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COLLABORATION IN CARDIOVASCULAR INTERVENTIONS: A NON-ZERO SOLUTION Department of Surgery Grand Rounds April 4, 2012.

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Presentation on theme: "COLLABORATION IN CARDIOVASCULAR INTERVENTIONS: A NON-ZERO SOLUTION Department of Surgery Grand Rounds April 4, 2012."— Presentation transcript:

1 COLLABORATION IN CARDIOVASCULAR INTERVENTIONS: A NON-ZERO SOLUTION Department of Surgery Grand Rounds April 4, 2012

2 DISCLOSURES No financial conflicts Off-label uses of devices

3 ASSERTIONS 1.Traditional barriers between medical specialties result in a provider-centric rather than a patient- centric healthcare system 2.These barriers are no longer compatible with the effective application of today’s interventional technologies 3.Elimination of these barriers improves patient outcomes (win) and offers a non-zero opportunity for providers (win-win)

4 Traditional barriers between medical specialties result in a provider-centric rather than a patient-centric healthcare system

5 ORGANIZED BY PROVIER SKILL SET NOT PATIENTS CONDITION Conditions-Disease Process Coronary Artery Disease Valvular Disease Heart Failure Aortic Disease Peripheral Vascular Disease Specialties-Skills/Knowledge Cardiology Interventional Cardiology Cardiac Surgery Vascular Surgery Radiology

6 CARE IS DECENTRALIZED Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Lack of centralization results in poor information transfer between providers and duplicative care Ultimately, patients forced to make decisions based on complex information provided by multiple disparate sources with competing interests Interventional Cardiology General Cardiology Surgery Treatment

7 QUICK POLL What is the difference between a “root aneurysm” and a “AAA”? Who is most appropriate to manage these conditions?

8 ANSWER When most physicians don’t know the differences and appropriate treatment... Why do we expect patients to know where to seek care... – Cardiology? – Interventional Cardiology? – Cardiac Surgery? – Vascular Surgery? – Radiology?

9 PATIENT CENTRIC MODEL Disease-Specific “Clinic” (eg, CAD, Valve, HF, Ao) w Cards/Imaging/IC/CVS Diagnostics Referring Treatment

10 REASONS FOR DIVISIONS Cultural – Education/skill sets/knowledge base – How physicians are identified – Mentors/Colleagues/Interests Resources – Tools – Physically location Office space Point of service (Clinic vs OR vs Cath Lab) Competition Resentment – “You only refer me your disasters... and your complications... and at night/weekends”

11 These barriers are no longer compatible with the effective application of today’s interventional technologies

12 DrugsOpen Surgery TREATMENT OPTIONS

13 DrugsOpen Surgery TREATMENT OPTIONS Medical Physician Surgeon Its clear who provides which services More likely to be complementary, less likely competing

14 ERA OF INTERVENTIONS Implantation pacemaker -1958 Balloon embolectomy - 1960 Angioplasty – 1974 Coronary angioplasty – 1977 Implantable ICD - 1980 Cardiac ablation – 1980s Self expanding vascular stent – 1985 Endovascular aneurysm repair – 1987 Thoracic endovascular aneurysm repair – 1994 Transcatheter valves - 2002

15 DrugsOpen Surgery CONTINUUM OF INVASIVENESS OF THERAPY Interventions MIS Hybrid

16 TAVR

17 Procedural Steps Planning CT and echo: Imaging for aorta, aortic valve, lower extremities Vascular access – Percutaneous – Femoral, iliac, apical, axillary, aortic Pass large bore sheath – Currently approved device is only slightly smaller in caliber than a garden hose Cross the aortic valve Balloon valvuloplasty/valve replacement – Under echo and fluoro guidance Vascular repair Specialty Rads/Cards/CVS IC/VS CVS CVS/IC IC CVS

18 ACCESS FOR TAVR

19 DEFINITION Team - Comprises a group of people linked in a common purpose

20

21 TEAM Have members with complementary skills and generate synergy. Especially appropriate for conducting tasks that are high in complexity and have many interdependent subtasks. Allow each member to maximize their strengths and minimize their weaknesses Improve on what is possible for an individual actor

22 IN HEALTHCARE, “TEAM” MEMBERS OFTEN HAVE NEARLY IDENTICAL SKILLS

23

24 Eliminations of these barriers improves patient outcomes and offers a non-zero opportunity for providers

25 REASONS FOR DIVISIONS Cultural – Education/skill sets/knowledge base – How physicians are identified – Mentors/Colleagues/Interests Resources – Tools – Physically location Office space Point of service (Clinic vs OR vs Cath Lab) Competition Resentment – “You only refer me your disasters... and your complications... and at night/weekends”

26 ZERO SUM GAME Participant's gain (or loss) of utility is exactly balanced by the losses (or gains) of the utility of the other participant(s). For one to gain, another must loss Example: if one person eats a piece of a cake there is less cake for the other partiers

27 STENT WARS Coronary Revascularization – different competing therapies offered by different specialties – PCI/IC vs CABG/CTS Peripheral Revascularization – a different therapy from one field, multiple specialties offering an alternative competing therapy – Vascular vs IR vs IC Dominate interaction between 4 fields: CTS, IC, IR, and Vasc – Not collegial but adversarial/competative

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29 NON-ZERO SUM “The more complex societies get... the more complex the networks of interdependence... the more people are forced in their own interests to find... [non-zero] win-win solutions instead of win- lose solutions... We find as our interdependence increases... we do better when other people do better as well” —an ex-US President, December 2000

30 GAME THEORY Zero-sum – participant's gain (or loss) of utility is exactly balanced by the losses (or gains) of the utility of the other participant(s). – If one gains, another losses; only Win-Lose – Example: cuts and eats a piece of cake there is less cake for the other partiers Non-zero-sum – a participant's gain (or loss) of utility is not balanced by the losses (or gains) of the utility of the other participant(s). – Win-Win (and Lose-Lose) scenarios exist – Example: Prisoners’ dilemma

31 PRISONERS DILEMMA The gains of one player are not equally offset by the losses of the other. If non- cooperation, they get total 40 years If both cooperate, total 2 years in prison

32 REVELATION 75 cardiac surgery programs and 79 cath labs in a 25 mile radius What if we work together and... try to take cases from guys across the street... rather than cases from the guys across the hall?

33 OUR EXPERIMENT Create a team composed of members with different skills sets/from different disciplines Cardiology Vascular surgery Radiology Looked for opportunities to collaborate to expand our services Leverage unique skills and existing systems Focus on patient centric care Interventional Cardiology Cardiac Surgery

34 KEYS TO SUCCESS

35 TRANSPARENCY/SHARE THE WORK Coronary revascularization cases discussed with both IC and CTS Valve cases discussed valve conf and valve clinic Aortic cases discussed aortic conf and valve clinic

36 LEVERAGE ESTABLISHED SYSTEMS Example: ECMO – Emergency surgery only exists in Level 1 Trauma Centers and on TV – It takes 1-3 hours to open an OR – Cath lab can be activated in 30 mins or less – >80% of ECMO is initiated in the cath lab – Faster (and cheaper) – Also allows an opportunity to collaborate

37 COMMITMENT TO PURPOSE 73yo Jehovah's Witness is transferred from OSH after being loaded with plavix with a diagnosis of Type A dissection – Accepted by cardiology (AS) – Repeat CT (KD) performed read by contained rupture Asc Ao – Reviewed by Vasc (RM) and CTS (MR) – Underwent replacement of AscAo/Hemiarch (MR) POD #4 – Discharged to rehab on POD #10 – Pt will return as outpatient for PCI

38 AO DEBRACHING/REOP ARCH Darwin Eton, MD Professor of Surgery

39 AB

40 D

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42 STENT LAD

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44

45 LCCA RCCA Cervical Debranching

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47 LCCA RCCA RAx LScA

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49

50

51 25 C

52 RCCA RAx LCCA LScA

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54 Vascutek Gelweave 4 Plexus

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56 RCCA RAx LCCA LScA Aorta

57 Edwards Magna Bioprosthetic Aortic Valve

58

59 Stepwise Disconnection of Extracranial Circuit on CPB from 1.LCCA, and repair artery 2.RCCA, and attach RCCA to Dacron Limb 3.RAx, and attach RAx to Dacron Limb FINAL STEPS

60 RCCA RAx LCCA

61

62 Ascending Aortic Pseudoaneurysm Ross Milner, MD Associate Professor of Surgery Co-Director, Center for Aortic Diseases

63 History 57-year old man Type A Dissection Repair in 2007 Presented recently with chest pain

64 CTA

65 Plan Aortogram Cardiac cath

66 Plan Aortogram Cardiac cath Multivessel CAD discovered: Potentially treatable with PCI

67 Cardiac catheterization Aortic root injectionSelective cannulation of pseudoaneurysm using coronary catheter

68 Cardiac catheterization 95% diagonal lesion Nonobstructive LAD disease 70% circumflex/ obtuse marginal lesion Moderate – severe diffuse RCA disease

69 Staged multivessel PCI Staged multivessel PCI via L radial approach – planned use of bare metal stents in order to minimize duration of dual antiplatelet therapy PREPOST s/p 2 bare metal coronary stents

70 Staged multivessel PCI PREPOST s/p 1 bare metal biliary stent

71 Treatment PCI completed on bivalirudin anticoagulation and clopidogrel (Plavix) (Dr. Sandeep Nathan) Wait 2 weeks and hold clopidogrel OR for repair

72 OR Bilateral axillary cutdown Percutaneous left femoral vein CPB TEE 3 specialties operating together

73 Axillary Cutdown

74 Stent Placement

75 Stent Placement (cont) Selective cannulation of left main coronary to protect during aortic stent grafting

76 Stent Placement (cont)

77

78 Team

79 Post-op TEE

80

81 Transcatheter Aortic valve Closure Atman Shah Co-Director, Transcatheter Valve Therapies

82 Introduction Left ventricular assist devices (LVADs) are increasingly being used in the treatment of end-stage heart failure Bridge-to-Destination or Bridge-to-Transplant Forecasts suggest 100,000 implants annually in the US Cowger J, et al. Circ Heart Fail 2010;3:668–74

83 Aortic Insufficiency AI can occur in 51% of LVAD patients at 18 months Associated with increased mortality The newly implanted LVAD may result in functional closure of the AV Exact mechanism of AI in uncertain, but aortic root dilation and myxoid degeneration may be factors Cowger J, et al. Circ Heart Fail 2010;3:668–74 Toda K, et al. Ann Thorac Surg 2011;92:929–3.

84 Closure Surgical pre-closure of the AV results in complete LVAD dependence and is not always successful Surgical closure after LVAD implantation necessitates another sternotomy Park et al. J Thor CV Surg 2004;127:264-8.

85 Severe AI

86 Transcatheter Closure Grohmann et al reported a case of AV closure via a surgical cutdown and use of an Amplatzer VSD device Riede et al reported transcatheter treatment of AI in a neonate with hypoplastic left heart syndrome Riede FT, et al. Cath Cardiol Int 2009;74:913–5. Grohmann J, et al. Eur J Cardiothorac Surg 2011;39:e181–3.

87 Approach After the AV was crossed, a 9Fr TorqVue catheter (AGA Medical/SJM) was advanced into the LV A 30mm Amplatzer Cribiform Septal Occluder was loaded and deployed across the AV Coronary angiography demonstarted patent coronaries

88 Cath Imaging

89 2D and 3D Imaging

90 Cribiform Across AV

91 Resolution of AI

92 Clinical Improvement

93 SUCCESS? Better working environment Learn new skill sets Broader understanding of disease process and available therapies Easier acquisition of others input even when unplanned – Complications Shift to patient centric delivery of care Expand practice

94 EXPAND PRACTICE ECMO Hybrid Coronary Revascularization Hybrid Peripheral Revascularization Hybrid Aortic Surgery/Arch Debranching EVAR/TEVAR TAVR

95 OBSTACLES Resources – local issue Reimbursement – payor issue Playing field – being addressed

96 For Providers: Win-Win For Patients: Win Win-Win-Win


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