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Introduction of the department of cardiology

Outline (history)
Fields of specidization at our department

Rdudant Cardiovascular diseases, including ischemic heart diseases such as angina pectoris and myocardial infarction (both in the acute and chronic phases), valvular disease, congenital heart disease of adults, myocardial disease, pericardial disease, heart failure, hypertensive heart disease, arrhythmia, and all other kinds of heart diseases, are covered at our department. Hypertension, aortic diseases such as aortic dissection and aortic aneurysm, arteriosclerosis obstructive, peripheral arterial diseases such as renovascular hypertension, pulmonary embolism, deep venous thrombosis of lower extremities, and all other kinds of Cardiovascular diseases can also be treated at our department.

Geographical regions served
For emergency services and treatment of acute disease such as acute myocardial infarction, we focus on an area of about 100 km radius from the hospital. This is an area served which is within 2 hour by mobile CCU. How quickly treatment can begin has great influences on the prognosis of acute myocardial infarction. Direct transport of a patient experiencing acute myocardial infarction to a nearby facility that is ready to perform coronary arterial recanalization around the clock is therefore critical to the patients progrosis. As for cases of disease in chronic or stable phase, referrals from all over Japan are welcome. We have accepted referrals from Hokkaido, the north end of Japan, to Okinawa, the south end of Japan, as well as from various Asian countries.

Characteristics and policy

From the start, our practice has constantly sought “locally accessible medicine of good quality”. What is essential for improving community medicine is (1) efficient and less invasive treatment of common diseases, and (2) seamless coordirection between the primary care physicians and specialized facilities. In light of these requirements, we have always managed our department on the basis of the following policies: (1) To aggressively wrestle with all types of diseases as the most reliable hospital in the region, while concentrating especially on the treatment of ischemic heart disease, which is the most common condition; (2) To hold frequent and regular local study sessions to deepen mutual understanding with other hospitals and clinics in the region; and (3) To introduce mobile CCU to transport patients requiring emergency care from local hospitals and clinics.The local study session has been named “Gathering of Circulatory Primary Care of cardiovascular in the West Region,” and has been held every month since 1981. In February 2000, we held the 213th session. Since the beginning, we have positioned cardiovascular medicine as a team effort in the region, through hospital-clinic cooperation, or hospital-hospital cooperation today. However, it goes without saying that refering physicians and institutions must understand and agree with the indications and usage of new treatment methods in order to jointly provide the state-of-the-art medicine. This is particularly important when that advanced medical treatment is so now that it may not be commonly practiced yet in the general medicine community. When utilizing a new treatment method that is still under going evolution, we think it is necessary that not only staff members of the facility performing the treatment and the patients (and their family), but also the physicians who referred the patients, share the same understanding. Moreover, the results of clinical trials, etc. must be informed to the local medical care providers, regardless of whether the results are good or bad. We think the “Gathering of Circulatory Primary Care in the West Region” is essential for us as a place to openly evaluate our daily treatment policies, as well as a place for guging the attitude of the entire region toward new treatment methods.

In less densely populated mid-sized cities like Kurashiki and neighboring regions, transportation of the patients from a relatively remote areas is often required, and traffic congestion is relatively rare. This is an environment favorable for mobile CCU. Mobile CCUs of our hospital were dispatched 450 times last year. The program has enabled acute phase treatment with excellent results for our patients and has come to be regarded as a great achievement for the entire in Kurashiki medical community. Moreover, as an institution treating a large number of patients, we have a duty to aggressively work on clinical studies to enable better diagnosis and treatment, and clinical trials of drugs or medical devices, and to feed back the results to the patients. We strike to determine the optimal indications, including safety and efficacy, of vanguard clinical techniques (redavdant)

Visions for the future
There are three directions in our vision for the future. The first is the construction of the Heart Disease Center, the second is improvement and expansion of each subspecialty in the department, and the third is research and development based on clinical experience. Key to each of these axes is the establishment of the effective infrastructure.

  1. Heart Disease Center
    In the treatment of heart disease in which many emergency procedures are required, it goes without saying that the physical distance between the physicians and the patients should be as small as possible, and that cardiologists and cardiac surgeons should constantly keep close communication while treating a patient. Ideally, outpatient clinics and twards of the departments of cardiovascular surgery and circulatory medicine, laboratory for physiological function tests, RI laboratory, angiography room, emergency center, and operation rooms should be all be in close proximity to exchother. We believe that the construction of the Cardiac Disease Center will provide an ideal intra-hospital facility for community medicine. We have envisioned its construction for more than 20 years.
  2. Expansion of subspecialities
    Our department is often seen to focus intensively upon coronary intervention. In fact, there is such a tendency, but we also have active programs in electrophysiology, ablation, echocardiography, and RI study. We hope to farther develop these programs, in cooperation with our medical community, thereby providing broader care and treatment choices.
  3. Pre-clinical studies and training using animal
    Since our hospital is neither a university nor a public hospital, it traditionally hard minimal involvement in pre-clinical experiments using animals, or clinical training by using large animals,(such as). In the past, we were required to utilize overseas and domestic facilities when conducting these activities. However, in order to provide medical care that is able to quickly cope with advancement of medical techniques, it will become necessary to conduct these experiments and studies within the hospital, or at study facilities affiliated to the hospital. Establishment of the infra-structure, transcending the framework of departments, will be necessary. Although the economic aspects and the trends of demand and supply must be considered, we are determined to realize this dream.

Contents of service

  1. Ischemic heart disease
    1. CAG and percutaneous transluminal coronary angioplasty (PTCA)
      Designed to provide patients with safest and most comfortable experience, coronary arteriography is conducted by an approach via the right brachial artery. As a general rule, the diagnositc procedure is conducted on the day of admission, and the patient is discharged in the following morning. On the other hand, catheterization for monitoring the course after PTCA is often conducted at the outpatient clinic without admitting the patient. In 1999, 4214 patients underwent coronary arteriography at our department, and 1171 patients underwent ambulant catheterization (without admission). Among these patients, 1196 patients underwent planned ischemic arterial intervention (PTCA), and about 223 patients underwent emergency PTCA for AMI. Stents were used in about 70% of the patients undergoing elective PTCA, and 80% of the patients treated by emergency PTCA. Rotablator was used in about 121 patients. In contrast, directional coronary atherectomy (DCA) was performed in about 10 patients. The results of coronary arterial intervention as a whole are presented in the table.

      While the management of patients at CCU and ward, as well as coronary arteriography are conducted by all physicians in the staff, echocardiography, nuclear medicine, electrophysiological examinations and treatment, and coronary arterial intervention are carried out under the supervision of respective specialists, with cooperation of other staff members.
      1. PTCA of chronic completely obstructed vessels
        Concerning the results according to the morphology of lesions, the dramatic improvement in the success rate in the cases of chronic complete obstruction is noteworthy. The improvement was realized by the use of new equipment guide-wires, notably developed at our department, as well as refined techniques. While the success rate was before the introduction of the new guide-wire 69%, this improved to 73% by utilizing the new guide-wire. Further, by using the new technique, this success rate improved to 85%. Incidentally, the success rate for such cases world wide is reported to be 64%.
      2. PTCA of acute myocardial infarction
        The results of emergency PTCA for acute myocardial infarction are also steadily improving, exhibiting a success rate of recanalization of 98%.
      3. Less invasive PTCA
        With the patients comfort and speedy recovery in mind, elective PTCA is conducted by an approach through the radial artery whenever possible (about 45% of the entire cases). The operation by the radial arterial approach is less invasive, and the patient is able to walk immediately after the operation. Although operation by the femoral arterial approach is inevitable in treatment of some lesions, when the patient feels overnight bed resting painful, percutaneous vascular suture is conducted to enable the patient to leave the bed earlier. These procedures have enabled discharge on the day following coronary arterial intervention.
      4. New stents
        A clinical trial of several new stents is being planned. All of them are coated stents designed to prevent restenosis. Biocompatible materials are coated over stainless steel, and are expected to prevent restenosis as indicated by the results of animal experiments. Coating material includes phosoryl chorine, which is the surface material of human cellular membranes, iridium oxide, and carbon.
      5. Acolysis (thrombolytic therapy using catheter)
        This is a technique of catheterized thrombolytic therapy in which thrombi are destroyed by ultrasound. While peripheral embolization with thrombi is a relatively rare but notable complication of PTCA, acolysis may provide an attractive treatment method in order to prevent the complication.

        A clinical trial will be started jointly with select centers in Japan.
      6. Radiation therapy
        While restenosis is considered to be a crucial drawback of PTCA, radiation therapy is expected to provide a useful method to prevent this. Clinical trials of this method are expected to commence when national regulartory changes occur in the near future. Our hospital will participate in the planned national trial as one of the evaluating institutions in the near future.
      7. Success rates of coronary arterial intervention and incidences of complications
          Results from the United States Results from Kurashiki Central Hospital
        (Statistics of NACI)
        1990-1994
        Same period as NACI
        1990-Feb.,1993
        Recent data
        March, 1993-July, 1998
        Number of patients 1985 1660 4200
        Success rate in the early stage (%) 85.8 91.6 95.2
        Complications
        Mortality rate (%)
        Emergency surgery (%)
        Myocardial infarction (%)
        1.8
        3.5
        1.5
        0.4
        0.1
        1.5
        0.17
        0.02
        1.11
    2. New techniques for restoring blood circulation ? Angiogenesis therapy and its navigation system
      1. NOGA
        NOGA is a new diagnostic system that allows real-time, accurate diagnosis of heart geographies and muscle viabilities. Since this system uses magnetic fields, it accompanies almost no exposure to radiation. Moreover, since contrast medium is not used, there is no burden on the kidney. Synchronization with ECG enables three-dimensional depiction of the left ventricular wall movement, and recording of intra-cardiac ECG. While it is suggested to enable diagnosis of the ability of the left ventricular viable myocardium, it is also very useful as a navigation system for the DMR described in the following section.
      2. noga

      3. DMR
        Direct Myocardial Revascularization (DMR) is a new technique for restoring blood circulation, with which the position within the ventricle is confirmed by NOGA, and small holes are created by laser at the desired position, thereby promoting angiogenesis. This technique is indicated to diffuse lesions which cannot be treated by PTCA and CABG. In the future, gene therapy and bone marrow therapy may replace lasers, and may demonstrate even greater efficacy.
      4. dmr

  2. Arrhythmia
    Electrophysiological examination using catheter and catheter ablation therapy are conducted at our department. While ablation therapy has been established as a less invasive radical therapy, its indication is gradually expanding. At our hospital, these techniques are indicated mainly for WPW syndrome, paroxysmal supraventricular tachycardia, and atrial flutter. It has also been indicated for ventricular tachycardia in a limited number of cases.
  3. HCM
    Percutaneous transluminal septal myocardial ablation (PTSMA) is conducted as a new technique to treat hypertrophic obstructive cardiomyopathy. With this technique, the septal branch vessel supplying the ventricular septum is necrosed by alcoholic cautery, thereby reducing differences in the pressure in the left ventricle. While further examination is needed to determine the procedures long-term prognosis, favorable acute effects on symptoms and pressure differences have been observed.
  4. Valvular disease
    Surgical therapy is used for radical treatment of valvular disease in many cases. In the treatment of mitral stenosis, we perform percutaneous transvenous mitral commissurotomy (PTMC) using the world-reknouwn Inoue balloon. With careful selection of indications, we have achieved about a 95% success rate. Recently, according to the decrease of Rheumatic fever, both the number of PTMC cases and the also number of institutes which are capable of performing PTMC has decreased. However, we continue to lean an active practice.


Others

  1. acility accreditation
    ngiocardiology Specialists Training Facility Accredited by the Japanese Society of Angiocardiology
    Accredited facility satisfying the standards for handling PTCA, pacemakers, and rotablators
  2. Study sessions
    The Gathering of Circulatory Primary Care in the West Region is held from 7:30 p.m. for about 2 hours on the 4th Monday every month. As a general rule, the session is held at Kurashiki Kokusai Hotel, but please check the newsletter of the Prefectural Medical Association, to confirm the next meeting.
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