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OneThousandOne represents the amount of time, verbally, that it takes to count to one second. In this one second of time, a great thing happened at Nebraska Medicine. In fact, several great things probably happened. A patient was cured, a researcher found the missing link, a nurse treated an injury, a doctor comforted a family or maybe a child just smiled.
MOMENTS IN MEDICINE
Spring | Summer 2013

A Heart in Check

There’s no doubt that running a cattle ranch is hard work. Like most ranchers, Kit Held of Leigh, Neb., doesn’t think twice about putting in 12- to 14-hour days. Combine that with operating a seed dealership and trucking company and you can bet Held has his work cut out for him.

It was 2008, and Held’s businesses were expanding — maybe a bit too quickly. He was up to more than 300 head of cattle in his drug-free feedlot; his seed dealership was robust and he had just added several more trucks to his fleet to bring the total to 14. Then came 2009. The economy slowed significantly. Seed sales were sluggish and Held was having a hard time keeping all 14 trucks on the road. The next two years were two of the most stressful years that Held can remember.

“I got hit hard, real hard,” recalls Held. “I was trying to do everything myself just to save money so I could keep my businesses afloat. If it meant working for 30 hours without sleep, I worked for 30 hours without sleep.”

Stress, lack of rest and taking care of everything else but himself — that’s what Held thinks led to the chain of events that happened next.

It was early Sunday morning on Nov. 7, 2010. Held was in the shop changing truck tires. “All of a sudden I got extremely winded and dizzy,” he recalls. “I felt a tightness in my chest, so I leaned up against the truck, got my wits about me and went into the house to tell my wife.

“I hadn’t been getting a lot of sleep so we chalked it up to fatigue,” he says. But the pain returned again and then another time — each time it seemed to get more excruciating. “That evening I knew something had to be wrong and that I had to go to the hospital,” he recalls. “I was in just too much pain to go to bed.”

So Held and his wife, Michelle, got in his truck and headed to the closest hospital in Columbus, Neb., about 30 minutes away. Held tried to hold a conversation, hiding how much pain he was in. “I didn’t want to worry Michelle,” he says.

“But after awhile, I was in so much pain that I can’t even remember what we were talking about.”

“All I could think about was my wife and two children and whether I would live to see them again.”
KIT HELD

When they reached the hospital, emergency room (ER) staff performed a cardiac enzyme test, which showed Held’s enzyme levels were significantly high. Low levels of certain enzymes and proteins are normally found in the blood. However, if the heart muscle is injured such as from a heart attack, the enzymes and proteins may leak out of the damaged heart muscle cells causing levels in the bloodstream to rise. The ER staff acted quickly. They gave Held some morphine for the pain, nitroglycerin, as well as a clot buster. Then they prepared him to transport to The Nebraska Medical Center.

The 90-minute drive was extremely emotional. All Held could think about was the funeral he had attended the week before for a 44-year-old friend who worked for him and had just died after undergoing heart surgery. He had been transported by ambulance to an Omaha hospital and taken to surgery. But he did not survive. Was he heading for the same fate?

“The pain was really bad,” recalls Held. “I remember asking the EMT for more morphine.”

Held arrived at The Nebraska Medical Center at approximately 1:30 a.m. A large team of doctors and nurses was waiting for him when he arrived. The team performed an ultrasound to try to find a blockage but could find nothing. In the meantime, Held’s enzyme levels continued to rise.

“They said they were taking me down to the cath lab to do a catheterization,” says Held. “All I could think about was my wife and two children and whether I would live to see them again.”

The next thing Held remembers is coming out of the recovery room and the doctor telling him that they couldn’t find a blockage.

The next morning, Held met Thomas Porter, MD, cardiologist at The Nebraska Medical Center. He said that he was going to perform a cardiac MRI study to look for a potential blockage. Without a firm diagnosis, doctors could not develop a treatment plan for Held.

CARDIAC MRI OF AN AORTA

Cardiac MRI is the most advanced diagnostic procedure available for detecting heart disease. The Nebraska Medical Center is the only hospital in the area that offers this important diagnostic tool. It is a noninvasive technique that uses radio waves, magnets and a computer to visualize the heart in more detail. It creates both still and moving pictures of the heart and major blood vessels to help doctors detect inflammation or the source of a heart attack so they can determine the best way to treat it.

The test is much more detailed than other traditional tests such as echocardiograms, angiography or CT scans. It also has the advantage of being noninvasive (unlike angiography) and uses no radiation (unlike CT scans). “It is the best way to detect a heart attack,” says Dr. Porter. “Other diagnostic procedures do not provide the degree of detail or clarity that cardiac MRI does, and therefore, a heart condition may go undetected.”

THOMAS PORTER, MD

Dr. Porter and cardiologist Sammer Sayyed, MD, and Matthew DeVries, MD, radiologist, are the only physicians in the area trained to perform cardiac MRIs, a skill that requires a full year of off-site training. They are supported by five cardiac MRI-trained technicians.

Dr. Porter, director of the Non-Invasive Cardiology Lab and courtesy professor of Pediatric Cardiology and Radiology at the University of Nebraska Medical Center (UNMC), has been performing cardiac MRIs for the past four years and receives referrals from all over the region. Dr. Porter attended medical school at UNMC and completed a residency in internal medicine and a cardiology fellowship at the Medical College of Virginia in Richmond. He completed his cardiac MRI training in 2007 at Duke Medical Center in Durham, N.C., followed by a two-year fellowship training in cardiovascular computed tomography at MD Imaging in Fort Lauderdale, Fla.

“Each year, there are more than 190,000 cases of heart attack that occur undetected and without symptoms.”
THOMAS PORTER, MD

Dr. Porter says the cardiac MRI test can be used to diagnose and assess many types of heart conditions including heart attack, coronary artery disease, heart failure, heart valve problems, congenital heart defects, cardiac tumors, myocarditis (inflammation of the heart muscle) and pericarditis (a condition in which the membrane around the heart is inflamed.)

It can also be used to assess the viability of the heart muscle if there has been damage caused by a heart attack. “It is considered the gold standard for viability,” says Dr. Porter. “It can help us determine the most appropriate therapy for a patient such as medications, bypass surgery, a stent or whether a patient should be put on the heart transplant waiting list.”

A patient at high risk for heart disease who is experiencing rhythm problems or other unexplained symptoms might also be a candidate for a cardiac MRI. “Each year, there are more than 190,000 cases of heart attack that occur undetected and without symptoms,” says Dr. Porter. “If these were detected with a cardiac MRI, this diagnostic procedure could potentially allow us to save lives by preventing complications from a heart attack.”

In Held’s case, the cardiac MRI test detected scarring in one of the small branches of the arteries, indicating a blockage had occurred. With this information in hand, Dr. Porter and his team were able to develop an appropriate treatment plan for Held to help prevent further heart incidents. Because the blockage was so small and had broken up on its own, Held did not require surgery. He is now on daily medications to control both his cholesterol and blood pressure.

“This has been an eye-opening and life-changing experience,” says Held. “I look at things completely differently now,” he says. “My business is still important, but the only things that really matter are my kids and my wife. Since then, I’ve learned to walk away from situations that make me stressed.”

Held says his care at The Nebraska Medical Center that frightening night back in November was “superb. These people work with situations like this every day, but they treated me like I was their most important patient,” he says. “They made me feel like they really cared about me. Their demeanor and bedside care was so good that it helped bring me some reassurance during a really scary time.”

KIT HELD WITH HIS WIFE, MICHELLE;
DAUGHTER, HALLEE; AND SON, HADEN

Research in finding new and better ways to diagnose and treat heart disease has been Dr. Porter’s passion since he completed his medical training. He has received several National Institutes of Health (NIH)-funded grants to pursue his groundbreaking studies. One of these included a clinical trial at The Nebraska Medical Center that used micro bubbles for cardiac perfusion imaging to detect changes in blood flow and problems with the heart muscle function. With this information, doctors can identify indicators of heart disease, blockages and even an impending heart attack.

Microscopic bubbles are encapsulated shells filled with fluorocarbons that act as red blood cell tracers. These are injected into the bloodstream through an intravenous catheter placed in the hand or forearm. The micro bubbles light up on ultrasound, allowing doctors to detect problems.

“This procedure allows us to evaluate both the function of the heart muscle and blood flow with higher resolution than available with nuclear procedures, improving our ability to detect blockages,” says Dr. Porter. “Using conventional diagnostic stress testing, up to 20 percent of blockages will be missed. Perfusion contrast imaging with echocardiography will pick up at least half of these. With its improved accuracy, perfusion contrast imaging has the potential to replace standard testing like stress echo and nuclear imaging.”

KIT HELD WITH HIS WIFE, MICHELLE

Currently, UNMC is one of a few sites in the country using micro bubbles to detect coronary artery disease. Dr. Porter presented the findings of his late-breaking clinical trial at the American Heart Association Annual Scientific Session and has submitted the findings from this study for publication in the Journal of The American College of Cardiology.

Micro bubbles may have other uses as well. Dr. Porter is also performing research using ultrasound and micro bubbles for therapeutic approaches such as breaking up blood clots to the brain and heart that cause strokes and heart attacks.

“It’s showing a lot of potential,” he says. “It may be a method of treating heart attacks and strokes in the future. The NIH has funded pre-clinical trials examining this ultrasound technique.”

“It was definitely a wake-up call. a lot of people don’t get the same break that I did.”
KIT HELD

With the help of his cardiologist, Kiran Gangahar, MD, Held believes he has turned the corner in both his personal and business life. He’s keeping his blood pressure and cholesterol levels under control; he’s watching his diet more closely; and he’s working on getting regular exercise. “It’s a constant battle,” he says, “But I know it’s important.”

And while his businesses are looking up again, Held has been careful to keep his heart in check and his stress load down. “It was definitely a wake-up call,” he says. “I feel very lucky. A lot of people don’t get the same break that I did.”

Next article in the Spring | Summer 2013 issue of One Thousand And One:
Lasting Impressions