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THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS
Issue #84
Four-Part
Much like the four chambers of the heart,
the KentuckyOne Health Heart Team works
in unison for the betterment of patients
Volume 5, Number 2
Harmony
Issue#84 1
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Four-Part Harmony
Much like the four chambers of the heart,
the KentuckyOne Health Heart Team works in unison
for the betterment of patients
By Jim Kelsey, Photography by Liz Haeberlin
A healthy heart has a beat and a
rhythm all its own, four chambers working
in unison to keep the life blood pumping.
It’s fitting, then, that one of the newest
developments in the care and treatment of
cardiac patients comes in the form of a fourperson physician team, working cohesively
to perform the most intricate of procedures.
KentuckyOne Health features the
first such team in Kentucky. The team
consists of two cardiothoracic surgeons –
Dermot Halpin, MD, FACS, and Hamid
Mohammadzadeh, MD, FACS, – and two
cardiologists – Michael Schaeffer, MD,
FSCAI, and Nezar Falluji, MD, MPH,
FACC, FSCAI.
Together, the four physicians merge
their specialties to bring expert care. They
assess patients’ needs and candidacy for
various procedures collectively and then
LEXINGTON
2 M.D. Update
perform those procedures as a team with the
assistance of trained staff.
“At Saint Joseph, we’ve developed
what I call a ‘Heart Team’ approach to
caring for the cardiac patient,” Halpin
says. “This unique team approach is a
game changer, and it puts the patient at
the heart of the matter.”
The team performed its first procedure together on July 7, 2013 at Saint
Joseph Hospital, but the genesis for this
team approach began a few years ago.
As advancements in technology have led
to more minimally invasive heart surgery
(MIHS), such as transaortic valve replacement surgery (TAVR), the lines between
cardiothoracic surgeons and cardiologists
have become blurred.
The FDA mandated that before a
patient could receive a percutaneous heart
valve, two heart surgeons had to separately
evaluate the patient and agree that the
patient was a high risk for traditional heart
surgery. The FDA also requires that a surgeon and a cardiologist be present at the
same time during the procedure.
After evaluating other programs and
seeing what worked and what did not, the
Saint Joseph team determined that a fourphysician approach represented the ideal
balance of opinions and most cohesive system in the operating room.
Taking the blending of specialties even
further, the physicians actually rotate roles
in the operating room. One physician puts
in the pacemaker, one puts in the catheter
that squirts dye into the aorta, a third pulls
in the valve and holds it in position, and the
fourth blows up the balloon, which inflates
the valve. Rotating the roles enhances the
Special Section  Cardiology/Pulmonology
overall expertise of the entire team.
“What we emphasize in our team –
which is unique in this town and to our
team – is that we actually exchange roles,”
Falluji says. “So at the time of the procedure
every one of us will do one step within that
procedure and we rotate that role. Each and
every one of us has performed a portion of
that procedure and we do that in sequence.”
“Cardiology and Cardiac Surgery have
always worked together, but only recently
have we found ourselves side-by-side in
the catheterization lab, operating room,
and specialty clinics,” Schaeffer adds. “It is
clear to us, that the skills of Interventional
Cardiology and Cardiac Surgery complement each other well for these complex
patients. It’s likely that future hybrid procedures will follow the same path.”
Saint Joseph Hospital introduced the
first hybrid suite in the state
nine years ago, and it has
allowed the heart surgeons
and cardiologists to treat the
patient together in a procedure for the first time in the
history of the two specialties. But the teamwork actually begins long before the
Cardiologist
procedure occurs. The process
Dr. Nezar Falluji
of assessing a patient begins
scrubs in to
with all four members of the
participate in a
“Heart Team” evaluating the
TAVR procedure
patient independently. Then
in a hybrid
they discuss their findings and
operating room.
reach a conclusion as to whether the valve
needs to be dealt with and whether or not
the patient is a surgical or percutaneous
procedure candidate.
Optimal Patient for TAVR
The ideal candidate for TAVR is a
patient with severe, symptomatic aortic
valve stenosis, determined to be high-risk
for surgical valve replacement, with an
expectation of living at least one year if
their heart valve can be replaced. This
assessment is made based on other medical problems, previous open heart surgery,
and overall degree of frailty. Before TAVR
many of these patients have been advised,
correctly, that there was nothing else that
can be done for them. Some may not have
had their options reconsidered since the
availability of TAVR.
The best candidates also have no significant peripheral artery blockages so they can
undergo the transfemoral approach, which
is the least invasive of the TAVR approaches
with the best outcomes.
The Edwards SAPIEN
Transcatheter Heart Valve™
is placed onto the catheter
and inserted into a crimper to
prepare for implantation.
right: The heart valve is
attached to the catheter and
ready for implantation.
above:
Issue#84 3
The four-person team, made
up of two cardiologists and
two cardiac surgeons, work
side-by-side and rotate
roles in the OR.
“We have patients declined TAVR due
to multiple, severe medical problems such
that we don’t expect them to live more
than one year, even if we have a successful valve procedure,” says Schaeffer. “We
have also had to decline a few patients with
aortic valve anatomy that was too large for
the two currently available TAVR valve
sizes. This will not be a problem with the
expected approval of larger valve sizes in the
near future.”
Patient Betterment
The real payoff of the MIHS and the
team concept is that many patients who
would not have been surgical candidates
a few years ago are now not only able to
receive treatment, but are leaving the hospital in a matter of days instead of weeks.
“We’re dealing with a general population that we have never encountered,”
Mohammadzadeh says. “These are the
patients that the cardiologists cannot help,
and they are also considered to be very high
risk for us to take care of them.
“Before, in order to fix an aortic valve
stenosis, we had to have a very invasive
approach, which involved cutting the chest
and stopping the heart and cutting the
heart open and cutting out the old valve
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and putting in the new valve, which took
a significant toll on the patient. With
these new technologies, frequently these
valves can be fixed with two little incisions
in the groin or the valves can be fixed by
a small incision on the side of the chest.
Overall, the patients do remarkably better
after this procedure. We see people leaving
the hospital in four days at the most,” says
Mohammadzadeh.
In addition to the core team of physicians at KentuckyOne Health Cardiology
Associates and KentuckyOne Health
Cardiothoracic Surgery Associates, investments have been made, including a PhD
in Nursing Valve Coordinator position
– currently held by Tara Blair – who is
dedicated purely to the structural heart
team. Blair works with the doctors to send
the patients home with a rehabilitation
and recovery program.
“These patients are decisively treated,
and they don’t need significant subsequent
follow up. They can be managed by their
own local cardiologist and primary care
physician,” Falluji says. “Our patients are
now offered an opportunity for decisive
therapy for something that was deemed
before as inoperable or high risk and came
with a significant tax of complications.”
Less than a year removed from their
first team operating effort, the Heart Team
is committed to maintaining high levels
of success and elite standards for the overall well-being and quality of life for their
patients.
“We have a tradition in this hospital
of caring for patients with heart disease,”
Halpin says. “The high-risk patients are
doing well not because we’re lucky, but
because we’re cohesive. We put our egos out,
and we work as a team. The complexity of
the patients that we now see in this structural heart clinic mandates that you have a
team approach that will put the patient at
the heart of the matter.” ◆
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