LEWISTON — More than a decade ago, Rich Livingston went to Augusta to urge the state to approve a controversial heart center in Lewiston.

Maine had only two such centers, which meant Lewiston-Auburn-area patients typically had to travel nearly an hour to Portland or two hours to Bangor if they needed a full-service program for open-heart surgery, angioplasty or other intensive cardiac care.

Central Maine Medical Center’s Central Maine Heart and Vascular Institute would be a great thing for the community, Livingston thought. A closer alternative for people suffering heart attacks. 

You know, other people.

“I certainly wasn’t planning to use it,” he said.

Then, one morning last fall, Livingston, 68, woke in a cold sweat. Intense pain flared across his shoulders and radiated down both arms. His jaw hurt. He was nauseated. 

He knew the symptoms. He was having a heart attack.

“I actually expected I was going to die,” he said. “I thought I’d be dead in minutes. Either the symptoms would abate on their own or I’d be dead. It couldn’t continue the way it was.”

But it did continue. Finally, sometime in late morning — three or four hours later — Livingston called his son and asked to be taken to the hospital.

He arrived at the Central Maine Heart and Vascular Institute within minutes.  

Ten years after it opened, Livingston credited the heart center with saving his life.

“I waited way longer than I should have to get to the hospital,” he said. “Had I, at that point, needed to be transported out of town, I would have been in even more trouble than I was.”

A decade ago, the proposed heart center was controversial, its fate uncertain. Other hospitals said it wasn’t needed. A state-commissioned study said the center would almost certainly be “a low-volume one that would face difficult challenges.” 

A decade later, the heart center has been lauded by residents, patients, doctors and outside rating experts, not only for its emergency procedures but also for its heart health rehab program. One of three such cardiac programs in the state, it is the go-to place for area heart patients.

Tomorrow, the Central Maine Heart and Vascular Institute will officially mark its 10th anniversary.

“The health-care capabilities of this community were not complete without this,” Livingston said.

Hospital wars

CMMC first proposed its heart center in the late 1990s. At the time, heart disease was the leading cause of death in Maine, but only Maine Medical Center in Portland and Eastern Maine Medical Center in Bangor had full cardiac surgery programs. Portland’s was the largest and the busiest, performing as many as 1,600 open-heart surgeries a year, among the most in New England.

All three hospitals — Maine Med, EMMC and CMMC — were large, regional facilities with trauma centers but only CMMC lacked its own heart center. It was most often losing patients to Portland. By 2000, MMC was performing open-heart surgery on about 200 of CMMC’s patients each year and angioplasties on 300 more.

CMMC officials wanted to keep those patients closer to home with a new, multi-million-dollar heart center. The hospital would benefit from serving more people and offering more services — heart programs can be large revenue producers — but officials also believed patients would benefit.

Back then, patients who walked into CMMC having heart attacks would likely have been given a clot-busting drug and a bed for the night. If it was determined they needed angioplasty, a stent or open-heart surgery the next morning, they were typically sent to MMC in Portland. The whole process could take hours, if not days. The delay meant there was a greater chance that heart muscle would die and patients could end up with congestive heart failure. In those situations, patients were saved, but they lost quality of life and, potentially, years off their lives.

A full CMMC heart center could change all that, advocates said, not just for nearby Lewiston-Auburn residents, but for 400,000 people from throughout western Maine.

“They could be at home (having a heart attack) . . . and be on an operating table within an hour and a half or so of the process starting, depending on how far away they’re coming from,” said Dr. Carmine Frumiento, who was one of the first heart surgeons hired by the institute and is now director of thoracic surgery. “Time is muscle.”

In its application to get state approval for the center, CMMC said it was doing no open-heart surgeries and no procedures to open blocked coronary arteries in 1999. With a heart center, it expected to perform 148 surgeries and 178 coronary artery procedures in the first year and 370 surgeries and 445 coronary artery procedures by year three.

The proposal sounded good to many in the community, including Livingston. An Auburn city councilor at the time, he was part of a delegation that traveled to Augusta to urge the Maine Department of Human Services to approve the heart center plan.

“I really did believe, and certainly do now, that it was the right thing for this community,” said Livingston, a retired business consultant who has since served as a freelance writer for the Sun Journal and is president of the Maine chapter of AARP.

Others didn’t agree. In particular, MMC officials fought hard against the proposal, saying their program was already serving Lewiston-Auburn heart patients and serving them well. They said Lewiston’s program would be low-use and, therefore, lower quality. 

“The more you do it, the better you get,” former MMC President Vincent Conti said in a 2000 interview with the Sun Journal.  

While CMMC officials said their heart center would quickly grow to do hundreds of surgeries and procedures each year, a private Portland research firm said that wasn’t likely. In 2000, the state commissioned a study to help it decide how to respond to seven hospitals, not including CMMC, that wanted to establish cardiac catheterization labs. The study predicted that a CMMC heart center would be so low-volume that it might not even meet state approval guidelines for performing at least 200 open-heart surgeries per year.

The Maine Department of Human Services considered the study, but ultimately wasn’t put off by it.

Weeks later, former Commissioner Kevin Concannon approved CMMC’s heart center under two conditions: CMMC had to report its patient outcomes to ensure it was meeting the same quality standards as MMC and EMMC, and it had to prove the heart center was financially feasible by reporting profit and loss to the state for the first three years.

In the years since, CMMC’s heart center has reported its outcomes to at least five professional organizations. It’s unclear how the state viewed the center’s fiscal feasibility in year three — records from that time were not readily available — but the center appears to be doing well enough now. The heart center was expected to bring in $15 million in its third year. It’s currently bringing in about $85 million, including revenue from cardiac diagnostics and other services since placed under CMHVI’s umbrella.

CMMC won its war, but smaller battles would continue, even as the facility was under construction. At one point, there was an outcry over CMMC’s plan to hire its own specialists and exclude other local doctors from caring for patients at the center. CMMC eventually agreed to allow in some local doctors with certain affiliations.

The controversies didn’t go unnoticed by the outside world, including the doctors CMMC was trying to recruit. Dr. William Phillips, now director of cardiology, said he thought long and hard before moving his family from New York to Maine and committing himself to starting a heart center in Lewiston.

“I didn’t want to go to someplace where I was fighting for every patient, where people didn’t really want the program,” he said. “But it seemed to me the people in the community and the surrounding communities really felt that having another heart program in the state of Maine would be a benefit to them. That’s what I was counting on.”

In the early 2000s, CMMC began building its six-story, $8.1 million facility, complete with 16 beds, office space, operating rooms, diagnostic testing space and a cardiac rehabilitation area.

In the spring of 2003, the Central Maine Heart and Vascular Institute opened its doors.

Best ratings in the state

The heart center happened to open just as cardiac medicine took a leap forward. In 2003, the FDA approved drug-eluting stents — coated scaffolding that is placed in narrowed arteries to keep them open and that slowly releases a drug to prevent scar tissue from forming and re-blocking blood flow.

MMC put in its first drug-eluting stent in April 2003. CMHVI followed a month later, almost as soon as it opened its doors.

The center has expanded twice, once in 2005 when it added an electrophysiology lab for patients with heart-rhythm problems and again in 2010 when it added an endovascular lab for patients dealing with vascular problems not in the heart.

It also started a program that gives trained paramedics the power to administer and read a patient’s EKG in the field and call ahead to tell the hospital to ready its cath lab. Since heart-attack patients didn’t have to wait for the test to be administered at the hospital, nearly 30 minutes were shaved off the door-to-balloon time — the time it takes a patient to go from the hospital’s front doors to an artery-opening angioplasty.

CMHVI was the first heart center in Maine to start such a program. The other two have since followed.

Today, the center’s overall door-to-balloon time is 54 minutes, more than half an hour below the 90-minute benchmark set by the American College of Cardiology. It has performed 3,500 angioplasties in the past decade, though the hospital could not say how many open-heart surgeries have been done in that time. Patients have ranged in age from 18 to 95, with an average age of 59. Sixty-five percent have been men and 35 percent have been women.

The Northern New England Cardiovascular Disease Study Group shows CMHVI’s bypass surgery mortality rates to be 1.8 percent, the same as MMC and lower than EMMC’s 3.4 percent. The Lewiston heart center had better rates than both MMC and EMMC for some complications, including bleeding that requires another operation. It had worse rates for other complications, including renal failure.

The Leapfrog Group, a Washington, D.C.-based organization that tracks health care safety, quality and value, for 2012 gave Lewiston’s heart center higher ratings for bypass surgery quality and costs than MMC or EMMC. It rated the institute’s heart angioplasty procedure higher than MMC and as high as EMMC’s.

A LeapFrog spokeswoman said a technical problem made CMHVI’s general heart-attack care rating currently unavailable through the organization. However, heart center officials show their LeapFrog heart-attack care rating to be higher than EMMC’s and as high as MMC’s.

Patients give the heart center high marks, as well.

“I think it’s the cat’s meow; I really do,” said Michel Lajoie, a state legislator and former Lewiston fire chief.

Lajoie, now 69, began having shoulder and back pain late last summer. It eased when he sat down and put ice on it, only to flare when he became active again. His family doctor sent him to six weeks of physical therapy. When that didn’t help, his doctor ordered a stress test.

It turned out four of Lajoie’s arteries were blocked, one completely. One type of blockage has a mortality rate so high that medicine dubs it “The Widowmaker.” Lajoie had a quadruple bypass at CMHVI. Three times a week for the following 12 weeks he participated in the heart center’s cardiac rehab program, learning about diet, stress and heart health.

He credits the rehab program for getting him exercising again. And for connecting him with people in the same situation.

“I actually enjoyed going through the whole (rehab) process,” he said. “It’s kind of hard to say, I guess, but I did. I enjoyed it because of the surroundings; they had very good equipment. The other thing was, there were other individuals I could talk with about my condition, as well as their condition. Some of them had received stents, others had full-blown open-heart (surgery) like I did. There was lots of common stuff there to make friends.”

Frank Sweetser, 56, knew about his heart problem for years. He was born with an aortic valve defect and doctors were watching him for signs of a problem. This winter, a sign appeared: He was getting short of breath.

Sweetser had time to consider his options. Several people suggested he go to MMC or out of state. His health insurance said it would waive his co-payments if he went to Boston.

“I said, ‘Nah,’ I don’t want my wife to drive that far,” said Sweetser, who lives in Buckfield.

So, three weeks ago, he checked into the Lewiston heart center for surgery. He liked his doctor. He liked that he had a private room. He liked that the floor was open for visitors at any time. He liked that he didn’t have to drive far to get all that.

He couldn’t imagine not having the heart center.

“I think it would be a big hole in that hospital community,” he said.

Overestimated numbers

Although the institute has been lauded for its work, it isn’t perfect. While most patients say follow-up care has been excellent, one said he had to wait weeks after his treatment for a heart attack to get an appointment with a cardiologist and then that appointment was repeatedly canceled and rescheduled because the doctor was too busy.

Heart center officials say that should never happen and that non-emergency patients are supposed to be seen by a cardiologist for follow-up within a month and heart-attack patients are supposed to be seen within a week.

Most L-A cardiologists work either for the heart center or are in some way affiliated with the program. The hospital believes the area has an adequate number of cardiologists, but it is looking to boost that number by hiring an electrophysiologist and a general cardiologist.

And while hospital officials had projected an ever-growing need for heart services in central Maine, that hasn’t happened.

“It wasn’t exactly as I anticipated it to be,” Phillips said. “Previously, throughout most of my career, our volumes were going sort of steadily upward and, basically, everybody could share in that growth. But coming to Maine, it was almost like every case was a case we were taking from Maine Med.”

With advances in medicine, angioplasties — in which a tiny balloon is inserted into an artery and inflated to open the artery and restore blood flow — started to become more popular for heart-attack patients around the time the center opened. In its first six months, the Lewiston heart center performed 110 angioplasties, outpacing projection. It performed 50 bypass surgeries, falling behind projections.

A decade later, neither procedure is performed as much as anticipated at CMHVI. The center had expected to perform 445 angioplasties by year three. Instead, it’s averaging 350 a year. It had expected to perform 370 open-heart surgeries by year three. Instead, it’s averaged 171 for each of the past two years.

Still, experts say CMHVI was — and is — needed. Heart disease has dropped from the leading cause of death in Maine to No. 2. The director of the Maine Center for Disease Control and Prevention credits some of that improving heart health to the three heart centers.

“We are doing a good job, and I, in my own heart, believe that it’s because we have a lot of great cardiologists throughout the state, at all of the cardiac heart centers, who are making incremental and great changes to help keep people alive with rapid door-to-drug treatment,” Maine CDC Director Sheila Pinette said.

She called the creation of CMHVI “a good thing.”

Others agree, even those involved in competing programs.

“It’s definitely necessary. It’s been a great benefit for the community,” said Dr. Roy Ulin, cardiology director for St. Mary’s Regional Hospital in Lewiston. 

Although St. Mary’s has heart program affiliations with MMC in Portland, it sends its acute heart-attack patients to the Lewiston heart center.

“What we want is the patient to get the quickest care possible when you’re dealing with such an emergency situation,” Ulin said.

A decade after MMC fought to prevent CMMC from opening a heart center, the two are now part of the Northern New England Cardiovascular Disease Study Group. Officials from Portland, Lewiston, Bangor and other New England heart centers get together twice a year to share data and talk about ways to improve care.

Tim Kafer, MMC’s vice president of cardiovascular services, said his hospital and the Lewiston heart center sometimes compete for patients, but, “I would not say that we are in a heated battle or anything like that. We support them when we can and when asked to.”

CMHVI plans to keep up with medical advancements. In the future, that will likely mean more work with endovascular care, minimally invasive valve procedures and possibly something with artificial hearts.

And leaders want to do more with community education and heart-disease prevention.

“I think this an exciting time,” Lisa Langburd, director of invasive cardiovascular services, said. “I think with the knowledge base that is available to everyone; I think to be able to communicate and engage the public is a huge thing we have potential for.”

Such prevention work is already helping.

Six months after his heart attack, Livingston credits CMHVI for saving his life both during his heart attack and afterward. With help from the center’s cardiac rehab program, he lowered his cholesterol, exercised more and improved his overall health. He’s done so well with those lifestyle changes that two other blockages he had have disappeared.

Doctors had recommended open-heart surgery. He doesn’t need that now.

“I feel better than I have in probably 35 years,” he said. 

ltice@sunjournal.com

Central Maine Heart and Vascular Institute by the numbers:

Number of open-heart surgeries at CMMC before the heart center: 0

Number of open-heart surgeries expected by year three: 370

Average number of open-heart surgeries performed at CMHVI now: 171

Number of cardiac angioplasties at CMMC before the heart center: 0

Number of angioplasties expected by year three: 445

Average number of angioplasties performed at CMHVI now: 350

Revenue CMHVI expected in year three: $15 million

Current revenue: $85 million

Average patient age: 59 (men: 57, women: 61)

Percentage of male patients: 65

Percentage of female patients: 35

Building size: six floors, 16 beds, with operating rooms, labs and office space.

Expansions: two (2005, when it added an electrophysiology lab for patients with heart-rhythm problems, and 2010 when it added an endovascular lab for patients dealing with vascular problems not in the heart.)

Mortality rate for bypass surgery: 1.8 percent

Patients who return to the operating room for bleeding after bypass surgery: 1.2 percent

Patients who end up with renal failure or insufficiency after bypass surgery: 3.8 percent

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