COLLABORATION IN CARDIOVASCULAR INTERVENTIONS: A NON-ZERO SOLUTION Mark J. Russo, MD, MS Assistant Professor of Surgery Co-Director, Center for Aortic Diseases

ASSERTIONS Traditional barriers between medical specialties result in a provider-centric rather than a patient-centric healthcare system These barriers are not compatible with the effective application of today’s hybrid technologies Elimination of these barriers improves patient outcomes (win) and offers a non-zero opportunity for providers (win-win) -> WIN-WIN-WIN

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

DISCONNECT BETWEEN PRESENTATION AND ORGANIZATION Patients present with Conditions-Disease Process Providers organized by Specialties-Skills/Knowledge Coronary Artery Disease Valve Disease Heart Failure Aortic Disease Peripheral Vascular Disease Cardiology Interventional Cardiology Cardiac Surgery Vascular Surgery Radiology

CARE IS DECENTRALIZED Interventional Cardiology General Cardiology Treatment Surgery

CARE IS DECENTRALIZED Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Interventional Cardiology General Cardiology Treatment Surgery

CARE IS DECENTRALIZED Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Interventional Cardiology General Cardiology Treatment Surgery

CARE IS DECENTRALIZED Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Interventional Cardiology General Cardiology Treatment Surgery

CARE IS DECENTRALIZED Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Interventional Cardiology General Cardiology Treatment Surgery

CARE IS DECENTRALIZED Patients are forced to seek care sequentially from various subspecialites (eg multiple appts) Interventional Cardiology General Cardiology ? Treatment Surgery

IMPACT OF DECENTRALIZED CARE System Perspective Patient Perspective Poor information transfer Duplicative care increases in direct costs Decreased quality Wastes patients’ time increase in indirect costs Patients lost in system delays care Patients lost to system go elsewhere Patients forced to make decisions based on complex information provided by multiple disparate sources with competing interests

Compared w 4 other comparable countries, U.S. patients more likely to: -undergo duplicative testing -tell the same story to multiple HCPs -experience delay in reporting of results

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

IT IS POSSIBLE. . . 87yo h/o B THR and L TKR, severe PHTN, walks w a cane but highly functional p/w severe AS; eval for TAVR Thurs: Referral secured by outreach team Facilitated direct MD-to-MD contact Tues: Next Valve Clinic date seen by Cards, CTS, IC, Vasc TTE (Cards) – previously unscheduled CTA C/A/P (Rads) – previously unscheduled Fri: Returned to referring MD for cardiac cath Sun: Spent Mothers Day with family Mon: Underwent TF-TAVR Uneventful case Awake and extubated < 30 mins after the procedure Fri: Discharged on POD #5 Home before the NATO riots Yes, but . . . this should NOT be a case study . . . it should be the standard of care

These barriers between specialties are no longer compatible with the effective application of today’s hybrid therapies

TREATMENT OPTIONS WERE DISCRETE ONCE UPON A TIME… TREATMENT OPTIONS WERE DISCRETE Its clear who provides services More likely to be complementary, less likely competing Medical Physician Surgeon Drugs Open Surgery

INTERVENTIONAL ERA: RECENT PAST Technologies were competing and mutually exclusive, eg: PCI (IC) vs CABG (CTS) aka “The Stent Wars” Open distal bypass (VS) vs peripherial stenting (IC/IR) Drugs Interventions Open Surgery

HYBRID ERA: PRESENT Drugs Interventions Hybrid MIS Open Surgery Differences are obscured Its unclear who provides which services/treats which pts Drugs Interventions Hybrid MIS Open Surgery

EXAMPLE: TAVR Procedural Steps Planning CT and echo: Aortic Valve Aorta Lower extremities Vascular access Percutaneous Femoral, iliac, axillary Apical, aortic Pass large bore- sheath -- approved device is only slightly smaller in caliber than a garden hose Cross the aortic valve Position Valve under echo/fluoro Balloon valvuloplasty/valve replacement Closure of access site Perc Open Complications Valve embolization Dissection Coronaries Vascular injury Specialty most suited Cards/CT Rads/CT/VS Rads/VS/IC IC/VS VS/CT CT IC CT/Cards/IC VS No single specialty competent to do all parts based on traditional training/skills. . . A TEAM IS REQUIRED

WHAT IS A TEAM? Comprises a group of people linked in a common purpose Especially appropriate for conducting tasks that are high in complexity and have many interdependent subtasks Members have complementary skills Allow each member to maximize their strengths minimize their weaknesses generates synergy Improves on what is possible for an individual actor

In baseball, team members have different skills and fulfill different roles

THIS IS A PITCHING STAFF… NOT A BASEBALL TEAM Curveball Knuckleballer Slightly different niches BUT… Working in parallel, not together All filling the same role Submarine Leftie Split-finger fastball

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

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

GAME THEORY Zero Sum Scenarios Non-Zero Sum Scenarios 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 possible Example: party goer eats a piece of cake…there is less cake for the other partiers Non-Zero Sum Scenarios a participant's gain (or loss) of utility is not balanced by the losses (or gains) of the utility of the other participant(s). If one gains, another may also gain Win-Win possible Example: Prisoners’ dilemma

WIN-WIN scenarios exist PRISONERS DILEMMA In a NON-ZERO scenario. . . one player does not need lose for another to win. . . WIN-WIN scenarios exist Prisoners DO NOT cooperate . . . more jail time (WIN-LOSE) Prisoners DO cooperate . . . less jail time (WIN-WIN) Prisoners DO NOT cooperate . . . more jail time (WIN-LOSE) Prisoners DO NOT cooperate . . . more jail time (LOSE-LOSE)

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

OUR WORLD IS INCREASINGLY NON-ZERO “The more complex therapies get . . . the more complex the networks of interdependence. . . the more clinicians are forced in their own interests to find. . . win-win [non-zero] solutions instead of win-lose [zero] solutions. . . We find as our interdependence increases . . . we and--our patients--do better when. . . people [around us] do better as well.”

REVELATION In a 25 mile radius of UofC, there are: 75 cardiac surgery programs (more than NYS - 7x the pop) 79 cath labs (more than Canada – 12.5x the pop) No dominant center Each center is doing a fraction of the total CV work in the area What if we worked together? try to take cases from the guys across the street . . . rather than cases from the guys across the hall?

OUR EXPERIMENT Create a team composed of members with different skills sets/from different disciplines Cardiology Vascular surgery Radiology Objectives: To expand our practice To increase our volume To improve our outcomes To deliver patient-centric care Methods: Sought out opportunities to collaborate Leverage unique skills and existing systems Interventional Cardiology Cardiac Surgery Anesthesiology

NEW SYSTEMS PRACTICES

TRANSPARENCY/SHARE THE WORK Eliminate the “I’m a hammer . . . you’re a nail” approach = Pt gets the procedure the MD can offer Instead, offer the best solution for the pt Coronary revascularization cases discussed (IC and CTS) Valve cases discussed in valve conf and valve clinic (Cards/CTS/IC) Aortic cases discussed in aortic conf and aortic clinic (CTS/VS/Cards)

LEVERAGE ESTABLISHED SYSTEMS Example: ECMO Emergency surgery only exists in Level 1 Trauma Centers….and on TV OR: 1-3 hours to active 80%+ of ECMO is now initiated in the cath lab Advantages Cath lab - Faster and Cheaper activated in 30-60 mins Cost < 20% of the OR Better imaging for perc access, if needed Opportunity for collaboration

EXAMPLES OF CLINICAL COLLABORATION

AO DEBRACHING/REOP ARCH 82yo s/p repair a 6 cm Asc Ao Aneurysm in 1993 4 Aneurysms Recurrent Asc Ao aneurysm extending into the arch (9 cm) Innominate aneurysm (4.4 cm) Right subclavian aneurysm (2.4 cm) Left common carotid aneurysm (2.8 cm) -> Also had mid-descending TA (5.0 cm) and AAA (~5cm) LAD stent placed by IC preop To OR after 2 wks of plavix

A B

Apposition of the aneurysm to the previous sternotomy with compression of the vena cava and innominate veins

Apposition of the aneurysm to the previous sternotomy with compression of the vena cava and innominate veins

Vasc Surgery LCA to LSCA transposition

Vasc Surgery LCA to LSCA transposition Graft LCA to RCA to RSCA bypass

Vasc Surgery LCA to LSCA transposition Graft LCA to RCA to RSCA bypass Graft was connected to the pump used as inflow

Circuit allowed for: Exclusion 3 aneurysms of great vessels Decompressed Ao during reop sternotomy Allowed for cerebral protection during distal mosis by clamping LCA to initiate ACP Chest opened with decompressed aorta intact

Cardiac Surgery Distal Ao under ACP (17 mins) AVR Prox Ao - new to old graft XCL time: 97 mins

VS and CTS Off Pump graft -> RSCA; graft to RCA Extubated on POD #2 D/c’ed: neuro intact nl EF baseline Cr

TRANS-ILIAC - TAVR Proctored case Proctor extremely experienced w TAVR IC does TF cases w/o surgeon Reviewed case and recommended cancelling 2/2 poor femoral access Proposed was approach was trans-iliac w iliac conduit via RP exposure by VS/CTS Proctor resistant b/c he had never done (seen) it Relented based on surgeons’ experience w approach for other procedures Procedure successfully performed < 2hrs skin-to-skin

ASCENDING AORTIC PSEUDOANEURYSM 57yo s/o Type A Dissection Repair in 2007 presented with chest pain PMHx: CRI, previous significant EtOH and smoking Found to have a PSA at prox suture line Operative mortality >>20%

Selective cannulation of pseudoaneurysm using coronary catheter WORK-UP Aortic root injection Selective cannulation of pseudoaneurysm using coronary catheter

THE PLAN 10mm graft to LSCA for device access (Vasc) 8mm graft to RSCA to initiate CPB (CTS) Selective catheterization of LCA (IC) Approach allowed for: Control BP/volume status for more precise deployment of device Protection if coronary covered

THE TEAM IC CTS VS Cards Imaging/Anes

THE RESULT Successful deployment Exclusion of PSA D/ced home POD #2

CSB/TEVAR 72yo w large penetrating ulcer requiring CSB and TEVAR Possible approaches: Advantages of Concomitant Approach: Single trip to the OR; Less OR utilization Potential for decrease LOS, faster recovery Advantages of Staged Approach No physician fatigue – 2 short cases “If complication occurs, we know who caused,” but…if the patient has a stroke, do THEY really case “who caused it”? Actual Approach - Concomitant HD #1: Spinal drain by Anes HD #2: 5 hours in OR; labor divided -> little stress/fatigue, max learning opportunity VS + fellow -> LCA-graft anastomosis CTS + fellow -> LSCA-graft anastomosis VS + CTS + fellows -> TEVAR HD #4: pt discharged

CSB/TEVAR Secondary advantage of collaboration – prepared for complications If arch is covered by VS – CTS likely is needed for bailout If iliac is avulsed by CTS – VS likely is needed for bailout If each service is not immediately available…complication is likely irreversible before help arrives If each service is committed to primary treatment choice, they will be more committed bailout if needed

COMPLICATION AFTER TAVR 77yo with severe, symptomatic AS Deemed in operable 2/2 h/o radiation to chest Undergoes uneventful TAVR procedure LFA sheath pulled in ICU At MN, noted to have no pulses below L knee Vascular surgeon involved in pts original TAVR case was consulted Taken immediately to OR for embolectomy No discussion of possible vasospasm, trial heparin, watchful waiting Pulses regained in OR Pts remaining hosp course uneventful

Even more compelling when hybrid room is available R/O AoD 68yo w substernal pain x 5 hrs presents to an OSH Reported to have moderate to severe AI and moderate pericardial effusion Presumed diagnosis: Type A AoD Outside ED called 855-808-2223 Transfer center paged covering surgeon, but in OR (unable to be reached) CT Surgeon was reached….accepted the pt UCAN (helicopter) dispatched Pt directly to OR TEE revealed: mild AI, trace effusion, moderate TR No evidence of AoD, but (+) RV dysfunction Pt transferred directly to cath for aortography, diagnostic cath possible PCI RCA stent placed Repeat CT and TEE on HD#1 – no evidence of AoD Discharged on POD#3 Even more compelling when hybrid room is available

AoD 61 yo M presented to OSH with substernal chest pain radiating to the back Diagnosis: Type A AoD Outside ED called 855-808-2223 -> paged Ao pager Reached Vasc Surgeon 1st….accepted the pt Pact to “Just say YES” eg AoD accepted by cards, AAA by CTS, Type As by Vasc Without collaboration, vasc surgeon will tell OSH to find a CT surgeon OSH may call other hospital

UCAN DISPATCHED

PROCEDURE Pt directly to OR TEE confirmed Type A – AoD w severe AI Cardiac surgeon made a 3F valved conduit in preparation for aortic root replacement (30 mins) Concurrently vascular surgeon performed R axillary cannulation in preparation for CPB Saved 30-45 mins. . . and possibly the patients life

PROCEDURE Type A repair w aortic root replacement and hemiarch under ACP At end of procedure, lactate = 10 Gen surg consult; diagnostic lap’scopy in OR: (-) ischemic bowel

FAMILY LETTER “I’d like to thank you for saving my father’s life last week. My dad is not only alive, but is walking, talking, and ornery as ever all thanks to your expertise. It truly has been a surreal week to say the least. I feel very fortunate to know that my father was in such good hands. “I wanted to extend my most sincere gratitude towards you and your extremely skilled and professional team at U of C for your amazing and miraculous work. Thank you a million times over, from the bottom of our hearts (and the top of my father’s newly grafted aorta).” Best regards

NEXT STEPS

BLURRING LINES Cross coverage Disease-specific pagers Clinics Cases TAVR covered by IC/CTS Aortic covered by VS/CTS Clinics Aortic staffed by VS/CTS/CV Radiology Valve staffed by Cards/Cards Imaging/IC/CTS/VS Cases Pact to “Just say YES” (eg .AoD accepted by cards; AAA by CTS; Type As by Vasc) Cross training: in combined cases, attempt the part less comfortable w under the supervision of more experience operators

COMMON OUTREACH CME w outreach team Disease specific contact/pager Aortic disease: 855-808-2223 (UCCAD)/8222 TAVR: 855-808-8287 (TAVR) Worked with the call center to initiate a phone tree Websites Visits/day: ~200 Pageviews/day: ~300 Clinic Visits/week: 1-3 4 OR cases per mo Retention of clinic patients Bottom line < $3000

POTENTIAL BENEFITS Patients Providers Healthcare System

POTENTIAL BENEFITS: PATIENTS Care focused on patients condition Avoid competing sales pitches Higher quality Receive appropriate therapies More eyes on the pts (attendings/fellows/APNs/PAs from multiple service) Decreased costs Direct and indirect Decreased delay in care Higher patient satisfaction

POTENTIAL SUCCESS: PROVIDERS Better working environment Common mission No finger pointing Egos checked at the door Easier acquisition of others’ input Planning procedures, management, complications Providers more invested in al CV patients Broader understanding of disease process and available therapies Learning new skill sets “CCF Effect” – MDs refer to team/organization, not a specific MD Decreases hurt egos when a CTS refers a complex CTS pt to an outside CTS; IC a complex IC pt; or VS a complex VS pt

POTENTIAL SUCCESS: PROVIDERS Expanding practice TAVR, Frozen Elephant Trunk, Asc Ao Stent Graft, Ao Arch Stent, Antegrade Ao Stent, Perc Closure of PSA, Perc Closure of Aortic Valve, Pararenal Snokel, MD-Modified Stent Graft Increased volume TEVAR: 2010 - 3, 2011 – 8, 2012 – 20+ (through Aug; 40 projected) EVAR: up 40% over previous year Academic productivity/TAVR Team 2011: 50 publications 2012: 40 (to date)

POTENTIAL BENEFITS: THE HEALTH CARE SYSTEM Decreased resource utilization Decreased duplicative testing Decreased need for multiple encounters Higher quality care More appropriate/balanced use of technology Team polices themselves for appropriateness rather than leaving it to an outside non-clinical entity (eg govt, insurance) Better outcomes

OBSTACLES Playing field – need a hybrid room; available in Feb “The Division of . . .Cardiac Surgery/Cardiology/Vascular Surgery . . .” Artificial divisions exist between groups that should naturally work together, particular in our 100% hospital-based employment model Resources no mechanism to share across disciplines; different services Billing who gets the RVUs; how to divide Personal Incentives Reimbursement Prob not maximizing Existing Culture buy-in not universal

Presenting ourselves separately? THE FUTURE? Presenting ourselves separately?

FUTURE Single CV Service Line Integrated Interventional Service Structural heart, PCI, TEVAR/EVAR, Hybrid cases Cross training/covering Present: CT and VS cross cover aortic cases Future: CT and IC; IC and VS cross cover cases IC/CT/VS -> CVI VS/CT -> CVS

VALVE DISEASE CORONARY DISEASE CORONARY DISEASE EP AORTIC DISEASE HEART FAILURE PVD

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