The Beat: A Bryan Heart Blog

Pulsed Field Ablation: New, Cutting-Edge Ablation Technology for AFib Treatment

Written by Peter Gallagher, MD

Treatment for Atrial Fibrillation (AFib) often times includes ablation of the heart tissue that is causing abnormal electrical signals within the heart which result in the development of irregular heartbeats. Historically there have been two different types of ablation techniques – radiofrequency and cryoablation to destroy the heart tissue. However, a new technology and technique has recently emerged – pulsed field ablation. This new technology involves a state-of-the-art catheter that ablates the various areas of the pulmonary vein using short pulses of energy directly to the AFib sites. Pulsed field ablation uses tissue-selective, non-thermal electric fields to ablate heart tissue and avoid damage to surrounding areas of the heart.

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Beta-Blockers Post MI; Is it Safe to Stop?

Written by Joseph Kummer, MD

There is hardly an area of cardiology where beta-blockers have not been helpful. For many decades, these medications have shown significant benefit for patients with ischemic coronary disease, heart failure, valvular heart disease, hypertension, and multiple rhythm disorders.

For many years, beta-blocker therapy has been a hallmark of treatment for virtually all patients who have had a myocardial infarction (MI) due to previous trials showing post-MI mortality reduced 20% with use of beta-blockers. However, as treatment for ischemic coronary disease has progressed, we’ve seen great advancements in the quality and quantity of life for patients following an acute coronary syndrome.

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Electrophysiology Expansion – New Team Members and New Lab

Written by W. Michael Kutayli, MD

2023 was a year of exponential growth for our Electrophysiology (EP) Team within Bryan Heart. We added two additional physicians, Dr. Peter Gallagher and Dr. Grant Wallace, as well as Jeff Dynek, PA-C.

With the expansion in our electrophysiology team, the need for increasing procedural or cath lab space was also necessary. We are excited to announce the opening of our third, dedicated EP lab this month. To date, Bryan Medical Center is currently the only facility in the state of Nebraska that has obtained American College of Cardiology accreditations for our Cardiac Cath Labs as well as Electrophysiology Labs. These accreditations certify safe, efficient and effective care in the cath lab and EP setting by ensuring evidence-based practice is implemented before, during and after procedures.

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First in the State of Nebraska to Implant Dual Leadless Pacemaker

On January 24, 2024, Bryan Heart’s Dr. Robert Percell was the first in the state of Nebraska to implant a dual chamber leadless pacemaker – the AVEIR™ DR. The AVEIR™ DR is the world’s first dual chamber leadless pacemaker system that treats people with abnormal or slow heart rhythms. Roughly one-tenth the size of a traditional pacemaker, the AVEIR DR pacing system is made up of two devices that directly pace the right atrium and right ventricle. It differs from traditional pacemakers in that the leadless devices are implanted directly into the heart through a minimally invasive procedure and eliminates the needs for cardiac leads. Despite its small size, the atrial and ventricular components communicate with each other to establish continuous, synchronized pacing therapy between the right atrium and the right ventricle.

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To Drink or Not to Drink - Caffeine and Its Impact on the Heart

Written by Joseph Kummer, MD

Caffeine is the most widely used pharmacologic agent in the world, with about 90% of adults consuming it daily. Despite numerous studies on its cardiovascular effects, the net benefit vs. harm remains unclear. Clearly, many people feel adverse consequences such as palpitations when they consume it, but such effects are mild. We have no data showing any true malignant effects. Considering how many people in the world love their morning coffee, it would be quite hard to significantly change caffeine consumption even if it is ever found to be detrimental to our health. Of course, moderation is often the key as many people have dose dependent effects.

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Pacemaker Placement - Times are Changing

Written by Matthew Kapalis, DO, FHRS

How do we place a pacemaker? This is no longer as straight forward as it used to be. Now a days as electrophysiologists, we have multiple lead and pacemaker designs which allow for new ways to place a pacemaker.

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Lp(a) - Little "a" with a Big Impact

Written by Chad Travers, MD, FACC

We have all known individuals that appear to be perfectly healthy and then suffer a heart attack or stroke. Research is showing that Liproprotein(a) – Lp(a) or LP little A – is emerging as a pertinent risk factor for cardiovascular disease (CVD). Determining a patient’s Lp(a) value may influence discussions that focus on your patient’s ability to reduce personal risk factors for a heart attack or stroke.

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Weight Loss Strategy: Starve, Shot or Scalpel?

Written by Joseph Kummer, MD

Earlier this month, Weight Watchers announced that it has purchased a company that specializes in pharmacologic therapy for weight loss. For six decades, Weight Watchers has promoted weight loss through meticulous calorie monitoring and encouraging exercise. It now appears that the company is ready to embrace the fact that weight loss in America is now dramatically different than it was even just a few years ago. While most people agree that calorie counting and exercise should be encouraged, new medications that greatly help with weight loss such as GLP1-RAs and SGLT2-Inhibitors have markedly changed this landscape among both clinicians and patients.

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Pacemaker Advancements

Written by Matthew Kapalis, DO, FHRS

Bryan Heart has continued its focus on delivering a comprehensive approach to complex heart disease. Cardiac catheter ablation is a cornerstone for safe, long-term treatment for many cardiac arrhythmias. Ablation uses radiofrequency energy or cryotherapy to neutralize electrical activity. Bryan Medical Center has maintained a state-of-the-art array of catheters, mapping systems and a robotic system to tailor care at the appropriate level to each patient. In the last year we have added another ablation procedure – epicardial ablation – which modifies muscles and nerves on the heart’s surface.

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Pacemaker Advancements

Written by W. Michael Kutayli, MD

Leadless pacemakers represent the latest in device technology and have revolutionized the treatment of bradycardia in recent years. Bryan Heart has been at the forefront of this revolution from the beginning and remains at its leading edge.

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Spontaneous Coronary Artery Dissection – A Wolf in Sheep’s Clothing

Written by Joseph Kummer, MD

Contemporary management of Acute Coronary Syndromes (ACS) involves comprehensive therapies derived from an abundance of scientific evidence. These are generally designed to treat acute rupture of an intracoronary atheromatous plaque. However, there are several “wolves in sheep’s clothing” that mimic a plaque rupture event in clinic presentation but involve a very different pathologic event.

One such entity is Spontaneous Coronary Artery Dissection (SCAD). A recent review article in The New England Journal of Medicine regarding this topic was very informative and I will highlight the issues discussed.1 It is very important to recall that not all myocardial infarctions are due to atherosclerosis, even in the setting of a typical clinical presentation for a plaque-rupture event. SCAD is a great example of this.

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Colchicine: A Novel Treatment Of Coronary Artery Disease

Written by Joseph Kummer, MD

The role of inflammation in development of atherosclerotic coronary artery disease (CAD) has long been a source of debate. Pro-inflammatory markers are often elevated in patients with CAD, and inflammation appears to be pro-atherogenic. Despite this, numerous studies of anti-inflammatory medications have failed to demonstrate a reduction in cardiac events. In fact, several agents actually demonstrate a tendency toward increased adverse cardiac outcomes. Renewed interest in this area was sparked by the CANTOS Trial in 2017 which suggested beneficial cardiac outcomes from the monoclonal antibody canakinumab. Although the results of this trial are compelling, this medication was not approved in the United States for cardiovascular protection.

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Bempedoic Acid: When Clinical Trials Come Full Circle

Written by Joseph Kummer, MD

Throughout the years, Bryan Heart has actively been involved in hundreds of clinical research trials. Research trials vary vastly from surgical procedures, cutting edge technology, devices, innovative medications and data registries.

Medication Study of Bempedoic Acid: CLEAR Serenity

One particular study – CLEAR Serenity – that Bryan Heart began in 2017, involved a study medication: bempedoic acid. The information obtained during that study has helped this medication come full circle to be available to patients today.

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Coronavirus and Arrhythmia

Written by W. Michael Kutayli, MD

Since emerging in Wuhan, China late last year, Coronavirus Disease 2019 caused by severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV 2), has taken the world by storm and Nebraska has been no exception. There have been over 113,029 cases in our state, resulting in the deaths of 905 of our fellow Nebraskans as a direct result of the Coronavirus pandemic.

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Status of ACEI/ARBs in COVID-19 Patients

Written by Todd Tessendorf, MD

During this year’s European Society of Cardiology’s Congress 2020 digital seminar, one of the more timely trials presented was The BRACE CORONA Trial. In the beginning stages of the pandemic, research was pointing toward membrane-bound angiotensin-converting enzyme 2 (ACE2) as a functional receptor for COVID-19. Data collected indicated increased mortality rates from COVID-19 in patients with coronary heart disease, diabetes and hypertension – which lead to some speculation that patients taking ACE inhibitors or angiotensin-receptor blockers were at an increased risk.

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A restrictive or liberal approach: which is the best for patients with Acute Myocardial Infarction and Anemia?

Written by Todd Tessendorf, MD

The European Society of Cardiology’s Congress 2020 recently concluded. During this year’s digital seminar, the REALITY trial shed light on the management of anemia in the setting of acute coronary syndrome.

The goal of this trial was to assess the safety and efficacy of a restrictive versus liberal red blood cell (RBC) transfusion strategy among patients with acute myocardial infarction (AMI) and anemia.

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Nuclear Cardiac Study Now Available for Diagnosis of Suspected Cardiac Amyloidosis

Written by Keith Miller, MD

A new cardiac nuclear imaging study is now available at Bryan Heart for the evaluation of suspected cardiac amyloidosis. Technetium-labeled pyrophosphate (99mTc-pyrophosphate; 99mTc-PYP) localizes to myocardium infiltrated with amyloid fibrils composed of transthyretin, the basis of the most common form of cardiac amyloidosis. Combined with cardiac MRI, which Bryan Heart has offered for nearly 10 years, the 99mTc-PYP study affords the capability to definitively diagnose most cases of cardiac amyloidosis safely and non-invasively, without myocardial biopsy.

Once thought of as rare and without viable treatment options, cardiac amyloidosis (or amyloid cardiomyopathy) is now thought to be much more common than previously recognized.

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Return to Sports and Exercise during COVID-19 Pandemic

Written by John Steuter, MD

Over the past few months we have witnessed almost every sport be impacted by COVID-19 – March Madness and basketball seasons ceased abruptly; then hockey, track, golf and baseball/softball seasons were vastly modified. But not just team sports took a hit, personal exercise also took on a new look/feel for many individuals. With local gyms closed, people have been forced to get creative with at-home workouts.

While exercise as a whole is great, how are those individuals who have been exposed or diagnosed with COVID-19 to proceed? What implications should we as practitioners be aware of?

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Comprehensive Therapy Lowers Risk for Cardiovascular Death or Heart Failure Hospitalization by Over 60%

Written by John Steuter, MD

Heart failure has long since plagued the human race. Over the years countless pharmacological therapies have been developed to help treat and increase the quality of life for patients suffering from heart failure. As more pharmacological therapies become available, the need to evaluate the effectiveness from one treatment versus another is necessary for the advancement of heart failure care.

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Novel Therapies for Cardiovascular Risk Reduction in Patients with Type 2 Diabetes

Written by Keith Miller, MD

Until recently, the secondary prevention of atherosclerotic cardiovascular events in patients with type 2 diabetes (T2DM) focused on lifestyle recommendations, antiplatelet therapy, lipid management primarily with statins and blood pressure control.

While aggressive management of non-glucose risk factors yielded major improvements in the natural history of cardiovascular disease (CVD), diabetics still face a major excess risk of heart attack, stroke, congestive heart failure and cardiovascular death compared with those without diabetes. Thus, CVD remains the leading cause of morbidity and mortality in patients with type 2 diabetes.

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Caring For Patients During a Pandemic

Written by John Steuter, MD

Every day we learn more and more about how SARS-CoV-2 virus impacts the health of infected individuals. The following diagram is an effort to explain the current understanding of how the virus changes cell signaling pathways and leads to clinical compromise. It also looks to identify methods of treatment. The mechanism for SARS-CoV-2 infection is the requisite binding of the virus to the membrane-bound form of angiotensin-converting enzyme 2 (ACE2) and internalization of the complex by the host cell.

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COVID-19 and the Implications it has on Cardiology Patients

Written by John Steuter, MD

As each day goes by, we learn more about COVID-19 and the impact it has not only those infected by the virus but also the general public. All of the top health care organizations – World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), etc. – are encouraging people to practice social distancing and especially those who are considered high-risk to stay at home to reduce their chances of potential exposure to COVID-19.

When it comes to cardiology patients the implications and risks from COVID-19 are real. Learn we have encountered so far.

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ISCHEMIA Trial: Findings & Conclusions

Written by Chris Balwanz, MD

Many of you may have heard about the ISCHEMIA trial results that were presented at AHA in November. This large, multi-center, randomized control trial has important implications on how we care for patients with STABLE ischemic heart disease (SIHD).

In addition, there was an associated study ISCHEMIA QoL that examined quality of life in these patients.

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Appropriate Use Criteria (AUC) and What it Means For You and Your Patients

Written by John Steuter, MD

By now you have probably heard the term "Appropriate Use Criteria" or "AUC" and with the January 1, 2020 Education and Operations Testing Period start date right around the corner, you may be asking yourself, what does this mean for me and/or my practice?

Chances are you most likely will need to modify a few things on your end.

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Heart Disease in the Diabetic Patient: It’s Not Just About the Blood Sugars

Written by Keith Miller, MD

November is Diabetes Awareness Month and as you know diabetes is a major contributor to many other conditions including cardiovascular disease. But did you know that as many as 50-60% of all diabetics will die a cardiovascular (CV) death?

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Adult Congenital Heart Disease

Written by John Steuter, MD

Congenital heart defects are the most prevalent type of birth defect. In children born with a heart defect, 1 in 4 are considered a critical case that require surgery or procedures within their first year of life. With advancements in technology and treatment, children nowadays facing the same diagnosis of CHD are looking at 85-90% survival rate of living to adulthood. This increased survival rate is leading to a growing prevalence of Adult Congenital Heart Disease (ACHD).

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Minimally Invasive Treatment for Myasthenia Gravis Patients

Written by John Steuter, MD

Various studies and trials conducted are providing the data needed to show that thymectomies are beneficial for clinical outcomes. Learn about the advances of thymectomies, surgical options and how Bryan Heart is performing minimally invasive robotic-assisted thymectomies for better precision and outcomes.

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The Latest in Management of Aortic Stenosis

Written by John Steuter, MD

The American College of Cardiology (ACC) held their 2019 Scientific Session this spring. One of the most talked-about sessions included findings from the PARTNER 3 and Evolut TAVR trials in low risk patients.

What were the results of the two trials? Find out.

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Is my swelling and shortness of breath normal during and after pregnancy?

Written by John Steuter, MD

Peripartum cardiomyopathy is a weakness of the heart muscle that begins during the final month of pregnancy through about five months after delivery, without any other known cause. Most commonly, it occurs right after delivery. While it’s relatively rare peripartum cardiomyopathy can be life-threatening. Rates of prevalence vary widely from one in 3,000 births to one in 10,000 births.

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Advances in Pulmonary Embolism Treatment

Written by John Steuter, MD

Pulmonary embolism (PE) is a common condition that nearly all medical professions encounter through their career. In cases of submassive or massive pulmonary embolism, this may lead to a strain on the heart’s ability to pump blood through the lungs which can then lead to heart failure and/or cardiovascular collapse. PEs can be immediately fatal and are responsible for more deaths in the United States each year than breast cancer and AIDS combined.

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When should I start Entresto?

Written by John Steuter, MD

When a patient is hospitalized for heart failure (HF), it is a sentinel moment for many reasons, one of which is that their risk for subsequent events is significantly higher. Also, following hospitalization, patients are much more willing to accept changes in their medical regimen, including aggressive titration of medication or addition of new therapies.

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What is my target number? 2018 ACC/AHA Multisociety Guidelines on the Management of Blood Cholesterol

Written by John Steuter, MD

The 2018 American College of Cardiology (ACC) and American Heart Association (AHA) multisociety guidelines aim at reducing risk of atherosclerotic cardiovascular disease (ASCVD) through lipid management. Compared to the 2013 these guidelines emphasize a more intensive approach based on recent controlled studies and expert consensus.

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MitraClip: Treatment of Secondary Mitral Regurgitation

Written by John Steuter, MD

The MitraClip device is already approved in the U.S. for use in primary mitral regurgitation (MR), a condition in which the mitral valve leaflets do not function properly due to a degenerative defect. Whether the device is useful for secondary MR, in which the valve structure is normal, but the ventricle is enlarged, has still been in question. The prognosis for heart failure patients who develop severe secondary mitral regurgitation is poor with limited treatment options.

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I have heart failure, should I keep walking?

Written by John Steuter, MD

Heart failure affects people of all ages, yet it is more prevalent among seniors over the age of 60. The American Heart Association (AHA) recommends people at risk should avoid smoking, exercise more, eat heart-healthy foods. But more specifically what can walking do to help heart failure?

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Does fish oil reduce my risk of heart disease?

Written by John Steuter, MD

Historically, ecologic studies found low rates of coronary heart disease (CHD) deaths among Greenland Eskimos consuming large amounts of seafood. Subsequent animal studies, observational studies and clinical trials examined the health effects of seafood consumption. These studies identified the long-chain n-3 polyunsaturated fatty acids (n-3 PUFA) in fish oil, eicosapentaenoic acid (EPA) and docosahexaenoic (DHA) acid as the likely active contributors to lowering heart disease.

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Treating Heart Failure and Atrial Fibrillation

Written by John Steuter, MD

Is the end of Digoxin nearing? Digitalis has been used for over 200 years to treat patients with heart failure and atrial fibrillation (afib). Digoxin is used for rate control of afib and in the treatment of heart failure, yet has recently come into question with concern for increased mortality.

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Understanding Advanced Heart Failure

Written by John Steuter, MD

A large spectrum of disease severity exists when it comes to patients with heart failure. Medical therapy, revascularization with stents or bypass, and defibrillator placement are some common tools utilized to treat a patient for heart failure.

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What is causing my chest pain?

Written by John Steuter, MD

Evaluating patients for coronary artery disease (CAD) is a common clinical scenario that providers face on a daily basis. A variety of tests exist that can be utilized to sort through the multitude of such patients from stress tests to heart catheterization. Tests can be categorized into either being functional assessments for significant CAD such as treadmill stress tests, nuclear stress tests or into anatomic, as in heart catheterization or cardiac CT. Each modality has strengths and limitations.

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What is my blood pressure goal?

Written by John Steuter, MD

Hypertension, the world’s most common and modifiable cardiovascular risk factor, has been the focus of multiple clinical practice guidelines. In hopes to address the ongoing controversies and to account for new evidence from recent trials that focused on hypertension, the American College of Cardiology and the American Heart Association (ACC/AHA) have now produced the 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.

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The WATCHMAN Device: An Alternate Treatment to Blood Thinners

Written by Robert Percell, MD

Atrial fibrillation (AFib) is a chaotic rhythm of the upper chambers of the heart called the atria and is the most common heart rhythm disorder. More than 2.7 million people in the United States have AFib. The average person with AFib is five times more likely to suffer a devastating stroke than someone with a regular heartbeat. More than 90% of stroke-causing clots originating from the heart are formed in a small structure called the left atrial appendage. A stroke results when a blood clot escapes from the left atrial appendage and travels to the brain cutting off the blood supply.

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Why Did My Patient “Pass Out”?

Written by John Steuter, MD

Syncope is a clinical syndrome in which transient loss of consciousness (TLOC) is caused by a period of inadequate cerebral flow. Typically the period of time with inadequate cerebral flow is relatively brief and, by definition, self-limited. It is often the result of cerebral hypo-perfusion due to transient hypotension.

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New Diabetes Therapy Lowers Risk of Death from Cardiovascular Causes and Could Reduce Weight and Blood Pressure

Written by John Steuter, MD

Type 2 diabetes mellitus (T2DM) patients often suffer from obesity and hypertension, increasing their cardiovascular risk. To improve outcomes for patients with T2DM, empagliflozin (Jardiance) a sodium-glucose cotransporter 2 inhibitor (SGLT2-I), was approved in 2015 as monotherapy or as an add-on therapy.

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Is it Safe to Participate in Sports? Cardiovascular Screenings for Athletes

Written by John Steuter, MD

Cardiovascular screening in athletes is universally supported, but the best model for accurate detection of athletes and children with potentially lethal heart disorders remains challenging and often controversial. Most athletes who suffer sudden cardiac arrest do not have warning signs or symptoms before their cardiac arrest. Some symptoms can be under-reported by athletes or go unrecognized by medical providers.

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For Afib Patients, to Bridge or not to Bridge? That is the Question.

Written by John Steuter, MD

To clarify questions and standardize patient care, in 2017, the American College of Cardiology (ACC) came forth with new guidelines and recommendations for which atrial fibrillation patients should be “bridged” during the perioperative period and which should not. The guidelines and recommendations apply to non-valvular atrial fibrillation (afib) patients undergoing surgery.

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PCSK9 Inhibitors: An Effective Option for Cholesterol Treatment

Written by Ryan Whitney, MD

Heart disease is a leading health problem in America. It affects over 92 million people and accounts for one of every four deaths each year. Aggressively treating cholesterol is a key component of managing cardiovascular disease and reducing the risk of future complications. A class of medications called the statins have been, and still are, the cornerstone of cholesterol lowering therapy. However, the PCSK9 inhibitors are a new class of medications approved to complement statin use in certain high risk individuals.

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Cardiac MRI: Powerfully Clear Imaging to Identify Heart Issues

Written by John Steuter, MD

In the last 10 years cardiac magnetic resonance imaging (MRI) has emerged as a tool to better visualize the heart and define abnormal disease states. This minimally invasive procedure does not involve radiation and delivers unparalleled image quality. Cardiac MRI offers new levels of specificity in the diagnosis and management of heart care.

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What is the Ideal Amount of Exercise?

Written by John Steuter, MD

With a new year upon us, resolutions to improve our physical fitness are plenty. Patients often ask how much should I exercise? Is it possible to exercise too much?

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Preventative Measures to Reduce Heart Disease

Written by John Steuter, MD

Heart disease is the leading cause of death in the United States and has carried the number one spot for many years. Yet, heart disease deaths are steadily decreasing in many states and cancer is gradually becoming the leading cause of death.

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New Coronary Stents Fully Absorb in Patients

Written by John Steuter, MD

Every day patients receive stents to keep their arteries open to supply blood to the heart. Interventional cardiologists at Bryan Heart now have a new approach to make this procedure easier and safer for patients.

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Revolutionary Pacemaker Lessens Patient Complications

Written by W. Michael Kutayli, MD

Micra is the newest and smallest pacemaker, approved for use in the United States by the FDA in April 2016. Bryan Heart is the first in Nebraska to offer this true revolution in pacing technology.

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