Chapters Transcript Video Introduction to Sentara's TAVR Program Dr. Matthew Summers provides the program history of Sentara's nationally recognized Transcatheter Aortic Valve Replacement program. At certain points in time, we give grand rounds and it gives uh our, our entire teams and the the system an opportunity to see the start to finish process of how we take care of patients with certain diseases. And what we've recognized over time is that this program has evolved into what it is right now. And there's never been a focal point in time where we've stopped with the entire team and sort of get, get folks to understand the process from start to finish. You all see in our critical and very important parts of the patient's care um during a procedure that most of the time goes incredibly well. But in a very small percentage of time, as you all see, it can be chaotic. We serve a lot like firemen and women. Uh you know, you have to be prepared for those rare instances and be able to be efficient and work in those environments. Uh Because if you're not good in those environments and something like tver uh patients die and you also don't get to see like doctor Kemp and I the patients come in the discussions with the family is always uh the urgency of the matter necessarily because they're stacked three days a week. And then, uh one of the things that, that I wish we could impart on you more is how critically important you are during the procedure or what impact it has on the patients afterwards. Doctor Kemp and I get to see them and then the A PPS get to see them at 30 days in one year. And it's remarkable to see these folks as elderly as they are, as much comorbidities as they have. It's remarkable to see how much better they are doing at 30 days in one year. And so the idea of this educational series is for us to take an intentional pause on things so that the entire team which has evolved into what it is today can understand the process from start to finish if we work together as a team, it's not just ra ra kind of stuff, we work together as a team or more efficient in those rare scenarios where complications occur and we save people's lives in those complications depending on how we work as a team. So this is critically important. Doctor Kemp and I have have thought about doing this for a while and we want to use these next uh two months to sort of outline the process from start to finish. Uh So you all can get a grasp for the, the clinical basis for why we do what we do how we make the decisions we make and understand what a patient sees as they go through the entire process. The other thing to keep in mind, as you can see, there's a full room here. It takes a village to Dover. There's c lab staff, there's or staff. One of the other things behind these series is to get everybody to know each other to know what everybody's and how it does really take both teams to be able to do these kind of complex procedures. And I know sometimes it seems like it's ro and it's very easy, but we take care of some, incredibly, you all take care of some incredibly sick patients and without all of you all and your expertise, none of these patients would be able to get through, I tell people and uh and when we do our consent that it takes literally four people, five people to do a tavern. And we have between 16 and 17 people in the room for every single tver that that extra redundancy built in is for rare complications where the surgical teams, the surgical members of the team that that usually do open cases are critical in life saving. And so in those environments, we are supplying patients with our best possible surgical options and the most devastating of complications. And so every member of this team is literally life saving when we use that extra surplus of team members. But even in the day to day. It's being prepared for those being engaged, uh understanding the process as much as you can like uh all the members of the team. And so this is the, the curriculum that we've, we've outlined over the next few months. Every Tuesday, there'll be breakfast, this will be 30 minute uh educational uh talks just about the basics of TVER it'll eventually roll into as you see, sort of the, the adjunctive procedures, Basilica lampoons those kind of things. Why we do those um, other structural uh heart procedures that occur in the hybrid or? So you're familiar with those. And then we really want to get into this idea of fire drills because that's really what it is. Um, there's five big complications of TVER. You all have seen these because we do such high numbers. But I would like to go through from soup to nuts the entire process of when we see one of those complications. What are the critically important things to do? Um It's not enough to, to say when we're docs looking at these things. Ok. The patient is hypotensive. What are the three or four things that, that can cause hypotension? You're already two steps behind in those scenarios. It's not what are the. Ok. So we have more people in the room watching the team. Can you? Yeah. Uh Amy, can you turn this up a little bit? No, no worries. I think you did already turn up. Ok. Uh text me if they can't hear one of the other things I want to just let you guys know too is, you know, we want this to be, we want these sessions to be interactive. I know you all probably have lots of questions. I hope you do feel free to speak up. We'll have a session at the end of each of these for questions. There's no question. That's too silly because the way we get through these is everybody understanding. And if something happened, you know, during the case that you don't understand, ask one of us, ask another team member because we want everybody to be on the same page for these. You all see this probably when you run codes, you've seen a well co ordinated well run code. That's because it's been practiced up front. Every single person knows the role in those codes. We had a, a very, very bad complication last Wednesday on Miss Sheridan, uh an LV perforation and the entire team was prepared for it. We anticipate it. We, we were worried about it and the, the tenor of the entire room was calm, coordinate, step by step, re evaluation, reassessment, escalating therapies as needed. And that's really what we want. That's what we're capable of. That's really what we want for every potential complication. So we're gonna go through these each week and then we're going to have fire drills every quarter. And this will be an opportunity for us to just practice these things. Um The way that we make already low complication rates even better and become not just one of the best programs, but the best program is in those rare complications when we all serve and work as a team together uh to save people's lives. So this is the, the outline of it. Um And we're planning on doing this uh and recording this so that as we get new team members, they can get acclimated orient to the process as well. What's important here is to understand the breadth of the problem in our area. Basically, we're it in the tidewater area. There are some tower programs that are cropping up at Mary View and at Riverside and they have some incredible operators at those facilities. They are relatively new. The programs within our uh uh Centa system are in Rockingham and here. Um And then to the south, we have Greenville um the triangle and to the north, we have DC. So it's a huge area, 1.7 million people in this area. Um And I think if you make it to your eighties and nineties, there's a good chance that you're going to have some level of aortic sclerosis. So it's a high uh uh uh population, a high percentage of, of folks in their eighties and nineties that have this problem that we're treating. We all know this, we have 563 beds at Norfolk General. 100 and 12 just in the heart hospital with 35 IC U beds, five cardiac cath labs. And then you are a part of a very important but singular hybrid or um where both cardiothoracic surgery can be performed at its highest levels. In anything, uh interventional can be performed at its highest levels. It requires bringing two teams together and having those teams that usually work apart, work very, very well and coordinate together. That's why this is so important. We are one of the largest valve centers in the country, one of the largest structural heart programs in the country. So we all of us um do about 500 tas a year for a frame of reference. Uh The largest programs will do between 607 100 per year. Um We also have one of the largest mitral programs in the country. The surgical program and the trans catheter programs are both at the highest levels as far as volumes and outcomes. And so we're all part of that. We have currently four structural heart I CS, one starting in September. We have one imager and we have currently five A PPS that are critical to the process and that you all have, have met at some point in time. Um That's going to expand to seven A PPS. We have five excellent cardiothoracic surgeons that can do all things uh surgical and that allows us a significant amount of freedom to adapt to new technologies and have a literal parachute in scenarios where they don't go well, so we can operate on the cusp of technology and on uh device therapies. Um Our program began in 2011 and then the Rockingham program started in 2021. This is the team. Uh it's broken up by uh uh cardiologists and cardiothoracic surgeons. There's four interventional cardiologists. Doctor Perique starts in September and Doctor Cohen starts in a few weeks. He's gonna be a dedicated imager. And then Doctor Kemp uh leads the surgeons uh for the T program, the structure heart and then the uh the valve center and, and you all know these, these folks well because you work with them every day in the other ors these are our A PPS. We're critically important, the continuity from when a patient comes in uh with an eval needing an evaluation for a valve problem. As I'll show you, the time starts immediately even before we see these folks and their natural history if left untreated is abysmal in the next several months by the time they get to us. So our IP PS see those patients, they work them up, they present them uh to doctor camp and myself, they organize all of their imaging, they do the CT reconstruction and simulations. They coordinate with those patients, the, the different tests that are necessary beforehand. And I tell folks that 90% of our work is done before we even uh, numb the skin because the amount of planning that's required. And Sarah leads this team of A PPS and they're, they're critically important to getting all the necessary information to make these taverns, uh, safe and, uh, and effective camp. I know you have some, uh, basis. You, you started the program and, or you, you started in the program in 2017, 2016 actually. And, you know, and, uh, we, we've come a long way with TVER General in 2011, all of these were in trial, right. So it was all the extreme risk at first and all of the delivery systems at that point required a cut down. I do remember I was a fellow back then. That's what they were. And we would do one TVER a day, maybe two tas a day, even when I started in 2016 later, we were doing three tas a day now because of how efficient you all are and because of how efficient the procedure is, we've gotten up to be able to do five Tas a day, including some very, very complicated tas. The other thing to keep in mind is, you know, until the last couple of years, most of these patients or a lot of them were in research trials. And now it's essentially FDA approved and C MS reimbursable for all indications for TVER. So that's why you're seeing an increase in the number of TVER. I think we've done a great job with our valve center reset over the last year or two in terms of making sure patients get the optimal therapy for them working together as a group. And that's frankly what we tell the patients. Often times patients come in with a preconceived notion of what they need, but it's really the heart team that works them up to figure out what's going to be best for them. So from the get go, all of the research that's been done that's been critical in structural heart has been done here and, and by our teams um by several cardiothoracic surgeons and interventional cardiologist, Doctor Talreja was here since the beginning. And so he's the continuity for our program and now the leader of our, our, our cardiology group. Um but he's the connection to the old taverns uh that you all probably hear about. And that t is really unfortunately known for in a lot of scenarios where these were patients that had zero surgical options. Um And as I'll show you in the natural history of aortic stenosis, the prognosis is worse than almost every cancer by the time they see us. And so we are literally providing the sickest patients with zero options, a therapy and it worked as opposed to doing nothing. And it's evolved over time to incrementally change the the patient risk going into the procedure to where now since 2019, it's approved for all indications and tricuspid valves over over 65 but that we're seeing is an incredible gray zone, not just in our capabilities to do it, but our, our understanding and our ability to take care of people through their whole lives. It's not enough just for us to take care of them during their initial valve, whether it be surgical or catheter, we have to think two or three steps ahead. So we're beyond getting the patients that are 90 years old that have no other options, getting them out of the room with a treatment that's better than doing nothing. Even 10 years. We've changed that from the standard is not just what valve they're getting on the front end, but what's their 2nd and 3rd valve can be? How long are they going to live? What are their comorbidities? How do we string together valve therapies, surgical and catheter based to allow these people to be taken care of for decades. One other thing about research too, we were in all of the major trials that allowed TAVR to be commercially approved, but the research hasn't stopped. We're still actively involved with research protocols. Um The TAVR for A I, the Yena Valve, the align a trial. We're the only, you all are the only center in the state of Virginia that are doing these. So we get patients from all across the state. Um very similar with the transcatheter mis and the transcatheter tr cuspids. There's only a handful of centers that are involved in those trials. And you guys are part of that, which is fantastic. It's great. One of the unique things about this program is this is the, the collaboration between surgery and interventional cardiology. That is rare. I haven't been in another center or in my training where it's been as collaborative and collegial as this. And I can truly tell you that when we evaluate a patient in M BC, we're trying to come up with individualized treatments for each patient. We don't behold ourselves to one valve company or another or one therapy sr versus TVER. We're trying to think about what's best for the patient then and there and what will provide them a durable result for the rest of their lives. And this is what we streamlined. So this, this process and this is part of this, this overhaul of the structural heart and Tor program is because it evolved from that old system where it was research trials on the highest risk patients. Then it became intermediate, low risk patients. And we're starting to do some B cuspids. There's different ways to repair the valve, replace the valve, surgical therapies and transcatheter therapies. It evolved into a little bit more of a chaotic scenario where efficiency was very, very important to get people through the process and get them into the or with all of us. Uh And this is, this is how things work right now. Um Sarah and, and uh one of these future uh uh educational series meetings will go through and outline the exact process that's necessary. But when we see a patient, they're almost always symptomatic and have severe aortic stenosis every week. From the time that Sarah our A PP and the, and the structural heart docs see them every week that we wait without them getting an aortic valve therapy reduces their mortality by 1 to 2%. So the time is literally ticking as soon as we see them. And imagine if they get to a slate with their ef already reduced or they come to us in the hospital, that's 15% of our tver patients already with decompensated heart failure. The urgency that you all feel from us, the urgency of getting five ta done or getting, you know, staying late and I know it's, it's uh it's terrible to do that day in and day out. But the urgency from our end clinically is not to get numbers not to have a certain volume. It's because we see those patients die on our waiting list and we're trying our best to get as many patients through and to the or with this team to get cured from a problem that's curable, but that the the clock is already ticking. We have to get AC T scan and do valve reconstruction beforehand. We have to have them see both teams and evaluated by both teams. We do uh cats often um and sometimes bridging balloon vop plasty to get them to and buy them time. We b A va significant percentage of our patients to get them more time to turn the clock back on their valve a couple of years so that we have the time to do this, this complex planning every single person in this room, whatever your your title is, uh any clinician is invited to this multidisciplinary valve conference at 7 a.m. every Monday. Doctor Kemp and I run this conference and we review every single patient in this much detail. Our A PPS are effectively structural heart images. They can do this reconstruction and look at the Iliofemoral. You've all started seeing these slides and our time outs, this is the way that we can evaluate 25 plus patients every single week and still provide individualized therapy, choose which valve we're going to pick head off procedural complications. We do very, very complex simulations. This was our patient from a few weeks ago where we do these simulations and see how the valve deforms all of that is occurring before they ever get to us in the in the hybrid operating room. And it requires uh an abundance of resources and it's incredibly time consuming. You all see it as a 30 to 45 minute tower where most of the time things are fine. Some of the times it's a bad cut down or vascular complication, complication and then sometimes it throws in a wrench into your entire day requires conversion a long night. The basis for that, how we head that off, how we get our numbers as low as they are is certain abundance of planning that you all may not see in the front end. One of the things we've been doing recently is we have a monitor in the room and we go through a detailed time out with all of these things with this information up there. And to Matt's point, you know, Sarah and her team do a lot of work up beforehand to make sure the procedures go as smoothly as possible. That being said, when we're there and we're giving the time out and we're going through this. If you guys have questions about why are you worried about this or why are we shock waving this? Why are we doing a basilica? Why are we ballooning this patient where we didn't the last patient, please ask because the more you guys ask and the more you guys learn, the better the team's gonna be as a whole. And, and you all provide very important contributions during those procedures. Our our structural heart Cath lab team is incredible at uh heading off things, seeing things and speaking up. That's the key, seeing if you see something speak up. We don't want anyone in the room regardless of what your title is or what your position is or how new you are in the room to feel like you can't speak up. If you see something again, we're dealing with very, very, very small numbers and trying to reduce those small numbers and we're all part of that. And so if t sees that the pacemaker isn't capturing, um she speaks up if Katie realizes we're still pacing as Kemp and I are very, very precisely trying to release the paddles on a ta uh Katie will say, do you want me to stop pacing? if someone sees a drop in the blood pressure and respiratory variation, uh should we get an echo, these kind of things? You, you should be speaking up and we expect you to and we want you to feel confident that you can speak up and you're part of the team when you see something that isn't, isn't uh to, to anyone's liking. OK. We do a lot of uh education programs. So you'll see this as well where the we're a uh international TVER Training Center. Um There's four of those for Medronic because we do a lot of evolut valves. Um We're a training program for Abbot as well for both their field clinicians and physicians. We do that usually in this room, but you all see it as live cases or cases where there's visitors either down here or coming into the or we get CME for our multidisciplinary valve conference. And then we'll do these uh locally broadcast uh cases just so that our nurses, our care unit, nurses, our members of our team can see um how these procedures actually uh occur. Then of course, Doctor Tara has evolved this regional conference into a really great conference that everyone's invited to. It's, it's usually in October Amy runs it. It's uh well attended. We have a lot of uh cardiology basics for, for primary care folks and for uh support team members. Um It's a wide variety of topics but it's, it's a nice opportunity to see the inner workings of the different cardiology services. This is our data. This is straight from what I what we present at shock. We've done 300 as of 2023 we've done 3585 taverns. There's, there's only a handful of people programs that have done over 3500 taverns. Um And you can see the volumes in which we, we do these each year. It's between 455 100 tas since 2020. Over the last four years, we're on pace to do about 500 this year as well. And we've got complication rates that rival any large center. Our conversion rate last year is 0.9%. So you all saw that. You saw, you see the worst of them too. You're here late working with doctor camp for doctor Barrero when we have a conversion. There were four of those last year. They're the ones that just like a, a question you got wrong on a test that are gonna be burned into your memory. So when you had to stay late until nine o'clock, because doctor summers perforated someone's heart and doctor Kemp had to save the day in the grand scheme of things. What we don't remember is the, you know, 440 that went beautifully and that patient went home the next day and they're, they're walking around their neighborhood a month later. Um, but we want to get these numbers even better and we can so large program excellent outcomes, particularly our stroke rates are, are as good as they can be. Um We take on a lot of very, very complex vascular patients. That's why you see Doctor Dexter a lot in, in the hybrid or that's why you see all the shock wave and alternative access. That's where it comes from is because we've got in, in the South, uh quite a bit of vascular disease that, that uh impairs our ability to get taverns in through compromised femoral arteries in the scheme of our total A VR volume because I think it's important that we talk about a s as far as a s therapies. And TAVR is one of those therapies. SABR is another one of those therapies and there's very good reasons for both of those. Um But if you look at our total aortic valve replacement volumes, it's second to only a few places. Um And our surgical volumes tend to rise with Tabor volumes and vice versa. So we're reaching more patients, we all of us are reaching more patients providing them life saving care uh every day. But the the the volume of this, this amount of care that we provide is second to only a few places. And then this is really what I want to drive home before uh we, we open it up for any questions is why are we, why are we doing this? And why does it feel rushed or why does it feel like we have to do so many or why does it feel like we're always under the gun or under the clock? It's what I mentioned earlier. This is the true data. This is the natural history of aortic stenosis. There's moderate to severe aortic stenosis and then folks get symptoms, that's when they get referred to structural heart to cardiothoracic surgery. And then we're on this slope and that's death. Once someone has symptoms from aortic stenosis, it's between six months and two years. If we don't get them treated, imagine if they're getting to us six months into that process already, which is 15% of our patients. That's why it feels like time is of the essence and why, why it feels like a high volume of patients. We, we're literally trying to keep up with a process that looks like this, that we have a therapy that if we do it correctly continues on as if they didn't have aortic valve problems. So we're literally curing cancers every single day when we put a patient on our table and get them off the table. And that's why it's so important that we, we have an efficient process on the front end and that we have an incredible team during the procedure to get people through, not just efficiently but safely and with a, with an attention to these rare complications where we can intervene and literally save people's lives twice. And that's exactly why we're going to do the whole series of fire drills because although they're rare as seen by the complications slide, those are the most complicated cases to take care of and we want to get those rates even lower. So having everybody on the same page knowing what we're thinking about and what we're needing to deal with all those complications is going to be key. So next week we're gonna do this same kind of thing. It's going to get down into the the workflow. What type of valves there are, what type of access sites there are? What is the basic workflow of a tor, why do we have the access sites we have? Why do we use the equipment that we have? What are some of the things that can happen? Um And that will be a jumping off point for the the specific complications and how we'll manage them each week. So just to summarize each of us, we all of us are part of an incredible team. We're one of the largest valve centers in the country and we take care of some of the most complex heart valve disease patients that can come in through any door. So we're fully capable, all of us are fully capable of taking care of those patients and literally saving people's lives, not just with therapies that currently exist, but with research devices that we're fortunate enough to have for our patients in this area, we're nationally recognized um because we have unmatched patient centered and individualized care because of excellent collaboration between our surgical teams and our, our cardiology teams. And we want that same collaboration that we see between Doctor Kemp and myself and surgeons, Dr Tara and Doctor Adler. We want that to be the same all the way through the process. And that includes our cath lab teams and our hybrid or teams each are used to dealing with different kinds of cases, different kinds of diseases sometimes. Uh but then we're kind of thrust into a really fast paced hybrid or that like I said goes very, very well most of the time, but in the middle of a chaos, literally like a code, we have to work together as a team despite being two separate teams on most other days. And so the big takeaway from this is we want this to be an evolution of what we see at the the the level of the physicians which is incredible collaboration that translates into awesome patient care. And you are key is that a key part of that TVER is best described by one of my old attendings as a choreographed dance. And most of the time you don't trip over your own feet, but you have to be prepared for those scenarios. It's literally being a fireman or a fire woman. You have to be, you have to train, you have to practice, you have to be prepared for when the fire alarm goes off. And every second, every minute matters in those scenarios. And we can't do that without every single person in that room in those scenarios. And that's, that's all of you um in our performance in the event of these rare complications is like I said, literally, life and death. We have the opportunity to save people when they come in to get a tavern when they leave with a tavern. But we also have the opportunity to save their life twice like last Wednesday, when that patient at the vast majority of other centers doesn't make it out of the operating room. And because of people in this room, she's extubated or she's getting extubated today, she's off all pressers and tros her heart function is normal. You all see it as a late night with a bad complication. We get to see it a week later as a as another life saved as far as dealing with these things efficiently and in a coordinate fashion and so these things matter. I know we all know that, uh but it's critically important that we work together as, as the best kind of team we can be. Published September 5, 2024 Created by Related Presenters Matthew Summers, M.D. Sentara Cardiology Specialists View full profile
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