State of the Union: Heart Care in 2020
An interview with Michael Argenziano, MD, Chief of Adult Cardiac Surgery.
With so many facets of heart care to cover, let’s start general and work our way through the specifics. What’s new?
Well, relative to the state of the specialty around the world, the first thing to say is what's normal here we like to call “Columbia normal” because it's not necessarily available everywhere. Some of the more complicated things that we are doing routinely now are still emerging elsewhere, and they involve all aspects of heart disease.
Starting first with structural heart care and valves: mitral valve, aortic, tricuspid. Our Structural Valve team is doing percutaneous [through the skin] catheter-based and hybrid approaches to diseases and conditions that were never previously treatable by nonsurgical means. Including, of course, TAVR [transcatheter aortic valve replacement], where we replace aortic valves minimally invasively, which is quite well-penetrated around the world but was done here first.
How has the use of TAVR changed since it was first introduced?
TAVR has moved from a life-saving alternative last-ditch treatment for those who have no other options really into the mainstream of care of patients with aortic valve stenosis. And there are all of the secondary ripples from that, which include not just being able to do TAVR in very high-risk non-surgical candidates, older patients, patients who are high risk for surgery, but also now continuing to drop the threshold of risk so we can do TAVR in patients who are at what we call intermediate risk, and even low risk for surgery. The same goes for the tricuspid valve.
All this work makes our valve center one of the breeding grounds for the development of all the structural valve technology. All of which can either be used entirely non-surgically or percutaneously or in many cases in hybrid applications, which we've been very active in.
What does hybrid mean, exactly?
Hybrid applications include the use of both surgical and percutaneous technologies, which in some cases actually work better together than either does alone.
Wow, walk us through that. How do hybrid applications factor into the determination of low risk, intermediate-risk, and high-risk patients?
Certainly, so, for instance, there might be a patient who has multiple problems, who has coronary disease and multi-valvular disease, in whom we can, say, use some percutaneous treatments for some of those problems, and then surgical treatments for others. And in those cases, sometimes doing them together, in what we call a hybrid room, which allows us to have both—all of the surgical instruments and equipment that we need as well as all of the cath lab instruments and products that we need—which doesn't traditionally occur in one or the other location.
Sometimes you're in the cath lab and all you have are cath lab instruments but you do your best with what you can and likewise for surgery in the operating room, but by being in an operating room that's equipped to do both you can say, "Well, I'm going to do A and B surgically, but C is going to put the patient at a really high risk. Normally I would have to do C because it's all I've got, but I can actually bring in one of the interventionalists or one of our hybrid operators like Isaac George for instance, and do that.”
I should mention that even though I'm the chief of adult cardiac surgery and I'm the leader of the program, the valve center component that I've been speaking about up to now is led by Isaac George. And Isaac is a unique individual who is not just doing hybrid procedures, he himself is a hybrid doctor because he's trained both as a cardiac surgeon and as an interventionalist; he’s all human, I think.
How do you determine when to use one of these hybrid rooms if problems can arise in that way?
There are certain operations or procedures that we specifically book in hybrid rooms because we know it's going to be a hybrid operation. And we also use them as regular operating rooms. But yes, ultimately in the future, I think every room should be a hybrid room.
You know, another surgeon I should mention is Vinay Bapat, Dr. Bapat is also an expert in these hybrid and advanced percutaneous techniques. He specifically joined us after years in Europe, where many of the regulatory hurdles that are faced by devices in the United States are not as difficult. He’s had a lot of experience with first-in-man treatment with many devices that are still experimental in this country. So, Dr. Bapat gives us an extra level of expertise that’s just not obtainable by US surgeons.
Wow, that’s amazing. How did this transformation come about, this hybrid shift and partnership with cardiology?
Historically speaking, cardiologists and cardiac surgeons had been far beyond the idea of cats and dogs, more like snakes and mongooses. Looking at it from a distance, cardiologists have been developing techniques that try to replicate and eventually replace many of the procedures that surgeons have done, so it’s a natural competition. But two things allowed that to change here—
Number one, the academic culture is strong at Columbia, which means we’re not governed entirely by the usual competitiveness and economic factors that all physicians and hospitals have to deal with to some extent. And because of that strong academic culture, it's been known for years that collaboration may wind up being more than the sum of its parts.
Secondly, the actual catalyst was very simple: Martin Leon and Craig Smith. Twenty years ago or so when Martin Leon's interventional group came over to Columbia from another hospital it had already established itself as one of the pioneer interventional groups in the world. And subsequently, over the course of their efforts, they have done literally hundreds of trials in tens of thousands of patients and have been one of the most important partners with industry in developing almost everything that's new.
Then they joined us here at Columbia where our cardiac surgery program had a very strong reputation for being forward-thinking, cutting edge, ahead of the times, et cetera. It really was a perfect peanut butter and chocolate moment.
Sounds like it took thoughtfulness on both sides to see beyond the status quo.
Absolutely. Frankly, all the credit for that spark, for that catalytic moment goes to Craig and Martin because it would've been very easy for each of them to dig in and say, "Listen, we're great and we're going to continue to do what we do." And it required a lot of compromises. It required the surgical side to accept something like TAVR and accept a leading role in such a trial.
For instance, Dr. Smith and Dr. Leon, are the two co-principal investigators of the international PARTNER trials [Note: the Placement of AoRtic TraNscathetER Valves--or PARTNER--trials were the primary studies proving the effectiveness of TAVR]. They're not just investigators here at Columbia, they are the overall PIs [principal investigators] for the entire PARTNER One, PARTNER Two, PARTNER Three trials and everything else that's come after.
It’s not easy for a surgeon to be so prominently involved as a leader in a trial that presumably may put surgeons out of business. Likewise, it's also not that easy for someone like Martin Leon who's very interested in blazing forward with technological development, to subject this percutaneous technology to the increased rigor and scrutiny associated with a big trial while so many surgeons around the world are looking for reasons why it wouldn't succeed. So, I think that it just took some element of academic bravery for those two to get together, but driven by a vision, which wasn't difficult to come by with those two.
Let’s jump back to some areas that still require surgery, what advancements should we know about?
On the purely surgical side, the things that we are very proud of and are really cutting-edge are first, our mitral valve repair program. Mitral valve surgery is one of the more common reasons people need cardiac care.
Have there been changes in the way mitral valves are repaired? Is it also an area that benefits from the hybrid approach?
Unfortunately, the vast majority of mitral valve operations done in the United States are replacements. In many cases, replacements are all that can be done due to pathology. But in many other cases, the surgeons who care for patients with mitral valve disease don't have the expertise or experience to perform mitral valve repair, which is more technically demanding and requires more experience. Though, in most cases, it is better for the patient because it avoids the need for prosthetic devices, which are associated with either the need for anticoagulation or a lack of durability of the device.
The mitral valve repair we do here is something we're very proud of. We’re one of the largest programs in the country with one of the highest repair rates and certainly one of the best success rates. And frankly, something that I think more people need to know about because many patients who are seen in small programs, which may have very good results for other types of operations like coronary bypass, just may not have the experience.
What does experience mean for patients? How does it make treatment different exactly?
Great question. Sometimes patients may not even realize they're candidates for a less invasive procedure or a non-invasive procedure otherwise. So, the next thing I think is very important to know is that the mitral valve is not the only valve that we repair—we obviously repair a lot of tricuspid valves—but one of the more exciting recent areas of development in our specialty has been aortic valve repair, which traditionally had never been done, but in the last decade or so is being done more effectively, often in combination. A lot of patients who have combinations of diseases are not coincidental but are actually are connected.
How common is it to have heart disease in multiple valves?
5% of people have disease in bicuspid aortic valves. So, it's a significant percentage of the population. And then even outside of the bicuspid population, there are tens of thousands of patients a year with aortic aneurysms, aortic dissections, and those things are often either directly related or sometimes consequentially related to valves.
Because the aortic valve and the aorta are not only anatomically related but also in many cases genetically related with similar diseases or shared diseases, it is important when you have an aortic problem or when you have valve problem to see someone who can look at the larger picture and make sure that you're getting the whole problem taken care of. These operations are amongst the riskiest that are done because of the branches of the aorta leading to the brain and to the spinal cord.
Let’s get into the aorta. How has the treatment of aortic conditions changed?
So Dr. Takayama, our director of aortic surgery, is a true world expert. And he has done a fantastic job in combination with Dr. Virendra Patel running our Aortic Center. They have thousands of patients in their database and see hundreds of patients a year for advanced aortic disease where treatment has gotten less invasive, more comprehensive, and more innovative.
Not only is it important to note that we're doing the most cutting-edge operations on the entire aorta from the ascending to the arch to the descending aorta but that many of those are being done again with nonsurgical endovascular stent grafting techniques. Not everyone with aortic disease and aortic valve disease necessarily requires only one operation or even requires an operation at a given time.
But because this disease is one that progresses over life, the most important thing is to be seen at our center, to be entered into our longitudinal follow-up database and to be followed appropriately with the right tests, the right intervals so that we can intervene if necessary before something catastrophic happens.
What does that look like? Say you have aortic disease and you're entered into the system, do you start by seeing a cardiologist?
Well, that all depends a little bit on your presentation. If you have any valve abnormality or aortic abnormality, you'll be seen at the aortic clinic, which is a dedicated clinic that runs twice a week where we see only patients who have these aortic and valvular problems related to the aorta. And you will be seen by surgeons, cardiologists, you'll have appropriate echocardiograms, CT scans.
One of the issues we see often is patients only get a patchwork of work up—a test here, scan there—and then often when they come to us, those tests have to be repeated because the techniques aren't adequate to look for what we need.
So, I think the important thing is to get to the right team, to do workup once, and have it done the right way. And if they are candidates for a procedure, either surgical or catheter-based, then they can have those done. But in many cases patients aren't quite ready, maybe they are one echo away from needing something done. A lot of times when patients like that are seen in traditional surgical centers the decision that's made is either, "Do you need surgery now or don't you need surgery now?" And in those cases, a patient will see the surgeon, the surgeon says you don't need surgery, and then loses follow-up.
Here, we are actually not so much interested in what the specific procedure or treatment is because we're not playing tug of war with the cardiologists. Actually, we are, but it's us and the cardiologists on the same side of the rope pulling against the disease.
So, this hybrid approach sounds almost holistic in a way, to use a buzzword, with each person’s heart disease falling on a spectrum. Does it make sense to look at it like that?
It does. The idea is that we're trying to get the patient evaluated, everybody is on the spectrum disease. Sometimes some patients have a disease that we’re fairly certain is never going to need anything done, others we’re not sure and we need to follow them.
You know, I saw a patient today that was seen in another hospital who had aortic and mitral valve disease, he's not quite ready for surgery, but he was lost to follow-up. He came to me because once he was told that he didn't need surgery and asked what the next steps were, he said they told him "go back to your cardiologist." So basically, then the cardiologist who's taking care of that patient in a community setting who's a very dedicated person, just doesn't know what to do—there are no guidelines.
What does “ready for surgery” mean in this context?
Right, good question! There are two kinds of “ready for surgery,” one is, of course, the patient's willingness to proceed with surgery when it's indicated, and that is actually an important part of what we do. But more importantly, when you've been followed over time and you’re at a well-respected center that does thousands and thousands of whatever operation you need, you're not just being corralled into the operative suite as unfortunately happens in many cases elsewhere.
When you see a surgeon who tells you, "You don't really need surgery, but let's watch." Then when it becomes time for surgery, you are more easily able to accept it because you realize that you're not being pushed into something. And in terms of what determines when that time is or what “ready for surgery” means? It depends entirely on the specific situation. So, for instance, with aortic valve disease, the indications and the triggers for surgery are different for aortic stenosis than for aortic regurgitation.
How much of this depends on how early the problems are discovered?
Aortic stenosis usually becomes more symptomatic, aortic insufficiency doesn’t always. And sometimes with aortic insufficiency, like mitral insufficiency or regurgitation, the heart begins to suffer and show signs of strain and damage on the echo without symptoms. So, the problem is that a lot of patients are walking around either without symptoms or with some symptoms that they've rationalized to old age or being overweight or whatever it is.
One of the things that we've learned over the last 20 years, specifically with respect to valve disease, is that many valvular problems can be insidious and can be very dangerous because unfortunately, in some cases, patients come to us after they’ve burned out and their heart is so damaged that the risk of surgery is high and the expectation for recovery is low.
And of course, what we're trying to do is get to people early. It doesn't take much to figure out what's going on, usually with one of three tests—an echocardiogram, cardiac catheterization, or a CT scan—we can almost always give patients a relatively clear idea of where they stand and whether they have no concerns, definitely need something done, or if they're in between what the timing of that evaluation should be.
What about the person who says "I think something might be wrong but I'm not sure;” when should they make an appointment?
I would say that anyone who's been told by a doctor, whether it's an internist or primary care doctor or a cardiologist, that they have a problem with their heart that involves potential surgical problems—so a valvular problem, problem with the coronary arteries, an abnormal rhythm and enlargement of the aorta, or anything that results in a change in their lifestyle, inability to do things that they could do before, chest pain, shortness of breath, unexplained weight gain, inability to keep up with others or to continue activities that they've been doing—then I think that warrants a workup. We can't see everything with those three tests, but we can see almost everything that needs to be fixed.
Alright, the number of Americans living with heart failure is steadily increasing. What do we need to know?
That’s right. There's something between five and 10 million people in the United States who are living with heart failure. And heart failure is any condition in which your heart is not strong enough to pump to your needs. Anyone who is having difficulty doing the activities of daily living or somebody who is not able to exercise, or not able to walk, or has lots of leg swelling and shortness of breath and body swelling, things like that.
Patients often think about coronary disease and heart attacks as being the big killer, which they are, but many patients who suffer coronary disease don't die immediately from their coronary disease, yet they develop what's called ischemic cardiomyopathy, which is basically gradual weakening of the heart muscle from lack of blood flow. But those cardiomyopathies also occur from valves. And they can occur for non-coronary non-valvular reasons too. Some patients get viral infections that cause a weakening of the heart, like the flu.
And a lot of patients are under the care of a cardiologist for heart failure with medications that have done wonders for stabilizing and helping so many people with heart failure stay alive. But in many cases, those patients could feel better and could have their lives prolonged by procedures, whether they be percutaneous, hybrid, or surgical valvular procedures. Also, there are procedures for patients with end-stage heart failure that start at high-risk valve surgery, high-risk coronary revascularization, moving to things like mechanical devices, artificial support, and even heart transplantation.
Since you mentioned coronary arteries, will you touch on coronary bypass? Any changes?
Coronary bypass is an operation in which we open the patient's chest in some way, whether by a large or small incision, we create bypasses to the blockages in the arteries on the heart using arteries from the chest wall, veins from the legs, et cetera. And in both coronary bypass and coronary vascularization we’ve seen tremendous progress with percutaneous and cardiac catheterization stenting of arteries over the last 20 years.
Many patients who would get a coronary bypass in the past are being treated very well now without surgery, with percutaneous catheterization procedures, with drug-eluting stents and other things. And again, much credit for the development of that field actually goes to our interventional group, led by Martin Leon, Ajay Kirtane, and Jeff Moses. And still, we do hundreds and hundreds of coronary bypass operations because in many cases, patients who have been treated for the last decade or more with percutaneous devices come to a point where their disease progresses and they need surgery or are not good candidates for percutaneous treatment.
So, does that mean surgery is still the best treatment option for coronary disease?
Recent studies, including the SYNTAX trial, have shown that there are some severities of coronary disease that are better treated with surgery than with stents. For all those reasons, we are still treating thousands of patients a year with coronary disease between interventional cardiology and surgery.
And again, if there is sometimes some uncertainty or some territorialism that occurs when patients are being referred for the treatment of a cardiac problem, nowhere is this truer and more important than in the space of coronary disease. Because even though we are doing a lot of structural valve work with catheters, most people aren't.
And it's interesting that when patients get sent to us for valve problems expecting surgery, we sometimes surprise them by offering them nonsurgical options. In terms of the catheters, it's quite the opposite because, over the last 20 years, there's been a tremendous interest in the public, and also tremendous progress made in catheter technology devices, stents. Patients are more and more hoping and desirous of catheter treatments.
How do you decide between stenting and bypass?
When a patient is told to have a bypass operation, the first question usually is, "Why can't I just get a stent?" And what we're learning now is that the initial allure of a stent sometimes arrived at a price. And I think that our interventional cardiologists, as well as our surgeons, have been working on international trials where we understand that it's not about pushing one procedure over another. It's about evaluating the patient's disease and offering them the best option, which in coronary disease may be percutaneous, it may be surgical, or maybe hybrid.
We're doing minimally invasive procedures where we sometimes combine surgery with stents and even when we're not doing stents, we're doing minimally invasive approaches. We're doing off-pump beating heart surgery, and actually Dr. Craig Smith, the chairman of the department has one of the world's largest experiences in off-pump coronary bypass.
What is off-pump coronary bypass?
So traditionally, coronary bypass was done on-pump, which means that you would put the patient on the heart-lung machine. But in many patients, we have learned that we can actually do this while the heart is beating instead, so we call this off-pump or beating heart surgery.
And in the right patients this is beneficial because it avoids all the risks of being on a heart-lung machine, less transfusion, fewer complications associated. But of course, that's only for patients in whom the operation can be done safely, which is a subset. But for those patients, the operation can be less traumatic and less risky.
And it’s not simply that we have off-pump techniques and we use less invasive approaches, it’s how we take the veins from the legs. In the very old days here, more than 20 years ago, and still in many places around the country and around the world, we would take the vein from the leg by making a long incision along the whole leg. And that incision in many cases was much more problematic for the patient than even the incision in their chest. For over two decades we've been using what's called an endoscopic sympathectomy approach where we use a little scope, a camera, and we can take out an entire legs worth of vein with only one or two half-inch incisions in the leg.
What are your goals for the next 5, 10 years?
I think that a lot of the progress that we're making is in catheter-based technologies, and that's going to continue to spit out significant advances that in the past happened only every 30 years. Instead, they’re probably going to be happening every three years.
The other area I think is actually just ripe for technological advancement is advanced imaging. The ability that we now have to potentially image disease in vivo, live through virtual 3D imaging and other VR-type technology is going to allow us to finally see a lot of anatomic processes that we never were able to get a good handle on. And I think that the safety and efficacy of our operations are only going to go to the next level when we have this advanced technology. And also, physiologically relevant imaging like being able to really image a beating heart, a moving heart, to be able to see exactly what the problems are. Once we can do that, things like robots and mini bots can begin to be deployed more effectively.
We have covered so much, and within all this transformation in care, what are you most optimistic about?
I actually think that we are just on the cusp of being able to do things that could never be done before. So, I am most optimistic about the fact that when I was a medical student, I was advised not to go into cardiothoracic surgery because it's a field of just bypass and valves and “eventually it's all going to be treatable and you're never going to have anybody to operate on,” and that it was a dying specialty. And although it's very true that so much of the new technology may actually have satisfied the predictions that were made, what couldn't have been predicted is the fact that by collaborating and being involved we are just as in the thick of it as ever.
And frankly, the way I look at it is that if your definition of surgery is the way surgery was done in 1980, yeah, that's dead. But everything is dead the way it was done in 1980, and anything that isn't should be. That's probably the closest I've ever sounded to being a millennial, but the point is that I think it's not about being a cardiac surgeon as it was conceived by someone at some time. It's about having a passion for taking care of patients with cardiovascular disease, whatever that takes.