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Viewpoint: transitions in cardiac surgery and interventional cardiology…team mates or rivals? Edward D Verrier,1 Michael J Mack2 1

Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington, USA 2 Department of Cardiovascular Disease, Baylor Scott & White Health, Heart Hospital Baylor Plano, Dallas, Texas, USA Correspondence to Dr Michael J Mack, Department of Cardiovascular Disease, Baylor Scott & White Health, Heart Hospital Baylor Plano, Dallas, Texas, USA; [email protected] Received 26 November 2014 Accepted 1 December 2014 Published Online First 23 December 2014

▸ http://dx.doi.org/10.1136/ heartjnl-2014-306131

To cite: Verrier ED, Mack MJ. Heart 2015;101:346–348. 346

INTRODUCTION New and effective minimally-invasive treatments for coronary artery and structural heart disease are emerging at an accelerating rate. Cardiac surgery, traditionally the gold standard treatment for most of these conditions, is no longer the immediate choice for discerning patients, attending physicians and healthcare funders. These factors when combined with pace of technological advances mean that cardiac surgery is undergoing a period of change. In this article, we consider how the transition from historical generalist–cardiologist–cardiac surgeon patients flows to more integrated patient specific care. Specifically, we will discuss how effective transition will require awareness of the drivers for change, models of best practice from other specialties and the potential benefits that this may have for patients, doctors and providers. To illustrate contemporary practice, we present a typical day in 2015 for our cardiac surgery teams: ‘We started out the day at the 06:30 with our weekly multidisciplinary heart failure/ventricular assist/transplant meeting to review the current inpatient and outpatient consults, the postoperative left ventricular assist patients and the current cardiac transplant waiting list. Present at the meeting were heart failure cardiologists, transplant/VAD surgeons, anaesthesiologists, mid-level and allied health providers. We adjourned to the operating room where a 23 y/o woman with Shone’s syndrome who had undergone two previous operations on her mitral valve as a child complicated by endocarditis was undergoing closure of a recurrent para-valvular leak by inserting a vascular plug in the left atrium under direct vision, augmented with a prosthetic patch, by an interventional and surgical team. This treatment plan was formulated in our multidisciplinary adult congenital team meeting and clinic a few weeks previously. Meanwhile, in the hybrid operating room, an 83 y/o with aortic valve stenosis was undergoing a transapical transcatheter aortic valve implantation by a team led by a cardiac surgeon and interventional cardiologist. This patient had a drug eluting stent placed in a coronary artery 2 weeks ago. In the electrophysiology suite, an infected pacemaker lead was being removed by a surgical and electrophysiology cardiovascular team. Our established afternoon heart valve clinic team saw eight patients with aortic valve disease before finishing the day to attend the meeting that will put together the team and clinic for the transcatheter mitral valve programme. Tomorrow won’t be much different’. The concept of multidisciplinary approaches in cancer care (tumour boards) and organ transplantation is widely practiced. The concept and practice of multidisciplinary care is cardiovascular medicine

is now rapidly following suit.1 There are a number of clinical and administrative forces driving this shift in patient management and clinical care. Similarly, there are a number of educational, financial and political forces resisting such change.

DRIVERS FAVOURING THE MULTIDISCIPLINARY TEAM CONCEPT IN CARDIOVASCULAR CARE In general, cardiovascular medicine has evolved into areas of subspecialisation that include ischaemic heart disease, valvular heart disease, great vessels disease, heart failure including ventricular assist devices and transplantation, electrophysiology, and congenital heart disease. Within each of these areas, there is an emphasis on patient-centred care, increasing complexity of both decision-making and procedures, rapidly evolving new therapeutic options, readily available outcome data with public reporting, evidence-based guidelines for care, and increased patient sophistication as a consumer of healthcare. Therapeutic decisions must be individualised, must be transparent, must be based on best practice guidelines and include patients in a shared decision-making approach to their care. In each subsegment of cardiovascular care, the preoperative decision-making, the intraoperative execution and postprocedural care is best done by a multidisciplinary, coordinated team. The demographics of ischaemic heart disease have changed over the last 20 years and the therapeutic options of optimal medical management, interventional cardiology and coronary artery bypass surgical approaches have been clarified using evidence-based criteria. The guidelines for myocardial revascularisation2 have recently been updated with clearer definitions of best diagnostic and therapeutic approaches. Many of the recommendations are based on the findings of the SYNTAX (SYNergy Between PCI with TAXUS and Cardiac Surgery) trial.3 However, despite robust, evidence-based guidelines, one size does not fit all, and individual patient factors, for example, frailty and patient preference, need to be considered when making treatment recommendations. Decisions in a particular patient must be individualised but the recommendations should distinguish between the patient with a single discrete single coronary vessel lesion readily amenable to a percutaneous approach and the patient with left main or complex diffuse multivessel coronary artery disease with a high SYNTAX score where the data would favour a surgical revascularisation. Since many patients fall in between these two extremes, multidisciplinary discussion within the team might not always reach consensus but conversations with the patient and family should be more transparent and representative of

Verrier ED, et al. Heart 2015;101:346–348. doi:10.1136/heartjnl-2014-306132

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Viewpoint alternative perspectives. This is best accomplished by a heart team approach. Valvular heart disease has changed significantly in the last 10 years and will continue to rapidly evolve since the introduction of the disruptive technology of transcatheter aortic valve replacement (TAVR) for aortic and pulmonary valve disease. For all TAVR procedures, the consensus document supported by the major US interventional (American College of Cardiology Foundation, Society of Cardiovascular Angiography and Interventions) and surgical (Society of Thoracic Surgery, American Association of Thoracic Surgery) societies emphasises the importance of a multidisciplinary team that includes interventional cardiology, cardiac surgery, anaesthesiology, radiology, intensive care and nursing.4 The document clearly recommends that: ‘Another mechanism for promoting a team approach that involves both surgeons and cardiologists is split or shared physician reimbursement for these procedures, which this writing group strongly endorses. This important principle will ensure that surgeons and cardiologists participate jointly in performing procedures, and that each patient receives the best and most patient-centered treatment.’ As the risks of transcatheter valve procedures go down and more long term outcome data are obtained, the penetrance of this technology will most likely expand into other valve locations and lower risk patients. The same four societies have recently published a similar consensus statement for transcatheter mitral valve repair, the recommendations of which were incorporated into the US National Coverage Determination by Center for Medicare and Medicaid Services.5 6 Optimal preoperative decision-making, effective patient communication and safest procedural outcome seem best assured with this multidisciplinary approach. Great vessel and thoracic aortic disease has traditionally been treated by open surgical approaches. Thoracic endovascular aortic repair is increasing used as an alternative to open repair for obliterative, traumatic and aneurysmal aortic disease. Disease involving the aortic arch is now commonly treated with ‘hybrid approaches’ precluding circulatory arrest. These approaches are again best designed and performed by an endovascular team involving vascular surgery, cardiology and thoracic surgery. Interventional cardiology is also often involved in many congenital great vessel anomalies partnering with surgery to obtain optimal therapeutic decision-making and treatment strategies. This once again emphasises the increasing importance of the team-based approach to aortic vascular disease. Particularly in the late stages of congestive heart failure, the decisions for optimal or prolonged medical therapy, short or long term ventricular assist, and cardiac transplantation become blurred. At most institutions with a cardiac transplant programme, a multidisciplinary weekly team conference has taken place for years to discuss these complex decision-making issues. With (new) interventional options for short term support such as intra-aortic balloon counterpulsation, continuous flow centrifugal (TandemHeart) or the miniaturised microaxial flow (Impella Recover) devices and more surgically orientated options for long term support such as the axial flow (Heartmate II), the centrifugal flow device (HeartWare) and even the temporary pneumatic pulsatile total artificial heart (Syncardia). Since these options can be used as bridges to recovery, transplantation or destination therapy, all options must be discussed in the multidisciplinary setting. As these devices become more miniaturised with the potential for treating less ill patients (‘the walking Class IV’), team decision-making will be critical in the management of these patients. Electrophysiology also bridges the expertise of medicine, intervention and surgery in the realms of pacemakers, Verrier ED, et al. Heart 2015;101:346–348. doi:10.1136/heartjnl-2014-306132

arrhythmia ablation and infected lead extractions. Although paroxysmal atrial fibrillation (AF) responds well to endocardial ablative therapies, persistent and longstanding persistent AF remains refractory. Recent trials combining minimally-invasive epicardial surgical approaches combined with catheter-based ablation are showing promise. Finally, children with congenital heart disease become adults and often require multiple interventions over a lifetime involving valves, ventricular muscle, rhythm disturbances, assist devices and transplantation. These patients are among the most complex challenges in patient care and decision-making which can be facilitated by heart team-based care.

FACTORS RESISTING THE MULTIDISCIPLINARY TEAM APPROACH TO CARDIOVASCULAR CARE Not unlike most other medical or business disciplines, factors resisting change are often unchallenged historical precedents, perceived or real financial threats, or local politics. For the last century, most of the clinical departments of medical schools and hospitals have been organised with some variation under the easily identifiable silos of medicine, surgery, radiology, obstetrics and gynaecology, anaesthesiology, pathology, psychiatry and paediatrics. Within each of these departments are multiple subspecialties, some with large clinical practices, others smaller; some that are procedurally oriented, others more cognitively orientated; some generating large amounts of revenue for the school or hospital, others very little. To maintain financial solvency and the desire to provide a full service line, there is often cost shifting within a department, the medical school and the hospital to maintain balance. Cardiovascular services have classically been busy, procedurally oriented, and the financial engines for the departments, medical school and hospitals. Thus, physicians who care for patients with cardiovascular disease have been split among different departments or ‘silos’ rather than working together in a patient-centred practice group. There has been the very real concern that if cardiac surgery, cardiology and cardiovascular anaesthesia were to combine into one cardiovascular medicine department, many other service lines would be forgotten or neglected and that cardiovascular medicine might overly dominate the medical school. Even on the profession side of revenue generation in the typical fee for service model, cardiovascular medicine would dominate leading to disruptive income inequality in the academic medical centre. The fee for service and departmental silo model also overflowed into the private sector for many years, often breeding competition among cardiac surgery, interventional cardiology and interventional radiology. One can argue that this historical model of maintaining balance by resisting realignment of services is changing by creating ‘service lines’; only a few very large institutions (eg, the Cleveland Clinic Heart and Vascular Institute) have been able to redesign departmental structures and the corresponding funds flow. Almost all educational models at the medical school level and during graduate medical education are based on the classic departmental structures which have changed little in the last century. Traditionally, cardiothoracic surgery training in the USA requires a 2–3-year residency after completing a 5-year general surgery residency programme (7–8 years of post-MD degree training), with an additional year or more for transplantation surgery. Cardiology training in the USA requires 3 years of internal medicine residency, followed by 3 years of general cardiology (a minimum of 6 years post-MD degree). Subspecialisation requires at least an additional year for interventional cardiology, adult congenital heart disease, electrophysiology, or advanced 347

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Viewpoint heart failure and transplantation. Recently, a 6-year integrated training paradigm right out of medical school was initiated in cardiothoracic surgery which may allow for flexibility in cardiac training. Currently, however, there is no pathway to shorten training of cardiologists with a ‘combined cardiovascular medicine training residency’ in the USA. Similar separations of cardiac surgery/cardiology exist in almost all training systems. There is no current pathway for integrated training of cardiologists and cardiac surgeons, starting straight from medical school; however, we are now beginning to see fellowships in structural heart disease or transcatheter techniques which are open to trainees in both medicine and surgery. Changing the basic training algorithms distinguishing medicine and surgery with more blended skills will remain a challenge. In the private sector, financial incentives frequently overwhelm other aspects of patient care decision-making. Hospitals and physicians are financially rewarded for procedure volumes. The more you do, the more you get paid! The current changes in healthcare which emphasise value-based care rather than volume-based care are promising in terms of aligning all stakeholder incentives. With the majority of cardiovascular physicians now in the employment of hospital systems and with the physician /hospital alliance becoming engaged with accountable care organisations and population health, the multidisciplinary care team approach, termed integrated practice units, appears to be rapidly evolving.7 How best to address these monumental shifts in the fundamentals of healthcare delivery can best be accomplished by forging ahead together.

THE WAY FORWARD Is there movement towards creating a more durable team-based cardiovascular disease model? Yes, the change may appear to be slow but the message is clear. Incentives must be aligned to emphasise evidence-based optimal medical, interventional and surgical management with a patient-centred approach. We are teammates and in no sense should we be considered rivals or in

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competition. This is not a ‘tug of war’ with the patient caught in the middle. Training models will evolve, medical school education will realign and hospitals will demand and reward transparent patient-centred teamwork in the years to come. After all, at the end of the day, patients’ treatment should not be determined by what door of the hospital or what physician’s office they happened to walk into. As professionals, we owe our patients better than that. It is fine to have differences of opinion and interpret the same evidence differently. But, it should be done in a transparent team-based approach, which includes the patient. We have found that with this approach, we agree far more than we disagree and the patient is more fully informed and better served. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.

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Holmes DR, Rich JB, Zoghbi WA, et al. The heart team concept of cardiovascular care. J Am Coll Cardiol 2013;61:9034–907. Patel MR, Dehmer GJ, Hirshfeld JW, et al.; Coronary Revascularization Writing Group. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology and the Society of Cardiovascular Computed Tomography. J Thorac Cardiovasc Surg 2012;143:780–803. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary artery bypass grafting for severe coronary artery disease. N Engl J Med 2009;360:961–72. Tommaso CL, Bolman RM, Feldman T, et al. Multi-society (AATS,ACCF, SCAI and STS) guidelines: operator and institutional requirements for transcatheter valve repair and replacement. J Am Coll Cardiol 2012;59:2028–42. Tommaso CL, Fullerton DA, Feldman T, et al. SCAI/AATS/ACC/STS operator and institutional requirements for transcatheter valve repair and replacement. Part II. Mitral valve. J Am Coll Cardiol 2014;64:1515–26. http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx? NCAId=273 Lee PM. The strategy that will fix healthcare Harvard Business Review. October 2013.

Verrier ED, et al. Heart 2015;101:346–348. doi:10.1136/heartjnl-2014-306132

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Viewpoint: transitions in cardiac surgery and interventional cardiology …team mates or rivals? Edward D Verrier and Michael J Mack Heart 2015 101: 346-348 originally published online December 23, 2014

doi: 10.1136/heartjnl-2014-306132 Updated information and services can be found at: http://heart.bmj.com/content/101/5/346

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Viewpoint: transitions in cardiac surgery and interventional cardiology…team mates or rivals?

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