News from the Interventional Council: The View from the Heart Valve Team
By Stephen Ramee, MD, and Michael Mack, MD
In 2003, we were working side by side—a cardiac surgeon and an interventional cardiologist—developing a percutaneous vascular anastomosis procedure that gave us a unique perspective of each other's talents. We realized that working together led to greater innovation than working separately in our own silos—and that we actually liked each other!
That year I (Dr. Ramee) gave a talk entitled "The Future of Cardiovascular Surgery: A Cardiologist's Point of View" at a national cardiac surgery meeting. At that time, the specialty had seen a tremendous decline from its heyday, when Rene Favaloro, Denton Cooley, and Michael DeBakey led the field. In 2003, there were too few applicants to cardiovascular surgery fellowship programs to fill all of the available spots. Interventional cardiology, on the other hand, had seen an explosion of investment and growth in coronary revascularization and structural heart disease. My advice to my audience, comprised almost completely of cardiac surgeons, was to "innovate, retrain, realign, or retire." Needless to say, I was not met with an overwhelming amount of applause at the time (and was not invited back the following year).
I'm happy to say, though, that much of the audience did heed this advice. The result of those innovation and retraining and realigning efforts is the Heart Valve Team. The current concept of the "Heart Team" was initially introduced in the SYNTAX trial, which noted that the Heart Team was required for assessment and suitability of left main and three-vessel coronary artery disease for trial enrollment. This subsequently evolved to the Heart Valve Team, which was critical to the development and clinical introduction of transcatheter heart valve therapies. Transcatheter aortic valve replacement (TAVR), in particular, would not have been possible without extremely close collaboration between surgeons and cardiologists. This integrated approach to patient care catalyzed by TAVR programs has had a significant halo effect into other aspects of cardiovascular care, including mitral valve disease.
Who's on the Heart Valve Team?
Members of the Heart Valve Team are led by a core group of cardiac surgeons and interventional cardiologists. Nurse coordinators, physician assistants, and nurse practitioners do much of the hard work. The echocardiographers and technologists, anesthesiologists, electrophysiologists, intensivists, gerontologists, social workers, and radiologists round out the team.
Members share a close collaboration:
- We talk, text, and email each other daily about patients.
- We see clinic, make rounds, and do TAVRs together.
- We review angiograms, CT scans, and echocardiograms together.
- We have weekly conference calls with our colleagues around the country.
- We make collaborative decisions about what the best management for patients with aortic valve disease.
What Does This Mean for Our Patients and the Future of Cardiovascular Medicine?
History will be the judge of that, but at this early stage, 3 years after FDA approval of the SAPIEN Transcatheter Heart Valve® (Edwards Lifesciences; Irvine, California), and with more than 270 TAVR centers in the United States, we can already appreciate that Heart Valve Team collaboration has allowed us to rapidly triage patients into low-, medium-, and high-risk surgical candidates.
Furthermore, we can determine whether TAVR is a possibility for the high-risk and inoperable patients, and select which access (percutaneous or surgical) would be best utilized. For those patients who are debilitated—but possible surgical AVR or TAVR candidates—we can rehabilitate them, frequently using balloon aortic valvuloplasty as a bridge, and then reassess their options. For those patients who face futility, we can offer them palliative care without dragging out the inevitable.
The Heart Valve Team concept was invented by cardiologists and cardiac surgeons and then mandated by the federal government as a requisite for reimbursement on our recommendation. The Heart Valve Team is an example of how physicians and their societies can work collaboratively with government and industry and lead to improvement in the lives of our patients in this era of tremendous medical uncertainty. Hopefully, it is a model that we physicians can repeat in addressing best care for other major problems in cardiovascular medicine.
Stephen Ramee, MD, is medical director for the structural and valvular heart disease programs at Ochsner Medical Center in New Orleans, Louisiana. Michael Mack, MD, is from Baylor Scott & White Healthcare System in Dallas, Texas. Dr. Ramee is Chair of the ACC's Interventional Section Leadership Council and Dr. Mack is a Council member.
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