Chapters Transcript Video Heart Team Approach to Coronary Disease Left Main Dr.Clinton Kemp shares case studies showcasing the heart team approach to left main coronary artery disease. Doctor Levine has already showed me up because I do not have any pictures of my family as thank you, but they are, they are alive and well and enjoying today nonetheless. Um Thank you all very much for the opportunity to be here with you. Uh I know a lot of you in the audience, but I think a lot of you thought I might not actually own regular clothes because some of you didn't recognize me. Um I'm Clint Kemp, one of the cardiac surgeons at Sana. And today we're gonna talk about the heart team approach to left main coronary artery disease. So in terms of disclosures, I am a cardiac surgeon, ok, unapologetically. So as my wife would tell you, but this doesn't mean that every patient I see with left main disease needs an operation or gets an operation. One treatment approach does not fit all patients what's best for one patient may not be even close to remotely possible in another patient. There are times where cabbage PC I or even a hybrid approach are best and the optimal care comes with a heart team approach. I will tell you, you know, the, the concept of a heart team is something that's been interesting to me because cardiac surgeons and cardiologists have worked side by side for 50 years before TVER and TVER. I think truly brought us all together as a heart team mainly I will say because it was mandated by C MS. But we've, but, but we've actually taken that one step further, at least at Centra, we do have a true heart team approach in lots of arenas. I see some of my advanced heart failure colleagues here for which we have heart team, my structural heart colleagues for sure, and my interventional colleagues as well. So formal or informal, the heart team is the way to go for most things including Left main disease. So we'll go through several case examples and show you why. It's not always. Hey, this patient has left Maine. Let's book them for a cabbage, right? We'll talk about a 79 year old with COPD and chronic renal insufficiency. And by the way, these are all real examples of patients. We'll talk about the left Maine and a 58 year old who's a great surgical candidate, but self-employed can't necessarily take time off to recover. We'll talk about a patient who comes to the clinic with left main disease, doesn't have the work up completely uh finished. And later on gets an echo shows that he has severe aortic stenosis. We'll talk about somebody with Left Main disease who is found to have an ef at 10%. And then what do you do with this patient? This is, this is a conundrum for cardiologists and cardiac surgeons. Someone comes in with an inferior sty clear culprit RC. A, open it up, think it's all great. Shoot the left side and lo and behold, they have residual left vein disease. What do you do with that patient? So, general thoughts about this, obviously, you need to have an indication for intervention, right? Um Typically, and conventionally, it's been geographically based. Um Some of the things my colleagues are doing with IVS with all of the, the uh fractional flow reserve measurements and things like that have really revolutionized how that goes. And I think you're going to hear about that from some of my colleagues later. In addition, not all left main are the same osteo and proximal left main is not the same as distal, left main. And it's certainly not the same as functional distal left Maine with true osteo led or circumflex disease. When I look at a patient, I look at two things, I look at operability and survivability. And yes, those sound like made up terms, but they're actually real. So operability is can the operation be done right? This is mainly technical, it's done with work up. The left heart catheterization shows me a lot of things. It shows me stenosis, it shows me the quality of the vessels are they calcified? And then it shows me the target vessels. Do I have an area to land in left main? It would be l ad in any of the obtuse marginal branches. Do they have on echo, sufficient cardiac function to tolerate cardiac surgery? So all of these are things that can be done with testing, survivability is, is a little bit more difficult and this is, will the patient benefit? I often tell patients and it's true. The easiest part of an operation is the cutting and sewing. That's something that you know, to Malcolm Gladwell's point, you do 10,000 times, you get pretty good at it. But the question is, will the patient benefit from it? You don't want to win the battle and lose the war? Nobody's benefited if you have perfectly functioning grafts in a patient who's on ECMO or a patient who still has cardiomyopathy or worse is trached or has had a stroke or things like that. So these are trying to separate the patients for whom it's technically possible. But there is a high morbidity and mortality associated with it. Operability again is really based on testing PV L testing echo, left heart cath, but survivability. There are a couple of things that we look at in terms of whether a patient is a true surgical candidate. So I want to point out the sts risk calculator for some reason. This just seems to be so mysterious and so strange and so unavailable to people. But it's super easy to use. Just put it into the google sts risk calculator, you'll get the site anyone can use it. This is a morbidity and mortality risk calculator and it's really powerful. It's based on the adult cardiac surgery database from the society for Thoracic thoracic surgeons and it's updated every three months. So this is real time, data, cabbage valve and even combined cases, cabbage, a VR cabbage mitral valve, things like that are included. And most importantly, you can answer those questions that the patients and their families ask you. How likely am I to be on dialysis? How likely am I to be to have to be intubated a long time? How likely am I to die? This traditionally has cohort of patients into low medium and high risk and this is really for mortality. So low risk is less than 3%. That's great. Intermediate risk is in between three and 8%. High risk is greater, greater than 8%. And the interesting part about this is if you have a patient with an sts of 15% or even say 25% if you're a betting person, there's a 75% chance they'll make it through the operation. All of us in this audience know that an sts a 25% patient. It's not just the mortality in there. It's the added morbidity that comes along with it. So it's really more of an exponential scale. A couple of things to keep in mind is not every case type is included in the calculator. We don't have things like ascending aortic aneurysms for reasons. I still don't understand the AC C and the STS does not have a good, have a risk calculator despite having hundreds of thousands of patients in the database. I know there's people far smarter than me out there who can take these and come up with a calculator, but that's one we really need. And some comorbidities aren't included, things like cirrhosis, things like pulmonary hypertension, things that make any sort of an operation much more difficult and increased morbidity and mortality unfortunately, aren't in the calculator. So just taking a look at what you get when you do put this into Google and you get to the sts risk calculator, ok. They just redesigned it about a month or two ago and it's a website and I know this is a busy slide and you probably can't read everything, but essentially there's several things that you put in. And again, this takes literally 30 seconds to do the planned surgery. What am I gonna do? Cabbage? Ok. In the surgery incidents. Is this a redo, is this the first time? What's the priority? Is this somebody with a balloon pump with ongoing ischemia or is this somebody I see in clinic then demographics very easy laboratory values as well, pre-op medications and then other risk factors and comorbidities. Things like diabetes, things like. Is this an endocarditis case. Are they a smoker? Um And then finally, things like coronary artery disease, arrhythmias and, and what this does is it generates what's now a PDF that you can print out and give to your patient if you want or you can even put it in the chart. That's what a lot of our pre op uh nurse practitioners will do because it's helpful for everybody on the team to see exactly what we're talking about. And this is completely transparent, very easy to do. And it's something we do as surgeons when we're evaluating a patient. But if anybody has a patient and they want to know, boy, I wonder how risky it would be to have their mitral valve repaired or their cabbage done. It literally takes 30 seconds. You generate this and there you are. So getting back to some of these cases and some of my colleagues in these in this room will remember these cases. This is a recent one, a 79 year old female who had a nonstemming after a knee replacement, ok. Had a balloon pump placed was sent over to the heart hospital on c she had a very heavily calcified mid to really distal left me and going into the L AD on echo, she had great function Noval or pathology. And I'll tell you on left heart cat, she had fantastic targets, ok. However, she had COPD, chronic cough, chronic renal insufficiency and impaired mobility. Sts at 25%. So this is one where operability for sure was there. Technically, absolutely could do survivability was not. And again, getting back to the heart team approach, this is one where I'm glad to have colleagues like doctor Summers who took her to the Cath lab got a fantastic result um with PC I and got her through the procedure. This is somebody where we were not going to be able to take them through, through an operation safely and she got the treatment she needed with the heart team case. Number two, also, Doctor Summers, I'm picking on you today. Um, 58 year old who came in with the nonstemming. Ok. He had proximal left main disease, echo could not have been better. No valvular pathology. Fantastic conduit on mapping. He had radials, he had bema, he had every possible opportunity for us to surgically revascularize no significant comorbidities. This is one where I got the consult from the office. I looked at it without meeting him and I said, oh, no problem. When's my next available or date? Well, go talk to him and he's not afraid of surgery, but he's self-employed and he's 58. And I tell him there is some convalescence after surgery. You're absolutely going to be in the hospital 5 to 7 days, a couple of weeks recovering. Really can't get back to what you need to do for about 6 to 8 weeks. And he said, gosh, doc that sounds great in terms of fixing my heart, but I'm going to lose my job. I'm gonna lose my company. I've got bills to pay a family to support this. This is another one where with the heart team, we decided what was going to be best with the patient along with the patient's wishes and don't get me wrong. Neither of us would do anything that wouldn't benefit the patient just for patient convenience. But this is one where he said, you know, I realized that I should have surgery. But if we can do stenting, even if, if you, even if 10 years down the line, we need surgery, I'm going to be retired by then and my grandkids can help take care of me. So that was the right decision for this patient. Here's another 1, 77 year old with the Angina was worked up with a stress test, had anterior ischemia, had a left heart cath with distal, left main disease, came to clinic before we had the whole workout. Sts for a cabbage alone was about 4 4.5%. So again, in that intermediate risk category, not to the point where they weren't operable and they didn't have survivability benefit, but we didn't get an echo yet in the echo. He was found to have severe A s right. So that changes. Things was a former smoker PFTs with mild obstruction, chronic renal insufficiency with a creatinine of 1.5 and functional and reasonably active. So this is another great one for the heart team, right? Some of these, if it truly is an sts, it's elevated, it's proximal or even osteoma PC I and TVER. Basically because of his coronary disease that was truly surgical in nature, we essentially recommended that he undergo a cabbage, a VR despite an sts six. And that's what he did and he did well, again, we can't do that without having a heart team where we look at all the available options. Case number four is a 73 year old who presented with a non sty, he had distal left main disease but very poor distal targets. We knew that his function wasn't going to be good based on left heart catheterization, but his ef was 10% he had a dilated LV. His cardiac MRI surprisingly showed 60 to up to 80% viability in all territories. So how to mix cardiomyopathy for sure. Um, reasonably active had some comorbidities and here's where some of the sts calculations don't make sense. I can tell you right now, this gentleman has a 50% chance of mortality after cabbage, not a five. And the sts did calculate out at five. So you have to use this with a grain of salt. And I will tell you we have a very nice conference every Thursday with cardiologists and some of the cardiac surgeons attend. And this is when we presented and it was kind of like here you take it, you take it. No, neither of us want it. It's not gonna work. And we finally decided, you know what revascularization is not going to be in his best end because we don't think he'll get through a cabbage. We don't think he'll benefit from percutaneous revascularization. So we switched gears to a different hard team approach. Had our advanced heart failure service come in and lo and behold, he's being worked up and he's going to get uh an L VA in the next couple of weeks. And then finally, 62 year old who presents with a classic inferior stemi goes to the Cath lab. There's a culprit, mid RC A inclusion and that appropriately so is fixed first, beautiful result, no residual disease on the right. When they go to shoot the left, there is mid to distal left, main, right, not 90% let's say 60%. I can't remember exactly what it was echo show normal function, no valvular pathology, active smoker, but no other comorbidities. Sts eventually checked out at 1.8%. This is one where actually where I got a call from the interventional cardiologist and said, hey, can you come down to the Cath lab? Let's talk about this patient. And I really like that because we laid out all of the options both between the cardiologist and myself. But eventually with the patient who was stable after the sty was fixed and we decided in the end that it would be better given how young she was and noncritical left Maine to allow her to convalesce and let her stent heal and come back later for a Lima to led and a radial to her om. So she got complete revascularization. So closing thoughts, not, not all left main stenosis are the same, not all patients are the same cabbage P CIA hybrid approach or even other treatments are what we will do for these patients. And the heart team approach as I hope to have illustrated is ideal for the left main disease, no family pictures, but I'm happy to take any questions. I'm the only surgeon, so I get to say what I want. But you guys can also give me as much flak as you want. I don't, I don't, I don't have a backup up here. Sure. Hi. Just, yeah. So that's interesting. Um, it wasn't so much that they were cleared. It was, they didn't have the work up I think necessarily to find coronary disease. And, and this is tough. I do lung surgery as well and a lobectomy is relatively higher risk. There's still no clear guidelines for what a cardiac clearance needs to be. Um I don't know because I wasn't there in the pre op for the orthopedic visit, but typically what I do for noncardiac surgery is I asked him about symptoms, family history, risk factors, things like that nonetheless. You can still have a completely normal or relatively normal stress test with balance three vessel disease. So this was a surprise to everybody. And interestingly, she got through the actual surgery itself, which is the most stressful and it was really as she was convalescing working with PT afterwards that this showed up. Yeah, a couple of questions first, I didn't see that you use syntax score on that. Can you just speak to that for everybody's benefit? And are you using that at all? Sure. Um That, that's, that's a great question. Um Carrie and actually Paul and I were talking about this beforehand. Um We, we don't actually calculate the syntax score. We all know what syntax scores are. It's essentially a measure of the severity of coronary artery disease. So similar to the sts risk calculator, it gives interventional cardiologists and frankly surgeons an idea of how complicated the lesions are to treat. Um We don't actually use that necessarily in the work up, but more, you know, if it's an osteo or a proximal left main, you know, very reasonable in our minds. And certainly based on the data to do PC I as opposed to an elevated syntax score, even with three vessel disease where PC I might be um feasible but may not be as long lasting. OK. And then the second question is for patients who have left Maine and need bypass versus other people with two and three vessel disease that need bypass is your approach different? And are your outcomes different? That's a very good question too. So, um if we're talking about three vessel disease or multi vessel disease, I'll just say to, to me it comes down to the severity of the L AD disease and whether they'll benefit from a Lima to L AD. Right? That's a whole separate talk. But essentially I could give that same talk about multivessel disease and it's every patient with multi vessel disease should get a cabbage or does get a cabbage. Right? If a patient doesn't have in my mind, the L AD disease is what drives me for the most part to think surgery first versus multivessel PC. I, but we've certainly had patients who are, are operable but won't have survivability benefits for whom PC. I will be better. All right. Thank you guys very much. Published October 17, 2023 Created by Related Presenters Clinton Kemp, M.D. Sentara Mid-Atlantic Cardiothoracic Surgeons View full profile
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