TEVAR, TAVR, OPCAB; IS THE PUMP (AND THE PERFUSIONIST) BECOMING OBSOLETE? Michael Mack, M.D. Baylor Healthcare System Dallas, TX April 28, 2012
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1 TEVAR, TAVR, OPCAB; IS THE PUMP (AND THE PERFUSIONIST) BECOMING OBSOLETE? Michael Mack, M.D. Baylor Healthcare System Dallas, TX April 28, 2012
2 Conflict of Interest Disclosure Uncompensated Member of the Executive Committee of the Partner Trial of Edwards Lifesciences
3 Conclusion The Pump (and the perfusionist) will not become obsolete if they (and their cardiac surgeons) are open and adaptive to change
4 Surgical Innovation
5 CABG Best Thing to Happen in Cardiac Surgery Worst Thing to Happen in Cardiac Surgery
6 CABG The Best Thing Fostered the growth of the specialty of thoracic surgery Promoted the expansion into other cardiac surgical procedures Gave growth to allied specialties-cardiology Financial engine that fueled the growth of especially nonacademic medical centers
7 Hugo Vanermen, M.D., FETCS,
8 CABG The Worst Thing Innovation Stopped When We Looked Up.
9 The surgeon waiting outside the cath lab for the next CABG case
10 Surgical Innovation Surgical Innovation is to Innovation as Military Music is to Music Anonymous Cardiologist
11 CABG will be gone in 10 years Friedrich Mohr Patrick Serruys Vienna 1997
12 Hugo Vanermen, M.D., FETCS, STS 2005
13 T Feldman EuroPCR 2007 Barcelona
14 Workforce Shortage CT Surgeons Negative Growth
15 Applications To Thoracic Surgery Resident Programs * Total Number of Applicants U.S. Medical School Graduate Applicants Active Positions Available Source: NRMP *As of June 11, 2008
16 The dogmas of the quiet past are inadequate for the stormy present. The occasion is piled high with difficulty and we must rise with the occasion.... We must think anew and act anew. December 1, 1862
17 Stanford i6 Integrated Cardiovascular Surgery Residency PGY- 1 PGY- 2 PGY- 3 PGY- 4 PGY- 5 PGY- 6 Thoracic CT / MRI /Echo Adult CVS Peds CVS Adult CTS (SCVMC) Adult CVS Thoracic GS (VA) Adult CVS Peds CVS Adult CTS (SCVMC) Adult CVS CV Anesth/CPB GS (VA) Adult CVS Peds CVS Adult CTS (SCVMC) Adult CVS Vasc/Endovasc GS- Trauma Adult CTS (KPMG) Peds CVS Adult CTS (SCVMC) Adult CVS GS GS- Trauma Adult CTS (KPMG) Peds CVS Adult CTS (SCVMC) Adult CVS GS GS- Trauma Adult CTS (KPMG) Peds CVS Adult CTS (SCVMC) Adult CVS GS- Trauma GS- Trauma Vasc/Endovasc Thoracic Adult CTS (VA) Adult CVS GS- Trauma GS- Trauma Vasc/Endovasc Thoracic Adult CTS (VA) Adult CVS CVT Surg ICU GS- Trauma Vasc/Endovasc Thoracic Adult CTS (VA) Adult CVS GS EP/pacing IC / Cath Thoracic Adult CTS (VA) Adult CVS Adult CVS Adult CVS IC / Cath Thoracic Adult CTS (VA) Adult CVS Adult CVS Adult CVS Thoracic Thoracic Adult CTS (VA) Adult CVS Adult CVS IR Stanford CV Surgery
18 Stanford Integrated i6 Program Number of First Year Slots Offered in the Department 2 Number of Applications Received 23 Number of Applicants Interviewed 12 Number of Applicants Ranked by the Division 9 Matched at 1 & 2 Ratio of Applicants to Offered Slots 11.5 Number of Residents in Program Stanford CV Surgery
19 Global Predictions The specialty will stop contracting and begin re-expanding Education/training is being/will be revamped Regionalization of cardiac surgery Focus on disease management and Heart Team approach Big Operations will gradually go away Focus on superspecialization and the role of the generalist cardiac surgeon will diminish
20 CABG The decline in CABG volume has slowed; PCI volume has plateaued and begun to contract Off pump CABG is flat at 20% and likely to stay so Public reporting of CABG outcomes is likely to shift procedure volume New studies will impact CABG
21 New Studies That Will Impact CABG ASCERT Trial SYNTAX- 5 Year Results CORONARY Trial C-PORT Trial
22 NEJM March 2012 ASCERT Trial STS Database ACC NCDR Database
23
24 Optimal revascularization strategy in patients with three-vessel disease and/or left main disease The 4-year Outcomes of the SYNTAX Trial Patrick W. Serruys, MD PhD Erasmus Medical Center, Rotterdam, The Netherlands On behalf of the SYNTAX investigators SYNTAX 4-year Outcomes EACTS 2011 Serruys October 2011 Slide 24 Conflicts of Interest: None
25 Cumulative Event Rate (%) MACCE to 4 Years CABG (N=897) TAXUS (N=903) 50 Before 1 year * 12.4% vs 17.8% P= years * 5.7% vs 8.3% P= years * 4.8% vs 6.7% P= years * 4.2% vs 7.9% P=0.002 P< % % Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates SYNTAX 4-year Outcomes EACTS 2011 Serruys October 2011 Slide 25 ITT population
26 Cumulative Event Rate (%) All-Cause Death to 4 Years CABG (N=897) TAXUS (N=903) 50 Before 1 year * 3.5% vs 4.4% P= years * 1.5% vs 1.9% P= years * 1.9% vs 2.6% P= years * 2.2% vs 3.2% P=0.22 P= % Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates SYNTAX 4-year Outcomes EACTS 2011 Serruys October 2011 Slide % ITT population
27 Cumulative Event Rate (%) Cardiac Death to 4 Years CABG (N=897) TAXUS (N=903) 50 Before 1 year * 2.1% vs 3.7% P= years * 0.6% vs 0.8% P= years * 0.9% vs 1.6% P= years * 0.8% vs 1.6% P=0.13 P= % 0 4.3% Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates SYNTAX 4-year Outcomes EACTS 2011 Serruys October 2011 Slide 27 ITT population
28 CABG % Off Pump 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
29 CORONARY Trial
30
31 HCR- Revascularization Strategy N= 202 PCI first, then MICS N= % Simultaneous N= % MICS first, then PCI N= % * 16 patients missing
32 MECC
33 Public Reporting of CABG Outcomes Voluntary Participation 332/1,029 Programs Participate
34 Consumer Reports Website ()
35
36 Dallas-Ft. Worth Metroplex 6 Million People 34 Heart Surgery Programs 14 perform < 100 Cardiac Operations/Year
37 C-PORT Trial
38 Heartflow- Non-invasive FFR
39
40 Coronary Revascularization
41 Cribier et al. Circulation 2002;106:
42 Aortic Valve Replacement Germany Isolierte Implantation einer Aortenklappenprothese konventionell chirurgisch kathetergeführt TAVR =23.9% 1,3% 157 7,0% ,6% ,9% ~ 5, %!
43 Transfemoral
44 Transapical
45 Subclavian Transaortic
46
47 ~1,150 Cardiac Surgery Programs in the U.S. ~1,600 Cardiac Catherization Labs in the U.S. How Many Centers Should Be Performing TAVR in the Next Two Years in the U.S.? 400 Programs Perform > One Surgical AVR/Week
48 Aortic Valve Replacement U.S Projections JP Morgan % 17% 21% 14% 8% 60 TAVR Surgical JP Morgan, October 4, 2011
49 Thoracic Aortic Disease
50 VAD s HM I (XVE) and HM II HM II with controller and batteries HMI HMII
51
52 HeartMate III*
53 HeartMate X * *In development and not available for clinical use
54 Fully-Implantable LVAS (FILVAS) * Implanted Controller / Battery / Internal TETS Coil HM II LVAD External TETS Coil (broadcasts electricity across the skin)
55 Instead of Traditional Specialties Non-Interventional Cardiology Interventional Cardiology Pediatric Cardiology Cardiac Surgery Pediatric Cardiac Surgery Radiology Electrophysiology
56 Reorganizing As Coronary Team (Primary Cardiologist, Interventional Cardiology, Cardiac Surgery, Emergency Service) Mitral Valve Team (Primary Cardiologist, Cardiac Surgery, Interventional, Echo, Heart Failure, EP) Aortic Valve Team (Primary Cardiologist, Cardiac Surgery, Interventioanl Cardiology, Imaging) Congenital Team (Pediatric Cardiologist, Cardiac Surgery, Interventional Cardiology) Aortic Team (Cardiac Surgery, Vascular Surgery, Interventional Cardiology, Emergency Service) Heart Failure Team (Heart Failure Cardiologist, EP, Cardiac Surgery, Emergency Service) Arrhythmia Team (Primary Cardiologist, EP, Cardiac Surgery)
57 Internal Medicine Intern-1973 Acute MI- one month hospital stay Surgical hip operations- 6 weeks recovery No knee replacements Acute leukemia-no cure Cholecystitis-6 week return to work Heart transplants- headlines to abandonment No interventional cardiology
58 What s Happened Since Then? Mortality from heart disease declined by 50% Total hip replacements routine Bilateral total knee replacements outpatient procedure Most leukemia is cured Lapcholy is an outpatient procedure Heart transplant and VAD s now routine Interventional cardiology
59 TEVAR, TAVR, OPCAB; Is the Pump (and the Perfusionist) Becoming Obsolete? Conclusions Not obsolete, but must be adaptive to change CABG will not decline much further Off pump CABG will not increase much further Hybrid revascularization is having a rebirth The percent of AVR performed percutaneously will increase to 20% over next 4 years Mitral valve surgery will increase over next few years There will be a consolidation of smaller programs More thoracic aortic disease will be treated by an endovascular approach VAD s is the major growth area
60 Walk a Fine Line
61 The Future of Cardiac Surgery The Only Constant is Change Heraclitus of Ephesus c.535 BC BC
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