COLLABORATION IN CARDIOVASCULAR INTERVENTIONS: A NON-ZERO SOLUTION

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

2. ASSERTIONS • Traditional barriers between medical specialties result in a provider-centric rather than a patient-centrichealthcare 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

3. Traditional barriers between medical specialties result in a provider-centricrather than a patient-centric healthcare system

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

5. CARE IS DECENTRALIZED Interventional Cardiology General Cardiology Treatment Surgery

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

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

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

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

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

11. IMPACT OF DECENTRALIZED CARE System Perspective Patient Perspective 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 • Poor information transfer • Duplicative care • increases in direct costs • Decreased quality

12. 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

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

14. 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

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

16. 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

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

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

19. EXAMPLE: TAVR Specialty most suited Cards/CT Rads/CT/VS Rads/VS/IC IC/VS VS/CT CT VS/CT IC CT/Cards/IC IC IC/VS VS/CT CT CT IC VS No single specialty competent to do all parts based on traditional training/skills. . . A TEAM IS REQUIRED 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

20. 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

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

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

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

24. Elimination of these barriers improves patient outcomesand offers a non-zero opportunity for providers

25. GAME THEORY 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

26. 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)

27. OUR WORLD IS INCREASINGLYNON-ZERO “The more complex societiesget . . . 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

28. OUR WORLD IS INCREASINGLYNON-ZERO “The more complex therapies get . . . the more complex the networks of interdependence. . . the more cliniciansare 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.”

29. 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?

30. 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

31. NEW SYSTEMS PRACTICES

32. 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)

33. 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

34. EXAMPLES OF CLINICAL COLLABORATION

35. AO DEBRACHING/REOP ARCH • 82yo s/p repair a 6 cm AscAo Aneurysm in 1993 • 4 Aneurysms • Recurrent AscAo 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

36. A B

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

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

40. Vasc Surgery • LCA to LSCA transposition

41. Vasc Surgery • LCA to LSCA transposition • Graft LCA to RCA to RSCA bypass

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

43. Circuit allowed for: • Exclusion 3 aneurysms of great vessels • Decompressed Ao during reopsternotomy • Allowed for cerebral protection during distal mosisby clamping LCA to initiate ACP • Chest opened with decompressed aorta intact

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

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

46. 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

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

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

49. 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

50. THE TEAM IC CTS VS Cards Imaging/Anes