Partners in Life

ARCTIC Medical Director Dr. Mary Ann Peberdy and her husband, Dr. Joseph Ornato, have created one of the world’s most renowned cardiac resuscitation programs.

The pair have been at the forefront of clinical care and research in cardiac arrest for decades.

With the recent arrival of the Weil Institute, VCU is poised to also become a basic and translational research powerhouse in this field.

“That day is a total blank in my memory. What I’ve been told is that I had been on an elliptical machine, and I left that and went to a stationary bicycle. At that point, I blacked out and fell off the bicycle,” recalled Bob Hershberger, 70, a U.S. Air Force veteran and retired executive vice-president of the Williamsburg Chamber and Tourism Alliance.

“The work Dr. Peberdy and Dr. Ornato did with the ARCTIC Program was pioneering. They did this at a time when no one was really thinking about cardiac arrest and post-sequalae to the brain. Much of the work was done quietly and without much fanfare. Now, this is the cutting edge of cardiovascular medicine.” — Vigneshwar Kasirajan, M.D.

Hershberger has pieced together some of the details from April 7 when he suffered a cardiac arrest—an often-fatal condition when the heart suddenly stops beating effectively—while working out at a local health club. Attendants at the club rushed to his aid and called a rescue squad. Paramedics shocked his heart with a defibrillator and brought him to Sentara Williamsburg Regional Medical Center, where he was stabilized and then loaded onto a critical care helicopter for transport.

At VCU Medical Center, he was placed under the care of Mary Ann Peberdy, M.D., a cardiologist and the medical director of the Advanced Resuscitation, Cooling Therapeutics, and Intensive Care (ARCTIC) program for post- cardiac arrest care. Peberdy and her husband, Joseph Ornato, M.D., chairman of the VCU Emergency Department, began cooling of patients at VCU in 2004, shortly after “new data became available that demonstrated that if you lower the body temperature you can improve survival and neurological outcomes in patients that have had cardiac arrest,” said Peberdy.

Following successful heart resuscitation after cardiac arrest, the patient often remains in a coma from lack of blood flow to the brain during the cardiac arrest. The body undergoes a rapidly escalating inflammatory response that can further jeopardize survival and neurological outcomes. To prevent and reverse this damage, ARCTIC patients like Hershberger undergo therapeutic temperature management with an intravascular cooling device, which chills their body temperature to 92 degrees for 24 hours, then gradually returns the body temperature to normal.

For Hershberger’s wife, Margaret, and other family members who gathered at VCU to wait and worry, it was a lot to process: The death of a loved one, resuscitation, then a coma. But Peberdy helped them through it.

“They were impressed by her. She was very calm, which helped to keep everybody else in somewhat of a calm manner, despite the precariousness of the situation,” said Hershberger.

Peberdy, the C. Kenneth Wright Professor of Cardiology, created the ARCTIC program, one of the first of its kind in the country, in 2004. The program is multi-tiered, with components including a continuum of clinical care, research, community training in CPR, and coordination with a highly trained network of EMS’s and partner hospitals.

“She is a master physician and truly devoted to advancing the science for the care of our patients,” said Vigneshwar Kasirajan, M.D., cardiothoracic surgeon and chair of the department of surgery.

In 1974, on the first day of his cardiology fellowship at New York Hospital—Cornell Medical Center, Ornato was assigned to oversee and hone the training of the paramedics. “At that time, it was the only 24/7 paramedic program in all of New York City,” he recalled.

Although he knew little about the work, he began joining the paramedics on calls during slow times in cardiology. “Within a couple of months, we actually had our first survival from cardiac arrest…which in 1974 was virtually unheard of. If your heart stopped out of hospital, you were going to die,” he recalled. A few days after she awakened in the coronary care unit, his elderly patient—who was looking forward to the birth of her first grandchild—expressed her gratitude to Ornato with a kiss on his cheek. “I remember thinking, `I’ve been kissed by a dead person’. That moment changed my career.”

Today, through his work as a cardiologist and Emergency Medicine specialist, Ornato still works closely with early responders, who play a key part in the “chain of survival” necessary for cardiac arrest patients to survive. In addition to his work at VCU, he is the medical director of the Richmond Ambulance Authority, Richmond Fire & EMS, and Henrico County Division of Fire. He ensures all are kept up-to-date on VCU’s ARCTIC program and cutting-edge science in resuscitation.

Peberdy, the C. Kenneth Wright Professor of Cardiology, created the ARCTIC program, one of the first of its kind in the country, in 2004.

He and Peberdy also oversee the training of ARCTIC attending physicians, a component of the program that separates it from others in the small club of top-tier cooling programs.

“We have five attending physicians who are on call, 24/7, to help with the decision-making for the therapy,” he said. “We really tried to have a small enough number so that we could ensure that every one of us is absolutely up-to-date on what the latest science is showing as to the proper use and selection of patients for this kind of cooling therapy.”
The volunteer group includes Ornato and Peberdy; Antonio Abbate, M.D., Ph.D., James Roberts Professor of Cardiology and vice-chair of the Division of Cardiology; Stephen Miller, D.O., assistant professor of Emergency Medicine; and Harinder Dhindsa, M.D., chair of the Division of EMS.

“Dr. Ornato is one of the leading international experts in cardiac resuscitation. He is not satisfied with the current state of the art, and he and his research and clinical partner, Dr. Mimi Peberdy, are developing new tools for treating and preventing cardiac arrest,” said Kenneth Ellenbogen, M.D., chair of the Division of Cardiology.

One of Ornato’s most important contributions was serving as principal investigator of the Public-Access Defibrillation study, which was funded by the NIH, the AHA, and industry. Peberdy served as the PI for VCU/Richmond. The 18-month study trained 19,000 people and placed 1,500 AEDs in 24 U.S. and Canadian cities in how to perform CPR and how to recognize a cardiac arrest and call 911. In half of the study sites, lay volunteers were also trained and equipped to use an AED on the victims before EMS arrival.

The study’s findings were published in the New England Journal of Medicine in 2004. “We were able to show that lay persons performing CPR and using an AED doubled the chances of survival from cardiac arrest out of hospital compared to having the lay person just perform CPR. And based on the study—which got a lot of national and international press—the AHA got Congress to pass the Cardiac Arrest Survival Act of 2006,” said Ornato.

Soon after the study was published and the Act was passed, all federal buildings in the country were required by law to have AEDs in public places, and all airlines and airports now have AEDs and personnel trained to use them.
The ARCTIC program underwent several big changes in 2008. The first was that VCU began serving as a regional hub to other hospitals for its advanced post-arrest therapies. The second was that the program’s attending physicians shifted their focus from cooling patients from the “outside in”—using cooling blankets, ice bags and gel pads—to the “inside out.” The latter involves endovascular cooling, which involves the use of a closed-circuit catheter that controls body temperature internally.

The newer process allows for “targeted temperature management,” which includes an induction phase, in which the body is cooled; a maintenance phase, in which the lowered temperature is maintained for about 24 hours; and a rewarming phase, in which the body is returned gradually to its normal temperature.

The process of caring for ARCTIC patients in the Coronary ICU is dynamic. “Care is minute-to-minute and hour-to-hour. It’s constant evaluation and re-evaluation,” said Michelle Gossip, BSN, ARCTIC care coordinator.

Nurses play a key role, she said. “It is the nurse who sees subtle changes in our patient population and, working with our physician staff, provides ongoing emotional support for patients and families.”

Unlike many other programs, continuous brain wave monitoring is performed and there is a strong focus on ventilation, hemodynamic, and metabolic parameters to improve outcomes. The ARCTIC program was also the first in the country to perform detailed neuro-cognitive testing in survivors to identify more subtle, persistent areas of brain injury and begin early rehabilitation treatment in these patients. Treatment plans require multidisciplinary teams, made up of heart doctors as well as nurses, neurologists, pulmonologists, technicians, social workers, nutritionists, rehabilitation experts, and physical, occupational, and speech therapists.

Hershberger, who exercised regularly and had no history of heart disease, was found to have blockages in the arteries supplying blood to his heart, which led to his arrhythmia and ultimately cardiac arrest. Once he completed the comprehensive post-arrest care and awoke from his coma, he underwent a successful double bypass surgery at VCU. Upon discharge, he started a 12-week, medically supervised cardiac rehabilitation program near his home.

“We want to arm our patients with all the tools they need to be successful when they’re discharged,” said Gossip, who coordinates the care for this complex patient population and runs a support group for cardiac arrest survivors. She also teaches Hands Only CPR and, with Peberdy, provides training to partner hospitals.

“Michelle is the glue [that holds this program together],” said Ornato. “I just can’t say enough good things about her.”

Despite the great success of the ARCTIC program, “the one thing we were lacking was the ability to go back and forth between the bench and the bedside to further increase our knowledge and improve outcomes,” said Peberdy.

That all changed in 2016, when, after a year-long search, the Weil Institute of Critical Care Medicine chose to move its world-renowned, basic science laboratory from Rancho Mirage, California, to VCU Medical Center. The institute, founded in 1961, was named after the late Max Harry Weil, M.D., Ph.D.—a mentor and friend of Peberdy’s and Ornato’s for over 25 years—who is considered the father of critical care medicine. Most of the institute’s work involves cardiac arrest and emergency care.

“Weil’s board of directors made the decision to come to VCU because they wanted the ability to have their basic science work translate into clinical work and they chose us, in part, because of the ARCTIC program,” she said. “We are working very closely with them so that the projects they do can be easily translated to the bedside if there are promising outcomes found in the laboratory.”

Wanchun Tang, M.D., who was trained by Weil and ran the Institute after Weil passed away in 2011, joined VCU as professor of Emergency Medicine and continues as the Institute’s director. Peberdy and Ornato were named co-deputy directors of the Weil Institute of Emergency and Critical Care Research at VCU, which held its grand opening in October 2016.

“We are learning more and more about how to better care for these patients,” said Peberdy. “And it’s our hope that we can further our research and continue to get better at what we do.”

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About the Doctors:
Mary Ann Peberdy, M.D., and Joseph Ornato, M.D., have devoted a significant part of their careers to cardiac arrest patients. Triple board-certified in Cardiology, Internal Medicine, and Emergency Medicine, Ornato has published over 400 papers in the field and recently was awarded the prestigious American Heart Association National Clinical Research Award for his work. Peberdy is also triple boarded in Internal Medicine, Cardiology, and Advanced Heart Failure and Transplant and has published over 200 articles.

Both physicians have served on the AHA national committees for resuscitation science and have been authors in the AHA Guidelines for resuscitation continuously since the 1980s. They are also founding physicians of the AHA Get with the Guidelines-Resuscitation Program, which is the world’s largest repository of performance improvement and research data for in-hospital cardiac arrest.

Learn more…
View the VCU ARCTIC Program on a PBS NOVA program that aired on January 26, 2011. To view it, visit PBS.org/wgbh/nova/body/can-we-live-forever (the segment starts around the 47-minute mark).

For updates on the Weil Institute research, presentations and awards go to: https://emergencymedicine.vcu.edu/research/

Save the Date:
Pauley Heart Center Consortium Event on Thursday, May 17, 2018 at Rhythm Hall on the first floor of Dorothy Pauley Square in the Dominion Arts Center.

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According to the American Heart Association, more than 350,000 out-of-hospital cardiac arrests occur in the U.S. each year, and overall survival is 10%. Chances of survival can double or triple with timely CPR and early defibrillation with an AED.