By Natalie Chang
Heart disease remains the leading cause of death in the United States (though COVID-19 has briefly outpaced it during the peaks of the pandemic). The American Heart Association has also noted that trends of lower mortality rates for certain kinds of cardiovascular disease have even begun to reverse in certain populations.
And as people live longer, the number of patients with heart disease will continue to increase, according to Dr. Isaac George, Surgical Director of the Structural Heart and Valve Center at Columbia University Irving Medical Center. “As older and sicker patients are treated, the problems that we treat have become more complex,” he says.
What does this mean for heart care? According to some cardiac experts, it means doubling down on innovative new approaches to heart surgery and care delivery overall.
“Traditionally, cardiac procedures were surgical, meaning large, open incisions. Eventually, catheter-based, or percutaneous, procedures were developed, such as coronary stents and transcatheter aortic valve replacement (TAVR),” says Dr. Michael Argenziano, Chief of Adult Cardiac Surgery at Columbia and New York-Presbyterian Hospital. “But recently, we have been able to use not one or the other, but both of these approaches in cases where patients benefit most from some things being treated surgically, and other things with catheters.”
Dr. Argenziano is describing what’s known as the hybrid approach, a more flexible and customizable intervention plan for patients that allows providers to combine cardiac care techniques that are usually administered separately and exclusively by different kinds of specialists. In contrast, based on an individual patient’s condition and needs, the hybrid approach allows for the delivery of services that might otherwise occur disjointedly, from multiple care teams, or not at all.
“[In hybrid surgery], individual anatomy and physiology are considered, and creative treatment plans can be made,” says Dr. George. “These solutions take place in the hybrid operating room, in which coronary stenting, transcatheter valve procedures, and standard cardiac surgery is possible to perform, often done in the same setting.”
The approach is still relatively new, and it’s a departure from our traditional approaches to heart care. It changes how we think about specialties in medicine, making cross-discipline collaboration a form of specializing in itself. “The hybrid approach is fundamentally a different way to understanding disease and therapy,” says Dr. George. “It is based on a wide base of knowledge and the ability to take multiple specialties and combine them for the best possible outcome.”
Dr. Argenziano, Dr. George, and Dr. Ajay Kirtane, Director of the Cardiac Catheterization Laboratories at Columbia, are all part of Columbia’s Hybrid Coronary Program, which combines expertise from a full range of heart health disciplines. That collaboration eliminates the implicit competition that often exists between cardiologists and cardiac surgeons, instead allowing different specialists to work together and co-create a bigger and more adaptable array of interventions they can use.
“The key part of this really is that the hybrid approach signifies a flexibility to optimize options for the patient by thinking outside of the conventional boxes or silos that we often work in,” says Dr. Kirtane. “In many respects it signifies the best portion of the collaborative approach that we seek to employ for our patients here.”
What does this mean for patients? People from around the world contact the Hybrid Coronary Program at Columbia to see if their heart conditions would be a good fit for hybrid treatment, Dr. George points out, so clearly the team is doing something right.
“The benefit of this approach is that it potentially allows the surgical procedure to capitalize on the less invasive nature of stents,” says Dr. Kirtane. The less invasive the procedure, the less risk of causing trauma to the patient’s body, improving the chances of positive outcomes.
“In cardiac surgery and transcatheter procedures, the paradigm is that surgical procedures provide durability at the cost of invasiveness,” says Dr. George. “In contrast, transcatheter procedures offer potentially less durability but a much better recovery and invasiveness profile and lower risk. By combining a cardiac surgery and transcatheter procedure, the hope is that you gain durability with lower invasiveness.”
By breaking down the barriers between different specialists, the Hybrid Coronary Program is proving that a multi-faceted and multi-pronged approach is both possible and beneficial to patients. It means that care providers, by working closely with a variety of specialists, can employ what Dr. Argenziano thinks of as a fully equipped medical “toolbox” that showcases the power of an open and collaborative team. As health needs become more demanding and complicated as our population ages, all medical disciplines could stand to take cues from this new paradigm.
“The amazing thing at Columbia is that this kind of close collaboration, which is so uncommon elsewhere, is in our DNA,” says Dr. Argenziano. “Our cardiac surgeons and cardiologists work together on every case, each contributing what’s best for each patient. The analogy I often use is that although a hammer is very useful for certain tasks, it can’t do what a screwdriver can, and vice versa. If you have a complicated project that involves nails and screws, you won’t get the same result if you use only a hammer, or only a screwdriver. You need both, and that’s what we provide in hybrid surgery.”