COLLABORATION IN CARDIOVASCULAR INTERVENTIONS:

A NON-ZERO SOLUTIONMark J. Russo, MD, MS

Assistant Professor of SurgeryCo-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• Coronary Artery Disease• Valve Disease• Heart Failure• Aortic Disease• Peripheral Vascular Disease

Providers organized by Specialties-Skills/Knowledge• Cardiology• Interventional Cardiology• Cardiac Surgery• Vascular Surgery• Radiology

CARE IS DECENTRALIZED

Interventional Cardiology General

Cardiology

Surgery

Treatment

CARE IS DECENTRALIZED

Interventional Cardiology General

Cardiology

Surgery

Treatment

• Patients are forced to seek care sequentially from various subspecialites (eg multiple appts)

CARE IS DECENTRALIZED

Interventional Cardiology General

Cardiology

Surgery

Treatment

• Patients are forced to seek care sequentially from various subspecialites (eg multiple appts)

CARE IS DECENTRALIZED

Interventional Cardiology General

Cardiology

Surgery

Treatment

• Patients are forced to seek care sequentially from various subspecialites (eg multiple appts)

CARE IS DECENTRALIZED

Interventional Cardiology General

Cardiology

Surgery

Treatment

• Patients are forced to seek care sequentially from various subspecialites (eg multiple appts)

CARE IS DECENTRALIZED

Interventional Cardiology General

Cardiology

Surgery

Treatment?

• Patients are forced to seek care sequentially from various subspecialites (eg multiple appts)

IMPACT OF DECENTRALIZED CARE

System Perspective• Poor information transfer• Duplicative care

– increases in direct costs• Decreased quality

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– Lost opportunity for shared

decision making

Relative to 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

Disease-Specific “Clinic” (eg, CAD, Valve, HF, Ao) w Cards/Imaging/IC/CVS

Diagnostics

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; 2 weeks and 1 day after referral• 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

Drugs Open Surgery

ONCE UPON A TIME…

Medical Physician Surgeon

• Its clear who provides services• More likely to be complementary, less likely competing

TREATMENT OPTIONS WERE DISCRETE

Drugs Open Surgery

INTERVENTIONAL ERA: RECENT PAST

Interventions

• 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 Open Surgery

HYBRID ERA: PRESENT

Interventions MISHybrid

• Differences are obscured• Its unclear who provides which services/treats which pts

EXAMPLE: TAVRProcedural 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• 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

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

Submarine

Split-finger fastball

Leftie

Knuckleballer• Slightly different nichesBUT…• Working in parallel, not together• All filling the same role

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– 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

PRISONERS DILEMMA

Prisoners DO cooperate . . . less jail time (WIN-WIN)

Prisoners DO NOT cooperate . . . more jail time (LOSE-LOSE)

Prisoners DO NOT cooperate . . . more jail time (WIN-LOSE)

Prisoners DO NOT cooperate . . . more jail time (WIN-LOSE)

In a NON-ZERO scenario. . . one player does not need lose for

another to win. . .WIN-WIN scenarios exist

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, (+) liver dz

(+) EtOH, (+) smoking

• Found to have a PSA at proximal suture line– Operative mortality >>20%

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:

– Concomitant - Advantages:• Single trip to the OR; Less OR utilization• Potential for decrease LOS, faster recovery

– Staged Approach – Advantages:• Less operator 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

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…. • Vasc Surgeon accepted a Type A Dissection

– 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 another hospital

UCAN DISPATCHED

PROCEDURE

• Pt directly to OR at midnight– 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 • 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 all 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, particularly 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

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

PVDAORTIC

DISEASE HEART FAILURE

VALVEDISEASE EPCORONARY

DISEASECORONARY

DISEASE

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