Kirmser discusses ‘phenomenal’ advances in cardiology
About 50 people gathered in the Wilton Senior Center lounge Tuesday, Jan. 23, to hear Wilton resident and longtime cardiologist Dr. Ralph Kirmser discuss some of the major advances in the diagnosis and treatment of many heart conditions.
“The changes in cardiology in diagnosing problems and treating problems have been phenomenal,” said Kirmser.
During his talk, Kirmser discussed the treatment of coronary heart disease with angioplasty/stenting, the non-operative treatment of aortic valve stenosis, and the diagnosis and treatment of atrial fibrillation.
“The heart is a muscle that contracts and relaxes. It’s stimulated to do this by a small electrical impulse that rises from the top part of the heart called atria, and this small electrical impulse travels through the atria down to the main pumping chambers of the heart, which are called ventricles,” said Kirmser.
“Each muscle cell is stimulated by this electrical impulse. Because this muscle contracts on average 70 times a minute, it needs lot of blood, and it gets that blood through coronary arteries.”
Coronary arteries are “the first arterial branches that come off the heart,” said Kirmser.
One way to treat coronary heart disease is angioplasty, which Kirmser said, has seen “tremendous advances in the last 40 years.”
“Angioplasty is a technique using a catheter — a long, thin, flexible tool that has a balloon at the end of it. That balloon is placed in an area of the artery that is narrow,” he said.
“When that balloon is in the right spot, it is inflated under high pressure and the vessel is forced open allowing better blood flow from the heart muscle.”
When it was first used, Kirmser said, angioplasty was a “useful procedure,” but “about half the people who had [it] came back within a matter of three months with recurring narrowing of that same blood vessel.”
Sometime in the 1990s, he said, small cylinder devices called stents started being used to prevent the artery from closing down again.
Although it reduced narrowing rates by about 50%, said Kirmser, about 30% of people still experienced re-narrowing “within three months of the initial stent procedure.”
The re-narrowing was not due to a build-up of cholesterol, “which is typical with coronary heart disease,” said Kirmser, but was “due to cells growing into the stented area and sort of choking off the opening.”
Someone then got the idea to coat the stents with a chemotherapeutic agent, said Kirmser, which reduced the re-narrowing rate to “somewhere around 5% or less.”
Kirmser said this procedure is now “the standard of care for treating people with heart attacks” and is also used for people with angina — heart pain that comes from a narrowed heart artery.
However, Kirmser said, it is not known if angioplasty will — and is therefore not intended to — improve the prognosis of people who have stable coronary heart disease.
Aortic valve stenosis
The heart has four valves that direct blood flow from the right side of the heart to the left and to the body.
The aortic valve “controls the flow of blood from the heart into the aorta and then to every cell in the body,” said Kirmser.
“This valve normally has three leaflets, or cusps, and when the heart contracts, the leaflets are supposed to open up widely and allow blood to go out to the body,” he said.
“When the heart relaxes, that valve should close tightly so that no blood leaks back into the main pumping chamber of the heart.”
The aortic valve “takes a beating over time” and can become “very tight,” said Kirmser.
“When that happens, the heart has to work harder to get blood out to the body.”
This is called aortic valve stenosis, and it’s “the most common heart valve disorder” that cardiologists see and treat, said Kirmser.
Symptoms of severe aortic valve narrowing include experience exertional chest pain, exertional shortness of breath and fainting. When a patient develops one or more of these symptoms, said Kirmser, his or her aortic valve needs to be replaced — and that’s the only cure for aortic valve narrowing.
“Traditionally, there’s been one way to replace the valve, and that’s been open heart surgery,” she Kirmser.
In the last 10 years, however, a new procedure called transcatheter aortic valve replacement (TAVR) has been used, said Kirmser.
This catheter-based, minimally invasive surgical procedure repairs the valve without removing the old, damaged valve and instead wedges a replacement into the aortic valve’s place.
Kirmser said the procedure is done “pretty much everywhere now,”and the results have really been “quite dramatic.”
Atrial fibrillation is the most common heart rhythm abnormality that cardiologists see and treat, said Kirmser.
On the right side of the heart is a small structure called the sinus node, which generates an electrical impulse every 60, 70 or 80 times a minute, said Kirmser.
“This impulse travels over each of the atria, and then it finds a spot between the two upper chambers and the lower pumping chamber called the AV [atrioventricular] node.”
Kirmser said the AV node is “sort of like a waste station” for distributing the electricity to the lower pumping chambers of the heart.
With atrial fibrillation, instead of a person’s heart rhythm being controlled by a “small, organized impulse,” said Kirmser, the atraia starts to “quiver.”
“There are multiple little electrical circuits that are stimulating the atria at a rate of 300, 600 times a minute — almost too fast to count,” he said.
“What this does is this then causes the lower pumping chamber of the heart to beat too fast.”
Kirmser said patients often find the symptoms of atrial fibrillation “intolerable.” These include “irregular, rapid heart action,” fatigue and sometimes shortness of breath over time.
The formation of a blood clot in the heart is “one of the most feared things about atrial fibrillation,” said Kirmser.
“When the top two chambers are quivering, blood tends to stagnate in them when it normally would be pushed along,” he said.
“Anytime blood stagnates, there’s a potential for it to clot.”
When a clot forms in the left atrium and breaks off, Kirmser said, it can travel elsewhere, cause a blockage and result in a stroke.
Additionally, if the heart rate is not controlled over time, said Kirmser, “the heart can actually beat so fast that it can subsequently become weak and heart failure can develop.”
The most common associated condition with atrial fibrillation is hypertension, said Kirmser. Other causes include chronic lung diseases, valve heart diseases, excess alcohol and sleep apnea.
Kirmser said there are two strategies for dealing with atrial fibrillation:
- Rate-control — Allowing the atrial fibrillation to persist, but controlling the heart rate so the patient is comfortable, and treating him or her with an anticoagulant so a clot doesn’t form.
- Rhythm-control — Attempting to get the rhythm back to normal and maintain the normal rhythm for as long as possible.
“We don’t know if one strategy is better than the other in terms of mortality rates … or if the stroke potential is lesser with one of those strategies over the other,” said Kirmser.
“We do focus very much on patients’ symptoms — if we can get them to feel good, then we generally prefer a rhythm control strategy before a rate-control strategy.”
Kirmser said monitoring capabilities have also been “increasing tremendously.”
For example, he said, a recent study in Denmark used a device called an implantable loop recorder, which gets inserted “just underneath the skin” and constantly monitors a person’s heart to see what kind of rhythm they have.
Kirmser said the implantable loop recorder can stay in for up to almost two years.
A graduate of Yale Medical School and the Yale cardiology fellowship program, Kirmser spent two years in the United States Air Force at Andrews Air Force Base, where he served as chairman of the cardiac catheterization laboratory. He now works for Cardiology Physicians of Fairfield County and is affiliated with Norwalk Hospital.