A CT scan assessment of the femoral access route challenges for a recent Central DuPage Hospital TAVR candidate. This image and the measurements were discussed by the heart team during its weekly meeting to determine if the TAVR delivery catheters could navigate the disease femoral artery and what options might best serve this patient.
While there is fear by many about the trend of hospitals consolidating into larger healthcare systems, one advantage might be faster matriculation of new cardiovascular technologies from flagship hospitals and academic centers in these networks to smaller community hospitals.
One example of this is in the Chicago area where Northwestern Medicine has purchased several smaller suburban hospitals in the past few years to expand its healthcare system. This has enabled these smaller community hospitals to offer new, cutting-edge cardiovascular medical technologies much sooner than might have otherwise been possible due to their new association with the luminary Bluhm Cardiovascular Institute in at Northwestern Memorial Hospital in downtown Chicago. To speed this technology transfer and better coordinate efforts with the downtown and suburban hospitals, Northwestern Medicine created a suburban arm called Bluhm Cardiovascular Institute West (BCVI-West). It is based at Central DuPage Hospital (CDH) in Winfield, Ill., about 30 miles west of downtown Chicago in the heart of the western suburbs.
The biggest draw for the new program so far has been its offering of transcatheter aortic valve replacements (TAVR), using the Edwards Lifesciences Sapien 3 device. The BCVI-West program also has brought several other cutting-edge cardiovascular technologies to the western suburbs. This includes transcatheter leadless pacemakers, minimally invasive left atrial appendage (LAA) occlusions, the implantable CardioMEMS device to monitor heart failure patients and two of the the latest surgical valve replacement technologies. CDH's electrophysiology team is also launching a hybrid procedure program that combines the surgical MAZE technique and catheter ablation to treat problematic arrhythmias.
"This relationship has really helped us raise our service platform very rapidly," said Nauman Mushtaq, M.D., medical director of cardiology for BCVI-West. "We have access to the experts and it helps us bring new technology to our patients. We have had a good experience because the foremost thing that we have been able to do is rapidly deploy technologies and programs that have traditionally only been at academic medical centers. And, we have been able to do it in a safe manner and do it in a manner that is patient centered. So, patients can get the best care available closest to their home."
Since the BCVI-West program was created in February 2017, CDH has performed more than 20 TAVR procedures. "In the case of TAVR, we don't have to relearn how to perform the procedure ourselves, we can learn from the experts who were involved in the trials for TAVR," Mushtaq explained.
Training for a Suburban TAVR Program
"The relationship with Northwestern Medicine has really helped us accelerate our TAVR program," Mushtaq said. "We wanted to make sure we learned from the experience that had been gathered already downtown and what the best practices are around planning for TAVR and doing them. It was not just on paper that we did that. We initially worked up all our patients here at CDH and then took them downtown and did these procedures there. That helped us fairly quickly learn the tips and tricks and bring that back to CDH."
When the first procedures were performed downtown, CDH brought its entire heart team down so nurses and techs also could gain experience and ask questions.
"We had an actual side-by-side experience with the experienced operators who were there," said Imran Ahmad, M.D., medical director of interventional cardiology at CDH. "It was not just watching a procedure from a control room, we were actually in the room doing the procedure. We also got a chance to see how patients came into the hospital and then see how they were taken care of afterward up to discharge. We were involved in the care of the patient and any events that may have occurred. It was a great experience for us because it was not something that we were removed from."
Training for the program included use of Claret Medical Sentinel Cerebral Protection System, a transcatheter embolic protection system deployed during TAVR to help reduce the risk of stroke during the procedure.
Creating a Heart Team
CDH replicated the Bluhm program that centers on a team of clinicians working together as a heart team to care for the patient. The team is composed of an interventional cardiologist, cardiac surgeon, a cardiac imaging specialist, valve clinic coordinator, structural heart nurse and a structural heart nurse practitioner. The team meets on a weekly basis to review patient cases to decide the best plan for that patient and to provide updates on other TAVR patients.
"The great part of working here as part of one team is that we are not working in separate silos, we are integrated and we are truly using a collaborative team approach," said Gyu Gang, M.D., chief of cardiac surgery, BCVI-West. "We don't consider these 'their' patients or 'my' patients, these are 'our' patients that we try to find the best solution for together."
He said some patients will need open surgery for one reason or another because that is a best option. But, if the team can offer them TAVR so their recovery is faster and spend less time in the hospital, Gang said they will come to that decision as a team based on what is best for the patient.
"As a surgeon, my specialty is to offer the rest of the team the ability to get to the valve," Gang said. The femoral access approach will be used whenever possible, but if an alternative access route is necessary, he can assist the team with transapical or trans-carotid access.
Sharing Information is Central For The Entire Heart Team
"I think we are really in a unique situation, where unlike some other facilities, we had Northwestern as a model and guiding us through the whole process," said Alyson Dong, valve clinic coordinator. "From the beginning and still today, I am in contact with their coordinators and nurses on almost a daily basis. At first it was them sharing their tips and tricks with me, but now that we have been doing this for a while it has become more of a back and forth where I am sharing my information and we learn together."
"There are a lot of pieces from both the inpatient and outpatient sides that need to be worked on, so it has been helpful to be able to meet and network with other people in the same type of situation and find out what worked for their program and what didn't," said Allison Kioutas, structural heart nurse practitioner. She added that not all programs will work the same, but it has been very helpful to have information shared from the existing program to see how it fits or can be modified to meet CDH's local TAVR program needs.
Communication is key to passing along information and insights from an existing TAVR program to a satellite hospital just starting.
"I think one thing that has helped us is adequate communications in between all levels and members of the team," said Catie Rosa, structural heart nurse. "We have weekly TAVR meetings where we can talk about the patients and any updates. It just helps ensure everybody is on the same page and aware, in case the patient calls in and asks questions."
"The communications I think is really key because your program from start to finish will always be changing," Dong said. "Once you think you have a good workflow, something will change and you need to be flexible with it."
Other New Technologies at CDH
"It has been fairly beneficial for our patients to have rapid use of devices that in the past were only available at an academic center," Mushtaq said.
At CDH, this has included implants for the Medtronic Micra leadless pacemaker that is implanted using venous transcatheter access to implant the device inside the heart. CDH also began use of the SentreHeart Lariat device for minimally invasive closure of the LAA, the culprit of stroke-causing clots in patients with atrial fibrillation. Heart failure patients at CDH also can now be monitored with the CardioMEMS pulmonary artery pressure sensing device that can alert patients and their doctors to worsening heart failure before the patient becomes symptomatic.
Mushtaq added CDH is also now equipped with the Abiomed Impella percutaneous ventricular assist pumps so they are able to support very sick patients that come into the hospital. "We can stabilize them and even perform high-risk PCI here, or at least support them so they can be transferred downtown where they can get something permanent for ventricular support. That has been very fruitful for us, because the program is seamless between sites because we really are one institution."
"There is institutional knowledge and expertise that is easily transferable from the surgical program downtown to here," Gang said. "In addition, they give us opportunities and early exposure with the newest technologies."
In the area of surgical valves, Gang explained CDH was able to begin using the Edwards Lifesciences Intuity Elite and Inspiris valve systems, both approved by the U.S. Food and Drug Administration (FDA) less than a year ago, much sooner than it would have otherwise. The Intuity valve is implanted similar to a TAVR valve to speed procedure time by reducing suturing. The Inspiris valve was designed to be more flexible, with the idea that it will allow easier valve-in-valve implantations using TAVR a decade or more in the future when the surgical valve leaflets wear out.
Advantages to Enterprise-wide Access to Patient Records
One technology advantage that is not related to therapy devices but has been extremely helpful across Northwestern Medicine is access from any of the hospitals to a single patient electronic medical record (EMR). Northwestern Medicine recently finished implementation of an Epic EMR to connect all the system's hospitals and clinics. A patient's images, labs and reports are now available anywhere, regardless of the hospital location. This has made care coordination between facilities much more seamless.
"There is really just one chart, there is no more pulling and pushing information, we can review anything in real time and we have access to all images in real time through a vendor neutral archive," Mushtaq explained. "This really helps with any patients who are transferred to other locations where they can get the care that they need."