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an online version of the magazine Winter 2007
Medical Rounds
Illustration of Older Workers


Expanding the Broken Hearts Club

Physically linked events, more than emotional triggers, prompt the cardiac syndrome.


CARDIOLOGIST ILAN WITTSTEIN grabbed headlines two years ago with his report on “Broken Heart Syndrome”—in which people who undergo severe emotional stress (triggered by the death of a loved one or a holdup at gunpoint) suffer episodes that mimic heart attacks but without lasting damage.

Now Wittstein is back, with findings showing the syndrome to be more prevalent than he and his colleagues here had first believed. He and his chief associate, Hunter Champion, have defined an expanded category of events, which are physically linked, that cause similarly transient chest pain in patients—and in much larger patient numbers. These events are wide-ranging: stroke, seizure, severe migraine headache, asthma flare-up, acute internal bleeding, major bone fractures, or sudden withdrawal from medicines.

The common element in all of them, says Wittstein, is the sudden release of catecholamines into the patients’ bloodstreams—at a level up to 20 times normal. Such a flood of neurohormones, says Wittstein, brings “acute stress to the system.” The net effect is to stun the person’s heart, making it look “horribly injured and weak,” says Wittstein, “but with no clots found in the arteries that supply the heart with blood. Within two or three weeks,” he says, “the patient’s heart is back to normal.”

Wittstein says this new group of syndrome sufferers is larger than the emotions-only group. According to his team’s latest survey of Hopkins patients since 1999, three-fourths of all cases of Broken Heart Syndrome stemmed from physical stressors.

In one detail sure to add to the notion that men are the more cold-hearted sex, Wittstein’s group reports that only one of the 19 patients who suffered Broken Heart Syndrome after an emotional event was a male. In the new round of patients with the more physically based cases of the syndrome, the number of male sufferers rises, but women still dominate that cohort as well.

Wittstein’s group also found that a fourth of BHS sufferers were using the popular class of antidepressants, the SSRIs, that block the re-uptake of catecholamines, possibly leading to a higher concentration in the bloodstream. He believes that this may make some patients more susceptible to acutely stressful events.

The good news for sufferers of Broken Heart Syndrome is that they are unlikely to suffer a recurrence of the event. The syndrome also now has its own diagnostic code, which should aid insurers in separating it from the higher risk of mortality borne by survivors of heart attacks that permanently damage the heart muscle.

Lest patients and their loved ones take the syndrome too lightly, Wittstein cautions that a third of patients with BHS are critically ill at the time of admission to the hospital. Their problems include chest pain, congestive heart failure, shock, and hypotension. Survivors also need follow-up treatment for several weeks to ensure their hearts return to their pre-BHS pumping capacity. 



Old Livers Offer New Hope

Elderly liver donors could vastly expand donor pool.

. . . nude woman bent over
      Illustration by Sherrill Cooper

For those with advanced liver disease, the wait for a new liver is grim.

With only 6,000 liver transplants performed annually in the United States, and a waiting list that has ballooned beyond 17,000, one in four transplant candidates may die waiting.

To expand the pool of potential donors, Hopkins liver transplant director Paul Thuluvath and surgeon Dorry Segev turned to a group that had previously been considered less than ideal: the elderly. Their rationale? Compared to other organs that decline naturally with age, the liver is known for its longevity in patients who die from unrelated causes.

Conventional medical wisdom has held that livers provided by donors over the age of 70 proved less reliable in recipients (up to 40 percent less reliable, according to some studies), as opposed to those obtained from ideal liver donors—those under the age of 40. What scientists hadn’t considered, say Thuluvath and Segev, was whether more careful selection of recipients could improve those outcomes.

The results of their four-year study, which the duo reported in the December 2007 issue of Hepatology, confirm that older livers do, in fact, hold great potential. The authors conclude that when ELD (elderly living donor) organs were matched with preferred transplant candidates, the patients’ outcomes virtually matched those of patients receiving organs from ILDs (ideal living donors). Three years out, 80 percent of patients from both categories were still alive.

“The key is to match the recipient with the donor in an objective manner,” says co-author Thuluvath. Before, physicians had turned to elderly
livers only as a very last resort, when their patients were most gravely ill, which accounts for the earlier experiences showing that ELDs were less successful.

The researchers could also quickly see that elderly liver donors are underused. Of the 23,763 liver transplant cases in the four-year study, only 1,043 of them came from ELDs. That’s just 260 ELDs per year. With more than 160,000 people dying yearly from strokes alone—and most of the decedents over 65 years old—“the potential to expand the organ pool by tapping into ELDs is huge,” says Thuluvath. “If we could retrieve organs from 5 percent of this population, we may have 8,000 ELD organs.”

With liver disease-related hospital admissions rising at an annual rate of 5 percent, there may be a new answer at hand. 




Better Zzzzs

A detail to muffle snoring


. . . nude woman bent over
      > Polyester rods are implanted on an outpatient basis.

The Pillar Implant is gaining traction as an effective weapon for preserving marriages. Matthew Kashima has implanted the small polyester rods into the palates of 10 men. The rods have reduced snoring in all but one man, who, Kashima reports, had “unusual tissues.” The patients pay $1500 for a set of three rods, plus the procedural fee. (Insurers currently do not cover this fix). It requires just a half-hour office visit, in which Kashima and his team insert the implants into the snoring patient’s soft palate to stiffen the tissues against vibration. Patients feel little pain during the procedure, and many are unaware of the implants’ presence just days later. Snoring typically abates within a month. “Nothing works for everybody,” says Kashima, who heads up otolaryngology at the Bayview Medical Center. “I’m conservative about who I put them in.”  




Joint Solutions

For some knee repairs, it’s out with artificial and in with biological.


Roger Blumenthal
      > Says Hooper, “I’m back.”

WHEN MICHAEL TRICE examined Tori Hooper’s injured knee in 2006, he weighed the options carefully. Surgeons had intervened two years earlier, after Hooper suffered an agonizing field hockey injury just prior to her senior year in high school. Now the pain was returning, and Trice could see why: In responding to the woman’s torn meniscus cartilage—which led to the painful loss of articular cartilage in the bone beneath it—the earlier surgeons took the conventional approach. They removed much of the injured cartilage to encourage scar tissue to take its place as a surface within the joint.

The traditional strategy works well for most patients, but sometimes fails in those who are younger and more active, especially those inclined to pursuits like field hockey. Hooper, now in college, found herself hobbling around her new campus on crutches. She hoped for a better fix.

Hooper’s youth guided Trice’s treatment decision. With an older patient, the orthopedic surgeon might have opted for some of the more advanced artificial joint materials. But artificial joints have a limited life span, typically requiring revision surgery; Hooper’s healthier activity level might easily wear one out within five years. And so—as he has numerous times during his two years at Bayview specializing in cartilage repair and restoration—Trice opted for a revolutionary approach that would mostly rely on Hooper’s own cartilage.

The procedure, called autologous chondrocyte implantation (ACI), has been steadily winning Trice’s confidence. It involves the extraction of some 300,000 chondrocyte cells—cartilage’s cellular component—from the patient’s knee. The cells are then cultured in a lab, multiplying to millions. In a second procedure, the physician injects the higher volume of cells into the patient’s injured knee area, where it is covered by a thin patch of membrane taken from the healthy shin bone. In Hooper’s case, Trice also transplanted a donated meniscus.

Though the ACI procedure has won some critics—recovery can be slow at up to eight months and it can be costly at up to $35,000—its success rate scores well at between 70 and 90 percent.

“It worked for me,” reports Hooper, who admits she’s shy of returning to competitive athletics because she doesn’t want to risk a new injury. Still, she says, she exercises normally, has thrown away the crutches and feels “like a normal college kid again. I feel like I’m back.”

Trice is currently one of the few central Maryland surgeons who use the procedure, and he expects his ACI case capacity will soon pick up. He and other colleagues plan to open the multi-location Johns Hopkins Cartilage Restoration Center before spring. 




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