Join Habib Samady, MD, Ronnie Ramadan, MD, and Tsuyoshi Kaneko, MD as they discuss further the Cardiovascular Grand Rounds presentation given by Dr. Kaneko at Georgia Heart Institute on the future of structural heart programs.
Good morning. I'm Habib sanity from the Georgia Heart institute. And it's my privilege on this morning of May 4th to host Dr Yoshi Kuniko from the Brigham and Women's Hospital in boston. Yoshi are currently surgical director of the structural program. And you just delivered a phenomenal G. H. I grand rounds and with us is Dr Ronny Ramadan, the director of our structural heart program here. So Yoshi welcome. Thank you and Ronnie. Thanks for joining and hosting Yoshi and inviting him down. Absolutely. I'm excited to see Yoshi. I've missed you. It's been a couple of months months to have you down here in Georgia. Yeah, thank you for having me today. Well, Yoshi, what a fantastic talk. And I think the title of your talk was, you know, the structural heart program and how whether surgeons and cardiologists can coexist. Um, so as a cardiac surgeon and leading the structural program at the Brigham tell us why it's important for cardiologists and surgeons to coexist and work in this incredible space that we're in structural heart disease, you know, so as I mentioned in the talk traditionally the surgeons and interventional cardiologists were enemies. That's we fought over patients. Um we fought over procedures and we were never really a team. Um despite the fact that the heart team concept really started with coronary disease. But with the creation of Tavern, we have this concept of heart team that really solidify within a lot of the institutions. And we have done a very good job so far of keeping this heart team structure and the question is can we keep this in the future and it really depends on how the surgeons and the interventional cardiologist get along and can coexist. No. And that's so true and Ronnie, I know you've lived this to both in boston and now here in Gainesville at northeast uh Georgia health system. Um so um you guys coexisted in boston. Um but tell us, what what are the secret ingredients? You talked about trust. You talked about the importance of diversity and the team. Um how do you ensure that that comes together? How do you sustain it? How do you put the team together? So I think that, you know, as I mentioned, I think trust is very important, but also at the same time, you know, we have to have a value in that both as an individual physician and also as a March, larger advantage view. Um so from the individual standpoint being in the team, you know, will create more teamwork, more collaboration. Right, realistically, you will get more referrals from the, from the cardiologists that you're working with. Um there's gonna be more interaction with the people that you want to work with. Um I think there's gonna be a lot of benefits from the individual level. And then I think there's another sort of advantage point um advantage view that you want to make sure that, you know, from a patient care standpoint. Um we're going to provide the best care by having two experts providing their opinions and based on the most recent evidence, what can we do to to provide the best care to the patient um you know from the program standpoint I think there's more and more pressure to do more cases, but at the same time as a team you'll be great as a team, not as an individual. So I think there's a lot of incentive from different standpoints um that will benefit this and I think having that value is so much important to making this really successful and I'll be really interested to hear what Ronnie thinks too. No, I completely agree. And you mentioned the the joy of working together. Right? So I think once you have that bond between your interventional cardiologists, your surgeons doing procedures, you develop this bond that you actually enjoy doing these cases together, you enjoy coming to work seeing patients together. So I think that adds another element. I mean obviously it's important for patient care and doing the best thing um as a as a team but also enjoying work and and working together. I think it's a definitely a big plus I know that you have that you know you and dr shaw Brigham, you guys are like you're like twins, you know, so I think it's it's really crucial but yeah, well okay, so let's pivot a little bit. Okay, so we've established a team effort and it's important to say that here Georgia heart, I think we've got a very strong, you know, team as well, Ronnie that you and Dan Winston and Africans are Kyle Thompson, the whole team and Alan Wolf. Right Allen, who is a phenomenal open surgeon. But let's pivot a little bit and just talk about the substance of this incredible field of structural heart disease. Right. It's, you know, it started 2030 years ago um and it's really expanded. Um I personally, as someone not doing those procedures, I'm fascinated by not only the tip of the iceberg, which is kind of where you see the sickest patients, but with the explosion of, you know, heart failure, these, you know, moderate valvular lesions that are, you know, whether it's metro as well as the complexity of assessing even ma severe aortic stenosis, low gradient aortic stenosis, and and it's become such a niche area with so much physiology, so many different sort of treatment options, whether it's medical, surgical or per catania's, that it's almost become the realm of the specialists in the valve clinic. So, talk to me a little bit both of you about how do you see the intake of valve patients as the years go by in the next five years. Yeah, absolutely. So you're absolutely right. I think I think it's um I would say it's a pandemic of heart failure patients that we're seeing and the concern that I personally have a lot of the patients that come to us with moderate um our moderate tr they're often not recognized as as a as a potentially an entity that's gonna become a lot worse down the line. And those patients are not receiving the care that they probably should at that point because you know they have a lot of other issues. They're often have heart failure. So there's a lot of focus on a lot of other conditions and what I what we're trying to actually do here at the Georgia Heart Institute. We're trying to develop a specialized clinic that we are calling. A cardiomyopathy Bachelor cardiomyopathy clinic. Were basically the heart failure dots the cardiologist the images, the interventional cardiologists and the surgeons could actually all see those patients at the same time. Because they're very complicated and trying to make sure that we do all the proper therapies medically potentially interventional like C. R. T. Or P. C. I. If they need to and then determine the appropriate timing when a potential procedure like a metro clip or track speed intervention might be timely for those patients. So I do think it's really important to identify those patients treat them early. Follow them. Because if you don't what we've seen, they come to you very late in the game at a point where they're LVs are or RVs are really in bad shape and they have no options whether pre cutaneous or surgical. I'm curious what you think about those patients. You know I think in the field of Tavern the next field in Tavern will be the asymptomatic severe stenosis. So there's been a couple of papers on the surgical side recovery trial and there was one more that came out recently avatar trial that both showed that asymptomatic severe A. S surgery early surgery provide Better outcomes. And there's a clinical trial on the tower side early Taber trial that closed. Um that will be probably presented in the next 12 months, 12-24 months about the results of asymptomatic severe aortic stenosis treating them early. So I think that's the next field. And then what you're talking about with the moderate aortic stenosis before reaching that severe is probably the next frontier after that. There's been some early evidence showing that even those patients don't do well if they have moderate A. S. But where is where is going to be the line of doing procedures in these, you know, moderate severe patients that are asymptomatic. I think that's that's something that we will see in the next 10, 15 years um in my opinion. And for us to do that, I think what you guys are doing is sort of pioneering this to have a non interventional cardiologist being engaged in the structural clinic in the heart team clinic. I think that will be the key moving forward. Um And we have a couple of them involved. Um It's gonna be very difficult, how we're gonna incorporate them with the efficiency that we want to provide to the patients. That's something that that I think we're gonna have to think about a little more in the future. Oh that's exciting. So I think you covered the metro tri custards and Yoshi. You you even extended that in the aortic space. Um Well um okay, so here's another question for the two of you, particularly Yoshi you is a, you know as a cardiac surgeon who I think we were chatting earlier, you spend 60% of your time doing open procedures, surgical procedures and 40 per Catania's. Um Obviously the the what the value that you bring to the table is you have and all of the above treatment strategy for the patient. Right. Right. You have all the perks cutaneous options and then you have Catania's failures and you have surgical options. From a surgical perspective. How realistic is it for surgeons to maintain that diverse skill set and how big of a program do you need to have that level of expertise? You know, as joe bavaria who was one of our sts president said there's no T in Taber anymore. Um Tavern has become the A. D. R. Um in this day and age. And for for the graduating surgeons if they're gonna do a valve, I think they just have to be involved in this structural space. That ratio. You know how much of surgery you're going to do and how much of a trans catheter therapy you're gonna do will really depend on number one how your practice is. Um, and number two what your interest is. So I think depending on what you want to be, I think that percentage will change if you want to be sort of expert and structural heart. I think that percentage has to be closer to 50. Um if your main Selling yourself as a valve surgeon but also want to be involved in that, you know, cutting edge technology, I think that percentage will be lower than 50%. So that's a hard question to answer. I don't think there's any perfect answer for that one. But one thing that I know for sure is that I think the surgeons we have to have a value and providing that surgical option definitely is one of them. Yeah, it's fascinating to me as someone who doesn't do structural work, not only how explosive the structural field is, but almost how the lines between surgeons and interventional cardiologist is blurring to some extent and the structural field. And yet as a surgeon, when you're on call, you need to also be able to take care of the bypass stations. And so in the coronary space, um, you know, I think although we work really closely with our sir surgical colleagues, we don't double scrub, we don't routinely see patients together and I don't know if I think the coronary feels mature enough that that's unlikely to develop over time. But so how does a coronary surgeon retain their coronary skills particularly that a lot of those easier coronary cases are done per Catania slee and really the tougher cases are going to surgery. Um As I mentioned in my talk to heart team concept started with coronary and I think the the actual heart team in coronary will look a little different because you know it doesn't mandate the Pc. I does not mandate having a surgeon in the room. Um you know vice versa. So I think the hard team on the corny side will probably be a little different but you know what what we have been discussing at our institution is to sort of have the coronary team whenever there is a complex in C. A. D. Um Of course the guideline recommendations with left main and three vessel disease. You know we can make it very very simple. But you know before I came down to Atlanta yesterday I did see a patient that was 79 morbid obese for vessel disease but was on a wheelchair and you know her husband was treated with Pc and she had a strong strong interest of being treated with P. C. I. Was she inoperable. No but at the same time you know she was high risk and I spoke to one of my interventional colleagues and you know he was willing to do it with two stage procedures and are we providing the best care for the patient? I think we are by doing that collaboration and heart team approach. So I think the the team may look slightly different from the structural heart team, but I think there's room to grow a coronary heart team as well. Were wonderful. What a great note to end on. I think we've covered you know, a lot about structural, you know, where the fields going, why the importance of the heart team for structural and brought it right back home to the coronary heart team where it all started. So with that, thank you so much for coming and giving phenomenal talk when we look forward to seeing more in the future. Thank you so much. All right.
