As the director of Cardiovascular Services at St. Joseph Hospital in Lexington, Dr. Robert Salley has seen the market grow from one of budding heart research, to the top-notch award winning healthcare facility it is today.
“I began in the Lexington area in 1988 when I was recruited to join the UK faculty,” Salley said. “I was charged at that time with re-establishing the congenital heart surgery program at the university.”
Salley became chief of surgery after 18 months and at that point he said they had an active research arm at the university as part of the division. “We did a great deal of work and interaction with the American Heart Association writing grant proposals and eliciting funding and during that time
I was on the committee to review applicants from several states submitting proposals,” he said.
Salley left the university in 1996 to join the Surgical Associates Cardiovascular Group at St. Joseph Hospital East, a very busy private practice, and no longer participated in any “significant research”. He has always appreciated his roots in research, as he has watched technological advances lead to not only a decline in deaths from cardiovascular diseases but also to less invasive surgeries and faster recovery times.
“Over the years as the number of open heart cases has declined on the basis of new technologies and better treatments – for example, at one point, we were doing over 1,600 heart surgeries a year at St. Joseph Hospital and today, we are doing almost 700 hearts,” he said. “But also during the time since 1996, we have seen the open heart program at St. Joseph East being discontinued and brought to St. Joseph main and the overall management of cardiovascular disease in central Kentucky is now of very high quality.”
Salley said the overall population in the state is “well served” today. Part of the decline in open heart surgeries is due to the opening of new programs in areas like Pikeville, Hazard and Ashville as well as a decrease in referrals into Lexington. At the same time, the technological breakthroughs, with stents, balloons and coronary circulation, have allowed better patient management, according to Salley.
“These cases can be better managed without open heart surgery,” he said. “They can be taken care of with a catheter based intervention and at the same time drugs have been improved dramatically over the years with the introduction of powerful Statins to decrease lipids and cholesterol and improvements in pacemaker technology and cardiac defibrillators. All of these lead to improvement of the overall care of the patient, a decrease in the severity of disease they may have as they grow older and a decline in the need for highly invasive procedures such as coronary artery bypass surgeries.”
Salley explained that the mainstay today for surgical management of patients is less directed toward surgical bypass and more toward valvular heart disease. “And we’ve had new technologies that have been brought to light on the more standard operations,” he said. “We now have catheter based procedures called Transcatheter Aortic Valve Implantation [TAVI] that are utilized for patients considered extremely high risk. It’s very expensive and we have stringent guidelines for what patients may or may not receive the technology but I think it’s an opportunity for us to approach patients that otherwise may have been inoperable.”
Somewhat similar to a stent placed in an artery, the TAVI approach delivers a fully collapsible replacement valve to the valve site through a catheter. Once the new valve is expanded, it pushes the old valve out of the way and the tissue in the replacement valve takes over the job of regulating blood flow.
“This (TAVI) was introduced in our hospital in 2011 and we are now doing about 50 of these a year,” Salley said. “So it’s not inconsequential and I suspect for 2015 we will be well over 50 in a year.”
Another new technology the hospital is utilizing is the “mitral clip”, a minimally invasive procedure designed to help patients who have severe mitral regurgitation, or a leaky heart valve and are not candidates for surgery.
“This is put in through the groin and this technology is for high risk patients and allows us to treat patients who are having recurrent congestive heart failure and to decrease mitral regurgitation and decrease their multiple re-admissions to the hospital.”
The mitral clip program is the only program of its kind in the state of Kentucky, according to Salley and until just recently unique to St. Joseph.
Salley said on the horizon for cardiovascular research is learning more about how to better manage heart disease and the diseases that lead to it.
“Right now there is a lot of interest in the new anti-coagulation drugs and research to prevent cardiovascular complications of diabetes,” Salley said. “There have been efforts to elevate the newer catheter based minimally invasive procedures to decrease the stroke risk patients may have, particularly those that have atrial fibrillation and cannot tolerate anti-coagulation drugs.”
He said what’s important now and the wave of the future in the management of cardiovascular disease is to move away from a “silo” approach to care of patients.
“We now are looking at patients in a multi-disciplinary view,” Salley said. “We want to take a far broader approach so a cardiologist is part of a team to handle coronary artery disease as well as diabetes. So we have a surgeon and an endocrinologist and the team might even include an end of life specialist. We have a highly specialized team to move the patient through the entire experience over the long term. It’s a multi-disciplinary approach that is leading us to improvements in overall care and we’re bringing everyone together to participate in the discussion.”