Ascension St. John Hospital and Medical Center, Detroit: Recruited to Detroit in 2012 by Mike Duggan, the former CEO of Detroit Medical Center and now Detroit mayor, and Dr. Ted Schreiber, one of the nation's preeminent cardiologists, Dr. Amir Kaki, an interventional cardiologist and director of mechanical circulatory support at Ascension St. John, has always been at the cutting edge of heart medicine and is one of a handful of doctors in the U.S. who have inserted the world's smallest heart pump and the first for a COVID-19 positive patient suffering heart problems.
Born and raised in a small town in the southern Florida Everglades, Kaki completed his medical residency at the University of Tennessee, completed fellowships at the University of Arizona and Lenox Hill Hospital in New York City. He was a faculty member at Cornell University when the call came from Schreiber, who also practices at Ascension Health.
Another draw to Detroit is that his wife, Dr. Reema Hasan, a medical transplant doctor at Michigan Medicine in Ann Arbor, is a native Michigander. They have three children, two girls and a boy born in early November. In late November, after the interview was conducted, Kaki and his family contracted COVID-19 and were recuperating at home.
What is the story behind you and the Impella heart pump, which temporarily keeps the heart beating while undergoing various repair procedures?
I implanted my first pump in 2012 along with Dr. Mahir Elder in an initiative led by Dr. Ted Schreiber and Dr. Cindy Griner to deliver the highest quality cardiovascular care with cutting edge innovative care to the city of Detroit. Another local luminary in the field is Dr. Bill O'Neill at Henry Ford Hospital. Bill and Ted really kind of led the charge for this type of treatment for the very sickest patients in Southeast Michigan that resulted in the Detroit Cardiogenic Shock Initiative, a treatment that has transformed treatment across the world.
You also performed a heart operation using the Impella on a patient with COVID-19 at Ascension St. John in Detroit?
We had a patient present in the emergency room to Dr. Schreiber this past spring with COVID-19 and breathing problems at the height of the pandemic at Ascension Macomb-Oakland Hospital in Warren that turned out to be a large pulmonary embolism. When they did the ultrasound, we found she had a huge clot in the right side of her heart. There was no real way to get a clot out without some heroic measures. We brought her to St. John Hospital and put her on cardiopulmonary bypass. We were able to suck this clot out through her neck, but some of the clot that embolized made her PE worse. Then her right ventricular failed and we did emergency CPR until we put the Impella pump in. Based on our knowledge of those cases, we thought it'd be reasonable to put the pump in there to save her life. The patient survived and is doing very well. What we have found is that COVID-19 is thrombogenic, which means the coronavirus makes people clot. We actually did the first procedure on a COVID patient using the Impella like this. The FDA recognized the value and granted emergency use authorization in June.
How does the coronavirus affect the heart?
We have seen data from Asia, Europe and the U.S. that COVID-19 affects the heart in several ways. Coronavirus is an infection that often affects the lungs, filling air sacs with fluid and mucus, but it also can cause myocarditis, or inflammation of the heart muscle. A lot of the manifestations of the heart from coronavirus are on the right side because COVID patients are more likely to form blood clots from a pulmonary embolism arising from deep venous thrombosis or clots in the legs. About 10 percent to 20 percent of the patients we have seen at St. John have had some cardiac manifestations of COVID. As a result, more patients are getting blood thinners.
How is the Impella heart pump used?
The pump is used for elective procedures, what we call high risk PCI (percutaneous coronary intervention). It's also used for emergency situations in patients who have impending death present with cardiogenic shock, which have 50 percent survival rates without intervention. There are two uses for the pumps on the left side of the heart. It supports the patient transiently during the duration of the PCI, usually for 60 to 120 minutes. Or we put it in a patient who has profound cardiogenic shock. It often stays in for days to allow the heart to recover. If the heart does not recover, there are more advanced therapies such as durable LVAD (a left ventricular assist device) implanted permanently to act like a heart or heart transplantation.
You are involved in a small clinical trial to test the effectiveness of a new Impella pump model that is believed to be the world's smallest?
The FDA has mandated a safety study on five patients. So far we have completed successful operations on four patients and I've done the first and third here at St. John. After the fifth, the FDA will decide if it is safe to continue the trial with a larger group of up to 20 patients. I'm optimistic. The first patient with massive pulmonary embolism was done Oct. 16 and the second was on Oct. 23. Both were very successful. The second patient did not want to undergo open heart surgery. We offered using the Impella and did a complete revascularization where we took out all three of his arteries successfully. He went home the next day and is doing wonderfully.
What is the improvement with the new Impella pump?
This one is much smaller, nearly half the size at the entry point. Anytime you can make these devices substantially smaller, you reduce the risk of vascular injuries. You also increase access for patients because the normal Impella sometimes is too big to fit and patients who have severe peripheral arterial disease can bleed from it. Now you have a device that can be much more broadly available for patients because it is three millimeters at the access point. Once it goes into the body, it expands. We are optimistic that within two years, assuming the research stands out, it will be safe and efficacious for patients and be commercially available.
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December 06, 2020 at 12:02PM
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Amir Kaki, interventional cardiologist, on what it's like to use the smallest heart pump to save lives - Crain's Detroit Business
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