thought she would be mad at me," Amber recalled. "She warned me many times about being careful late at night, and here I was in the Trauma Center." But in that moment, Doris cared only that she could hear the sound of Amber’s voice. She rushed to the hospital, where she would stay for the better part of the next 10 days while the Chief of the Trauma Center, Dr. Sanjeev Kaul, and his trauma team orchestrated Amber’s care and set her on the road to recovery.
When Every Second Counts
"When trauma patients come in, we establish within the first five minutes whether there is an immediate threat to their lives," Dr. Kaul said. "We evaluate their airways, their breathing, their circulation and any other disabilities." Amber passed all those tests, but Dr. Kaul was concerned about internal injuries. His team straightened and splinted Amber’s ankles and sent her for a set of CT scans. They showed she had fractured her fourth lumbar vertebrae in the small of her back and shattered the fifth.
With this information in hand, Dr. Kaul called in neurological and orthopedic specialists to consult. Together, they decided their first priority was to stabilize Amber’s spine, remove shattered bone pressing on nerves leading to her legs and fuse the vertebrae. Then they would repair her ankles. "We’re fortunate at the Trauma Center in having such excellent relationships with our consulting specialists," Dr. Kaul said. "We give them the overall picture, and they help us decide our priorities for dealing with individual issues."
Later that afternoon, Amber underwent an operation to clear away the bone fragments pressing on Amber’s nerves and inserted a temporary fixation system to stabilize her back.
The next day, Dr. Harshpal Singh inserted a titanium scaffold around the damaged vertebrae and seeded each end of the scaffold with new bone that would ultimately fuse together. "This was a true neurological emergency," Dr. Singh said. "She already had significant weakness in her feet and legs when she came to us."
Not surprisingly, Doris Fernandez was worried about that, too. "My greatest fear was Amber, who was always so athletic, was never going to walk again," her mom said. "I remember thinking I need to mentally start preparing myself."
Before he operated, Dr. Singh made a point of reassuring her. It will take time, he told her, but he had no doubt Amber would get back to being a very functional kid and even play soccer again. Four days later, Dr. Michael Benke, an orthopedic surgeon, repaired her ankles.
Amber’s immediate concern, naturally, was missing graduation, but through the kindness of her friends and the nurses at the Trauma Center, she was able to celebrate nevertheless. Her friend brought in her cap and gown, and the nursing team decorated her room with balloons they made from their gloves and gave her a bracelet that said Positive in a number of languages.
"Even though she wasn’t able to attend graduation, we didn’t want to let the day go by without acknowledging it was special for Amber – a real milestone," said Kirsten Sommer, one of Amber’s nurses. "We are always looking for ways to show our patients they are important regardless of the condition they’re struggling with - they’re not just a patient in a bed but a real person."
Regaining Her Stride
After she was discharged, Amber spent three weeks in rehabilitation and the rest of the summer and fall increasing her mobility and rebuilding her strength. Along the way, there were milestones, like her first venture outside her home. Doris took Amber to their local pool and watched her slip into the water. "It was one of the happiest days of my life," Doris said.
Amber has almost completely recovered and looks forward to playing soccer again as Dr. Singh predicted, but the experience has also inspired her to think about her future. She is considering physical therapy as a career option. "When I was in rehab, I saw what a tremendous difference they made," she said. "I thought this was something I might like to be part of."
For physicians like Dr. Kaul, Dr. Singh and Dr. Benke, Amber’s outcome is its own reward. "We put in long, long hours," Dr. Singh said, "but at the end of the day, to see someone you’ve treated walk into your office is the best feeling in the world."
We put in long, long hours, but at the end of the day, to see someone you’ve treated walk into your office is the best feeling in the world.
Dr. Harshpal Singh
Managing a High-Risk Pregnancy
Nacha Messina-Mejia is extremely well-organized. "I am a planner," she says. She earned her degree and secured a good job with a company that is a leader in the food industry. She and her husband, Lary, bought a house in Teaneck. Because of their financial stability, the couple became a beacon for family members who needed a home. "We’ve always had relatives living with us," she says.
But when her father, who had been living with them, passed away in 2012, she and her husband started feeling lonely. "We began to joke that we bought our house and are paying a mortgage just so our dogs have a place to live," she says. She and her husband decided to have a child.
This was, they knew, a momentous decision. Nacha has inherited thrombophilia, a condition that causes her blood to clot too easily. In 2009, she developed a clot that blocked the vein leading from the liver. The consequences were high blood pressure and an enlarged spleen. Women with thrombophilia have difficulty becoming pregnant and are prone to complications during pregnancy. In fact, pregnancy only makes the condition worse.
As a result, Nacha knew that her pregnancy would have to be carefully managed from start to finish if it were to be successful—and so she put herself in the hands of a remarkable team of physicians and nurses at HackensackUMC.
Today, she has not one, but two little boys—and her house is now full of life.
It Takes a Village to Have a Child
Nacha’s success is a testament to the quality and coordination of the care she received, as well as the caution of her physicians. Before Nacha started, they prescribed an exhaustive battery of tests that took almost a year to complete. "When you are considering a high-risk pregnancy, you want to leave nothing to chance," says Dr. Manuel Alvarez, the maternal fetal specialist who supervised her pregnancy. Nacha also agreed to take an injectable medication during pregnancy that would prevent deep vein blood clots. "We have a large gestational thrombophilia program at HackensackUMC that attracts women from around the world," says Dr. Stanley Waintraub, her hematologist. "About 95 percent of the time, we have successful pregnancies because of our expertise in managing blood-clotting disorders."
Working with Dr. Jacquelyn Loughlin, her reproductive endocrinologist, Nacha became pregnant quickly. At eight weeks, Dr. Alvarez took over. “Our philosophy is to watch our patients very, very closely, especially in situations like this when there are twins.” Dr. Alvarez says. “We have them take more frequent ultrasound exams, order different blood tests and have them see more specialists than the typical mom-to-be.” And to make sure patients get the care they need when they need it, Dr. Alvarez maintains an open-door policy. “When a patient comes to our office, I tell them we are here every day,” he says. “ They don’t have to worry about calling and getting an appointment. They can just come in.”
Because they are in the office so often, Dr. Alvarez’s patients develop close relationships with his team. Nacha soon found she had a special connection with Magdalena Pawlik, Dr. Alvarez’s nurse practitioner. “Because I have twins myself, I could give Nacha advice as a mother as well as a health provider,” Magda says.
A House Overflowing with Joy
As Dr. Alvarez and his staff see it, every week that passes without a complication is a victory for the high-risk mom. According to Dr. Alvarez, Nacha was the ideal patient who followed his recommendations to the letter. She carried the pregnancy through the 36th week, when she gave birth to Mario Orlando and Emilio Nelson. “My husband came up with the idea of naming them after their grandparents,” she says. Magda and her colleagues shared Nacha’s joy. “It’s a great moment for us when one of our patients gives birth,” she says. “We know how precious these pregnancies are to them.”
The two babies, however, created an unexpected problem, but one that Nacha is more than happy to live with. “I can see that we’re going to need a bigger house,” she says. “We need two of everything. From a house being empty, we have a house that is starting to overflow, not just with strollers and car seats but most importantly with joy.”
“When you are considering a high-risk pregnancy, you want to leave nothing to chance.
Dr. Manuel Alvarez
A Safer Approach to Pain Management
Addiction to prescription painkillers has reached epidemic proportions in the United States. According to the Centers for Disease Control and Prevention, 44 people each day die from an overdose of these powerful drugs, and 7,000 are treated in emergency rooms. The challenge for medical professionals: find alternative, non-habit-forming methods of managing pain.
At HackensackUMC, physicians like orthopaedic surgeons Dr. Michael Kelly and Dr. Yair Kissin have become exponents for safer effective pain management, not only adopting new approaches but also speaking to professional groups about the urgency of change.
“The vast majority of patients under medical supervision who receive opioids like Vicodin® or OxyContin® for pain do not become addicted, but there is always a risk that a patient will,” says Dr. Kelly, chair of the Department of Orthopaedic Surgery at HackensackUMC. “By sharply reducing opioid use after surgery, we can reduce that risk while hastening recovery and improving managing pain.”
Knee Replacement With Opioids
Bill Murray’s experience illustrates Dr. Kelly’s point perfectly. An avid golfer, Bill had his first knee replacement four years ago when he was in his mid-60s. Even in the hands of a world-class physician like Dr. Kelly, knee replacement is a painful procedure. After surgery, Dr. Kelly put Bill on a patient-controlled analgesia device that gave Bill the ability, within bounds, to regulate the amount of opioids he received through an intravenous line. While the opioids successfully controlled his pain, they also made Bill miserable. “I felt nauseous the entire time,” Bill recalls. Other side effects that patients encounter include constipation, vomiting, and fainting when standing up.
Reliance on opioids grew from the best of intentions, Dr. Kelly points out. There was a consensus among physicians in the late 1990s and early 2000s that they needed to do a better job treating pain. “We began considering pain the fifth vital sign,” Dr. Kelly says. “Opioids had proven themselves very effective in treating cancer pain. Physicians began using it in other situations.”
Knee Replacement Without Opioids
Since that time, physicians have developed new approaches that reflect a more sophisticated understanding of pain management. When it came time last year for Dr. Kissin to replace Bill’s other knee, orthopaedic surgeons at HackensackUMC had abandoned opioids for multimodal pain management, a nuanced approach that weaves together a variety of nonopioid and opioid strategies. “Our goal is to stay ahead of the pain,” Dr. Kissin says.
Before the operation, Bill’s nurse gave him a Tylenol and an anti-inflammatory medication. During the operation, his anesthesiologist used a short-acting spinal anesthetic, and before completing the operation Dr. Kissin injected fat globules into Bill’s knee containing an analgesic pain medication that would be released gradually over the next three days. He followed up during recovery with more Tylenol, anti-inflammatories, and muscle relaxants, with opioids available only in small oral doses as needed.
This new approach not only managed Bill’s pain effectively but also spared him the side effects of opioids and accelerated his recovery. “As soon as I got out of the recovery room, they had me up and walking,” he recalls. “I didn’t experience nausea, and I left the hospital feeling better.” Not surprisingly, Hackensack’s length of stay for knee replacement under this pain management system is below the national average.
Moving from an opioid- to a nonopioid-based model of pain management was a collaborative effort that brought together joint surgeons, anesthesiologists, physical therapists and others, but it has paid off, for patients like Bill as well as communities that bear the social costs of addiction.
“I was impressed by the depth of Hackensack’s commitment to improve medical practice,” Bill says. “It made a real difference for me.”
I was impressed by the depth of Hackensack’s commitment to improve medical practice. It made a real difference for me.
An Absolute Miracle
Determination is the overriding reason Audrey Peppi-Donaldson is alive today: her fierce determination to stay alive for her four children despite given a death sentence, the determination that drove her sister Joelle and the rest of Audrey’s family to do everything humanly possible to find a doctor willing to treat her and the determination of Dr. Stanley Waintraub, a breast cancer expert at John Theurer Cancer Center, who insisted on delving deeper into the unique nature of Audrey’s cancer to find an effective therapy.
Their collective determination set the stage for what Dr. Waintraub, who has been in practice for four decades, calls a miracle. “Her original PET scan was as white as snow,” he says. “There was cancer all over her body. After four months of therapy, it now looks normal.”
Never, Ever Give Up
Audrey developed breast cancer in 2011, and for a while it was in remission. When the cancer returned in 2014, it had metastasized to her liver, lung and bone, and a year later, it suddenly became much more aggressive. A prominent cancer center treating Audrey told her there was nothing more they could do. “I couldn’t accept that,” Audrey says, “Never, ever was I going to give up.”
Joelle came down from Boston to direct the search for Audrey’s next option. “My sister is a fighter,” Joelle says. “She absolutely refused to see this as the final word. Since that is what she wanted, we needed to push and find a way to help.”
Two more prominent institutions reviewed Audrey’s case, and both told her to go home so she could die in peace. Joelle frantically worked the phone, fielding suggestions from family and friends in desperate search of a physician willing to work with her. “We didn’t know if there was anything we could do, but we understood Audrey’s only chance of survival was to be treated,” Joelle says.
In the meantime, Audrey’s condition was deteriorating quickly. Her liver was failing, her skin turned yellow and her bones were riddled with tumors. Audrey was wasting away before her family’s eyes, when Joelle, thanks to a connection through a family member, reached out to Dr. Waintraub. Three days later, he had Audrey’s files in hand and her family assembled in his office.
State-of-the-Art Personalized Cancer Care
“I stressed the seriousness of her situation,” Dr. Waintraub recalls, “but I also felt strongly that the other centers gave up on Audrey prematurely – they left her to die.” This wasn’t going to be the case in his hands. Dr. Waintraub put Audrey on platinum-based chemotherapy, which bought her more months. Equally important, it gave him time to plan his next move.
When the new therapy failed in August, Dr. Waintraub was ready. He sent her tissue for next-generation sequencing and her blood to be analyzed for circulating DNA. During the last five years, researchers have uncovered meaningful genetic and molecular differences in breast and other cancers and linked these variations to the effectiveness of specific treatments.
“This is the cutting-edge of cancer care,” Dr. Waintraub explains. The cells in different forms of breast cancer have characteristic mutations that allow them to corrupt normal cellular processes, allowing cancer cells to divide uncontrollably and spread. State-of-the- art cancer therapies target these processes.
The lab found a biomarker from the cancer in Audrey’s blood, one that was missing previously, that indicated her cancer used a specific cellular process to grow. Fortunately, there are drugs that stop this process and they were prescribed by Dr. Waintraub.
Today, Audrey has begun to pick up the pieces of her life. She gained weight and no longer takes pain medications. She started to drive again. In a short time, Dr. Waintraub plans to stop Audrey’s chemotherapy and put her on a maintenance regimen—targeted therapy every three weeks and a scan every four months.
In Dr. Waintraub, Audrey found a physician whose exclusive focus on breast cancer, knowledge of state-of-the-art treatment and expertise, and creativity paved the way for her remission. “If you have breast cancer, you go to someone who lives and breathes breast cancer, who studies it and thinks about it constantly,” Dr. Waintraub says.
Equally important, Audrey found in Dr. Waintraub a physician whose commitment to help his patients equaled her determination to live. “He told me the reason I come to work is people like you,” Audrey says. “That says a lot about him.”
Dr. Waintraub told me the reason I come to work is people like you. That says a lot about him
Disarming? Not a Chance!
When Eileen Prince and her family arrived at the John Theurer Cancer Center, they were in a state of utter despair because two premier New York City institutions said her arm needed to be amputated. These specialists said, in no uncertain terms, that the tumor growing through the web of large nerves controlling Eileen’s left shoulder, arm and hand would not respond to chemotherapy and couldn’t be removed.
They offered Eileen a radical approach – a total amputation of her shoulder, arm and a piece of her chest wall. They couldn’t provide any wellness guarantees because they weren’t even sure they could remove the tumor with an amputation. However, she was given one assurance –Eileen would be permanently disfigured.
This devastating news was presented with utter indifference dramatically intensifying the insufferable prognosis. Things seemed beyond hopeless. Imagine going to two of the best institutions in Manhattan and the only option given is a disfiguring and debilitating amputation. If Eileen moved forward with their recommendation, she would live a painful existence with a quarter of her body missing and very little hope afterward for being cured.
In stark contrast to Eileen’s New York experiences, she was met with positivity and compassion at the John Theurer Cancer Center. Eileen connected with a remarkable team-- Dr. James Wittig, an orthopedic surgeon, and Dr. Andrew Pecora, an oncologist—who took a very different approach, both medically and surgically. “They focused on every avenue that could potentially yield a positive result and every decision they made from that point forward reinforced their commitment to my physical and emotional well-being,” said Eileen. “In short, they were as invested in my quality of life as they were in identifying a cure.”
Upon examination, Dr. Wittig had no doubt in his mind – he was extremely confident that he could save Eileen’s arm. He told her, “We can get the tumor out and save your arm as well as your life. You don’t need an amputation - I can get it out! The cancer will also respond to the chemotherapy that Dr. Pecora is administering!”
The news was almost unfathomable to Eileen based on the initial dire diagnosis until their recommendations came to pass. “How could I possibly receive such disparate reports?” said Eileen. “Thankfully, HackensackUMC’s diagnosis was both dramatically desirable and accurate.”
Together, Dr. Wittig and Dr. Pecora—supported by a talented and dedicated multidisciplinary team of cancer care experts at JTCC—not only removed the tumor, but also saved Eileen’s arm, preserving function in her hand and most of her forearm. Insteadof having to resign herself to disfigurement, Eileen is full of gratitude and is now dedicated to sparing future patients from the trauma she suffered needlessly.
Saving a Patient’s Arm
Dr. Wittig and Dr. Pecora routinely work together as a team that treats patients’ with very serious, complex cancers. They knew they could save Eileen’s life and limb based on numerous previous experiences. This is an ambitious undertaking, requiring exceptional skill and creativity – the rewards are immeasurable on so many levels.
When Dr. Wittig and Dr. Pecora reviewed Eileen’s records, they realized her tumor had been mischaracterized. She had a fast-growing tumor—the result of radiation used to treat Hodgkin’s lymphoma when she was 17—that would respond well to chemotherapy. The more they could kill the tumor with preoperative chemotherapy, the greater the chance of saving her arm.
Dr. Pecora constantly monitors the field for developments that might improve his patients’ outcomes. This time he added a therapy, taken from kidney cancer treatment, which impeded the tumor’s ability to create the new blood vessels that fueled its growth. “ Coming up with the right mix of chemotherapy agents and the right schedule is a bit like doing calculus,” Dr. Pecora said. “You have to integrate the wishes of the patient, the biology of the disease, and the available therapeutics and make a decision.”
Dr. Pecora’s regimen shrank Eileen’s tumor by 80 percent in just six weeks. The process of tumor death made it easier to peel the remaining tumor from healthy tissue. It also gave Dr. Wittig more space to maneuver in an area of the body, near the neck and shoulder that is crammed with major nerves and blood vessels.
In the meantime, Dr. Wittig had ordered a new, clearer MRI. “When we looked at the new image, we could now see that the tumor died and affected only a portion of the brachial plexus,” Dr. Wittig said. “This made my job of removing the tumor and saving Eileen’s arm easier.”
Preserving a Patient’s Humanity
From the very first contact with Dr. Pecora and Dr. Wittig, their goal—regardless of the diagnosis—was to offer Eileen hope and quality of life. This meant bringing all their experience to bear to explore every possible medical and surgical avenue. Equally as importantly, it meant making the emotional leap that enabled them to see Eileen and her family as full human beings with real lives and to approach them—people at their most vulnerable—with the utmost care and respect.
Eileen’s parents, David and Alice Jurist, have long been mainstays of the Tomorrows Children’s Fund, the nonprofit that has raised more than $40 million to improve the lives of children with cancer and their families. “I’ve spent most of my adult life working closely with people whose children have cancer, and I know how important that sense of commonhumanity is to families,” David said. “As a father, I found this quality of caring at Hackensack.”
This regard for a patient’s humanity extends to every member of the team. “I have been an oncology nurse for 29 years, and I know what it is like to wait for a biopsy to come back and to lose people you love to cancer,” said Melinda Weber, Dr. Pecora’s advanced practice nurse and team manager. “Even when we have exhausted our options for curing someone’s cancer, there are always options we can offer to help people live despite the diagnosis.”
Among Melinda’s other responsibilities is supporting the entire Advanced Practice Nursing team to provide empathic, comprehensive evidence-based oncology care, to every patient. This especially requires being a staunch patient advocate and guide throughout the daunting healing journey. For Eileen and all the patients at the JTCC, this requires continual comprehensive support throughout all treatments, including all aspects of care.
Melinda regularly interacts and coordinates care with Dr. Wittig’s team of physician assistants and nurses who perform similar functions as Melinda for surgical patients. In addition to many, Jill Kossove was a great comfort and resource to Eileen whenever needed. “This team approach in coordination of care is one of a kind in the entire United States,” said Dr. Wittig. “You cannot get better care anyplace in the United States than here at JTCC and HackensackUMC.”
Eliminating as much tertiary stress as possible for Eileen by making appointments with specialists for treatment and consultation, and making sure she has all the necessary forms and documents is critical. She has nothing but praise for the commitment and compassion of the JTCC team. “I am very proud of my team and how we work together to help people,” Melinda said. “There simply is no other cancer center that merges the latest science with the greatest humanity”. It’s like music. It really is.”
They were as invested in my quality of life as they were in identifying a cure.
A Revolution in Valve Replacement
Wally Reiling is a lucky man. After feeling short of breath for quite some time, the former toy manufacturer made an appointment to see his cardiologist. The diagnosis: aortic valve stenosis, a narrowing of the valve between the left ventricle—the chamber that pumps blood into the body—and the aorta.
Five years ago, this diagnosis would have been a death sentence for a man with Wally’s medical history. He had a coronary bypass operation in 1993 involving six blockages and he also had a pacemaker inserted in 2001. At the time, the only procedure for replacing the valve was open-heart surgery, but at his age—he is 81—and with his history of a prior open heart surgery, his odds of dying or never fully recovering were quite high. The only option would have been to go home and make the best of the time he had remaining feeling short of breath with minimal activity. “Half the patients with untreated symptomatic aortic stenosis die within two years,” said Dr. Atish Mathur, a Structural and Congenital Heart Disease Fellow who consulted on Wally at HackensackUMC.
But because Wally’s symptoms appeared in 2015, not 2010, his prospects were excellent. In the intervening years, the FDA approved a revolutionary technology called TAVR, which stands for transcatheter aortic valve replacement. Physicians insert a catheter—an extremely narrow flexible tube—in an artery, often in the groin, and thread it through the body and into the heart. The new valve is passed through the catheter, deployed on top of the faulty valve and the catheter withdrawn.
The operation takes approximately an hour and a half to three hours utilizing either general or local anesthesia with mild sedation depending on the patient’s clinical needs. Wally’s procedure was done with local anesthesia and only required a two-night hospital stay for observation. Recovery from TAVR is significantly reduced compared to traditional open heart surgery patients who typically face an 8-10 day stay in the hospital. Because TAVR is a minimally invasive procedure, most patients resume normal activities days after the procedure.
The improvement patients feel is immediate. “I could feel the difference right away,” Wally noted. “The quality of my breathing was totally different.” Within a month of the procedure, he was cleared to go to rehabilitation to regain his strength.
“If you perform the procedure in the morning, the patient can be walking around by the end of the day,” said Dr. Pranaychandra Vaidya, the interventional cardiologist who placed Wally’s new valve. “And they’ll be feeling great for the first time in months, if not years.”
A Team Approach
Although TAVR seems simpler than traditional aortic valve surgery, it is a complex, new procedure that still has its risks. After all, physicians are replacing a major valve in the heart. “The aortic valve team spends hours meeting and discussing each case,” noted Dr. Carlos Ruiz, a TAVR pioneer and the newly appointed director of the Structural and Congenital Heart Disease Program. “For every hour in the operating room, we probably spend 10 hours meeting with patients, gathering information and planning the procedure.”
Members of the team have different roles. An interventional cardiologist often places the valve. Another cardiologist conducts the imaging needed to map the blood vessels, assess their condition and determine the proper valve size to use. A cardiac surgeon evaluates the patients’ risk of conventional surgery—currently, only high-risk patients are eligible to undergo TAVR—and stands by in the operating room to make sure nothing goes wrong.
“This is the new model,” said Dr. Elie Elmann, the cardiac surgeon who participated in Wally’s care. “It’s no longer one doctor making a decision for one patient. Putting all our minds together, looking at the same information and meeting with the patient has an enormous impact.”
In other words, TAVR technology makes the procedure possible. Teamwork ensures it's done correctly and with minimum of complications.
Since they were introduced, TAVR valves have advanced rapidly. “What we saw with stents over a 20-year-period, we have seen in TAVR in five,” Dr. Elmann said. Second-generation valves are smaller, which means they can be used in people with smaller blood vessels. There are now two different valves with different deployment mechanisms and a repositionable valve. “Precision is critical in valve placement,” Dr. Vaidya said. “A few millimeters can make a tremendous difference.”
A Miracle in Medical Care
For physicians and nurses who formerly have had very little to offer high-risk patients like Wally, TAVR seems miraculous. “To see a person like Wally, a wonderful man, get so much better is incredibly satisfying,” said Pilar Dolcimascolo, PA, and manager of the Structural Heart Team. Dr. Mathur, the cardiologist responsible for Wally’s imaging, agrees. “In our first meetings, he seemed pretty anxious and apprehensive. Now he’s a new man.”
Of course, Wally is the person who most fully appreciates this miracle in medical care. “I am constantly recommending it,” he says. “It gave me a new lease on life.”