The VOICE of UPMC Shadyside Winter 2022–2023

An Exciting Time in Heart Care

Dustin Kliner recalls that when he was a medical student, there came a day he observed two major heart operations: bypass surgery to create a new route for blood flow around a blockage in a blood vessel, and another to replace a valve. Both procedures involved opening the chest to expose the heart, connecting the patient to a heart-lung machine, and stopping the heart so that the surgeon could work on it. Each patient stayed in the hospital for at least a week.

Afterward, the surgeon who performed the procedures made a surprising prediction: “By the time you’re done with your training, you will be doing these procedures through tiny incisions in arteries. You will not have to open the chest or stop the heart. And patients will go home the next day.” 

“I became an interventional cardiologist because of that experience,” says Dr. Kliner, medical director of the cardiac cath lab programs at UPMC Shadyside and co-leader, with Dr. Ibrahim Sultan, of the hospital’s TAVR (transcatheter aortic valve replacement) program.

“And because of remarkable advances in recent years, we are now able to help patients whose heart problems might not have been treatable before,” says this husband, dad, and avid baseball fan. 

“This is an exciting time in heart care. And the high-risk interventions that we do make Shadyside unique.”

Because of remarkable advances in recent years, we are now able to help patients whose heart problems might not have been treatable before. This is an exciting time in heart care. And the high-risk interventions that we do make Shadyside unique.
- Dustin Kliner, MD

So what’s going on?

“Many people know that cardiac catheterization involves threading a tiny tube [catheter] into the arteries to bring miniature cameras and instruments to a disease site in the heart or blood vessels,” says Dr. Kliner. “We do that to evaluate chest pain, identify narrowed or blocked arteries, or restore blood flow to the heart.

“The strengths of our technology at Shadyside have advanced over the years,” he continues. “In the cath lab, we are focusing more on radial artery access. Instead of the more standard way of inserting the catheter through the femoral artery in the groin, you go in through the smaller radial artery in the wrist.

“I do almost all of my catheterizations that way, even fixing multiple blockages. The advantages involve a significantly lower bleeding risk. Patients can sit up in a chair immediately afterwards, and they are likely to be able to go home the same day.

“We also do complex, high-risk PCI (percutaneous coronary intervention) procedures that would in the past have been treated with open heart surgery,” Dr. Kliner says. “These minimally invasive procedures offer hope for people who are at too much risk for surgery.”

The TAVR revolution

With similar minimally invasive advantages, “TAVR has revolutionized the treatment of valve disease,” according to Dr. Kliner. “And UPMC Shadyside is the hub for TAVR procedures in the Allegheny County area.” 

“TAVR enables us to replace a patient’s aortic valve without opening their chest or stopping their heart,” explains Dr. Sultan, director of the UPMC Center for Thoracic Aortic Disease and surgical director of the UPMC Center for Heart Valve Disease. 

“The major advantage of TAVR is that patients who are older and not as active can recover and get back on their feet much faster than if they were to have open-heart surgery,” Dr. Sultan says. “Through a quarter-inch incision in the femoral artery, a patient’s defective aortic valve is replaced with a biological tissue valve — while their heart continues to beat. The new valve is put in inside the old valve, and the old valve holds the new valve in place.” 

Both specialists explain that TAVR is typically recommended for patients with aortic stenosis who are at moderate or high risk for open-heart surgery. However, every patient is evaluated individually. An interdisciplinary heart team — cardiologists, surgeons, imaging specialists, research personnel — meets weekly to discuss the best and most effective therapy for each individual.

“I just feel good”

John Brady, a model railroad fan who owns Brady’s Train Outlet in Greensburg, had been told that he needed a new valve. “They wanted to crack open my chest,” he says. “I didn’t want that. Then I heard that they do this TAVR down at Shadyside. Well, that’s for me. So I went and talked to Dr. Kliner.

“My procedure was not a problem at all,” he reports. “When I was in the operating room, I said, ‘Let me ask you guys a question. Do I have the A team here?’ They said, ‘You got the A team!’ So anyway, next thing I knew, I was back in the recovery room, about an hour and a half later. Never felt anything and there was no pain. I stayed one night in the hospital. Felt like a new man. The nurses and all the people that worked there, they were all fantastic. It was all first class.” 

Mr. Brady also likes to tell about a customer who gave him a bottle of holy water before his surgery. “On the day I went to the hospital, I sprayed some holy water on my shirt and then took a little swig of it. I wanted to make sure I was covered!”

He was happy to get back to his shop and his customers. “Toy trains are a fun, friendly business,” he says. “I love trains. I like to talk to people, meet people. I love when the kids come in.

“And now, since the surgery, I feel I got a little extra energy. I just feel good.”

Vascular care has come a long way

“Approximately 60 to 70 percent of vascular surgery procedures are performed with a minimally invasive approach,” says Michael Singh, MD, chief of Surgical Services and chief of Vascular Surgery at UPMC Shadyside, and co-director of the UPMC Heart and Vascular Institute Aortic Center. 

Dr. Singh explains that “vascular surgeons have the ability to manage conditions that affect the arteries, veins, and lymphatic system from the head down to the toes. The exception is the heart, which is best managed by the cardiology and cardiothoracic surgery teams.” 

Dr. Singh’s area of expertise is the thoracic and abdominal aorta, the main blood vessel emanating from the heart and extending into the abdomen, where it bifurcates to the left and right iliac arteries. For a variety of reasons, the aorta can develop stenoses, dissect, or degenerate, which is called an aneurysm. It represents a focal weakening of the blood vessel wall and leads to a dilation of the vessel. This can be a very serious condition, because if an aneurysm ruptures, the mortality rate is between 80 and 90 percent. 

Traditionally, aneurysms have been managed with large incisions to perform open surgical repair. “However, the standard of care has changed,” Dr. Singh says. “Patients often request ‘the least invasive way to fix my aneurysm that is not going to change my long-term quality of life.’ The good news is that we can offer patients a less invasive aneurysm repair where they can essentially walk out of the hospital the following morning with nothing more than a small bandage covering the needle puncture on the top of both thighs. It’s a tremendous advancement in patient care. These less invasive treatment options improve patient care, reduce recovery time, shorten hospital length of stay, and reduce the risk of future aneurysm rupture. These less invasive repairs can be offered for aneurysms in the chest, abdomen, and pelvis.” 

Dr. Singh oversees several aortic clinical trials that are underway and acknowledges that such trials will “expand treatment indications and hopefully improve vascular care for all patients.

“People deserve to receive high-quality care performed at a spectacular institution, which Shadyside is,” Dr. Singh states. “We’re very fortunate to have state-of-the-art resources and cutting-edge technology here. UPMC is at the leading edge of technology advancement, and we expect to stay there for many decades to come.”