What does the future hold for interventional cardiology? Spencer B. King, III, M.D., M.A.C.C. St Joseph’s Heart and Vascular Institute Professor of Medicine, Emeritus Emory University CRT 2/6/2012

Spencer B. King, MD Honoraria: Celonova Biosciences nContact Surgical Consulting Fees: Network for Continuing Medical Education

What got us to where we are? What are the issues going forward? Technology Evidence / Guidelines Appropriateness Reimbursement Credentialing

What got us to where we are? Catheterization & coronary angiography Co-axial catheter vessel lumen expansion Balloon angioplasty Steerable wires Stents Plugs Valves

What got us to where we are? What are the issues going forward? Technology Evidence / Guidelines Appropriateness Reimbursement Credentialing

Technology Stents are a commodity Wires have arrived CTO efforts continue to evolve (a little) Plugs will become differentiated Valves are perhaps not in their infancy but at least their adolescence Guidance systems will become more sophisticated

Percutaneous Aortic Valve – Current Technique During position of the PHV, we rapidly pace the right ventricle at rates of 200-220 beats per minutes. This causes a sudden and predictable drop in cardiac out put as shown in the aortic pressure tracing. When the cardiac output is this depressed, the stent valve can be positioned without potential ejection by the left ventricle. Once the stimulation is stopped, aortic pressure quickly returns. We never stimulate more than a few seconds and we have never had a problem with subsequent ventricular arrhythmias. 8

Technology (cont.) New applications for interventional techniques Structural heart disease Hypertension CHF Angiogenesis & Myogenesis Diagnostics

What got us to where we are? What are the issues going forward? Technology Evidence / Guidelines Appropriateness Reimbursement Credentialing

Evidence / Guidelines Online Updating Increasing awareness & adherence Trials sponsored by payers to address issues not interesting to industry

What got us to where we are? What are the issues going forward? Technology Evidence / Guidelines Appropriateness Reimbursement Credentialing

Method of Revascularization of Advanced Coronary Artery Disease Patel, M. R. et al. J Am Coll Cardiol 2009;53:530-553 Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply.

Appropriateness Useful but evolving tools Main Benefit: Expanding quality improvements efforts Main Risk: Used to deny reimbursement (This will happen) Look for a paper by Marso and an editorial by Blankenship in JACC:Interventions February issue.

What got us to where we are? What are the issues going forward? Technology Evidence / Guidelines Appropriateness Reimbursement Credentialing

Reimbursement Not going up! Bundled reimbursement – ACO’s coming Favors “Heart Team” approach My best source is the Jack Lewin Blog

What got us to where we are? What are the issues going forward? Technology Evidence / Guidelines Appropriateness Reimbursement Credentialing

Credentialing Certification is the job of ABMS Credentialing is local and will need to address local circumstances General Principles Experience and current activity count – vs – Coverage for STEMI call requires bodies Competition forces reduced requirements Consolidation enables more restrictive requirements

Conclusion The future of interventional cardiology is bright. Deregulation and a leveling off of coronary interventions bring into question how many interventionalists are needed and what skills are needed. Consolidation produces the opportunity to improve quality and reduce costs THIS WILL BE YOUR JOB!