Surgeon Involvement in Transcatheter Valve Therapy
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1 Surgeon Involvement in Transcatheter Valve Therapy Prof. Hendrik Treede Mid-German Heartcenter University Hospital Halle (Saale)
2 Once upon a time. classic interventional cardiology classic cardiac surgery Less need for a true Heart Team approach...
3 Different Therapy Options for Cardiovascular Diseases Aortic Valve Procedures (AVR vs. TAVI) Mitral Valve Procedures (MVR vs. MitraClip) Aortic Diseases (Operation vs. TEVAR/EVAR) Revascularization (Bypass vs. PCI) Electrophysiology (Thoracoscopic Ablation vs. PVI) Heart Failure Therapy / Ass. Devices / Transplantation
4 Cardiology and Cardiac Surgery Merging Professions 4
5 Evolving scenario of cardiac disease Patient Perspective Aging / Increased life expectancy Changing style of life Quality of life over longevity Productivity Esthetic appearance Circulation of information Patients awareness Active choice of hospital Limited resources / cost containment
6 Need for Interventional Valve Procedures? Medical Perspective Reasons not to perform surgery Reduced LV function EuroScore Porcelain aorta Malignoma COPD, renal insuffiency,.. Pulm. Hypertension Liver cirrhosis Dementia European Heart Journal (11):
7 A New Paradigm Yesterday Today Cardiac Surgery Cardiology Cardiac Interventions Imaging Birth of the Heart Team
8 Things to do for surgeons Trends in Cardiac Surgery - Reconstruction instead of replacement - Standard: minimally invasive - Integration of new techniques - Hybrid procedures - Achieve catheter skills - Become imaging specialists Become Structural Heart Intervention Specialist to prepare for the future Work in a Heart Team
9 Things to do for cardiologists Take profit from surgical experience - Feel for tissue quality and strength - Tying and sewing techniques - Understand surgical valve reconstruction - Endoscopic or direct vision instead of imaging only Become Structural Heart Intervention Specialist to prepare for the future Work in a Heart Team
10 Interventional Cardiology Credo Anything a cardiac surgeon can do, an interventional cardiologist can do as well or better percutaneously AH Gershlick, 2003
11 Heart Team Idea under attack Endangered species
12 What is Working in a Heart-Team? A true Heart Team : Team of interventional surgeons and cardiologists Performs all procedures together Respects and uses individual expertise: Cardiac Surgery: conversion, surgical access, ECC Cardiology: wire-skills, echo, PCI Ideal: Everybody does everything! Shares a common budget!
13 TAVI: A Heart Team Success Story Working Heart Team Approach for TAVI Individualized patient specific indication Free choice of access routes Mandatory in Germany (no reimbursement without Heart-Team approach) Highest possible safety for patients Unfortunately not implemented in many centers
14 TAVI from a surgical resident s perspective: will there be any conventional AVR cases left? at least the mechanical valves? or VinVinVinV? only root abscess endocarditis? do I need to become a cardiologistogist?
15 A Surgeon s Dream of a Heart Team may have been a bit too romantic!
16 Heart-Team in Real Life Cardiac Surgeon Cardiologist Only few surgeons perform transfemoral TAVI procedures on a regular basis.
17 What is Not Working in a Heart-Team? A bad Heart Team : Interventional surgeons and cardiologists dispute or even work separately No discussions on right indications Limited choice of access Lack of procedural safety: Annulus rupture, wire perforation, coronary occlusion, pericardial effusion, access site bleeding, etc. etc. etc. Worse results for no reason Money driven decisions!
18 Transcatheter Mitral Valve Procedures The next big playground for the Heart Team MitraClips routinely done by cardiologists and surgeons at many centers Cardioband: a perfect case for the Heart Team Transcatheter mitral valve implantation: Rebirth of transapical access (at least for a certain time)
19 FIM: CardiAQ Neovasc Tiara Edwards Fortis Tendyne Twelve Caisson HighLife The next big thing in cardiac interventions Percutaneous MV Replacement Larger number of patients than TAVI More difficult intervention compared to TAVI Predominant surgical access for the first 2-3 years Great chance for the working Heart- Team of cardiologists and surgeons
20 Heart-Team
21 Courtesy of Francesco Maisano 21
22 TAVI+TMVR interventional cardiology Cardiac Interventionalist a new profession? Cardiac Interventionalist TAVI+TMVR cardiac surgery
23 Political environment The future of the Heart Team : surgeons need to be actively involved A sleeping cardiac surgeon on stand-by present during interventional procedures can NOT be considered a Heart Team
24 The True Heart Team It s Time to Jump on the Train
25 Heart Team Idea under attack mission accomplished
26 Heart Team Centers make a difference Individualized Cardiac Medicine
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