When interventional cardiologists get together, they sometimes joke that they are just plumbers – as if they spent their time cleaning up clogged sinks. In fact, these cardiac specialists perform sophisticated, high-tech procedures such as angioplasty (percutaneous coronary intervention) to open up clogged coronary arteries; use balloons to dilate the mitral valve on the left side of the heart; and close the flap between the two upper chambers (patent formen ovale) to prevent a blood clot from moving into the brain and causing a stroke.
They may also open up obstructed non-coronary vessels such as the carotid, femoral and renal arteries and should know how to use drugs that improve the outcome of procedures as well as how to integrate the results of new imaging techniques like the CT scan and MRI to decide how to treat their patients.
Other specialists in the field include the general clinical cardiologists who focus on prevention, diagnosis and management of heart disease and sit mostly in community; electrophysiologists who deal with irregular heartbeats (arrhythmias); cardiovascular investigators who research the field; pediatric cardiologists who specialize in treating children from birth through their teens; heart transplant surgeons; and cardiac surgeons, who do open-heart surgery and whose caseload has been significantly reduced (up to 70 percent) by procedures performed by interventional cardiologists.
Even aortic valves can be replaced using catheters instead of open-heart operations.
At Jerusalem’s Shaare Zedek Medical Center, in which the entire 10th floor is dedicated to prevention, diagnosis, treatment and rehabilitation of heart disease, Prof.
Giora Weisz is the new chairman of cardiology.
He was appointed to replace the longtime and highly respected Prof. Dan Tzivoni, who retired but still sees patients in the department. “I was Dani’s student in medical school,” he recalled.
Weisz took over the department – with 50 inpatient beds the largest cardiology department in Israel – in January this year after spending 13 years in New York. A native of Haifa, Weisz got his MD degree at the Hebrew University Faculty of Medicine in 1988 and was an intern and resident in internal medicine and then a fellow in cardiology at Haifa’s Carmel Medical Center until 2000.
The following year, Weisz moved with his family to the US, where he spent two years training in interventional cardiology at the heart and vascular institute at the 652-bed Lenox Hill Hospital. Although they had planned to return home, the interventional cardiologist was offered by Prof. Martin Leon – director of the Center for Interventional Vascular Therapy, at Columbia University Medical Center/New York-Presbyterian Hospital – a job he felt he could not turn down. The prized position was director of clinical cardiovascular research at the hospital, and Weisz was also named associate professor of medicine at Columbia University Medical Center. He and his family thought they might stay on indefinitely but spoke only Hebrew at home.
“As I wanted to be an interventional cardiologist, I was so excited to be accepted to a world center in interventional procedures.
The work in New York was incredible, as I was exposed to the latest developments in the field. Not a few of the technologies were actually developed in Israel. I ran over 50 research projects simultaneously and also treated cardiac patients. Cardiology is very technological, and being there made it possible to advance in my skills. I really enjoyed it,” Weisz recalled. He also taught medical students.
“My time in New York made it possible for me to pioneer many new technologies involving robotic navigation and simulation and to understand the catheterization lab of the future. The GPS-like system knows exactly where in the body the catheter is located, so one doesn’t have to use so much contrast media and radiation, which are not so healthy. It was one of my first steps there in the highest level of cardiac technology. It actually was developed by Mediguide, a company in Tirat Hacarmel near Haifa that was the first system of its kind to be introduced in the US. I also worked with simulators of catheterization and angioplasty so I can devise a plan to work on each patient the day before I actually treat him. It can be used to clean out plaque in the carotid arteries leading to the head and prevent strokes, as well as to prevent an aortal aneurysm.” said Weisz.
“When I started at the research center, there were 12 people working or me.
When I left, there were 26. A great deal of money for research came from the industry.
Research helps the large corporations such as Medtronic and Johnson & Johnson sell more, and they want to give back to the community and help to find better treatments for patients. ” But “[SZMC director-general Prof.] Jonathan Halevy worked on me for two years to get me to come and work for him in Jerusalem,” Weisz said in an interview in his office with The Jerusalem Post. Now he is in Jerusalem with his wife, a molecular biologist, and three daughters and happily working on the medical center’s 10th floor.
He does not at all regret his return, even though his salary is considerably lower than what he was earning in New York.
Highly technological, he surprised staffers when he requested two computer screens for his computer to manage his work better.
IN HIS new job, continued Weisz, he continues to work with and advise industry “so I can bring more advanced technology to my patients. There’s a gray area; I have to be careful. But if a technology they have developed and want to sell doesn’t work, I tell them unequivocally. I remember that a stent a company made was found to have a serious defect, and I demanded that the company take it off the shelf. They repaired and improved it, and now it works fine.”
With more than 20 physicians working under him at SZMC, his cardiology department is larger even than that at Sheba Medical Center, which is the largest hospital in Israel. “But here we have a different concept. In other hospitals, people complaining of chest pain are sent to the internal medicine department.
They wait for a cardiologist to see them.
Here, they come directly to cardiology, and treatment is much faster. We save them days of waiting in a hospital bed until the cardiologist comes to them,” said Weisz.
“The US has a different cardiology system than in Israel. There, the clinic cardiologist who wants to hospitalize patients sends him to a hospital where he has privileges to work. A benefit is that he knows the patient and his medical history. But the US system is billing oriented. The doctors care about their patients, but the medical administrators are primarily concerned in billing for services. Americans are not any healthier than Israelis; life expectancy is significantly longer here, even though Israel spends less than half of its GDP on healthcare.”
Here, the patient is sent from the clinic to the nearby hospital with which his health fund has arrangements. “The doctor who treats him doesn’t know him personally, but the system is much more efficient,” said the SZMC cardiologist.
Interventional cardiologists conventionally are exposed to health dangers during their work. They wear lead shields to minimize their exposure to radiation, but these do not provide absolute prevention, leading to higher risks of cancer and cataracts. In addition, constantly standing and wearing the heavy protective gear can cause orthopedic strain on their bodies. In a study of 36 doctors with brain tumors apparently linked to radiation exposure over their career, 86% were left-sided tumors, indicating a correlation with the physician’s table position.
In a survey of interventional cardiologists conducted by the US Society for Cardiovascular Angiography and Interventions, 42% reported spinal problems, 28% had hip, knee or ankle problems and a third said their work was limited by these health problems.
Many hospitals bar female interventional cardiologists from working during pregnancy, while others require them to wear two times as much protective gear to protect from radiation exposure.
Prof. Rafael Beyar – director-general of Rambam Medical Center in Haifa and himself a prominent interventional cardiologist – invented a much safer work environment for himself and his colleagues. The result was a vascular robotic system in which the physician sits a distance from the patient at a cockpit/console with three computer screens and two joysticks to perform catheterization and angioplasty. There is no need for heavy protective equipment.
The technology, called CorPath and manufactured by Corindus, and the system will soon arrive at SZMC where Weisz, who has become world renowned in this field, will be the first Israeli to use it. “I am happy to introduce it in Israel. It has great potential.”
“The doctor is relaxed and can concentrate better, and he can reach blood vessels using the robotic system that he can’t always reach by hand,” said Weisz. “Because it is more exact in deciding on the sizes, I think it can also save 10% to 20% on stents.”
Weisz is also a principal investigator of a study being conducted in 250 hospitals in 25 countries (including SZMC and nine others in Israel) on the use of oral drugs that protect the heart muscle to make angioplasty and stents more successful. A drug called ranolazine reduces ischemia (lack of oxygen) in the heart muscle. “The drug is already approved for use, but it hasn’t been used a lot because it was relatively expensive,” Weisz said. “We will soon finish the research and see the results. It is a wonderful experience to be responsible for research that can improve things for patients.”
Another new technology that excites him is called optical coherence tomography.
“There wasn’t anything really new in intravascular ultrasound [imaging inside blood vessels] for 20 years. It wasn’t used much because it takes time, and you have to have a lot of experience looking at ultrasound scans. But this new technique uses laser light that returns to the catheter and provides a very sharp, high-resolution image.
The interventional cardiologist can know how much plaque is inside the artery and if it’s soft or hard calcium. We are studying much more about atherosclerosis.”
In the field of stents, Weisz predicts that the “next big thing” will be supports made of polymers (plastics) that will serve as a temporary scaffold and then dissolve as time passes. The vessels are able to remain open without this support.
For several years already, heart disease has dropped to second place, after cancers, among the causes of death in Western patients. “Nobody argues anymore that smoking kills, and many have stopped or not started. Another important factor is the giving of statin drugs to reduce harmful cholesterol.”
Even though it is regarded as a man’s disease, cardiac conditions affect plenty of women, but the problems often appear later. “Women pay less attention to themselves.
They worry about their families. It is a myth that heart disease and its symptoms are different in women. They may get treatment that is not is as good in men because it takes longer for them to be diagnosed.”
“I was attracted to cardiology because I liked the integration of intensive care and evidence-based medicine. I know that when a patient comes to me with a clogged coronary artery, after I extend his life by opening up the vessel and inserting a stent, I am not finished. The real treatment is to prevent a subsequent heart attack by getting patients to change their lifestyles. They must stop smoking and start to eat right and exercise. I myself like to use a bike,” said the thin and fit cardiologist, “and I take statins as a preventive measure, as I have a strong family history of heart disease in my family.”