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Multidisciplinary cath lab may represent future of intervention
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Miami Cardiac & Vascular Institute at Baptist Health recently unveiled a $120 million expansion project that will enable multidisciplinary teams of specialists to work together by treating the CV system as a single entity.
The project includes a state-of-the-art cath lab with the first North American installation of a next-generation image-guided therapy system (Azurion, Philips Healthcare) designed to reduce radiation exposure, cut preparation and procedure times, and minimize preparation errors. Patients with conditions from heart disease to stroke to aneurysms will be treated in the lab.
Barry T. Katzen, MD, FSIR, chief medical executive and founder of Miami Cardiac & Vascular Institute, spoke to Cardiology Today’s Intervention about how the new technology might benefit patients, operators and the system of CV care.
Q : Why did the institution decide to embark on this project?
A: This project began a long time ago, around 2008. It had to do with the recognition that CV care was advancing extremely rapidly from a technology point of view and that the environment that we were currently working in had great opportunities for improvement.
In the space of CV therapy, a significant number of the procedures that we do today, we were not doing 10 to 15 years ago, and we were using environments that had fundamentally been the same for 20 to 30 years. We began to look at trying to design platforms that would allow us to be able to better do procedures that didn’t necessarily exist today. The driving concept was to be able to create platforms for innovation, to be able to create an expansion that had historically been a unique environment of multidisciplinary collaboration and integration, and to allow us to take care of our patients better and more expeditiously. It was essentially driven with the principal goals of improving our operating efficiency, supporting multidisciplinary collaboration and integration, and providing technology and designs that would allow us to better anticipate procedures and technologies of the future.
Q: What are some of the most important technologies of this project and how do they have the potential to change the cath lab?
A: We have a unique architecture and organization of our labs here. All the specialties are integrated, rather than having a group of rooms where cardiac intervention is done and a group of rooms where vascular intervention is done, another group for neurology, electrophysiology and so on. All our suites are interdigitated with a common control room that connects everything. We create an environment where disciplines are working side-by-side with each other accomplishing different tasks.
We found that in our previous iteration prior to the expansion that architecture and organization were essentially reflecting the philosophy here and encouraging it — meaning encouraging physicians of different disciplines to work side-by-side with one another. To a large extent, that reduced or eliminated the “them and us” dichotomy that occurs between disciplines.
No. 2, we understood that some of the highly complex procedures that are evolving involve multiple disciplines working together on the same patient. It could also involve the need for surgery. All the suites are committed to image-guided therapy first, whether it be coronary — obstruction of the heart or electrical — or vascular — the whole circulation, neurovascular, etc.
We’ve built in the capability of bringing in different disciplines, particularly surgical disciplines. We understand that for some of the complex procedures we’re doing, you’ll require not only interventional cardiology and cardiac surgery, but you might also have vascular surgery, interventional radiology, anesthesia and electrophysiology. We need environments that have the space to accommodate those individual specialties but also the space to accommodate the technology that goes along with them that may be unique.
Q: How does that impact the physical space?
A: What that translates into is very large suites. We’ve created an environment called the Center for Advanced Endovascular Therapies. These are what some might term “hybrid rooms.” We generally don’t use that term here because it sometimes has geopolitical significance, meaning to most people it means putting imaging equipment in the operating room, but that’s not what we’ve done. We’ve done it the other way around, which is to bring the surgical capacity to the cath lab environment in terms of design.
Within Baptist Health, there aren’t any hybrid rooms in the operating rooms. These advanced endovascular suites are environments that are optimized for image-guided therapy and the support of whatever kind of surgery we might need. If the patient needs to go on cardiac or pulmonary bypass, or we might have to do a branching, or we need to do a peripheral case with accommodation of vascular surgery and an interventional radiologist, these rooms are all designed for that purpose.
Also, what’s happening is that our access into the circulation now can come from anywhere. It’s sometimes called “alternative access,” but the way we view it is that any artery is like an on-ramp to the interstate, so to speak. We need designed environments and equipment that allows us to access radial, subclavian, carotid, femoral arteries and more, and allow for all these complexities. The design took into account support structures such as monitors and radiation shields to create an optimal environment that can give us access to anywhere in the circulation to get where we’re going.
We spent a huge amount of time in development trying to think about the future and trying to analyze the past. For 1 or 2 years, we took a lot of photographs of where people were in rooms, how many people, what kind of case and where things were colliding. We tried to spend the time and effort to improve the environment to the extent we could, taking into account that these environments can be very stressful from an orthopedic point of view, from a radiation exposure point of view, and so on.
Q: Which patient populations do you expect to benefit?
A: We treat the heart and the circulation as an integrated organ. Virtually any patient who requires any type of image-guided therapy within the CV system is going to benefit from this technology. They’re going to benefit by having their procedure done in an environment where physicians of all different specialties are working side-by-side. The way we see that play out in real life on a day-by-day basis is that, when things go well, any single operator can handle it. The measure of excellence is what happens when things don’t go well or when you have challenges, and getting through those. It’s the ability of engaging other doctors that are working right next to you that might be from a different specialty or have a different expertise or a certain skill. The spirit of everybody chipping in and helping from these disciplines is something that’s palpable in our environment. It’s hard to quantify, but patients benefit from that, as well as physicians.
The other way patients are going to benefit is that we have no limits on what we can do. So, when we’re confronted with a challenging problem in cardiac and vascular care, understanding the total breadth of this, we don’t have to think with blinders on or with barriers on because all hands are on deck. We can be an interventionalist and need to have surgery involved, and we can be a surgeon and need to have intervention involved. We don’t think of problems only in the scope of what we do individually, we think of solving problems in the broadest available skill sets. It goes back to the carpenter and the nail: If you’re a carpenter and see a nail, you have a hammer and that’s your solution. But we don’t work that way here.
Q: How will the expansion impact your research efforts?
A: Part of what our expansion does is anticipate growth. It provides us with more infrastructure and more environments than we had before. Research is one of our pillars, and the availability of having those suites and to be able to conduct more research cases that may involve more time, and we will have the ability to collect more data.
Also, the technology itself is generating its own research initiatives. We’re looking at everything from workload issues to new environmental designs.
The commitment of resources by the institute toward this is a significant investment and is the result of 30 years of multidisciplinary collaboration. I think that strongly influenced our health system’s willingness to invest this kind of capital in the future. – by Erik Swain
Disclosure: Katzen reports serving on advisory boards for Boston Scientific, Graftworx, Philips Healthcare, PQ Bypass and W.L. Gore & Associates.