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

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

3. 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.

4. 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

5. 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.

6. 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.

7. 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?

8. 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

10. Team Concept

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

12. 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)

13. 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

14. 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.