Welcome to the 4th Annual Lakeland Regional Health Cardiovascular Symposium. Tired of CV Symposiums that focus on the procedures that can be done to your patients rather than prevention of CV disease?!? This year we’ll be focusing on the PREVENTION of CV disease. Please click to attend the Symposium for 5.5 hours of free CME on Saturday February 8, 2020. I’ll be adding links to any talks the speaker has permitted so you can follow along on day of Symposium.

7:30 – 7:55A Registration and Continental Breakfast
7:55 – 8:00A Welcome Remarks
8:00 – 8:40A: Lipid management and risk panels for cardiovascular disease, Dr. Stephen Kopecky


8:40 – 9:30A: Prevention of Sudden Cardiac Death, Williams


9:30 – 10:00A: Prevention of Cardioembolic Stroke, Dr. Khanna


10:00 – 10:20A: Ask-the-Experts Refreshment Break
10:20 – 11:00A: DM2 and CV Disease, Dr. Owen

11:00 – 11:40A: Frequent Touch Primary Care and CV Disease Prevention, Drs. Ghany and Syed

11:40A – 12:20P: Applying Evidence-Based Guidelines to Lower Heart Failure Readmissions, Dr. Navin Rajagopalan


12:20 – 12:30P: Ask-the-Experts Refreshment Break
12:30 – 1:30P: Luncheon, Plant-Based Diets and Prevention of CV Disease, Dr. Monica Aggarwal

Many thanks to the faculty of the 2019 LRH Cardiovascular Symposium! We had over 200 registrants for 6 hours of great cardiovascular CME. From left to right, Dr. Parag Patel (Mayo Clinic), Dr. Anuja Dokras (University of Pennsylvania), Dr. Jeff Williams (LRH), Dr. Carl Pepine (University of Florida), Dr. Edward Tadajweski (WellSpan Health), Dr. Philip Owen (LRH), Dr. Matthew Martinez (Lehigh Valley Health Network), and Dr. Kathryn Lindley (Washington University). Dr. Denise Edwards (University of South Florida) is not pictured.

We had over 200 registrants to this year’s CV Symposium with physicians and nurses traveling from all over Florida. Our faculty was fantastic and their lectures are included below.

Anuja Dokras, MD, PhD, Associate Professor, Penn Fertility Care, University of Pennsylvania Medical Center, Philadelphia, PA. Dr. Dokras lectured about the role of obstetric and gynecologic issues and the future risk of heart disease in women.

Denise Edwards, MD, Director, Healthy Weight Clinic, Assistant Professor of Internal Medicine and Pediatrics, USF Health. Dr. Edwards lectured about the assessment and treatment of obesity in adolescents and women.

Kathryn J. Lindley, MD, Assistant Professor of Medicine, Director, Center for Woman’s Heart Disease, Washington University School of Medicine. Dr. Lindley spoke about the risks of women’s heart disease in pregnancy.

Matthew W Martinez, MD FACC, Associate Professor of Medicine, University of South Florida, Medical Director – Sports Cardiology and Hypertrophic Cardiomyopathy Program, Lehigh Valley Health Network. Dr. Martinez discussed the current state-of-the-art in the management of cardiovascular disease in sports participation.

Phil Owen, MD, FACC, Interventional Cardiology, Lakeland Regional Health. Dr. Owen gave a nice summary on the potential risks and management of CV disease with cancer therapies.

Parag Patel, MD, Mayo Clinic, Program Director for the Advanced Heart Failure/Transplant Fellowship. Dr. Patel described issues and techniques to decrease readmission rates for congestive heart failure.

Carl J Pepine, M.D., MACC, Professor Emeritus of Medicine, University of Florida Health. Dr. Pepine discussed the management of resistant hypertension including common treatment issues.

Edward Tadajweski, MD, FACC, Director of Cardiology, WellSpan Health (Good Samaritan Hospital, Lebanon, PA). Dr. Tadajweski spoke about acute coronary syndromes in women.

Jeffrey L. Williams, MD, MS, FACC, FHRS, Co-Director, LRH Heart Rhythm Center, Course Director, 2019 Lakeland Regional Health Cardiovascular Symposium. Dr. Williams lectured on the diagnosis and treatment of common supraventricular tachycardias.

Join us on February 9, 2019 for 6 hours of free CME. You’ll have the chance to hear topics ranging from acute coronary syndromes and resistant hypertension in women to cardio-oncology as well as management of CHF. We will have speakers from Washington University, Lehigh Valley Health System, WellSpan Health, University of Florida, and others. To register, call 863-687-1190 or online at 2019cvsymposium.eventbrite.com

Atrioventricular nodal tachycardia (AVNRT) is one of the most common supra ventricular tachycardias (SVT) that we find during electrophysiology studies. Fifteen to thirty percent of the population has “dual AV-node physiology.” Most day-to-day conduction is from “fast” AV node pathway. Patients with “dual AV node physiology” may occasional use the “slow” AV node pathway and this can set up the reentrant arrhythmia.

Atrioventricular nodal tachycardia (AVNRT) is one of the most common arrhythmias. This short video gives an introduction to the mechanism and treatment options that are available.

Wondering how you as a doctor or nurse can make a difference? Join us on February 9, 2019 for 6 hours of free CME.

We are excited to have Dr. Denise Edwards (Assistant Professor of Internal Medicine and Pediatrics, Director of the Healthy Weight Clinic at USF Health) speaking about Weight Management in Women and Adolescents. To register, call 863-687-1190 or online at 2019cvsymposium.eventbrite.com


2019 Lakeland Regional Health Cardiovascular Symposium: Special Focus on Women’s and Adolescent Heart Disease

We are excited to have Dr. Anuja Dokras the Director, Penn Polycystic Ovary Syndrome Center speaking about role of obstetric and
gynecologic issues and the future risk of heart disease in women. To register, call 863-687-1190 or online at 2019cvsymposium.eventbrite.com 

This PA and Lateral CXR was taken the day after an uneventful defibrillator implantation. I have saved these images for close to a decade as I never wanted to forget this is always a possibility. In full disclosure, this was not a procedure I performed.

This was an eye opening case of an operative sponge left in the pocket. As I recall, the patient was very gracious and sponge was extracted uneventfully the following day. Years later a practice partner of mine called me about an interesting case he was doing on a generator change in a can that went ERI at 8 years. He found an oddly healing pocket and ultimately dissected this sponge (see following picture) out from the pocket. Amazing that the pocket healed at all though clearly the pocket was very abnormal.

The iconic Olga’s Diner in Evesham, NJ

Delivering papers, cutting grass, washing cars and shoveling snow were all formative jobs of mine and I suspect most would jump to their first job out of college or intern year. Given my engineering degrees, my first “real” job should have been selling apps I developed programming in BASIC with my dad’s state-of-the-art Radio Shack TRS-80 but alas there was not a large market for Pong at the time. My first “real” job was bussing tables at Olga’s Diner where I got that first paystub and the reality of paying taxes hit hard. I learned a lot during that summer and certainly it registered enough “likes” in my daughter’s brain to trigger a quick text from her when she was visiting family. My kids have heard me go on and on about this job and my daughter recently sent me a picture showing the South Jersey icon Olga’s Diner being demolished. The picture made me smile thinking about the lessons I learned from that job.

Honesty. The first day on the job I was offered a deal to sneak tips into the bus pan and the dishwashers would split the take with me 50:50. This was an easy first lesson. Don’t steal.

Punctuality. You don’t show up on time, you don’t get those hours on the paycheck.

Humility. It builds character to be the bottom rung of the restaurant ladder and doesn’t hurt to be forced to change before you walk into the house because of the kitchen smell embedded into your clothes.

Interpersonal Communication. At the end of summer, I had to give my 2 weeks notice so I could return to school. My middle-aged boss with a heavy Greek accent initially refused to accept my resignation. Ultimately he did accept my resignation but I translated his first response to mean that I was a hard worker and my absence would be his loss.

Parenting. My parents had to drop me off and pick me up every day (I was only 15 and biking to the corner of Routes 70 and 73 was not a great idea). They knew the lessons the job would teach me were more valuable than that pine-scented tree hanging on the dash to overcome the South Jersey diner kitchen stink that I reeked of.

Career Planning. I learned about career preferences such as air conditioning and whether I not to continue with the hard work and long hours of the restaurant business.

Pride. It’s a good feeling to tell your friends how hard you worked all day. Even nicer to have your work ethic rewarded by a boss who wanted you to abandon school and bus dishes full time.

Work Ethic. The diner was a frenetic place and every job has got to be done efficiently or the whole process breaks down. No dishes or glasses translate into angry patrons. One work-averse employee hurts everyone.

Learning on the job. Like any job, people may just assume you know the nuances but you’ve got to adapt. I was handed a large, gray bus pan and told to get started; I looked around for a server that already seemed to be angry with me and brought my new gray partner. Once I dealt with every dirty table, I then learned the most important 3 lessons in work life: Keep your head down, mouth shut and always be seen working! I can usually follow two of those three at any given time.

Preparing for a job interview. Clearly, my resume at the time was somewhat thin but got my first experience with interview questions such as “Will you show up on time?” “Do you have a ride?” and “Are you a hard worker?”

Respect for others. Simple courtesies like “please” and “thank you” go a long way. Respect servers at a restaurant… especially before you get your meal!

Common sense. I met hard working people who may not have scored well on standardized tests but had tons of common sense… Don’t scoop ice with a glass, only enter the right side of swinging doors, and reward hard work with a tip when appropriate. I learned nonsmokers looked younger and didn’t cough all day.

Great desserts can follow humble meals. To this day, I have never had better cheesecake than Olga’s Diner!

Pay attention to the new young, unfamiliar face at your factory, hospital, or office; this may be their first “real” job and what are you going to teach them?

Radial intracardiac echocardiography adds significant anatomic correlation during invasive EP studies. In particular, coronary sinus (CS) anatomy can be evaluated during CS access or ablation of the slow AV nodal pathway during AVNRT ablations.  A steerable sheath (Agilis, St. Jude Medical) flushing with saline holds a 9MHz radial ICE catheter (UltraICE, Boston Scientific Corporation) and is positioned along the inferoseptal aspect of the tricuspid annulus.

Radial ICE CS Os Anatomy Final

The left image shows the posterior aspect of the CS os and you can often visualize the right coronary artery (RCA) in this view. One can see a thickened roof of CS (or often a prominent Eustachian ridge).  As the steerable sheath holding the ICE probe is advanced toward the right ventricle (RV), the main CS is brought into view as seen in the middle image.  As you move more ventricular, the septal insertion of the tricuspid valve leaflet is brought into view.  Finally, the right image depicts the radial ICE view when the anterior aspect of the CS os is brought into view as the probe is advanced even closer to the RV.  This is where the traditional position of the slow AVN pathway is found – the slow AV node pathway is generally located at the anterior edge of the CS os near the septal insertion of the tricuspid leaflet.

A nice anatomic study from Choure et al (“In Vivo Analysis of the Anatomical Relationship of Coronary Sinus to Mitral Annulus and Left Circumflex Coronary Artery Using Cardiac Multidetector Computed Tomography: Implications for Percutaneous Coronary Sinus Mitral Annuloplasty,” JACC, Vol. 48, No. 10, 2006) shows some detailed CT imaging of the relation between the coronary arteries and coronary sinus.  The following image (taken from Choure et al) gives a nice visualization of the CS os and its relation to the RCA.  One can see the circumflex crossing the mid-distal CS.  They found the circumflex artery crossed the CS at a variable distance from the CS os (ranging 37 to 123 mm).

RCA and Circ Relation to CS on CT

For more information about the use of radial ICE during EP studies:

Radial Intracardiac Echo Guided Ablation of AVNRT

Radial Intracardiac Echocardiography Guidance in the Electrophysiology Lab

Radial Intracardiac Echo (ICE) Guided Atrial Fibrillation Ablation