Tag Archives: PARTNER

Let’s Hear It for the Heart Team

A relatively new, somewhat revolutionary concept appears to be quickly crystallizing for cardiac disease management: the Heart Team. Simply put, the heart team is a collaboration of interventionalist cardiologists and cardiac surgeons (and maybe non-interventionalist cardiologists too) at a single center who work together to combine their endovascular and open-surgical skills in a collaborative and complementary way to give patients optimized treatment that thoughtfully combines the best of both approaches.

The heart team concept has even given birth to a related, new phrase: the hybrid cardiac suite, which is the ultimate collaborative site, a room that accommodates both endovascular and open-surgical procedures under one roof.

Peaceable Kingdom By Edward Hicks/courtesy Wikimedia Commons

It sounds great and makes a lot of sense, but until very recently seemed to be the stuff of dreams, as endovascularists and surgeons traditionally acted as worst enemies, jealously guarding their turf and touting their approach as best.

Those days now may be coming to an end. Get ready to root on the heart team.

When I covered the annual meeting of the American Association for Thoracic Surgery in Philadelphia earlier this month, it seemed like I kept bumping into the heart team idea. There was a report from the PARTNER study, which compared endovascular aortic valve repair to open-surgical repair, and relied on heart teams to run the show. PARTNER, a U.S.study, is also credited with providing fertile ground for the heart team idea to take root in America.

In Europe, the heart team concept got jump-started by the European-based SYNTAX trial, which compared coronary stenting and coronary bypass and relied on a heart team at each participating European center to run the trial. The SYNTAX spirit of cooperation led the major European cardiology and thoracic surgery societies, the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery to last year co-write a new set of guidelines for managing coronary revascularization, and endorsement of heart teams is a key feature of those guidelines. These days, in routine practice at the Thoraxcenter inRotterdam for example, a heart team meets every morning to discuss the pending coronary cases and how they’ll be managed, said heart surgeon A. Pieter Kappetein at the meeting.

Heart teams also got mentioned at the meeting as the new way that patients with ruptured aortic aneurysms are getting managed at selected U.S. sites, as endovascularists and surgeons quickly decide on the best way to treat an emergency aneurysm rupture.

Will U.S.guidelines soon appear that follow the European lead and give a formal nod to heart teams? Yes, said John D. Puskas, chief of cardiac surgery at Emory in Atlanta and a member of the joint American College of Cardiology and Society for Thoracic Surgeons guidelines-writing group that will soon issue their recommendations. “The new guidelines are embargoed, but all of the cardiologists and surgeons who wrote the U.S. guidelines read the European guidelines with interest with respect to the heart team,” he told me.

Will the concept catch on for U.S.practice, after so many years of catheterist-surgeon animosity? Dr. Puskas said yes to that too, citing the changing character of U.S.medical practice as a major factor easing the transition.

“Cardiologists and surgeons are being bought by networks and are becoming salaried. That will lower the barriers that have led to competition. I think we’ll see better collaboration in our specialties than ever before. It gets down to patient-centered decision making.”

—Mitchel Zoler (on Twitter @mitchelzoler)

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Filed under Cardiovascular Medicine, Drug And Device Safety, Health Policy, IMNG, Internal Medicine, Internal Medicine News, Practice Trends, Surgery, Thoracic Surgery

Keeping Score on the STS Risk Score

The Society of Thoracic Surgeons has a formula for estimating a patient’s risk of dying following cardiac surgery, the STS Predicted Risk of Mortality score. Some new data reported during the past 2 months suggest that the score doesn’t predict death as well as some experts thought. It looks like when it’s applied to very sick patients, it may produce an overly pessimistic estimate and predict more deaths than patients will actually experience.

"Death's Door" by William Blake; courtesy Wikimedia Commons

A patient’s mortality risk score derives from a list of 30 clinical and demographic inputs, factors like type of surgery, age, sex, hypertension, diabetes, cardiac history, vascular health, hemodynamics, etc. Based on all this, the formula spits out a patient’s probability of dying during the 30 days following the proposed surgery.

The PARTNER trial enrolled patients with severe aortic stenosis to compare a new technique of percutaneous aortic valve replacement with standard open surgical replacement. An initial report on results from the randomized portion of the study occurred last month at the annual meeting of the American College of Cardiology, and some more details on strokes and other neurologic outcomes got reported a few days ago at the American Association for Thoracic Surgery’s annual meeting in Philadelphia.

The patients entered into PARTNER were very, very sick. Their average age was about 83 years, and about 95% had the two highest grades of heart failure, New York Heart Association class III or IV. Their STS risk scores were also high, averaging about 12, which meant these patients had a 12% predicted risk of dying during the 30 days following open surgical replacement of their dysfunctional aortic valve.

These patients “were probably the highest 10% of risk on the STS score,” said Dr. D. Craig Miller, the cardiac surgeon who presented the neurologic data at the AATS meeting. “STS scores have never been validated at this extreme. Never before were enough patients [with scores this high] operated on to validate the STS score ” at this level, Dr. Miller said.

The reality was that the scores broke down. Instead of having a 12% 30-day mortality rate, the patients who underwent open surgery had about an 8% death rate. “We were pleasantly surprised by the low death rates,” at least in comparison to what the STS scores predicted, he said.

The only caveat to this good news was that the less-than-dire outcomes of some patients might have been very specific for the high-level treatment that patients received at the 26 centers that participated in this carefully structured trial. “What would be the results in the real world? That remains unanswered,” Dr. Miller said.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Filed under Cardiovascular Medicine, IMNG, Surgery, Thoracic Surgery