Local doctor’s mission to improve health care in Southern Nevada counters common myth

In July 2014, Dr. Dhiraj Narula became the first physician in the Western United States to conduct a revolutionary procedure. He was among the first handful of cardiologists in the world to conduct an implant of the Evera MRI implantable cardioverter-defibrillator (ICD) system.

Editor's note: This story was originally published in Health Care Quarterly, magazine about Southern Nevada's health care industry. Stories in Health Care Quarterly were submitted by doctors and their affiliates.

Dr. Dhiraj Narula still remembers the line from a news article years ago that made his stomach sink.

“The newspaper story asked, ‘Where can you get the best health care in Las Vegas?’” he said.

He didn’t appreciate the answer: the airport.

“The story implied that if you want the best medical technology, you need to travel to California or Utah because Las Vegas doesn’t have the best health care available,” said the cardiologist with HealthCare Partners Medical Group. “To me, that was a big issue. Las Vegas is my home, and it appeared as if our health care system was deficient.”

Passionate about providing patients in Southern Nevada with the most cutting-edge medical technology, Narula has devoted his practice to proving that article wrong. His efforts haven’t been in vain. He recently made a tremendous step in advancing medical technology on a global level.

In July 2014, Narula became the first physician in the Western United States to conduct a revolutionary procedure. He was among the first handful of cardiologists in the world to conduct an implant of the Evera MRI implantable cardioverter-defibrillator (ICD) system. Narula and the HealthCare Partners Medical Group research team played a key role in efforts to hopefully make this technology available to patients across the globe.

Narula sees this as two achievements, not only providing the latest technology to help patients survive, but also positioning Las Vegas at the center of this innovation.

“I feel that we have been able to move health care in Southern Nevada a significant step forward,” Narula said. “That’s really the key for me.”

Life-saving technology... with an issue

Many cardiac patients are familiar with ICD systems, a technology that has existed for roughly 20 years. The battery-powered device, implanted under the skin in the upper torso, serves an essential function for patients with advanced heart disease who have or are likely to experience cardiac arrest. Monitoring an individual’s heart rate, an ICD system provides life-saving electric shocks to the heart when an abnormal heart rhythm occurs.

“The device plays an important role in preventing people from experiencing sudden death as a result of cardiac arrest,” Narula said. “It’s a technology that saves lives.”

But there has long been an issue with this technology. Throughout the device’s history, individuals with ICD implants have typically been unable to undergo magnetic resonance imaging (MRI), which can diagnose numerous health issues. The powerful magnetic fields and radio waves of MRI scanners raise the risk of causing harmful reactions with the ICD, Narula said.

“The device would prevent you from dying of a cardiac arrest, but if you experience another medical condition such as back issues, you can’t get clear imaging of it with an MRI,” Narula said.

That was the understanding until recently. Medtronic, the world’s largest medical technology company, recently sought approval from the Food and Drug Administration for the Evera MRI, an MRI-compatible ICD. The new technology, roughly half the size of an iPod, would serve as the first ICD specifically engineered to provide a SureScan mode, ensuring patient safety during MRIs.

When Narula heard that Medtronic had been approved to conduct a clinical trial of the device and was investigating potential clinical research sites across the globe, he recognized a valuable opportunity. This could be a chance to provide unprecedented technology for patients in Southern Nevada, while providing the research team at HealthCare Partners Medical Group with an opportunity to influence the future of cardiovascular care. It was also a chance to remind the world that Las Vegas offers cutting-edge health care services.

“I knew this would be a significant opportunity to have a lasting impact on Southern Nevada,” he recalls.

Tapped for the trial

There’s nothing simple about participating in a global clinical trial for unprecedented medical technology.

Only 40 research sites around the world would be selected to participate in the trial, which would involve each site’s research team surgically implanting patients with the new technology and conducting follow-ups. It was a painstaking process in which the capabilities of hospitals and research teams were carefully scrutinized for their abilities to conduct a thorough, reliable trial.

“It’s a highly competitive process,” Narula said.

Despite the high stakes, Narula was successful in early 2014 in securing approval for the HealthCare Partners Medical Group team to conduct implants for several patients at Summerlin and Desert Springs hospitals.

“When we tested this technology in Las Vegas, it wasn’t available in Phoenix or Salt Lake City or Los Angeles,” Narula said. “That’s a big step forward for Las Vegas. We have moved to the point where we can provide cutting-edge technology to patients right here at home.”

He attributes being tapped for the study to HealthCare Partners, the Southern Nevada medical network that includes Narula’s cardiology division. Offering more than 310 primary care providers and more than 1,700 specialists, the organization prioritizes research and advancing health care practices.

The organization has invested in providing a full-scale cardiology research department, outfitted with a team of research nurses many health care organizations lack, Narula said. The organization also offers established practices for conducting medical research, and a large cardiology practice with an electrophysiology division that is well-equipped to handle clinical trials.

“Medtronic selected us for the clinical trial because HealthCare Partners Medical Group had invested in research infrastructure. It is a central tenet of our philosophy to provide the best health care in the world,” Narula said. “That’s been an ongoing goal of the organization, and this was one example of achieving that goal.”

Finding patients

The research team adopted a careful approach to identifying nine patients to enroll in the trial and test the new technology, Narula said.

“The patients had to be made aware that if the trial was successful, they would have the newest medical technology available, but there were also unknowns,” he said.

There are a multitude of safeguards in place to ensure patients are protected during a clinical trial, he notes, and this was no different. Summerlin and Desert Springs hospitals contracted a review board to carefully analyze every aspect of the team’s research plans, including specific details of how patients would be treated.

Although the implant of the Evera MRI wouldn’t be any different from other ICD surgeries Narula conducted throughout his career, there is always an element of risk with clinical trials, he notes.

“We had to disclose this to patients,” he said.

The risks didn’t dissuade Roy Randall, 72, Narula’s first patient in the trial to undergo surgery for the implant.

Randall had been referred for the clinical trial based on his medical history, which included two silent heart attacks that damaged his heart. These issues affected him every day, he said, noting that he felt constantly tired.

“I could wash the car, but then I’d have to sit down for a couple of hours and rest,” he said.

When he met with Narula to discuss the details of the clinical trial, Randall was optimistic that the ICD could have a positive impact on his heart issues. He felt especially motivated by the prospect of having an ICD that allowed for MRIs, which he anticipated needing down the road.

“I’m 72. I’m wearing out,” Randall reasons.

The possible risks weren’t so daunting after he discussed the trial with his brother-in-law, a spine specialist who was aware of Medtronic and assured him the manufacturer was reputable.

“It’s always good to get help from someone who knows more than you do,” Randall said with a chuckle.

The results

It appears that Randall’s decision paid off.

The nine patients selected for the trial in Las Vegas have demonstrated great success with the Evera MRI devices, Narula said. Since July 2014, when the first device was implanted, neither Randall nor any of the other trial patients have experienced significant issues with their devices. Roughly half of them were randomly selected to undergo a study MRI. The research team has carefully collected data during these tests, analyzed the results and submitted them to Medtronic, along with other trial participants around the world.

“If any particular issue comes up, everyone participating in the trial will be alerted. If they see a problem in Berlin, everybody needs to know,” Narula said, emphasizing the importance of ensuring patients’ safety. “We put our information into a database that is constantly being analyzed to make sure nothing is going in the wrong direction.”

So far, no issues have been reported.

“We haven’t discovered any problems here, and there haven’t been problems discovered elsewhere,” he said, adding that he expects the FDA to approve the device for general release later in the year. “It’s our belief that this is going to be a new technology that will benefit a lot of patients.”

Randall said he has been pain-free throughout the process. Since his surgery, he has returned to the hospital to undergo an MRI, and again for testing of his ICD. There have been no issues when the scanner passes over his torso, he said.

“I don’t even know the implant is there anymore,” he said.

Randall has also noticed a difference since the surgery. He doesn’t feel as tired, and his previously pale complexion has gained a healthier color. There still remain issues with the rhythm of his heart, but his health care team believes this is a result of an issue they hope to soon address with an additional procedure called a cryo balloon ablation.

The HealthCare Partners team has offered constant support throughout the trial, he added. Team members were happy to explain details about the process and carefully monitor his overall wellness. He appreciates that an entire team is devoted to his care, including Narula, the research nurses and MRI technicians.

Randall considers the clinical trial the latest in a long line of technological advances he has observed during his lifetime. After watching cars, appliances, airplanes and more go through dramatic evolutions, he is excited that the latest technology is resting under his skin.

“I’m lucky to be in Las Vegas, where a lot of big steps are being made,” he said.

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