For more than 60 years, we have been at the forefront of cardiovascular medicine, research, and education.  Standing on the shoulders of visionaries such as Drs. Denton A. Cooley and James T. Willerson, today’s THI is committed to the pioneering archetype that defined the Institute and led to many of the advances that are now foundational elements of patient care. While the focus of our efforts has evolved over time, THI remains committed to bringing the future of cardiovascular health to life.

The past year witnessed dramatic growth in our clinical practice.  New, modernized clinical space houses our cardiovascular care, providing a single stop for patients seeking our expertise in nearly every cardiovascular health and disease domain. We have coupled our commitment to improving cardiovascular health with state-of-the-art, in-office testing and access to cutting edge clinical research that uniquely offers our patients the newest diagnostic and treatment options.

The scientific programs at THI, focused on translating fundamental discoveries into patient care, continue to push the boundaries of science and medicine by challenging current paradigms and innovating new solutions to the most challenging problems in cardiovascular disease.  For example, the Molecular Cardiology Research Laboratory has developed a class of molecules that stimulates the immune system and can be used as vaccine adjuvants for infectious diseases that impact the heart and are now also being clinically tested as a treatment to enhance the effectiveness of immunotherapy in drug-resistant cancers.  The IDEA Laboratory has been working on a novel system to extend the time that donor lungs can be maintained outside the body – an approach that would revolutionize the field of lung transplantation.  And our work in gene and stem cell therapy research continues to provide key insights that promise of restoring cardiac function following injury.  In 2023, our innovative scientific programs were recognized with the highest level of peer-reviewed, federal funding in a decade.

THI’s commitment to education in 2023 was steadfast with specific initiatives that define the Institute as a trusted source of medical information.  In addition to a series of patient-focused webcasts, THI education web pages were translated into 104 languages enabling patients from around the globe to understand cardiovascular conditions in their native languages.  Our provider-targeted educational programs have been cataloged and posted online to allow colleagues access to the outstanding CME materials generated at THI each year. 

The spirit holds true to our mission- to improve cardiovascular health today through trailblazing research, thought leadership, education, and patient care.  We look forward to 2024 with an enthusiastic confidence that we will serve as a source of scientific advancement, excellence in clinical care delivery, and impactful educational programs that will shape cardiovascular health. 

A collaborative, multi-institutional team spearheaded by researchers at Baylor College of Medicine has been awarded a $31 million grant by the Patient-Centered Outcomes Research Institute (PCORI) to determine the safety and effectiveness of commonly used pacing treatments for cardiac resynchronization therapy in people with heart failure. 

The research team is led by Dr. Mihail G. Chelu, Associate Professor of Medicine–Cardiology at Baylor College of Medicine, who is the study’s Principal Investigator; Dr. Kenneth A. Ellenbogen, Professor of Cardiology at Virginia Commonwealth University; and Dr. Richard Holubkov, a biostatistician with the University of Utah. The study will focus on the use of conduction system pacing for cardiac resynchronization therapy in patients with heart failure and conduction system disease.

Heart failure affects every aspect of life for an estimated 6.2 million Americans. This debilitating disease not only decreases quality of life but puts stress on patients and their families by imposing a substantial financial burden. Patients with heart failure are also often faced with frequent hospitalizations and an increased risk of premature death. 

What is cardiac resynchronization therapy?

More than one-third of all patients with heart failure have conduction system disease—a disorder of the heart’s electrical system, which controls the heart’s rhythm and rate of the heartbeat. Cardiac resynchronization therapy treats this conduction system disease by improving cardiac heart function while also increasing the patient’s functional capacity, thereby reducing hospitalizations and prolonging survival. Cardiac resynchronization therapy is the standard treatment in patients with heart failure with reduced ejection fraction and a wide QRS complex. (QRS represents the electrical impulses in the heart as they spread through the ventricles.)

Cardiac resynchronization therapy can be accomplished by one of two strategies: biventricular pacing or conduction system pacing. 

Biventricular pacing is the standard of care, improving heart failure in 60% to 70% of patients by pacing simultaneously from two discrete muscle sites: the right ventricular apex and the left lateral wall. On the other hand, conduction system pacing relies on the direct, rapid pacing of conducting cells, either at the His bundle—the part of the heart that carries signals to the atria and ventricles—or the left bundle branch—the branch that distributes the electrical impulses to the left ventricle. This re-establishes activation of the entire arborized conduction system and cardiac muscle in a highly choreographed and efficient manner that closely reproduces the heart’s natural function. 

The study

In their study, Drs. Chelu and Ellenbogen will evaluate the safety and effectiveness of these two pacing treatments in a cohort of 2,136 patients enrolled at 65 sites in the U.S. and Canada. 

In the initial stages of the study, these investigators have worked with patients, leaders in health care, and research collaborators to identify the outcomes most relevant to patients: quality of life, patient activity, hospitalization for heart failure, and death. They have also collaborated with the Heart Rhythm Society, American Heart Association, American College of Cardiology, the National Hispanic Latino Cardiovascular Collaborative, the Pacemaker Patient Advocacy Group, WomenHeart, and Mended Hearts.

“In 30 to 40 percent of patients with heart failure and conduction system disease, treatment with biventricular pacing does not improve the heart’s function,” said Dr. Chelu, Principal Investigator of the study. “This might be explained by the slower activation of the heart muscle from only two points. Conduction system pacing, however, has the potential to advance the treatment of heart failure. Pacing in the His bundle or left bundle branch leverages the rapid propagation of electrical impulses through the network of the conduction system, leading to more efficient contraction of the left heart. Furthermore, conduction system pacing involves less expensive generators and leads and sometimes fewer leads, as well as a simpler implant procedure than biventricular pacing. We anticipate that conduction system pacing will lower the great burden of health care costs for patients with heart failure.”

Drs. Chelu and Ellenbogen’s study was selected through a highly competitive review process in which patients, caregivers, and other stakeholders joined scientists to evaluate the proposals. The funding is awarded through a PCORI initiative to support large-scale, high-impact comparative effectiveness research trials that are conducted in multiple phases, allowing the testing and refinement of the study approach. Therefore, this study will involve an initial feasibility phase to maximize the likelihood of full trial success. The study was launched on January 1, 2023 and is anticipated to enroll participants in October 2023.

“This study has the potential to fill an important gap in the evidence that is relevant to a range of health care decision makers, helping them better assess their care options,” said PCORI Executive Director Dr. Nakela L. Cook. “We look forward to following the study’s progress and working with Baylor College of Medicine in Houston and Virginia Commonwealth University in Richmond to share its results.”

PCORI is an independent, nonprofit organization authorized by Congress in 2010. Its mission is to fund research that will provide patients, their caregivers, and clinicians with the evidence-based information needed to make better-informed health care decisions. For more information about PCORI’s funding, visit www.pcori.org.

Genomics and biotechnology are making a significant impact on both the diagnosis of disease and the development of new therapies.

“You can’t escape your genetics, but you can be proactive and prevent disease later in life,” explains Dr. Richard Gibbs, Wofford Cain Chair, Professor of Molecular and Human Genetics, and Director of the Human Genome Sequencing Center at Baylor College of Medicine. This is why researchers at Baylor College of Medicine’s Human Genome Sequencing Center are working with cardiologists at Baylor St. Luke’s Medical Center to determine patients’ genetic risk factors for cardiovascular disease. These investigators recently completed the HeartCare genomic medicine project, which was awarded the CommonSpirit Health Physician Enterprise Vision Award in Academic Excellence for advancing the practice of medicine through key research. As part of the HeartCare study, participants underwent genetic testing for genes that influence the risk of cardiovascular disease. Publications from this study have shown that both physicians and patients found the information valuable and that it positively affected both patient care and family screening for genetic disorders.

“Genomics has the potential to drive precision medicine,” Dr. Gibbs explains. “Some cardiovascular risk factors can be predicted or detected through genomic methods, making treatment options specific to each person. This program provides the perfect opportunity to introduce genomics into the adult clinical care system. It can potentially shift the paradigm from reactive care to risk prediction.”

Hundreds of patients were tested in the HeartCare study. For some, the results changed their doctor’s approach to their clinical care, such as recommending changes to the patient’s diet, exercise, lifestyle, and pharmacologic intervention, as well as recommending further genetic testing for family members.

“So often in patients with cardiovascular disease, we look at the symptoms and make a probable diagnosis. Now, we have the ability to tell patients exactly what they have. It’s remarkable the impact genetics can make on cardiovascular care,” said Dr. Christie Ballantyne, Professor of Medicine at Baylor College of Medicine and cardiologist at Baylor St. Luke's. 

“We’re focusing on adults, but the same methods will ultimately be useful for children, as well,” Dr. Gibbs said. “If you can predict cardiovascular disease at an early age, then you can intervene.”

The HeartCare genomic study report was named one of the ten most significant papers affecting genomic medicine in 2021. After the success of the initial pilot study performed at Baylor St. Luke's, the study is being expanded to south Texas and will include genomics for patients with both cardiovascular disease and diabetes. The Houston Study team and the clinicians in south Texas meet weekly via videoconference. 

Several other precision medicine trials are ongoing at the Center for Cardiometabolic Disease Prevention, including RNA-silencing strategies targeting inherited lipid disorders and cardiovascular disease. In collaboration with other academic institutions, Baylor investigators have recently shown that genetic testing in patients with high triglyceride levels can help to identify individuals who have the highest risk for developing pancreatitis and the most severe elevations of triglyceride levels. In addition, researchers have been involved with genetic epidemiology studies to identify novel targets for new drugs. Several trials are underway for therapies that target the mRNA of specific genes to silence the production of the corresponding proteins. To date, these studies have shown that mRNA therapies dramatically reduced levels of triglycerides, even in patients with a disease that is the most difficult to treat. Another important factor in the development of heart disease is the level of lipoprotein (a), which is 90% determined by genetics. RNA-silencing strategies that are being tested in clinical trials have been shown to reduce lipoprotein (a) levels by 80% to 95%. The trials will examine whether this in turn reduces the development of heart attacks and strokes.

José L. Díaz-Gómez, MD, is the Section Chief of Cardiovascular, Mechanical Circulatory Support, and Transplant Critical Care, as well as the Director of Critical Care Echocardiography at Baylor St. Luke’s Medical Center. He is certified by the American Board of Anesthesiology (ABA) and the National Board of Echocardiography (NBE) in Advanced Perioperative Transesophageal Echocardiography and Comprehensive Echocardiography. He is a Fellow of the American College of Critical Care Medicine (FCCM) and of the American Society of Echocardiography (FASE). 

Dr. Díaz-Gómez is transforming the assessment of patients suffering from shock and acute respiratory failure by using point-of-care ultrasonography (POCUS). The members of the interprofessional Critical Care team, including physicians and advanced practice providers, continue developing their skills to become proficient in POCUS. Dr. Díaz-Gómez is actively working with Dr. Raymond Stainback to develop a policy regarding resuscitative transesophageal echocardiography to ensure that this modality is used properly in unstable patients when POCUS with transthoracic assessment is not feasible or indicated. Currently, Dr. Díaz-Gómez is mentoring Dr. Jackie Sohn (an intensivist and cardiovascular anesthesia fellow) on an original investigation that seeks to determine whether fluid overload can be diagnosed with critical care echocardiography.   

Last year, Dr. Díaz-Gómez published a review article titled “Point-of-Care Ultrasonography” in the New England Journal of Medicine. Furthermore, he led the production of NEJM’s first Video in Clinical Medicine to feature a multidisciplinary and interprofessional team of anesthesiologists, cardiac sonographers, and specialists in cardiac imaging and pulmonary medicine. The video, titled “Focused Cardiac Ultrasonography for Right Ventricular Size and Systolic Function,” provides instructions for performing a practical qualitative and semi-quantitative assessment based on previous research in advanced echocardiography. It empowers the clinician at the bedside in modern times when health equity is a priority for humanity. 

Dr. Díaz-Gómez currently co-leads the Society of Critical Care Medicine’s writing committee for its upcoming critical care ultrasonography guidelines. He also serves as co-chair of the writing committee for the upcoming POCUS Nomenclature Statement by the American Society of Echocardiography. He works closely with all intensivists of different professional backgrounds and emergency medicine specialists in authentic collaboration with advanced cardiac imaging specialists. Lastly, Dr. Díaz-Gómez is finishing a master’s degree in Healthcare Quality at the Bloomberg School of Public Health at John Hopkins University.

Doctors evaluated the safety and efficacy of using a novel device for the treatment of heart failure in the RELIEVE-HF (Reducing Lung Congestion Symptoms in Advanced Heart Failure) trial. The device, which is implanted in the heart of patients between the two atria, allows blood to shunt from the left to the right side of the heart. This decreases the pressure inside the left side of the heart to alleviate symptoms of heart failure and improve the patient’s quality of life. Recently, Drs. Alexander Postalian, Zvonimir Krajcer, and Guilherme Silva successfully performed the first operations to implant the device in patients at Baylor St. Luke’s Medical Center. The participation in this trial highlights our commitment to groundbreaking research as it remains at the forefront of cardiovascular care.

Coronary stenting procedures have been performed routinely since the late 1980s and can be lifesaving if used appropriately. When evaluating the efficacy of these interventions, the details surrounding the case are important. Currently, the two technologies used to assess the coronary blood vessel in detail before and after the implantation of a stent are intravascular ultrasonography and intravascular optical coherence tomography. These imaging tests help the physician to decide if a stent needs to be implanted, if special treatment is needed before implanting the stent, what the appropriate stent size is, and if the result was adequate. This insight can significantly improve long-term patient outcomes and reduce the need for repeat procedures. Doctors like Dr. Alexander Postalian are making use of this cutting-edge technology in over 90% of cases, despite its use in only 10% of all coronary interventions performed in the U.S.

The very first coronary care units were established in the early 1960s to help reduce mortality rates among patients with acute myocardial infarction. The main purpose of the CCU was to closely monitor these high-risk patients during the post-infarction period, and specifically to expedite the rapid deployment of external defibrillation and treatment for malignant dysrhythmias in the hope of reducing rates of sudden cardiac death. This required a highly specialized and well-trained intensive care unit team and formed the basis of our current understanding of cardiac critical care. 

Over the past few decades, the coronary care unit has gradually undergone significant changes in structure, patient demographics, and overall purpose. With the advent of timely revascularization, clear improvements in the peri-myocardial infarction period were quite evident.

Over 4 million intensive care unit (ICU) admissions occur annually in the U.S., and mortality rates among admitted patients are as high as 20%. This is because, with modern health care, patients are living longer despite having more comorbid conditions. A large proportion of these patients have significant cardiac comorbidities such as heart failure, ischemia, valvular heart disease, pulmonary hypertension, and arrhythmias. Therefore, the Coronary Care Unit has now shifted its focus to a more encompassing Cardiac Intensive Care Unit role. 

Changes in patient demographics have been met with a novel approach to training future generations of cardiologists in critical care medicine. Often, patients with significant cardiac comorbidities are admitted to the ICU with non-cardiac primary diagnoses, which requires a highly specialized ICU team to manage all aspects of care. 

At the Cardiac Intensive Care Unit (CCU) at Baylor St. Luke’s Medical Center, we strive to continue evolving and adapting to the challenge of providing optimal care to our patients. The CCU forms the backbone and safety net for our patients, who are being provided cutting-edge procedures and care. As early adopters of a cohesive co-management model between our world-class cardiologists and intensivists, we have set the standard for modern-day CCU care. Our unit is staffed by compassionate, dedicated nurses, dual-trained cardiologists with critical care training, and seasoned cardiac intensivists to help support our world-class cardiologists. 

Creating this model—which focuses on key quality parameters such as preventing hospital-acquired infections, sedation protocols, expedited weaning and ventilator liberation, and optimizing non-cardiac comorbidities—has helped decrease our mortality index to 0.43. 

We continue to develop care pathways for different cohorts of patients. These include our ever-increasing group of structural heart patients who undergo transcatheter heart procedures for acute coronary syndrome and cardiogenic shock. This work further illustrates our commitment to provide the best possible care for our patients.

Raymond Stainback, MD, FACC, FASE, recently concluded his term as President of the American Society of Echocardiography (ASE). During his tenure, Dr. Stainback championed a key ASE collaboration with other leaders from the National Board of Echocardiography (NBE) and the Society of Critical Care Medicine (SCCM). This has enabled intensivists to become certified in echocardiography, ultimately benefiting patient care.

Dr. Stainback, an expert in echocardiography and Medical Director of Non-Invasive Cardiology at Baylor St. Luke’s Medical Center, has led the ASE for the past year. The ASE is the largest international organization for cardiovascular ultrasound imaging, setting practice standards and guidelines for professionals in the field and advocating for excellence in the use of the imaging technique.

Dr. Stainback has a long history of support for education and quality in cardiovascular imaging, including serving as the Course Director for the Houston Echo Review: Boot Camp for Echo Board, an annual two-day course designed to prepare cardiovascular specialists for the NBE examinations and offered in cooperation with ASE.

Echocardiography is a specific type of ultrasound imaging—medical imaging that uses sound waves—to noninvasively produce images of the heart. Cardiologists use this method to diagnose problems with the heart valves, chambers, or muscles, including the detection of blood clots in the heart or the presence of fluid around it. Echocardiograms are often performed in response to a patient’s report of shortness of breath, chest pain, or an irregular heartbeat.

However, cardiologists are not the only medical professionals who rely on echocardiography to assess heart function. Intensivists, specialists in critical care medicine who treat patients in the intensive care unit (ICU), may also need to perform echocardiograms as part of their comprehensive role.

In recognition of this vital overlap, Dr. Stainback supported an alliance between ASE and the Society of Critical Care Medicine.

Dr. Stainback explained, “The American Society of Echocardiography supports all users of cardiovascular ultrasound, and this certainly includes all critical care physicians. During my year as President of the ASE, I have been proud to demonstrate how our teaching lab serves as a model training center for our highly regarded critical care trainees in practice and not just ‘as recommended.’ The Echo Lab welcomes our intensivist trainees as they learn to scan from the masters and participate in the supervised analysis of at least 150 comprehensive echocardiography exams in preparation for their NBE Critical Care Echocardiography certification.”

The value of these efforts is already evident. THI and Baylor College of Medicine Anesthesia Critical Care Medicine fellows Nabil Othman, MD, and Jacqueline Sohn, DO, performed over 150 comprehensive ICU echocardiograms and passed NBE’s Examination of Special Competence in Critical Care Echocardiography (CCEeXAM), all within a 10-month timespan. Jose Diaz-Gomez, MD, FCCM, FASE, Director of Critical Care Echocardiography at Baylor St. Luke’s Medical Center and Program Director of the Critical Care Fellowship program, credits the accomplishment to the fellows’ hard work, the professional collaboration between ASE and SCCM leaders, and Dr. Stainback’s leadership, stating, “The ASE president is a transformational leader.”

This certification opportunity is part of the partnership that Dr. Stainback fostered between the echocardiography experts and critical care medicine professionals. With the establishment of the Critical Care Echocardiography Council this July, intensivists will now be able to belong to the ASE. Notably, this is the first new ASE Council in over 14 years. According to Dr. Diaz-Gomez, who is part of the Council’s leadership, “The establishment of the Critical Care Echocardiography Council is an important milestone. It will benefit the careers of many colleagues and, above all, the safety and efficiency of patient care.”

Stephanie Coulter, MD, FACC, FASE completed a fellowship in advanced echocardiology at Massachusetts General Hospital and uses this specialized imaging technique on a daily basis to help her patients. Dr. Coulter said, “Putting this technology into the hands of the critical care community provides real-time, actionable data that has an immediate impact on patient care.”

Just like a person’s own aortic valve, bioprosthetic replacement valves can become calcified or stenotic (narrowed) over time, which can prevent the valve from opening completely with each heartbeat.

Rather than subjecting a patient to another open-chest surgery to replace or repair a dysfunctional bioprosthetic valve, surgeons may be able to place a new transcatheter valve into the existing valve by accessing the heart through a blood vessel. The technique was described in a recent case report from cardiothoracic physicians at Baylor College of Medicine in Houston, Texas.

This so-called “valve-in-valve” approach was used in a 61-year-old patient who, five years previously, had undergone aortic valve replacement with a 25-mm Edwards INTUITY Elite bioprosthetic valve. This valve is made of bovine pericardial tissue and a metal stent framework that includes a stainless-steel “skirt” for support.

As a rapid-deployment valve, the INTUITY Elite requires far fewer sutures during surgery than traditional prosthetic aortic valves. It is expanded with a balloon to seal and secure the valve’s skirt after the patient’s own aortic valve is removed.

At this patient’s annual checkup, calcium deposits were found on the INTUITY valve’s leaflets. These deposits can cause structural deterioration and severe narrowing of the valve opening, which impedes blood flow through the valve.

Case discussion by a multidisciplinary care team led to the decision to use a femoral artery approach to deploy a 29-mm Medtronic Evolut PRO+ self-expanding transcatheter valve inside the patient’s existing INTUITY valve.

The new valve was positioned flush with the bottom of the INTUITY valve’s skirt—intentionally lower than is generally recommended—to avoid blocking the coronary arteries, which supply oxygenated blood to the heart itself. Mild leakage around the valve after it was deployed was corrected with additional careful balloon expansion. The patient recovered well and was discharged two days later.

Rapid-deployment bioprosthetic valves like this patient’s INTUITY device have gained widespread use for valve repair. Valve-in-valve placement of a transcatheter valve inside one of these existing bioprosthetic valves avoids the injury and complications associated with redo sternotomy and is therefore of great interest to both patients and surgeons. Both balloon-expandable and self-expanding transcatheter valves can be used for valve-in-valve placement, with similar survival outcomes.

Inherent drawbacks of valve-in-valve procedures include a considerable frequency (up to 25%) of persistently strained pressure across the valve, the risk of getting a valve that is slightly too big or too small for the patient’s body size, the need for a pacemaker, and the risk of overexpanding the INTUITY valve skirt during deployment of the new valve, which can rupture the aorta.

Senior author Joseph S. Coselli, MD, a cardiothoracic surgeon at Baylor College of Medicine, said, “In this particular case, we showed that a self-expanding Evolut transcatheter valve can be successfully implanted into a degenerated, stenotic INTUITY valve. To our knowledge, this specific approach had not been described in the literature before we published our case report. By positioning the Evolut valve a bit lower than the manufacturer suggests, we were able to maintain reasonable space for future coronary artery access, if needed, yet still achieve good hemodynamic outcomes and reduce strain across the valve.”

As part of The Heart Beat series of interviews with Dr. Mehdi Razavi and his team, recent graduate of the Rice University Global Medical Innovations Program, Kunal Shah, MBE, shares details about an entirely new way of treating cardiac arrhythmias and preventing sudden cardiac death.

The research underway in the THI’s Electrophysiology Clinical Research and Innovations (EPCRI) Lab, in partnership with The University of Texas at Austin’s Dr. Elizabeth Cosgriff-Hernandez, is testing the ability of hydrogel electrodes to deliver pulses of electricity to the heart. This paradigm-shifting work caught the attention of science writer Robert F. Service at the American Chemical Society meeting in San Diego.

The novel solution, described simply as “liquid wires,” aims to facilitate painless shocks to failing hearts. The goal is to improve the quality of life for patients living with implantable cardioverter defibrillators (ICDs). 

The new therapy in development works by injecting a fluid hydrogel solution into a patient’s cardiac vein. Researchers say this method transforms the vein into a flexible hydrogel electrode and captures more heart tissue than current electrotherapies can touch. 

The next episode of The Heart Beat will explore how engineers from Dr. Razavi’s lab are developing a unique catheter-based system suitable to deliver this hydrogel therapy.

Led by Kenneth K. Liao, MD, PhD, the team at Baylor St. Luke’s Medical Center is focused on using state-of-the-art robotic technology to perform minimally invasive mitral valve repair and coronary artery bypass grafting surgery. The advanced robotic technology uses 3D high-definition scope and robot-controlled fine instruments inside the chest, which allow the surgeon to perform gentle and complex surgical maneuvers inside the heart. The advantages of robotic cardiac surgery include very small incisions (1-2 inches) through the rib space, less blood loss, lower risk of stroke and wound infection, and quicker recovery.

Currently, Dr. Liao is among a handful of highly experienced robotic cardiac surgeons in the U.S. and the only cardiac surgeon in Greater Houston using the da Vinci Robotic Surgical System to treat valve and coronary disease. His robotic cardiac surgery program at Baylor St. Luke’s Medical Center is among the top 10 programs in the U.S. Since his arrival at Baylor St. Luke’s Medical Center in 2019, he has performed over 400 robotic heart operations, making it the fastest-growing program in the country.

Robotic Heart Surgery Procedure Leads United States in Program Growth