Mount Sinai Heart at Mount Sinai Morningside treats the full range of cardiovascular diseases. By far, the most common is coronary artery disease—often simply called heart disease—which is not only the number one killer in the United States, but also worldwide. Mount Sinai Morningside is the designated Center of Excellence for the surgical treatment of coronary artery disease within the Mount Sinai Health System. Our cardiovascular surgery team has special expertise in treating coronary artery disease, as well as many other heart conditions, including even rare disorders of the coronary arteries, such as blocked coronary arteries after previous stenting, anomalous coronary arteries, coronary artery fistulas, and coronary artery aneurysms.

Coronary Artery Disease

Coronary artery disease occurs when fatty material builds up within the walls of the artery. This narrowing and hardening of the arteries—called atherosclerosis—limits delivery of oxygen and nutrients to the working muscle of the heart. If left untreated, coronary artery disease can cause heart attacks and even death. In mild cases, one may not experience any symptoms. Fortunately, diseases of the heart can be identified through a regular check-up with your cardiologist.

Symptoms of coronary artery disease may include:

• Chest pain or pressure (angina)
• Shortness of breath
• Fatigue and weakness
• Pain or numbness in your neck, jaw or arm(s)

If you are experiencing any of these symptoms, call 911 immediately.

Mount Sinai Heart at Mount Sinai Morningside specializes in treating coronary artery disease. Many cases of coronary artery disease can be treated medically or with coronary stents, avoiding surgery. In consultation with cardiologists, cardiovascular surgeons, and other specialists as needed, our team will work with you to come up with the best treatment plan for your specific condition. We always employ a Heart Team approach, with surgical and medical cardiovascular specialists working together and with patients and their families to design the best therapy for each individual patient.

“Diffuse” or Widespread Coronary Artery Disease

Some patients, especially those with diabetes, may develop very widespread atherosclerosis of their coronary arteries. This can be very difficult to manage with medications or stents and yet most surgical programs shy away from such cases because of the technical difficulty of performing coronary artery bypass grafting in this scenario. We excel in the management of advanced coronary artery disease, employing a variety of sophisticated techniques to optimize outcomes for all patients.

Blocked Coronary Artery Stents

While coronary artery stents work well in many patients, in some patients these stents become blocked again, especially in patients with diabetes. In that case, coronary artery bypass surgery may be appropriate and necessary to prevent heart attack and prolong life. We have enormous experience (literally thousands of cases) in performing successful coronary bypass to heart arteries that have had previous stents. In the case of repeat blockage in the artery that feeds the front wall of the heart, a minimally invasive robotic bypass may be possible. In some cases, when the entire coronary artery is full of blocked stents (a so-called “full metal jacket”) we can even remove the previous stent(s) to make it possible to do a bypass to that coronary artery.

Anomalous Coronary Arteries

A very small percentage of otherwise normal human beings are born with one or more coronary arteries that originate abnormally from the aorta. This condition is called an anomalous coronary artery and can occur with either the right or left coronary artery. Whenever the left coronary artery has an anomalous origin, it poses a serious risk of heart attack and sudden cardiac death and warrants surgical correction.  Most patients with anomalies of the right coronary artery do not require surgery. However, some will have symptoms of chest discomfort or shortness of breath during exertion and these symptoms typically develop relatively early in life, even at ages 30 through 50. We are expert in the evaluation and surgical management of anomalous coronary arteries by sophisticated non-invasive imaging tests and minimally invasive surgical repair techniques.

Failure of Previous Coronary Bypass Grafts

Mount Sinai Morningside specializes in the use of arterial rather than vein grafts in coronary bypass surgery. While vein grafts are easier for the surgeon to deploy and are much more commonly used nationwide, arterial grafts last longer and therefore benefit the patient more. We can often replace vein grafts that have failed after previous coronary bypass surgery performed elsewhere, using arterial grafts.

Coronary Artery Fistulas

Another congenital abnormality of the coronary arteries is an abnormal connection between a coronary artery and the pulmonary artery or one of the chambers of the heart itself.  This connection “steals” away blood supply from the coronary artery and deprives the heart of normal blood supply, contributing to symptoms of chest discomfort, shortness of breath and even heart attack. 

Coronary Artery Ectasia and Aneurysms

Sometimes extensive coronary artery disease causes enlargement of one or more coronary artery, especially in the setting of high blood pressure. These coronary artery aneurysms may cause angina, chest pain, heart attack, and abnormal heart rhythms and require specialized care in a Center of Excellence dedicated to the management of complex coronary artery problems.

Heart Valve Disease

Valve disease occurs when one or more of the four valves of the heart are not functioning correctly. Your valves are key to maintaining the proper flow and pressure of your blood. Failure of one of more heart valves can cause heart failure, with symptoms of shortness of breath and swelling. The team at Mount Sinai Heart at Mount Sinai Morningside has expertise in treating all types of valve disorders, including aortic, mitral, tricuspid, and pulmonic valve disease.

Aortic Valve Disease

The aortic valve is the valve the blood passes through before leaving the heart to circulate throughout the body.  In most people, the aortic valve has three leaflets that open and close. Some people are born with two leaflets that are fused together, called a bicuspid aortic valve. In general, a bicuspid aortic valve functions normally. However, over time, it can undergo more stress and cause leaking of blood back into the heart. It can also lead to hardening of the valve, or aortic stenosis. Symptoms of aortic valve failure tend to occur for people with bicuspid aortic valve in their 40s or 50s and for patients with tricuspid aortic valves in their 60s, 70s or 80s. This condition typically worsens over time and ultimately requires surgical repair or replacement of the aortic valve.

Our faculty in the Department of Cardiovascular Surgery at Mount Sinai Morningside is expert at the surgical replacement of the aortic valve. We offer a variety of options for treatment of the failing aortic valve, including minimally invasive surgical replacement with a mechanical valve in the very young patient and minimally invasive surgical replacement with a biological (tissue) valve in the older patient.  We most commonly use the INSPIRIS RESILIA valve, manufactured in the United States, which does not require blood thinner after surgery. 

Transcatheter Aortic Valve Replacement

Recently, new technologies have allowed the Heart Team at Mount Sinai Morningside to insert a new biological aortic valve within a narrowed aortic valve by using an ultra-minimally-invasive technique called Transcatheter Aortic Valve Replacement (“TAVR”). This procedure is performed by Heart Team members from both the Department of Cardiovascular Surgery and the Department of Cardiology at Mount Sinai Morningside and uses a series of wires and catheters to insert the valve through an artery in the leg without any incision in the chest. This least-invasive approach to aortic valve replacement is especially appropriate for elderly patients and those for whom a surgical approach may be difficult.

Mitral Valve Disease

The mitral valve controls the flow of oxygenated (“red”) blood back from the lungs to the left ventricle of the heart, from which it is then pumped through the aortic valve and around the body. Like the aortic valve, the mitral valve may fail by either leaking (called mitral regurgitation) or becoming narrowed (called mitral stenosis).  The mitral valve can usually be repaired when it leaks and this repair can be accomplished with high reliability by a minimally invasive approach at Mount Sinai Morningside. We use the safest and most reliable techniques to achieve a durable repair for virtually all patients with degenerative disease of the mitral valve. Those patients who develop mitral valve narrowing (stenosis) caused by rheumatic heart disease may require mitral valve replacement.

Tricuspid Valve Disease

The tricuspid valve controls the flow of de-oxygenated (“blue”) blood back from the body to the heart. The tricuspid valve most often fails by leaking, due to backing up of blood caused by mitral valve regurgitation. The tricuspid valve can almost always be repaired rather than replaced. This is most commonly performed at the time of mitral valve repair. Less commonly, rheumatic heart disease may lead to tricuspid stenosis, requiring tricuspid valve replacement.

Infection of Heart Valves

Infection of heart valves is called endocarditis. It is most commonly caused by bacteria entering the blood stream from an infection elsewhere in the body. Endocarditis can affect any heart valve, but is most common on the aortic, mitral, and tricuspid valves. It can often be treated with powerful intravenous antibiotics alone, and surgery can be avoided. However, if the valve is destroyed by infection and heart failure results, surgical repair or replacement may be required.  Sometimes infected material may break loose from an infected heart valve and cause stroke; this also leads to surgical intervention. The cardiovascular surgery team at Mount Sinai Morningside has extensive experience in the treatment of patients with infection of the heart valves and uses state-of-the-art techniques to achieve the best possible results, even when multiple valves are infected in an individual patient. This scenario may occasionally require an extensive debridement and replacement of both the aortic and mitral valves (a “Commando Procedure”), a technically challenging operation in which our faculty has special expertise.

Diseases of the Aorta

The aorta is the main conduit from the heart, supplying the body with oxygen and nutrients. At times atherosclerosis may occur in the aorta, leading to the formation of aneurysms which can cause life-threatening internal bleeding.

In general, the primary aortic disorders include:

• Aortic aneurysms, which occur when the walls of the aorta balloon out and become distended
• Aortic dissection, which is a tear in the lining or wall of the aorta
• Aortic stenosis, which is the narrowing of the aortic valve
• Aortic insufficiency (sometimes called aortic regurgitation), which is leaking of the aortic valve

Most patients do not experience any symptoms from an aortic disorder, and it is usually discovered during a diagnostic procedure—such as an X-ray or CAT scan—related to another disorder. Patients may be treated medically, or just be monitored. “Watchful waiting” is another term often used for monitoring, which is the purpose of the Aortic Surveillance Program at Mount Sinai Morningside. Some patients have been monitored for 20 years and never needed surgery. However, once a patient starts to show progressive enlargement of the aorta or experience chest pain, shortness of breath, or fatigue, surgery is usually indicated. For patients that do require surgery, Mount Sinai Morningside specializes in minimally invasive techniques, open-heart surgery, and hybrid techniques.

Disorders of the specific parts of the aorta can be caused by a variety of conditions, from lifestyle to genetics.

Aortic Root Aneurysm

The aortic root consists of the first two to three centimeters of the aorta that extends from the left ventricle of the heart. Aortic root aneurysms are relatively rare. However, when the next segment of the aorta—the ascending aorta—develops an aneurysm it can also affect the aortic root. Aortic root aneurysms can be caused by genetic conditions, such as Marfan Syndrome or Loey-Dietz Syndrome. These are genetic disorders of the connective tissue, resulting in weakening of the aortic wall, which can cause an aneurysm.

The expansion of an aortic root aneurysm can affect the ability of the aortic valve to seal properly. This can cause blood to leak back into the left ventricle of the heart. The aortic root aneurysm can also cause dissection, or tearing of the aortic wall. Many patients don’t experience any symptoms, but over time may experience shortness of breath, fatigue, and chest pain. Unfortunately, often the first time a patient becomes aware of this disorder is at the time of an acute aortic dissection, which requires emergency surgery.

Ascending Aortic Aneurysm

The ascending aorta is the next section of the aorta above the root. Ascending aortic aneurysms are typically found in patients in their 60s and 70s. They are most often caused by smoking, high blood pressure, stress, cholesterol, excessive weight lifting, bicuspid aortic valve, and genetic disorders such as Marfan Syndrome or Loey-Dietz Syndrome. Most patients do not have any symptoms, however, the most common symptom is a dull, non-specific chest pain. An ascending aortic aneurysm can lead to dissection, which, if acute, may require emergency surgery.

The first line of treatment is regulating blood pressure through medications called beta-blockers and angiotensin receptor inhibitors. In addition, careful monitoring of the size and rate of growth of the aneurysm helps determine whether surgery is needed. That is why the Department of Cardiovascular Surgery at Mount Sinai Morningside maintains one of the largest aortic surveillance programs in the United States.

Aortic Arch Aneurysm

The next section of the aorta, the aortic arch, is intricate with major arteries branching off to the brain, neck, face, and upper extremities. It then begins its curve downward to the lower part of the body through the descending aorta. Aneurysms and dissections are commonly caused by smoking, high, blood pressure, atherosclerosis, and infection. Consequently, treatment consists of strict blood pressure management, smoking cessation, and cholesterol-reducing medications. Mount Sinai Heart at Mount Sinai Morningside has been in the forefront of developing safer, more effective surgical techniques to repair aortic arch aneurysms and dissections.

Thoracoabdominal and Descending Thoracic Aortic Aneurysms

As the aorta descends into the chest and abdominal cavity, aneurysms may be caused by atherosclerosis or dissection. Causes include smoking, high blood pressure, high cholesterol, inflammatory or infectious aortitis, connective tissue disorders, or tearing of the aortic wall. Most patients will not exhibit any symptoms, though in advanced cases, they may feel chest or back pain. Less common symptoms include difficulty swallowing, hoarseness, difficulty breathing, and cough. In most cases, watchful monitoring, heart-healthy lifestyle changes, and medical management through blood pressure and cholesterol-lowering medications are the first course of treatment. The gold standard for surgical repair is open surgery, however endovascular surgery may be more suitable for patients who are elderly or have other medical complications. Because of the descending aorta’s proximity to the spine, extreme care and expertise is required for these procedures to avoid paraplegia and few centers perform them frequently. Mount Sinai Heart at Mount Sinai Morningside is a leader in spinal cord protection techniques for lower aortic aneurysms, and has extensive expertise in both open and endovascular surgery. 

Pulmonary Embolism

Pulmonary embolism is the third most frequent killer among cardiovascular disorders after heart attack and stroke. A pulmonary embolism is a clot that lodges in the arteries of the lungs. Such clots typically travel from the legs or abdomen through the heart and lodge in the pulmonary arteries. The clot can cause unusually high blood pressure in the right side of the heart and in the lung arteries.  As the heart works harder, it may fatigue and fail.  Pulmonary embolisms can cause acute symptoms—such as difficulty breathing, chest pain, or fainting—or symptoms may build up over time. Pulmonary embolisms are common in the elderly, but also common in young women—especially during pregnancy or post-partum (after giving birth). Pulmonary embolism may progress to pulmonary hypertension when the blood pressure in the lung arteries is unusually high, due to build-up of obstruction. Pulmonary hypertension is also more frequent among African Americans. Over the past five to six years, physicians have been able to diagnose pulmonary embolism more easily with the use of computed tomographic angiography (CTA).

As pulmonary hypertension progresses, it may develop into a rare disease called chronic thromboembolic pulmonary hypertension, or CTEPH. Symptoms include shortness of breath, fatigue, and swelling in the extremities. CTEPH is a serious condition that, left untreated, may lead to death within five years. It is difficult to diagnose because the symptoms are similar to diseases, such as asthma, emphysema, and chronic obstructive pulmonary disease (COPD). Mount Sinai Heart at Mount Sinai Morningside has extensive experience treating pulmonary embolisms and CTEPH. Often, there is an underlying reason for the formation of clots, and the Heart Team approach at Mount Sinai Heart at Mount Sinai Morningside brings in specialists as needed to come up with a comprehensive plan of treatment for both acute pulmonary embolism and chronic thromboembolic pulmonary hypertension.

Atrial Fibrillation

Atrial fibrillation (AF) is a condition in which the upper chambers of the heart (the “atria”) do not beat normally in coordination with the lower chambers.  Instead, the atria quiver and this quivering, called fibrillation, leads to a less efficient heart beat and decreases cardiac performance.  While a few patients with AF may have no symptoms, many feel weak, fatigued and may experience shortness of breath, light headedness and even chest pain. Because blood does not flow normally through the left atrium, atrial fibrillation increases the risk of blood clots forming in the left atrial appendage (a part of the left atrium), which can dislodge and cause stroke.

While most patients with AF can be treated with medications to thin their blood and/or return them to a normal rhythm, some will require a procedure to ablate the electrical pathways within the atria that perpetuation atrial fibrillation. Sometimes this ablation procedure can be performed with catheters, avoiding surgery. For patients with longstanding persistent AF, especially those having cardiac surgery for another reason, a surgical ablation can be performed at the time of coronary artery bypass or valve surgery.

Hypertrophic Obstructive Cardiomyopathy

Hypertrophic obstructive cardiomyopathy is a hereditary condition in which an individual develops an abnormal growth of muscle in the wall of muscle that separates the right and left ventricles, called the septum. This abnormal growth can obstruct the flow of blood out of the heart. Every time the heart beats and squeezes blood out, it has to go around or over the growth which looks like an elevated mass. This mass can also interfere with the proper function of the mitral valve, further reducing the normal flow of blood through the chambers of the heart and out the aorta.

The increased workload on the heart can cause shortness of breath, fatigue, chest pain, and occasionally, abnormal heart rhythms. However, many individuals may exhibit few, if any, symptoms. Sometimes the condition may be suspected because of a heart murmur. We use the latest imaging tools—such as cardiac MRI, echocardiograms, and cardiac catheterization—to arrive at a definitive diagnosis. Mount Sinai Heart at Mount Sinai Morningside is one of the few nationally-recognized centers with expertise in treating hypertrophic obstructive cardiomyopathy.

Heart Disease in Women

Heart disease is the number one cause of death of both men and women in the world.  Dr. Sandya Balaram has spent much of her career caring for a population of inner city and underserved patients who have had little previous exposure and access to medical care. She has over two decades of experience in the dedicated care of cardiac surgical patients in New York City, and brings a special insight into the important nuances of the treatment of heart disease in women.

These are a few of the wide range of heart disorders that we treat. You will be evaluated by a full multidisciplinary team as needed, including cardiologists, cardiovascular surgeons, and other specialists for any additional underlying conditions you may have. Our goal is to carefully develop a comprehensive treatment plan with you and your family—a true “Heart Team approach.”