Tsuyoshi Kaneko, MD joins Georgia Heart Institute as a Cardiovascular Grand Rounds speaker during the CME lectures for 2022. Dr. Kaneko is the Surgical Director of Structural Heart Program of the Division of Thoracic and Cardiac Surgery at Brigham and Women’s Hospital in Boston, Massachusetts. Dr. Kaneko discusses the future of structural heart programs and expounds on the question “Can surgeons and cardiologists coexist?
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Yeah. Okay, good morning, everybody. Welcome to Georgia Heart grand rounds. Thank you for being here. I'm just going to give you the CMI talk really quick. This program is provided by Georgia Heart Institute with support from our industry partners. The planners have disclosed no relevant financial relationships with commercial interests. The presenter receives grant and research support from Edward's Life Sciences. Boston Scientific Lan, Thea's medical and Novartis and is a consultant for Edward's Life Science, Medtronic and Abbott. These relationships do not influence today's presentation. And now Dr Ramadan, the Director of the Structural Heart Center of George of Georgia Heart Institute will introduce Dr Kuniko. Thank you, good morning, everyone and thank you for attending this month's grand rounds both in person and remotely. It's my great pleasure and honor to introduce uh this month speaker Dr Kuniko. Uh Dr Kuniko comes to us from Boston Massachusetts from the Brigham and Women's Hospital where he serves as the surgical director of the Structural Heart Program, the director of the Aortic Surgery Program, the Director of the Clinical Outcomes Research Program, as well as the associate director of the cardiac surgery residency program. He's also an assistant Professor at Harvard Medical School, Dr Kuniko trained um at Brigham and women as a cardiac surgery resident at a time when structural heart was still in its early, very early stages. Uh Yet he had the vision and insight to recognize the potential impact uh this evolving field would have on the care of patients with cardiac conditions and elected to do a dedicated fellowship in interventional cardiology with a focus on structural heart interventions. Um quite a, quite a unique um step at the time, a process that has become more common these days. Um Dr Kuniko is really a true example of the triple threat um academic triple threat. He's a, he's a great uh teacher, educator and a mentor. Uh He's a phenomenal surgeon and a structural interventional ist. Uh And he's a prolific researcher, has published over 100 and 50 manuscripts and his P I and the CO P I on over 15 funded grants. And he's uh he's just an overall great human being um which I guess makes you a quadruple threat. Yoshi, it's a term familiar to you cardiac surgeons quadruple. Um So without further ado would like to welcome Dr Kaneko. Okay. This one works. This works. Okay, Ronnie, thank you for um very kind introduction. Um You know, the dinner at the winery, having a talk on the next day is very, very difficult. Um with a little bit of a hangover. I know that was your plan. So I'll be talking about the future of structural heart programs. Can the surgeons and the cardiologists coexist? So it's a very broad topic and I'll try to do my best and there are parts that you guys might have some questions. Um Please hold on to it um because it will not be that bad. So these are my disclosures and the object of this talk is to understand the current state of the heart team within the field of cardiovascular disease. And to recognize the current training and structural heart program and to design the future of the heart team that surgeons and the cardiologists can coexist. So I love history. Um the Treaty of Westphalia. I don't know if anybody knows this, but it ended the 30-year war, the Holy Roman Empire and the significance of it was that it has sovereignty that that came up each state. So each of the land now has an exclusive sovereignty over its territory. And it's a concept of modern state. Just wait. Um French revolution. Um You know, this is the storm of the steel. I don't know if any of you guys are really interested in this, but it was truly the start of liberal democracy. And it really gave this concept of nation state, which really means that the political unit where the nation, where we think France and the land are congruent. So this is when all this started and the concept of nation state really has been routed to us now. So when we watch Olympics, we root for Simone Biles going for a gold medal and you want Kevin Durant to make that shot to get a gold medal. So that really has been the concept of nation state that we really have. So please bear with me where this is going. So, Yuval Harari, I don't know if any of you have read this book Sapiens. Um He's probably one of the geniuses that we have in our generation. And what he has said is that for this Homo Sapiens, for human beings, the biggest invention was this concept called imagined orders. So what does that mean? So there's objective reality, which other animals see and then there's imagined orders, what only human beings see, for instance, tree is an objective reality. Even, you know, the monkeys will see the trees. But the money is something that human beings invented and that's what we see otherwise cars and mountains. Um doctor somebody drives Tesla, but you know, the monkeys won't see that mountain and U S A. So that's where that usa the nation's state concept really comes in. And then of course, you know, the animals will see buildings but you guys C G H I and more importantly, Homo Sapiens is objective reality, but cardiologists and cardiac surgeons are imagined orders. So these are something that we've created, but at the same time, these are something that we really hold our value to. So, cardiologist, insurgents over the years have fought really hard. So P ci versus cabbage, right? Um You know, I'm sure if your age has fought over this for years, the pacemaker and the I C D s were originally implanted by the surgeons. Now, almost exclusively implanted by the ep physicians. And of course, tavern versus severe. So I don't know why we always talk in the form of versus tavern. It should be tavern or severe or tavern and severe, but it's always tavern versus suburban. So the first heart team concept Really came up interestingly from coronaries. So this was a syntax trial that was published in 2009. And when you look at their methodology, um they say that the local interventional cardiologists and cardiac surgeons at each site evaluated the patients. So this was sort of the beginning of the heart team concept And this heart team concept was incorporated into the guidelines back in 2010. And this was mainly for the coronary disease. Contrary to what we think now, a lot of the heart team concept is in the structural field. It originated from coronaries. And you see that in the EHF, the European guidelines and also the American guidelines, both actually state the heart team approach for coronary disease and that's where it first was created. But the heart team concept nowadays has been challenged a little bit. Um a lot of you might have heard this battle between PCI versus cabbage in left main disease. Um David Taggart has been a big proponent on criticizing the Excel trial. Um he acts actually withdrew their recommendation from the from the the guidelines that was published in 2018. And there's been ongoing battle with this, especially this field has been. Um this fire has been fueled with a recent um the cabbage guideline that was published by the American Heart Association American College of Cardiology. So changing the tone a little bit. So what how was it in Tavern or to be in the early days? So in the early days, the cardiac surgeons did the cut down for the growing um not a lot of places did it with total pure cutaneous approach. And we did a lot of trans local approach back in the days and the interventional cardiologist, they did per cutaneous aspect of the procedure to cross the valve and deploy the valve. So we really, we really had a good separation of the parts of the procedure that we can coexist And that really changed around 2013. So up until 2013, About 50% of all accesses were performed um with trans a pickle. So initially when it began, they only launched trans femoral. So back in 2012, there were a lot of trans femoral, but in 2013, it became almost 5050. And after 2014, the trans femoral has been dominant. And what happened at that time was this new introduction of shaping XT system where before the sheep size was 22 French or 24 French. After this, it became 16 and 18. Now, as we all know, it's 14 and 16. So it's much, much smaller compared to when it first came out. Um some of you may remember iliac on a stick where the artery comes out with the sheet on these really, really tiny ladies. And this is the data from 2019, of all towers are being performed through a transformational approach. And when you look at the non transformational approach, about half are being done transit, vehicle transit. I think this rate is even lower in 2022 and transparent. It has been really increasing um in the United States. So we're not doing a lot of alternative access. So you know, what do we do with the surgeons? And back in 2012 when the tab was first approved, the CMS, the Center for Medicare and Medicaid Services had made a national coverage decision. And they said initially that two cardiac surgeons have to independently examine the patient face to face. And some of you may remember this painful clinic encounter that you have to do endlessly to see these tavern patients. And the other recommendation was the hard teams, cardiologists and surgeons must jointly participate. So this still goes on and this part of the reason why the surgeons continue to be involved in this field. And we all know that a lot of places the interventional ists have taken ownership of these and it really depends on the politics of the program and I will give credit to Dave Holmes and Micmac for creating this N C D. Um That's why we do have this hard team concept that is ongoing um after this, after this launch of Tavern. So what is the benefit of having a multidisciplinary team? It's been published multiple times in surgical specialty and interventional specialty. We all know sort of what multidisciplinary team can do to you. But when you look at the benefit, we sort of try to break it down the benefit of heart team is that you can actually discuss the option of surgery or trans gather at the same setting. I think that is very, very important for the patients. Um And you, the real time discussion is very important. You do have input from multiple specialists. So when we talk about the heart team, it's not just cardiologists and the surgeons where we have the imager, we have the anesthesiologist, we have input for multiple specialists and we do have an effective communication. We sort of build that over time and it does expedite referrals. Um You guys might be seeing this too. But nowadays, when the referring non interventional cardiologist sees valve patients, they just send it to the valve clinic because that's so much easier for the referrals rather than sending it to each of the surgeons or cardiologists. But most importantly, it avoids the turf war and it provides a patient centered care. That's sort of the crux that, that, that's sort of the, the the importance of having the heart team. For instance, when we have a tabby for bicuspid aortic valve. Um this is the paper that I was involved in um when we have a bicuspid aortic valve versus trikus aortic valve in certain patients, Tavis do find they have a great result um shown in this film. But when you break it down by anatomy, some of the anatomy, they just don't do well. So if you have a all the way on the right, if you have a calcified Rafei plus excess leaflet calcification, these patients have poor outcomes um even at two years um after tavern. So when you have a bicuspid aortic valve that looks like this and the patients young and low risk. After heart team discussion, this patient in my mind should go for surgery rather than tavern and that's part of the benefit of the heart team. So, going back to that 2012 N C D coverage, um I will emphasize the importance of the other team members such as echocardiography, furs. We have a heavy involvement with the cardiac anesthesiologist who does the echoes and we also need help from intensive ist nurse social workers, most importantly, the coordinators, we need all that to, to establish and this is called the diversity paradox. I'm not going to go into the details of the study. It uses some ai calculation, but I'll make it very simple when they looked at the performance of a team. When you have a team of randomly selected people with diversity performs a team comprised of best performing agents. So what that means is that when you have a team, you want a group that has different identity, diverse groups, you don't want the top performers, you know, you don't want the New York Yankees, you know, having all the, you know, the home run hitters that's just not gonna work. So you have to make a team that has diversity and that actually has a better performance and that's what we have to be thinking when we create these hard teams. So moving forward, I think it will really be important because the structural heart will dominate. So this is the latest slide from the from this is the data combining the TVT registry and the STS database. Um briefly explaining this blue line up on the top is the total surgical aortic valve replacement numbers. So it's not just Savin, it includes Savage plus cabbage, Sabir plus Metro or even includes the root replacement numbers. And you can see a significant drop from 2019 to 2020. Some of it is the effect of COVID, but the surgical numbers went down from 62,000 to 50,000. And you can see that during that same period of time, the orange line is the tavern numbers. It has increased um, in that same period time despite the COVID. So this is the universe that we're sitting in and same thing we're seeing with the mitral valve. The total mitral numbers are about 23,000. Um You can see the mitral clip numbers up down in orange, which has been steadily increasing. And this is in the light of the most recent valve guidelines for tear. The most recent one for degenerative mitral regurgitation. When they're hire private surgical risk with anatomy favorable, there's a class two a recommendation more importantly for functional micro rigor education When they have EF less than 50%. And when they meet all these co op guidelines, the tier has class to a recommendation. Contrary to the surgical recommendation is to be recommendation. So tear in certain anatomy has a higher recommendation than surgery and secondary MR. And when you look at the surgeons performing mitra clips, um this is a number that I got from Abbott. The number that you see on the left is the surgeons who were involved in metro clips. There are about 19%. When you look at the primary operators who do mitra clips, there's only 8.8%. So a lot of these mitral clip procedures are being done by the cardiologist and the cardiologist and some of it is due to the updated national coverage decision for the mitral clip procedure. So for degenerative mitral regurgitation, the heart team has to include both cardiologists and a surgeon. But for a secondary M are the most updated NCD recommends that you have to have cardiologist and heart failure, cardiologist. You don't need a surgeon for this and for the procedure, it's either a cardiologist or cardiac surgeon must perform the procedure. And this movement towards, you know, single operator will be accelerated in the future, especially with all these trials that are upcoming. So, repair in our trial is a clinical trial that is sponsored by Abbott. This is a randomized trial. Um You can see in the middle between surgery and mitral clip, an intermediate risk population. There's also an NIH sponsored trial that is looking at all risks randomizing between surgery and metro clip. And depending on that result, we might be recommending metro clips for some of these young low risk patients and that may be coming in the future. I know that surgeons in the room will feel, you know, differently and have mixed opinions about that, but that's definitely where the field is going. And these are some of the Micro Valve repair devices that are being tested in 2020 and this is the replacement device that are out there, the most hot field in structural heart, in my opinion. Um and I think in the next five years will be via the tricastin valve therapies. Um, I don't know what happened. Everything good. Okay. Um, I think the trick will be the hottest field in the next five years, in my opinion. And there are all these devices that are upcoming that will probably accomplish that. And this was the, the survey that was done back in 2017, Joe Bavaria, who was the president at the time, surveyed all the surgeons throughout the country and said, what part of the procedure are the surgeons involved? And a lot of the parts of the tavern procedure, surgeons that they're involved. And the conclusion of the study was, you know, everything's all good. We're, we're perfect, we're all fine, which I don't know if that really is the case. Um You know, looking at all the data that I've shown. So, one of the concerning data that came out from Ontario is that, you know, they're hard team utilization in Canada, specifically in this Ontario District has diminished. And when they broke it down with number of taverns done by institution, which is that yellow bar, a lot of the the high volume centers had less utilization of heart team concept. So people were moving away a little bit from heart team. Why, you know, we're saying that hard teams cool and awesome and it's so great, right? But it does have a downside. I would say downsides One is inefficiency um, a lot of you have been involved in the structural clinic, know that the structural clinic is very inefficient. Um, you know, you this urgency, the patient, the cardiologist sees the patient depending on the time timing of it. The patients have to wait, you know, 15, 20 minutes. Um, inefficiency is definitely there and you really have to have mutual respect, respect. Um, I know so many programs where the cardiologists and the surgeons don't like each other and they really don't really have that heart team. You know, the surgeons will try to operate and the cardiologist will try to do towers. And of course, there are politics within the team, the politics are everywhere and it really depends on the individual. So if you have a really, really collaborative person, that program will be very collaborative if the, if the person's alpha male and wants to own the program that really changes the landscape of that program and it's really dependent on that individual. So the future of the structural heart specifically for Tavern, um there's gonna be a movement towards two operators. Um This is what my my senses and I think a lot of people feel the same way. Um in the next five years, I think it's going to be, you know, as you saw previously for Travers, it was both cardiologists, interventional cardiologists and the surgeons that both have to be jointly performing the procedures. But in the future, I think it will be two operators. It could be two surgeons could be to I C S and I think that change of wording may change the landscape a little bit. Um And I think it eventually will move towards one operator and it's a tug of war going to start in the future. So that's some of the concerns that we have. But we always have to remember going back to my original story, cardiologists and cardiac surgeons are just imagined orders. Um We created them, right? And if we can work as a team, we're gonna function much, much higher compared to just a single team, single, single operator. So I want to talk a little bit about how can we coexist. And this is a book that talks about the dysfunctions of the team and the most foundation of creating a team is absence of trust. Um And that's how you can have a dysfunctional team. So you have to have a trust in order to create everything and what can we do to create that trust, at least from the surgical side. And I think the first thing that we lack is the proper training to foster structural operators. I don't think we have the right training to do this at this time. Um Ronnie sort of mentioned, I mentored under Dr Dr Michael Davidson who tragically got shot at the Brigham. Um He passed away and, you know, we I wrote about his visionaries in the past and I sort of trained under him. I was lucky enough to carry his legacy. But the structural heart, both the cardiology side and the surgical side. We don't have a fellowship formal program. So we just don't have a formal training anywhere. Um at the moment, and that really is a problem and I think that people are calling for some drastic change in these training. And there, there are multiple papers that have focused on this but and there's been some talks about about the cardiology side, interventional cardiology side based on the sky recommendation that they're trying to create a fellowship with minimal numbers. But a lot of these experts see that we should have in the future, we should have a structural heart experts. And you know, through the training through milestones, we would have certification that is sort of equivalent for both. And I think that would create some mutual trust in these cases. Um these are some of the structural heart fellowships for interventional cardiology. There's about 40, I think there is even more because this slide is probably air too old. Um and for surgeons, these are the requirements currently for the American Board of Thoracic surgery. So if your cardiac focused on the left side, you need to do five travers as a primary and 10 is an assistant and you can get board certified and you can go out and practice tavern. And is that enough? I think everybody knows the answer to that question. And right now, we do have a couple of programs that have structural fellowships for cardiac surgery. Um, we have one, um I think there's two in this Atlanta area, but there's just lack of formal training in the structural heart. And this is something that we propose to the boards, um as sort of the group that does a lot of these surgical structural programs. And you know, these are some of the recommendations we wanted all these graduates do at least about 50 taverns when they graduate. 10 metro clips so that you can sit on the equivalent ground as the interventional cardiology graduates. And I personally believe that proper training will gain trust of other members of the heart team and therefore you can work together. Um I think a lot of the procedural lists that are doing this at this time, the operators, I think their grandfather then um you know, we were talking about the about the surgeons here and I think you guys have transformed, you guys have incorporated and embraced this technology and I don't think that's relevant, but these are more for the future um graduates coming into your program. I think you want them to have this under their belt so that you can have, you can have trust each other. So the second point is a structure to create trust. So, you know, depending on how you create these structures, I think there could be a better bond between the teams. So, say, for instance, we have two cardiologists, which I'm gonna, I'm gonna point as blue here and the surgeons red. And if they do cases, you know, with different people, then there's multiple arrows, there's four teams, um, that you can create, um, if they cross act, but if you have six intervention, cardiologists and six surgeons and they all cross, then there's multiple teams and you may operate with the same group once a year, right? And that's not going to create a trust. So what we model is that, you know, we have currently, we have two and two, you know, because Ronnie left us. Um but with two and two, we have the main teams that work together almost all the time so that, you know, you know, they're going to be your partner. Um And I think those are some of the structures that you can create. Um so that the heart team will function better with mutual trust. And I think this has worked very, very well. Um from the surgeon standpoint, I think input on the complex structural cases will be important moving forward. And, you know, this is one of my interest which is a Tavern X plant. Um The video on the left was a patient with, with infected Tavern Valve that that had to be taken out. Um This one was structural valve deterioration after a short period of time. Um These Tavern X plants could be technically challenging sometimes um more so with a self expanding valve because they have the hourglass metal really adherent to the aorta itself and you know, the stamp frames could be occurrence. Um Sometimes you can have difficulty cross clamping, especially for self expanding valves. And if they're really stuck to the order, you may have to accommodate erotic procedures which makes it a much, much bigger operation. And some of these cases may need mitral or try custard surgeries can confidently. And the main reason for that is they come when these valves fail very late in the ballgame. So you know, when the, when the valves fail, they first go to the cardiologist, they get multiple echoes and then once they confirm that they come to us and by that time, their heart gets very, very sick and these procedures um become very, very high risk. And this is something that our group has published. Um looking at the Medicare data. Um strikingly when we looked at 227 patients with tavern x plant, the 30 day mortality was 13.2%. So that goes along with a lot of the other publications that came out so far. I think we're gonna see more and more of this. The criticism is that a lot of these Tavern X Plants are on patients who were very, very high risk to start off with. So can we lower this risk on a lower risk patients? That receive tavern in the future. And that's something that I think all of the surgeons in the future will face. Um similar things have happened in tier. Um this is a patient that we treated who came in with a cardiogenic shock. Um she was on presser, she was intubated, her lactic acid was 10, we placed two clips. Um and she dramatically turned around. Um she got out of the hospital but four months later, um she came back with severe M R. Um and she really hasn't recovered, you know, her, her shortness of breath never really went back to baseline. So I ended up taking this patient to the O R. Um you know, fast forwarding it really quickly. I don't operate this fast, but, you know, this is a case that metro clip was removed and replaced, replaced it with the mitral valve and the patient did very well afterwards. Um There's more and more talk about how to remove these clips surgically without having to do the replacement. Um I thought that was sort of beyond the scope of this talk. So I didn't include it. But um I think we're gonna see more and more of these um these failed trans catheter procedures appropriately performed at the time. But um we'll need some surgical interventions in the future and that will be one of the field that, that the surgeons can definitely contribute um in the future. So this is how the Metro valve goes in for those who don't really see surgery. Um And this is an epic valve which is a poor sign valve and this patient did really well afterwards. So similarly, the micro clip X plant, the mortality was very high. It was, it was 15% in hospital mortality. So again, you know, we're doing these on a high risk patients. But I think, you know, I tell my fellows that in the future you will be doing more and more of this. Um And there's gonna be a, you know, post tavern post here surgeon that we're gonna be seeing. Um some of the things that, that I have been thinking more and more is that when patients come for, you know, either valve in valve Taverner versus re operative server. Um This was a young patient that came in who had a bye prosthetic valve at a younger age, she wanted to be pregnant. So she had, she had by prosthetic valve in her twenties. Um and she came back in the thirties, her valve um implant. This is sort of the assimilation of implanting the valve. And you can see that the distance to the quarry was very, very, very, very short. So there was a risk of coronary obstruction. So she still wanted to be pregnant. So, you know, we decided to go with the bio prosthetic valve. Um I end up doing a root replacement on this patient. Um the val salva graft um those who have, you know, those of all the surgeons in the room know that the the actual graft comes with the val salva, the sinus of val salva. And that distance is actually Enough to create larger distance between the coronaries. So after I replaced it with the Val Salva graph, the BTC, the valve to the coroner distance went up to 5.8. So now we can perform valve and valve in the future for this lady. So I think we're gonna have to start thinking about some of these things. Um so that patients can get the second procedure um that is less invasive in the future. And we spoke about this a little bit on the dinner yesterday. So I put this in. But um one of the one of the arch enemies for the surgeons when we do mitral valve surgery is the mac is the mitral annular calcification. So this is the the sort of the actual view of the mitral valve. And you can see that along the analysts, you see the significant calcification and these are really, really high risk cases if you try to take them out, um it causes a possibility for atrial ventricular dissociation. So basically, the chambers can split and you know, it's very hard to salvage that or it has a higher chance of injuring the coronary arteries. So in this particular case, when we modeled, placing the SAPIEN valve, one of the risk for trans catheter micro valve replacement is the L V O T obstruction. Um The leaflet, this leaflet when you don't respect, it will move towards that L V O T when the new valve goes in and that can obstruct the pathway of the blood. So instead, um in this case, we started off with performing septal myomectomy, we cut off part of the muscle so that, that ele bot will be a little wider. Um You can see a small piece of muscle that we cut and then we cut the anterior leaflet of the mitral valve. Um so that the risk of that L bot obstruction will be much, much lower. So after respecting this, we actually implanted the valve. After placing the valve sitters, we placed valve centers where there's not a lot of calcification. Um In that previous view, you saw the anterior aspect of the mitral valve didn't have a lot of calcium. So here we took the SAPIEN valve, which is supposed to stick to the calcium. So under direct vision, I'm implanting this um the SAPIEN valve and you can go as slow as you want, the heart's arrested. So you don't really need to worry about about anything at that point. And then afterwards, you secure these um these sutures that you place in the annuals and I personally had have had very good success and this is actually a very, very cool view. So people talk about the Neil L V O T or L bot obstruction. When you look through the aortic valve, this space where that suction is, that's the new ele bot. You can see that part of the valve is actually obstructing the pathway. And if you had that anterior leaflet, if we didn't cut that out, that entry leaflet would cover the entire ele bot and would have no cardiac output from the left ventricle. So this, I thought we had the echo at the end. But unfortunately not. So the other aspect that, you know, going, going back to the heart team. So what we can do is that we can continue to invent and innovate. And, you know, we spoke about I pee a little bit yesterday, but this is one of the pictures of the patent that was, that was obtained. Can anybody, can anybody guess what this patent was up here? Yes, you almost correct. But it's a mitral clip. It was the, it was a patent for mitral clip and they're the people who got the mitral clip patent, there were three or four people combined, but one of them was people who we all know who's Dr Mehmet Oz. Um And you know, he was the one that created this device, um, other devices on the left millipede. Unfortunately, this sort of went out. Um But Steve Bowling in Michigan was the one that created this and the harpoon device, which is being studied by Edwards right now. My good friend Jim Gammy was the one that created this. So I think surgeons have the mind to innovate. Also, interventional cardiologists have made numerous inventions in the, in the past and it doesn't have to be a new device. Um It can be, you know, new structure, any innovations that we can create, I think will make the heart team more stronger. And that's what we thrive for and that's what we want to do last but not the least we have to have skin in the game. Um Importance of skin in the game. Um To leave is one of my favorite authors that I like to read in the airplane. Um And what he says is that the skin in the game means that you do not pay attention to what people say only to what they do and how much their neck they're putting on their line. So if you put this in the heart team, what that means is that by surgeons by not being involved in the heart team can criticize trans catheter technology all day long because they have no skin in the game. Um I have some of my colleagues like that, but surgeons who are involved in the heart team can assess the technology critically because we have skin in the game in interventional cardiology. Similarly, who's involved in the heart team discussion is less likely to criticize Sabbath um because they have skin in the game and we see this all the time on Twitter. Um they're, they're interventional cardiologist, criticizing the surgeons, surgeons, criticize interventional cardiologists. Um But I think we just have to have the skin in the game. And I think that will change the mindset within the team. So my view of the structural heart team um in the future is that I think the hard team and structural heart will continue to evolve. We're gonna, we're gonna have this hard team concept for a very, very long time. But I think proper training is the key to being respected member of the heart team. We have to have that proper training, especially for the upcoming graduates. And it will be critical to create a structure which enhances trust within the team. We just have to have a trust within our team and the members of the heart team must have a skin in the game to make best decision for the patient care. And you know, having skin in the game will change everything. The first generation started the heart team concept in structural heart and it's up to the next generation um to take it to the next level. And I think they're, they're much more, much more that we can do in this field and most of all teamwork brings happiness. So this was from Harvard Business School Review and they evaluated the jobs and the more right you go, the more teamwork you have and the more teamwork involving job, had more happiness So if you're going to be happy, you know, you might as well, right? If you're going to do something, you might want to be happy. So I think teamwork brings happiness and that's what we want to do in the future. So future of the hard team shouldn't be Godzilla versus King Kong should be shared value, shared mission with mutual trust and we should look like this. Thank you so much, Dr Cho. Thank you so much. This was wonderful. Um I have one question before I open it up for the rest of the audience. So uh the guidelines have recently changed in terms of which patients do we offer tavern or server? And uh and the age limit has become a big hot topic of discussion, right? So the guidelines say between 7065 and 75, you know, you have to make a decision below 65 Sabir after 75. So you've talked a lot about the concept of a lifetime management. And if you get a patient, 65 or 70, how do you think about the future? How many valves are gonna get? So, do you want to just elaborate a bit about that concept? And how do you approach those younger patients? Right. No, thank you for that question, Ronnie. So the lifetime management concept has been booming and you know, whatever meetings you go, people talk about this. But in the past tavern was only used on 80 year olds and they got one valve and they typically died with that valve. Right. But now we're, now we're putting these valves in on 65 year olds. And assuming that the tavern valve lasts about the surgical valve durability similar to the surgical valve durability. These patients who got valve at 65 will need another procedure at 75. And, you know, should they get surgery or tavern at that time? And as I've shown briefly, um, if you try to take out that tavern valve, at least we know as we know so far that risk is not negligible, right? So, should we be thinking about surgery first in those patients and then do a valve and valve Traver when the, when that valve fails? I think that's sort of the concept of a lifetime management. Um, to answer your question in a very short brief form. I don't think we don't know anything that this time we don't know how long these valve and valve taverns last in the first of all. Um, and also we don't even know how long these Tavern valves last. So I think we're still scratching the surface of it, but I think it is important to think about the second procedure when you're doing the first procedure. I think that's what we're starting to recognize. So if you have a patient that will have zero chance of getting a Tavern and tavern when they're very young, then you might want to be thinking about surgery and those cases potentially with root enlargement, um, to, to ensure that they will have second procedure done per cutaneous lee. And the guidelines do say that patients less than age 65 should be considered for server. But again, that's just a guideline, right? And that's just a piece of the guideline. That's not the entire perspective of guidelines. So age is just one piece of it. Um, if the patients under 65, but if they're higher risk, they should get tavern. Um, in my opinion. Um and if the patient's age is less than 65 and if they have perfect anatomy for tavern, I think those patients can get tavern only if they will be a candidate for future tavern, tavern. Um so I think there's more to learn. We're gonna hear more and more about this in the next 5 to 10 years. I think that's gonna be the next hot topic for, for travers. Hey, good morning. Thanks for that and Latin discussion. Um You know, it's a hard feeling cardiologist and someone who spends a lot of time taking care of bad patients and patients with severe ph and stuff, probably spent a lot of time looking at RV function and so on. And I would say during training, I probably learned the most about RV physiology by scrubbing into the, you know, transplant and bad procedures and mostly from the surgeons because they do a lot with RV, try custom involved. It's a whole different ball game, so to speak, you know, the leaflets are thinner. Trans ethical approach is probably not going to be optimal. Um You don't have as much support and, and that kind of stuff. So as we look at getting into the tri custard space, which I think we do need to get into, I think this represents an opportunity for the surgeons and interventional is to sort of get back together. Um And as we know to the imaging of the track and survive is somewhat suboptimal and T E. So you may have to involve ice. So what are some of the lessons we've learned from what we've done with the metro and aortic valves that we can put to try to improve what we can do on the right side for these patients. And how do we get the team back together and, and how do we apply some of the stuff we've learned in terms of the heart team approach? Yeah, I know that's, that's very, very hot topic. Um like I said, I think in the next five years, the the hottest field of structural heart will be tried to spit. There's, there's no doubt about that. And part of it is because we just don't do a lot of isolated valve surgeries. Um you know, as you've seen, we do about 5000 aortic valve surgeries, over 20,000 mitral valve surgeries. Track is if it's isolated, it's about 500. So we just don't do too many. And that's because these patients have poor outcomes. Um their RV dysfunction with pulmonary hypertension, they just don't really have the reserve um to treat them. So, to answer your question, I think a couple of the lessons that we learned from aortic valve and mitral valve that we can use for Eric valve. I think it's a concept of the heart team. So, you know, having both the surgeons, cardiologists and having the heart failure, cardiologist will be critical. Um in those cases, learning from the mitral side, it is the importance of guideline directed medical therapy. Um I think that's, that's what it really comes down to in terms of trying to spit. So what we have seen so far, um and again, you know, none of these clinical trials both try illuminating Tristan has been finished. But from, from what we have been involved, these are some of the things that we've learned. Some of the TRS. If you maximize medical therapy, they go away. So I think that's the first thing that you have to attempt and the RV, dysfunction is actually a very, very critical aspect, especially when you're thinking between replacement and repair. So when you do a replacement of that trick, a spit valve, usually that tr completely gets eliminated. So it just goes away. But this trick, a spit valve sort of work as a pop off for that RV. So if the RV, squeezing these, having that tr will make that R V a little more happier because they have no resistance going backwards. So RV can squeeze a little more. But when you take that off by replacing that valve, sometimes the RV gets shock, um it just doesn't move. So in those cases, we've had some struggles after replacing the bicuspid valves. And I think those are some of the things that we need to learn um moving forward. Um and also maximizing that, that medical therapy, we also have seen that the annual list of the valve has shrunk like geometrically. You don't see that too often in mitral, but did they get big and small very quickly? So I think those are some of the things that, that we have, you know, we can learn the less that we've learned from the left side of valves to the right side of valves. But I think there's a lot of things that make that right side valve, the valve specifically um that is very appealing to treat in the future. Number one is the less surgeries that are being performed. And number two, you don't have to do trans septal access. And um you know, these patients don't really have any other options um when they have severe RV, dysfunction. So, yeah, that was an amazing talk. Um And it's, um you know, as you were talking, I was, you know, frankly learning a lot and I love the anchoring and history and some of the, some of the concepts that you elaborate on, but I also was feeling actually pretty proud of our structural team here because the way it's evolved is that it is actually very efficient. Um, when folks are seen in clinic together. And I just wondered if, um, I know Dan Winston. Um, and I don't know if Panov is here but with Ronnie Dan and Pry Nav and Kyle, um, I think we've, we've developed a very, very strong team to try to get that, that efficiency you're talking about and also that team structure. Um So I know we only have a few minutes because we gotta get you over to get the interview done. But I wondered whether either Ronnie or Dan had any additional comments about the way our, our program is run. Would you mind taking this up there? Thank you. So, the, I actually thought about that slide when you said that, I think we, we run extremely efficient. Um, we, so if Ronnie and I are in the clinic together, we would, we kind of, we probably know what we're gonna do before we even go in the room. We look at the echo, we look at the history. We oftentimes see the patient walk in from the door. So we kind of have that concept before we go in and we actually go in together And sometimes that, you know, 90% of the time, I would say maybe 75% of the time that preconceived notion is already made. And we agree when we get in there, now, we will change that sometimes when we go in there. Um But that does really improve our efficiency. And I think the patients like that and we're both in there at the same time and the cardiologists and the surgeons are working together. This is a hard team approach and they, I think they really, the families like that as opposed to hearing two different things at two different times, we're hearing everything upfront together. That really makes a big difference. No, I think, um you know, I've seen a lot of structural programs and there certainly is structural programs that are completely dysfunctional and there are programs that are very, very functional and it really depends on, like I mentioned in my talk, it really depends on each of the individuals. So if they get along and if they have good teamwork, they have mutual respect, it just works and we know it, um there are a lot of high functioning heart teams that really has provided really good patient care and that's what we really want. And you know, it's, it's good to see a model here. I think the next step that we're gonna be seeing is increase in the volume. I think we're all seeing increasing the structural valve clinic volume just because the cardiologist, like I said, um rather than referring to specific individuals, they just want to refer to the valve clinic. That's just so much easier. And that's, that's been happening throughout the country. And as you saw in that volume imploding in the travers were we're gonna see more and more patients in that structural clinic and we just have to improve in that efficiency so that we can see those patients in timely fashion. I think that's, that's, that sounds like, you know, that's where you guys are going, which is much, much higher level compared to some of the other programs. Uh Yoshi perhaps you can comment a bit about where you see the role of the cardiac anesthesiologist within the heart team, especially with the new devices and new technologies and the role of imaging. I know Brigham, um you know, the cardiac anesthesiologists are heavily involved and I think that every program has that same concept. So I just kind of curious about what you think about the role of a cardiac anesthesiologist, right? Um Who does the cardiac imaging for Eclipse is a cardiologist that comes out both mostly cardiac anesthesiology for us? Okay. Okay. Um The cardiac anesthesiologists are important for two reasons. Um One is, you know, for cases that the anesthesia is needed. Um If they have no skin in the game, going back to that skin in the game, they will take their time and they'll do whatever they just don't care, they'll treat it like any other patient. But you know, we have our own dedicated structural people um for our cases and when they are involved in try custom cases, metro clip cases, they are so excited, they would just call us like the day before. Um You know, what are you guys doing today? You know, what can we show you? Right? It's that skin in the game that really changes it. Um So I think from the anesthesia aspect, it's very important to have a dedicated person. Um The second aspect in our institution is the imaging and I think you alluded to for the for the tri caspit um similar to my troll. Um you know, the taverns guided by flow Rosco p micro clip and Tricastin procedures are echo guided. So we just need a good imager for these procedures. And if your cardiac anesthesiologists and imager, then you have to have them involved so that, you know, they'll, they'll join you, they'll join the discussion, they'll, they'll chip in and by doing that, they will show you a better image next time, right? Um They will know what you guys are thinking the next time. Um So I think from that perspective there, I think there are two different components of cardiac anesthesiologist being involved. Um Once the anesthesia aspect and the other side imaging aspect, and if your cardiac anesthesiologist is an imager, you have to include them in a hard team. Um I think that will make your team more diverse um and having their skin in the game. Alright. Well, I guess uh we are done with questions. So Yoshi again, thank you so much for coming and giving us this wonderful talk. Um And uh thank you everybody else for, for being here. Thank you all.
