The Role of the Heart Team in the Cath Lab in 2017 Jeffrey A Southard, MD, FACC February 19, 2017

Jeffrey A Southard, MD, FACC Disclosures   I have financial relationships Proctor/Honoraria- Edwards Lifesciences  Proctor/Honoraria- St Jude Medical

Patient Care Health Care in general Fragmented and disruptive Specialists separated by weeks- do they talk? Not a single unified team approach Concept of “Heart Teams” If you are healthy- this is fine- no need to have multiple physicians If all that you need to do is work with your primary care MD or NP that is fine IF you begin to need specialty care- that is when the system is not as fluid and coordinated as it should be.

Heart Teams PCI vs CABG Carotid Stent vs Carotid Endarterectomy Who is the bigger dog in the fight? Carotid Stent vs Carotid Endarterectomy Surgeon- “I am not losing another procedure” Are we focused on what is best for the patient? Who forced us together? There is a continuous struggle for less invasive procedures- patients will always prefer less invasive means That is usually not SURGICAL in nature- usually that is the more invasive route for sure That means that one side is usually on the “potential” losing side all the time

Heart Teams Transcatheter Aortic Valve Replacement CMS Approval 2012 “The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care” CMS approval document in 2012 (Centers for Medicare and Medicaid Services) You will not be paid unless these measures are met.

CMS Mandates “The heart team’s interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-operative technical aspects of TAVR” This protected the surgeon Interventional Cardiologists tend to take over Just ask our Radiology Colleagues Michael Mack has been very influential but fair in making sure our surgical colleagues are taken care of Surgeon does not have to be there for Mitral Clip procedures and only one needs to see the patient ahead of time.

Valve Clinic Novel concept- collaborative Get doctors and patients together at the same time Coordinate their care – one trip Valve meetings-ppt presentations Complex patients CT scan, Echo, PFTs, Labs and ABGs, Clinic visit- all that is needed is a cardiac cath- if that is not done the next day Make it easy for the patients- make it easy for the families. This is not always that easy for surgeons- IF there are no PAs in clinic and they have to do their own note?

The Beginning Remember in 2012 how big the sheaths were- how stiff the valves were and how much more difficult it was to work on these patients than it is now. There were struggles- surgery- who is in charge- whose patients are they? I took the high road- did as much work as I could to make it easy for the surgeons. I did not want them to feel threatened by our presence- how could they teach me and how could I teach them? OR 45 –hybrid room- who is this in my backyard? What do they think they are doing here- we worked in the trenches with them. We began to understand how hard it is to operate on patients- with an STS of 3% even though they had liver disease- were obese – etc etc

Team Concept

Heart Team Interventional cardiologist Cardiac surgeon Valve clinic coordinator Nursing Anesthesiologist Referring cardiologist Imaging specialists Heart Team

Everyone Benefits Colleagues not Competitors Patient referral patterns change Friends when mishaps take place Patient Satisfaction- way up Why isn’t all care done this way? Very time consuming- more expensive (nurses hired etc)

Springboard Complex coronary cases- hybrid- BVS Complex vascular cases- work together Complex congenital cases- now vs future Complex structural cases- Mitral/Tricuspid Surgery now? Percutaneous later? What about the future of team care? You have to remove the threat from the other side- You have to be inclusive- you have to realize that you need the other side to make this work - You have to realize that if you don’t play well in the sandbox- YOU are the one that will lose out- surgeons hold the cards at this time

The heart team is not going away – as long as it is mandated by CMS Ultimately it should stay- but it is very difficult to coordinate.