October 23, 2020 by John Fernandez
Cardiac and Kidney Health: Innovative Approach to Address Both
Michael Soltis, a retired executive, had been experiencing difficulties with his kidneys for several years when doctors diagnosed him with heart disease. The conditions may often go together: kidney disease can cause heart problems, and vice versa.
Treating certain heart conditions when the patient has kidney issues can be tricky, however. While contrast dye during imaging helps physicians see how the arteries are functioning and typically guides interventions during cardiac catheterization, the dye can be harmful to the kidneys if they are compromised.
Fortunately, interventional cardiologist Phillip Erwin, M.D., PhD, offered Mr. Soltis an alternative at Miami Cardiac & Vascular Institute at South Miami Hospital: a multi-step procedure that requires only a few tablespoons of dye, versus several cups. It’s an uncommon approach Dr. Erwin has been refining for a number of years, he says.
“Patients shouldn’t have to choose between their heart and their kidneys,” says Dr. Erwin, the hospital’s director of complex coronary and structural intervention. “Through the use of multi-modality imaging, we are able to fix coronary disease without putting the kidneys at risk.”
An Innovative Approach
Mr. Soltis, 79, had received a pacemaker to control an abnormal heart rhythm, but he still was experiencing considerable shortness of breath and angina, chest pain that occurs when narrowed arteries prevent enough oxygenated blood from reaching the heart. But because of his advanced kidney disease, he didn’t believe he was a candidate for percutaneous intervention, a minimally invasive procedure to open clogged arteries.
Mr. Soltis says he knew the situation was dire when he sought help at South Miami Hospital. He was relieved to have his condition carefully evaluated by a multi-disciplinary team of experts, including Dr. Erwin, nephrologist Alberto Esquenazi, M.D. cardiologist Elie Haddad, M.D., and hospitalists Ariel Moses, M.D. and Kliti Tane, M.D.
“The doctors all got together and talked — the cardiologists, the hospitalist and the nephrologist,” Mr. Soltis recalls. “I liked the idea that the doctors collaborated and came up with a plan to deal with everything, not just one thing. Sometimes doctors rush in to do things and ignore the other problems. I was very happy with how they approached my situation.”
Dr. Erwin’s plan to use a minimal amount of dye was designed to put less stress on Mr. Soltis’ kidneys in an effort to save him from having to go on dialysis as a result of the procedure. “It’s like instead of using bright headlights to see what is going on, I use night vision goggles,” Dr. Erwin explains.
Breaking up the intervention into two procedures also reduces the load on the kidneys, Dr. Erwin says. “We take the pictures with a small amount of dye on one day to get an idea of what’s there, then we send the patient home. We let the kidneys rest and flush out the contrast agent before we bring the patient back two days later,” he says.
“At that point I don’t need to do more pictures with dye, I already know what it looks like. Because you can see the calcification under X-ray without using dye, I have landmarks to follow,” says Dr. Erwin. “Using instravascular ultrasound — a small ultrasound camera that you put inside the vessel — you can see inside and find the blockage.”
With this complex approach, Dr. Erwin succeeded in threading a tiny rotary drill through Mr. Soltis’ blood vessels to the hardened, cement-like blockage that was impeding his blood flow. Once the artery was cleared, Dr. Erwin put in a stent to support the artery and keep the blood flowing without causing kidney damage. “Everyone expected him to end up on dialysis from this procedure, but because his heart’s pumping function improved so robustly immediately after the revascularization, his kidneys rallied. Their function actually improved.”
A grandfather of six teens and young adults, Mr. Soltis, 79, is grateful for the skillful care he received. “Dr. Erwin told me how conservative he had been with the dye, and I told him, ‘I think you saved my life.’ ”
A Wider Application
Dr. Erwin believes the approach he took with Mr. Soltis could benefit many.
“There a lot of people with chronic kidney disease who forgo treating their angina or coronary artery disease because they fear they are going to end up on dialysis. They suffer a lot,” he says. “Of course, nobody wants to end up on dialysis. But they have been given a false choice — ‘If you go to the cath lab, you will end up on dialysis.’ That doesn’t have to be true.”
Preserving the kidneys is key, but addressing cardiac issues is also important.
“If you can avoid dialysis and keep the kidneys healthy, that certainly is better for the patient’s lifestyle and health,” Dr. Erwin says. “Now we have the opportunity to restore people to their lives without them paying the tremendous price of losing their kidney function.”