2020 Virtual Cardiovascular Evening Symposium: Cardiovascular Prevention & Surgical Updates
Originally Broadcast: Tuesday, December 15, 6-7 PM CST
We invite you to join your fellow clinicians to learn about cutting-edge best practices in cardiovascular care. Minneapolis Heart Institute® providers discussed topics in prevention, diagnosis, managements, and treatment of cardiovascular conditions.
being the president of M. H. I is a true blessing. I get to help create a new environment for people to be helped by our teams for those people that come to us when they need us and to create that environment that's gonna bring them the care that they deserve. Combining forces with the maps are incident Abbott Northwestern Hospital with the United Heart and Vascular Clinic really makes it a powerhouse in terms of most importantly, patient care sharing best practices from one of the preeminent groups in Saint Paul with one of the preeminent groups in Minneapolis and really the opportunity to learn from each other. It's just gonna be great for patients. We're bringing a group of excellent cardiologists together with a group of excellent cardiologists and surgeons and nurses and a PPS and administrators and really aligning them all together to deliver better health care, too. Not just add, but be synergistic. I think what will define success for the new group is if we can leverage the best practices of MH I and bring that to the East Metro M. H. I s historically done exceptionally well in advanced heart failure. Advanced imaging adult congenital heart disease. I think that affords a lot of opportunities for patients here in the East Metro Most of the time in previous institutions, I look in the operating room and I get a sense of what my day is gonna look like. And when I have to pay more attention to based on the people who were there here, the quality of the individuals and the team members from all walks of specialties and subspecialties is so high it doesn't even cross my mind. I walk in there, I know I'm gonna have a good day. But Minneapolis Heart Institute, as part of a line of health, is a national leader in leveraging something called an enterprise data warehouse. It's information from over 75 sources, all linked together into our data warehouse that allows us to analyze real time costs, quality and outcomes and to make changes in our care so that we can improve the cardiovascular care for patients throughout our population. Outreach, the MH I provides provides an opportunity toe interact with the community beyond just the Twin Cities area. MH I serves patients from five plus states in our region and the opportunity to provide. That outreach helps us make sure that we're really in the homes in the neighborhoods where those patients live with the capabilities, especially of telehealth and being able to remotely see patients. We still need someone there who's kind of the steward of that. Patients. Overall care and communication with them is very important. In order, Thio give our patients the best care, especially post operatively. We begin the next chapter of our 10 year heart of new own project by studying the prevalence of heart valve disease in an entire community, and we continue to advance our existing scientific centers for the study of heart valve disease and for complex coronary artery disease. We now have tests for cardiovascular disease that we didn't have when I was in training. And for the primary caregiver. Those things are all new and to decide which test to use in which condition you can go on our app to figure out what's the best test for that patient, and then you can hit a button and be connected directly with our scheduling department and get that test scheduled. The future of MH I is incredibly bright. We all know that health care is moving very quickly. We have to keep up with all the technology and the latest and greatest science to deliver to our patients the same time. We wanna keep that carrying touch and be the patient's advocate on the person that they want to come to because they feel safe and cared for. Mhm. Good evening, everyone. Welcome to the final 2020 Cardiovascular Virtual Evening symposium. Thanks for taking the time today. My name is Dr Mark Newell. I'm a general Cardiologists with me Officer Institute and again appreciate you spending a night with us and happy holidays. And I guess, more than ever, happy New Year is something we're all looking forward to. So thanks again for joining us. So I have the privilege of being one of the vice president's for the Minneapolis Star Institute and serves our chief of clinical cardiology and also direct our telehealth program. And so this is a bit of introduction for me. Tonight will be walking it through a few of our programs, and this is listed here in terms of what programs and services we have to offer. And actually tonight, with two speakers, will highlight several of these areas, including cardiothoracic surgery, cardio vascular disease prevention, hypertrophic cardiomyopathy, valvular heart disease and even imaging. So we've got two speakers and and really five topics that air covered tonight you can see the breath of knowledge and expertise that we have with my ample saarne institute. And again, it's something that I think we're all very proud to be a part of as you saw an introduction video. Uh, there's been a merger in 2020 with the Minneapolis Heart Institute in the United Heart and Vascular Clinic in ST Paul, and it's it's really been a wonderful merger and something I've been blessed to be a part of. And we're actually showing that off in a way tonight by having one of our experts, surgeons from the Minneapolis side, Dr Robbie Stephan and one of our expert cardiologists from the same Paul side and Doctor Luis two. We present this evening. So it's been a great year. There's been a lot of success despite the pandemic and all the stress that health care has been under, um, it's been a need time to see this really come together. As you look at the map here, you can see now with our metro locations. We have our main centers in Minneapolis and ST Paul in several areas here in the Twin Cities, with the red ones being highlighted where we call Metro hubs sites that have five days a week of cardiology services, including imaging. So your patients can actually go into the suburbs where they live and work and play and get all of the cardiac care that they need in the Metro hub locations if they don't want to, or can't get downtown to one of the main locations a Z you see, we cover much of Minnesota and into Wisconsin, a Czar partnership and these little green tab Zahra telehealth locations. So sites that air further away by distance but immediately available to some of our specialists and some specialists to get the care that they need where they live. As was mentioned in the introduction video and something I hope you all know and uses our cardiology curbside program, A Z you can see here. It's just one phone number. It's a direct dial number that'll get you directly to one of our cardiology experts during the day. This is available from 7:30 a.m. to 5 p.m. Monday through Friday, and it's truly a simple I was just picking up the phone and dialing the number. This can really be any question. Big or small, it could be. What do I do with this cholesterol profile to this person? Just had a cardiac arrest. What do I do now? And everything in between s so there's no question too big or too small. The whole point is to be available and to partner with you and to really help you guide that care of the patient without you having to decide. Well, is it worth me paging someone and trying to hear back? Um, so this is meant to be a convenience factor and hopefully very helpful. So please feel free to use the service if you haven't. Also highlighted in the introduction video is the MH I mobile app. We're so connected to our phones these days that it makes sense that have a nap available not only for um, common questions, you know, somewhere outpatient examples are here on the far side of the screen. How do I pick a stress test? How do I pick a staten which blood thinner should I use in this particular patient care and as well as our emergency protocols? If somebody's having emergent issue on em? I on abdominal aortic aneurysm. Any sort of urgent issue can also be access for protocols. You'll notice that the top on the bottom of the APP are the ease of use is the highlight. I think of our application. The top button is the transfer button. You simply click that button is depicted here and get directly connected to the transfer team. If you click the button at the bottom, you'll be directly connected to the cardiology curbside program that we mentioned at the beginning. So again, the beauty of this app is that it's easy to use and it's immediately available. And so I encourage you to download it. Use it, feel free again to call curbside as you need, because we wanna be available. We want to partner with you. A couple of other kind of fun updates that as we're all in this virtual world in 2020 it's nice to get you know, some brief educations, and I think this virtual symposia are a great way to do that. Oftentimes it's just best to do it on our own time. So we've We've had a new partnership with broadcast medical toe to do short videos and updates in particular areas. Some are, you know, very broad, like current concepts in atrial fib relation. Some are more specific, like carne itis, um, Carney, total inclusions of a coronary artery and everything in between. So things are available for your use, and they're meant to be successful at any time. Which is, of course, this virtual world that we're living in these days. Um, actually, starting in a few weeks here in January of 2021. We also have a podcast recorded, which is a new service. We call them cardiovascular conversations, and you'll see the list on the menu here on the side of the screen. These are experts in their field, giving very brief, very easy to understand updates on common things. You know what's new and prevention, what's new and heart failure, what's new in vascular surgery, and, uh, and you'll see the menu there. Ah, lot of great talks, a lot of great expertise that's immediately available again to you at your convenience on a podcast. So please you look forward to. This is well here in the very near future. And tonight I am honored to actually introduce to people that I would call friends and certainly happy to be partners with both of them and also two of the best doctors that I know. So it's really my privilege to introduce our speakers tonight. First will be a doctor. Lives to we. Liz was part of the United Heart and Vascular team and has now merged with the Minneapolis Heart Institute at United Hospital and serves as our cardiovascular prevention director on campus. She also, of course, does clinical care in the hospital and in the clinic and is an expert CT imager as well. So we'll certainly enjoy listens talk this evening and looking forward to that after Liz will be a doctor. Bobby Stephan Bobby is a cardiothoracic surgeon will give us an update tonight on surgical therapies for heart disease. Bobby has expertise in coronary artery disease in heart valve surgery and also hypertrophic cardiomyopathy surgery, and he'll touch bases with you tonight on all of those topics. And so I'm looking really forward to these talks. I hope you are as well, and we really appreciate you joining us again this evening. So just some brief updates on our disclosure of policy and statements. Good evening. Thank you very much. Mark. I appreciate the nice introduction. Can you guys hear me? Okay, great. So my name's Elizabeth Chewy. Uh, tonight I'll be speaking about cardiac calcium scoring. I have no financial disclosures through the talk this evening. I hope that you'll be able to understand the indications for coronary artery calcium scoring. Be able to explain the clinical significance of an abnormal calcium score and understand the current guideline based treatment recommendations for those found to have significant coronary artery calcification. As we all know, the coronary arteries lie on the surface of the heart and supply blood flow to the heart. Mile cardio, The various image ing modalities that we have provide different degrees of sensitivity for detecting coronary atherosclerosis. When plaque initially forms in its early most stages, it's usually not calcified. Yet instead made of cholesterol, cellular debris, inflammation and that degree about those closest might not be detected on our various imaging modalities. Over time, calcium deposits form in the blood vessel hardening of the arteries as they say. And that is where cardiac calcium scoring can be one of our most sensitive tests to detect early plaque where there isn't yet and obstruction of blood flow so a patient might not have symptoms, and a stress test would look normal. A swell. But there is already evidence of subclinical disease. It's not until more advanced stages, when there's actually obstruction of flow when a patient might have symptoms or a stress test would be abnormal. So for screen purposes, a stress test can clearly look normal, even though a patient might already have plaque formation. This is a representative image of a single slice from a coronary calcium score for the media. Steinem is in the center here, with the lung fields appearing black, the sternum anterior lee with a bright white calcification of the sternum bone. And when we look at the vasculature, beds, weaken See as well that there's calcification in the distribution of the left anterior descending coronary artery. So with coronary calcium score image ing, it's really easy test for patients, which is nice. It takes no preparation on their part at all. Oftentimes, patients can be added same day from when they've had their clinic visit. Patients ideally should be able to lie still on the table and hold their breath for several seconds to minimize motion of the heart. During the image acquisition, the pictures air obtained very rapidly. It does not utilize contrast, and they do the slices at about 2 to 3 millimeters of thickness throughout the heart from based Apex. And that's how we can look for the calcification and the vessels. The amount of calcification is typically quantified, using what's called the aghast in method, which the computer software will measure the size of the plaques, the area and the density and provide a score So a score of zero would mean that there is no coronary calcification at all, and the higher score, the greater the burden of plaque formation. The screening test does use a little bit of radiation on the order of about one millisecond Bert, which is comparable to that of a screening mammogram for women. So it's a very low dose of radiation, and most centers offer this for approximately $100 out of pocket for the patient. At this time, it's not well covered by most insurance plans, so When should we consider coronary artery calcium scoring? I would highlight three topics where the score can be very helpful in the management of our patients. First and most importantly, it can provide very individualized risk assessment in people who have a predicted risk for actual Socratic cardiovascular disease that's more intermediate. And in this it can guide our medical treatment, which I'll review further in our future slides. Sometimes we also use this in those who otherwise, you would think is low risk based on not having very many typical risk factors. But they have a family history of premature heart disease, So this is an optimal screen tool for more individualized assessment of their coronaries, and sometimes we use it for interval follow up. If someone has had a calcium score that, fortunately was normal, then we let approximately five years passed and might do a reassessment, doing them more more frequently than every five years. There usually isn't too much clinical change, so I would highlight the people for whom calcium scoring is not appropriate, and that would be people who are definitively low risk, you know, worried well, 25 year old who is asymptomatic really shouldn't have a calcium score and, similarly, someone where you know that their risk of heart disease is high, such as a person with longstanding diabetes who smokes and has high cholesterol. Regardless of any sort of calcium score. Those patients should be treated aggressively with primary prevention measures, so they should save their 100 bucks and the military road of radiation. We use coronary, calcium, uh, coronary calcium scoring Thio. Look for the presence or absence of coronary calcification, but then also can quantify that and get an idea of the burden of plaque when the score is zero. That means there's no detectable calcification. An absolute score of 1 to 99 is considered a mild burden. The plaque 100 to 3 99 moderate burden and scores 400 or higher are considered a severe burden of coronary calcification. A nice study United States that looked at the prevalence of coronary artery calcification in our population was the Mesa studied multiethnic study of atherosclerosis. This evaluated just over 6800 men and women who were asymptomatic, representing four different racial groups, including Caucasian, African American, Hispanic and Chinese individuals who did not have known cardiovascular disease or diabetes. Just over half the group was women, and the average age of the population was 62 years old. This group was followed for 3.8 years to look for cardiovascular death and nonfatal coronary events. And amongst that group of people, they tallied up the prevalence of coronary calcification in men and women in these different racial groups. Among Caucasian men, the prevalence of coronary artery calcification is extremely high. 70% of men have evidence of calcification, 59% of Chinese men, 56% of Hispanic men and 52% of African American men and women. The absolute prevalence of cuss ification is lower, albeit still high. 45% of Caucasian women have coronary calcification, 42% Chinese women, 37% of African American women and 35% of Hispanic women. And it's important to note that while women have overall lord prevalence of coronary calcification, the prognostic value of that burden of plaque is equal between men and women. And here's this next slide highlights the clinical significance of having coronary calcification. If we compare a person with a score of zero, then instead to someone with a coronary calcium score in the moderate range of one on 1 to 300. Even a person with that, that moderate range score has over seven times greater likelihood of having the clinical cardiovascular events. And for those with calcium scores over 300 their risk is nearly 10 fold higher. And that's after adjustment. For other risk factors, the way that calcium scores can also help to reclassify people eyes highlighted by this data that in people who would have thought had intermediate risk six, almost 7% of them actually had calcium scores over 400 which is a high risk score and has significant clinical impact. That's almost as bad as having clinical cardiovascular disease. And this next set of graphs, I think, shows that very well, the additive benefit of calcium scoring. On top of our traditional risk factor assessment, the top graft looks at mortality per 1000 people per year and then compares that amongst age groups and also amongst calcium scores. So on the X axis, you see the different age groups of 45 to 54 year olds and aging as we move to the right, and then on the Z axis, the calcium scores. So at any age group, if we have calcification a score above zero, you can see that their mortality significantly increases on especially a calcium score. Even over 100 drastically increases the risk of mortality. The bottom graph looks up beyond age. What about our traditional risk factors? Things like smoking, high blood pressure, total cholesterol, low HDL and diabetes. If we look at risk factors, zero risk factors one risk factor two or three or more. The added information that calcium scoring provides tells us a lot more about a patient's risk for mortality. If we look at, for example, ah, patient with zero risk factors. If they're custom score zero. The risk of mortality is very low. But if they have significant coronary calcification, their risk is of mortality is quite a bit higher. And we might be more aggressive with preventive care efforts. And similarly, if people with multiple risk factors also have coronary artery calcification, it shows us that that is a more aggressive status with greater risk. So the most recent guidelines that help us decide what to do with this information is Thebe, 2018, American College of cardiology. American Heart Association guidelines on the management of blood cholesterol. And it's important to note that beyond calcium scoring, we've, ah, lot of data has shown us that there are four groups of people who have definitely been shown to benefit from Staten medications. That includes people established atherosclerotic cardiovascular disease, people with diabetes, those with severe primary hypercholesterolemia within lbl over 1 90 despite lifestyle efforts that's really trying to target the familial hypercholesterolemia population, and then those who have for primary prevention a predicted 10 year risk of a major cardiovascular event over 7.5%. So again, we'll talk about different levels of risk and whom should treat. But the science to date would really but show us that the benefits of statins outweigh the risk when the 10 year risk is over 7.5%. So bear with me as we get into the nitty gritty a little bit. But in that patient discussion where we're trying to decide for primary prevention, should we put a patient on a statin? The guidelines would recommend that we really have to emphasize a thorough discussion with the patients reviewing their major risk factors considering some additional risk factors, which I'll summarize on an upcoming slide and then also just discussing with patients the pros versus cons of treatment with us. DATIN, what's actually the risk of adverse effects compared to what? Their perception of that, maybe considerations of cost and considerations of their values. And when we use that risk tool to predict risk, the most commonly used tool is the pulled Cohorts Equation calculator from the American Heart Association. Ah, lot of electronic medical records now even have that in great and embedded into the system so that it's pretty easy to pull in. But incorporating their age, gender, cholesterol values, blood pressure, smoking status. We can predict, on average what their risk is about major cardiac event in the next 10 years, and low risk is defined as those with a risk less than 5%. And in that group, Staten medication could be withheld. Borderline risk are those with the risk predicted risk of 5 to 7 points. Some 70.4% intermediate risk are those with a risk that's predicted to be 7.5 to nearly 20% and this population again, a lot of its data would say that there's benefits to stands, but we might want to consider more individualized risk assessment. But in high risk patients where we know that they're estimated risk of heart disease is high statin medications. Air certainly recommended, so those additional risk factors to consider are the following that we want taken to count their family history. There is no way to include that in the risk calculator, but certainly clinically is important. That was with moderate hypercholesterolemia with l deals over 1 60 metabolic syndrome, chronic kidney disease, history of preeclampsia or premature menopause younger than 40 years and women chronic inflammatory disorders such as rheumatoid arthritis, HIV, psoriasis. Certain ethnic populations, especially those of South Asian ancestry, persistently elevated triglycerides over 1 75 people be levels over 1 30. High sensitivity CRP over to and in those without clinical peripheral arterial disease. If they have a screening a B, that's less than 0.9. That's an indicator of subclinical disease, and we don't always routinely check lipoprotein A. But elevated levels over 50 are also associated with higher cardiovascular risk, so any of a patient has any of these additional risk factors that might sway you to more strongly recommending statins and those who might be otherwise intermediate risk. But the current guidelines now highlight that if, after all of the review of the major risk factors, the additional risk factors patients values, it's still uncertain as to how to proceed that then coronary artery calcium scoring can be utilized to improve the specificity of that risk assessment. If the calcium score is zero and they have no evidence of coronary calcification, then their clinical risk of events in the next 10 years is very low, and statin medication can be withheld or at least delayed. And you might want to reassess in five years, but again to remember that people who smoke or who have diabetes or really strong family history limitation of the calcium score is that it will miss plaque that's not calcified. So still in those individuals, we should be counseling on smoking cessation and might still consider statin medications a score. A calcium score of 1 to 99 generally favors treatment with a Staten, especially in younger people, because they're just going to continue to develop more plaque as time goes on. And for any patient who has a calcium score over 100? Or is that the greater than 75th percentile? It's recommended to treat the stands that the benefits certainly outweighs the risk, and it's important to highlight that percentile ranking. The absolute score is very different for a 40 year old compared to an 80 year old, for example, calcium score of 50 and someone who is 40 years old is markedly abnormal. They'd be at the 99th percentile, and that would be associated with a higher lifetime risk of cardiovascular events, whereas a eight year old individual the score of 50 that would be actually very good for their age. So that percentile ranking is an important consideration. These next couple slides demonstrate the benefit that statin medications can have in lowering their risk of major Edwards cardiovascular events based on calcium scoring. So here these graphs highlight the cumulative incidence of major adverse cardiovascular events stratified by calcium scoring and statin therapy. So the panel on the left are those who have a calcium score zero and the treatment lines blue being no Staten Red. Being with a staten are complete superimposed, and you can't tell the difference between the two groups. So that is what supports the idea of a calcium score of zero. It's appropriate or reasonable to withhold statin medication with a mildly elevated score of 1 to 100. We start to see the lines diverge where there is benefit to Stanton and reducing the risk of cardiovascular events, but most significantly, is when we see a higher burden of calcification. So here, in all the panel on the left shows calcium scores of 100 to 400 and the panel on the right scores over 400. And as you can see, as the years passed, that cumulative incidence of major cardiovascular events increases. And that line really improves with treatment with a statin where we can really cut their cardiovascular risk significantly. So while the guidelines do focus on who with whom? That we should prescribe his dad. And it's always important to emphasize that heart healthy lifestyle matters, it can significantly lower cardiovascular risk and sometimes some cases more powerfully than statins. So emphasizing that smoking, eating a heart, healthy nutrition, getting regular exercise and maintaining a healthy weight. So in some I would advise that coronary artery calcium scoring might be considered when you need further cardiovascular risk stratification for your patients. Do you think are in the middle, intermediate or on the fence about statin medications, or in those with otherwise predicted low risk but have additional risk? Can't risk enhancing factors. I hope you couldn't appreciate that The risk of cardiovascular events increases significantly as a person's burden of calcification increases and that treatment with statin medications are generally advised for those with calcium, score off over 100 or over the 75th percentile. Thank you very much. I appreciate your attendance tonight. It's nice to do this with you. All right, Perfect. So thanks for joining us tonight. My name's Bobby stuff, and I'm one of the heart surgeons over Abbott, and I'll talk about three big topics today. This is the bulk of what I do, and most the top two are the bulk of what most of us do, and we have a few things we've been working on and so shared some of those with you. So first thing I'll talk about is, um, coronary artery disease, second valvular heart disease and lastly, hypertrophic obstructive cardiomyopathy. So this is a pretty typical angiogram of ah patient that gets referred to me. So, um, this is Ah, shot of both the left and the right coronary arteries, and there's blockages in all three of them. So the question then is what to dio. So open heart surgery, coronary bypass, or take him to the lab, put a stent in and send him home. So the guidelines say that there's three groups of patients that really benefit from coronary bypass, and this is the vast majority of who we operate on. And this these are people who I could tell I can help improve your survival with coronary bypass. So patients who have blockages in their left main coronary artery patients who have blockages in all three of the coronary arteries onda patients that have what we call left main equivalent or two of their arteries, but also involving approximately lady. So these patients are the typical ones that we operate on. So coronary artery bypass crafting is the operation for coronary artery disease. It remains the most common operation we dio. Uh, it's a very safe operation and provides a very durable result, both for survival and freedom from recurrent symptoms. So these are our numbers from last year. We don't have the ones from this year yet, but this is what I mean when I say this is a safe operation. So in 2018, we did 228 coronary artery bypasses with to death. So when I counsel patients about this, I say we have a greater than 99% survival. So it's open heart surgery with a greater than 99% survival. And those are data from our hospital. Real data from the surgeons at our hospital. Um, major complications are rare. Aziz. Well, so, um, sternal wound infection. Very rare stroke, very rare. So this is a very what I tell patients. A very safe operation. The standard way we did it for a long time is on the left. So what it is is using the internal memory artery and then some vein from the leg to bypass the blockages. So there are a lot of redundant arteries that aren't necessarily completely needed for their original purpose. So we've been using mawr of those for for bypass. So, as you can see, not only is there the left internal mammary artery, but there's the right internal mammary artery. Um, the radio star, the radial artery in both of your arms on. But there's also an artery that runs along your stomach that can be used. So, um, there's been interested in using MAWR arterial grafts instead of using vein from your leg in patients, especially younger patients with coronary artery disease. And this is why So there's more more evidence coming that multiple arterial grafting is associated with better outcomes. Um, so I'll just share one slide with you. This is from that paper eso This is major adverse cerebral vascular and cardiovascular events, and this is using, uh, the top line. The blue line is for patients who on Lee got that single internal mammary artery. And this red line is for patients who got another artery. Either they're right internal mammary artery as well, or radio graft. And what you could see is two things. One. The difference in using the second arterial grafts starts very early, so there may be a benefit as early as one year out, and that benefit continues to increase out to eight years. So it's a continual increase in benefit, even out that long. So, um, in patients who are going to undergo coronary bypass grafting who have this much longevity left. We strongly strongly think about using a second arterial graft. So this is what a modern day coronary bypass graft may look like when it's done. So it has that left internal mammary artery coming down. It's got the right internal mammary artery coming down to the graph, this vessel using part of a radial artery over here to graft the lateral wall and then additional one taken off that left internal mammary artery. So it's pretty common toe. Have, uh, younger patient have there post surgical anatomy look like this? So next talk about valve. So a valve function is to allow one way flow and prevent back backflow. So that's the perfect valve. Completely allow one way flow, prevent all backflow. So that's what a normal aortic valve looks like. This is what the most common pathology of aortic valve disease looks like. So just like we talked about on the first talk calcium development, there's calcium on over all over. These leaflets at these leaflets aren't opening, so typically the way it fails is it doesn't allow one way flow very well these leaflets don't open the hearts having toe work against higher pressures. Um, this one is a combination of both. This valve is not gonna open very well. And also, it's not gonna close very well. So when the patient has aortic stenosis, a needs a new valve, we really have two options. So one is a mechanical valve and the other is a tissue valves. So the mechanical valve last quote unquote forever. There's a 1 to 2% risk annually of bleeding and clotting, but theoretically last forever. But patients have to be on Coumadin, and as of today, it's Coumadin, not any of the newer anticoagulants. We're actually enrolling patients in the study here to randomize one of the mechanical valves to Coumadin or one of the dough acts. But right now, everybody is getting Coumadin tissue valve. Benefit is you don't need to be on Coumadin long time, but ah, long term. But they do to generate over time and the length of which they degenerate depends on multiple factors. Um, the patient specific how old they are, how big of a valve we get in Onda valve itself. So, um, typically for patients in their forties, sometimes even early fifties. We really push the mechanical valves hard. Um, for the tissue valves. Uh, if you're 60 we tell you somewhere in the 10 12 years, and then actually, as your older, um, they tend to last longer. So, um, these are pretty much going, you know, anybody more or less 70 75 or older is getting a tissue valve, and then in the middle, it's really patient preference. Um, what they want. So traditionally, heart surgery was done through a full stra nana. Me So an incision from the top of the breast bone to the bottom. Um, but we're having We've had success using smaller and smaller incisions toe access the valve. So the majority of our aortic valves are done through some sort of minimally invasive techniques. So this is a heavy Eastern autumn E. So instead of going all the way down to the bottom of the bone, we go usually toe what's the four thinner? Okay, so, um, Bennett, one of the benefits is much smaller incision. Usually, these patients end up with seven or eight millimeter incision, another option that's used for the aortic valve and also the mitral valve is a right thoracotomy. So this spares the breastbone and goes through the inner space. Um, things is another option, and one of the benefits of this is no sternal precautions afterwards. So we're doing some of this is well in, ah, specific subset of patients that qualify. This has been the biggest game changer for us when it comes to valves by far. So, uh, this is a trans catheter aortic valve. This is the safety, and three and it has changed the way we think about valve disease completely. So, um, this is a valve that replaces the aortic valve through the growing. So it is a perky Taney ISS. The devices now are perky Taney ISS. We could do a per Catania's closure on most patients there. They are staying overnight and go home the next day. Andi, it's really changed our thoughts in two ways. One who should get this primarily so what? Patients should just go right to tavern and to you know, that 60 to 65 year old patient that is thinking about a mechanical valve thinking about a tissue valve, um, this gives them an option, or at least some hope that if they choose a tissue valve and 10 years, 15 years down the road, that valve fails. They may not have toe have redo open heart surgery. They may be able to get their valve place through their groin. So, um, we use lots of these. This has completely changed the way we like, I said. We think about it and use incredibly frequently, Um, as I mentioned, So they go in through the groin. So instead of traditional open heart surgery, we take out the old valve, put suit your material in the valve analysts and then so that valve in place. These are deployed through a balloon dilation in the cath lab, so there's no, um, incisions. So one of the factors that allows people to get this or to not get this is they need to have some calcium on the valve to be able to grab onto the valve. They can't have calcium in bad places that won't let the valve expand because it can leak around. So it's still a subset of patients that are getting this. But it's getting to be a growing and growing lee bigger subset of patients that are becoming candidates for this benefits of it. Much easier recovery. Historically, there's been a higher pacemaker rate. Um, that seems to be going down a little bit. Um, that's been one of the Knox historically. And then we don't quite know the durability, Mostly because we just haven't put these long in long enough. So we don't know, um, in vivo how long they're gonna last. But the initial studies indicated maybe not quite as long as a surgical valves, but they're pretty good. And then, as I mentioned, we think about this technology when we're doing surgical valve. So, um, let's say you have 60 to 65 year old patient that you're putting a valve in, uh, that you'd like to be able to win that valve degenerates put a tavern. And what are some things that will be helpful? Well, um, ideally, you want to get the biggest trans catheter valve in. So this valve, one of the valves, um, actually, the stent is expandable. So what we can do is balloon dilate, increase the size of the sewing ring and put a even bigger valve in through the groin, and then it's well seen on X ray. too. So the valves that are being designed and implanted now are being built with the thought of down the road. How can we do trans catheter valve replacement in these patients? So some valves open up just fine, but they leak, So that's the other not supposed to allow backflow. So this is a pretty classic echo of a mitral valve with P two pro laps in a 51 year old gentleman. So ideally, so, this this is what it looks like. So this is his entire leaflet of his mitral valve. This is opposed to your leaflet, and so what? Right there is this. That's accord that's ruptured. So, um instead of co opting well on with the anti elite foot, it's coming all the way up, um, past that entire legal and it's leaking right in here. So, um, unlike the aortic valve, which almost always leaks but becoming because it's stay gnomic, the mitral valve off frequently leaks because it frequently is dysfunctional because it leaks. And so oftentimes we can actually repair the valve. And there's actually a lot of benefit for repairing the valve, so specifically a survival advantage. So this is three different subsets of mitral valve disease, post yearly foot prolapse, Bailly, foot prolapse and anti leaflet prolapse. The type doesn't matter so much as it is just that we can dramatically improve their survival by repairing the valve. So post your leaf of prolapse huge survival benefit by repairing instead of replacing the valve by leaflet prolapse significant, um, survival advantage by repairing the valve. So instead of like the aortic valve replacing it, we're really looking at, um, most mitral valves. Can we repair And how do we repair? So sorry, mine skip. So usually what you could do is just take that segment out so often times one of those cords two of those chords has ruptured. Just excised that segment. So it back together, which is what was done on this case. And as you could see, it doesn't leak anymore. So with mitral valve disease we're frequently looking at Can we repair this valve? What do we need to do to repair this valve? Atrial fibrillation is super common in patients with mitral valve disease. So, um, in patients who are undergoing surgery for mitral valve disease, is there anything we can do besides repairing the valve that will allow them to increase their chance of being free of a fib. And the answer is yes. So if we in patients with mitral regurgitation, if we just do microsurgery alone on Lee, 30% will be free of a fib. If we do an ablation, 63% will be free of a fib, so we can double the number of people who are free of a fib just by adding an ablation at the time of mitral surgery. So we're going to repair your mitral valve will replace your mitral valve. We assess you for atrial fib relation, and if you have it, we likely will treat it. There's two different ways to treat it by atrial maze and the PV. I both worked pretty well. There may be a little bit of benefit from a little bit more of an ablation, but you will likely get some sort of ablation, and this is essentially what you're doing, and I don't won't go into all the details, but you're its's called a maze procedure. And so what you're doing is creating a maze that minimizes your chance of getting these macro reentry circuits. So by either cry or radio frequency ablation will create this giant maze throughout your right and left atrium Onda helping restore Sinus rhythm. And then the last part is, will lie. Get your left atrial appendage, which is where a lot of, uh, cloths come and that will minimize your chance of of a stroke. So just like tavern trance, Catherine, Mitral repair is the super exciting area that people are working diligently in. We're not quite as far in my trolls as we are in a oryx, but we're getting there. This is the tendon device. So this is a device that's deployed from left thoracotomy little incision in the apex of your heart and then is deployed in your mitral valve. And, um, it looks like this. So here's your aortic valve. Here's your mitral valve. Here's the 10 9 sitting right in your left ventricle, and it's had very good results. So these are the results with the 1st 100 patients, as you could see out to 12 months, 98% free of significant mitral regurgitation. So, um, there's hope that Mawr and Mawr valves will be able to be treated via trans catheter methods, and this is one way one of the newer devices that's being used for mitral valve patient. So sometimes your valve doesn't leak because there's anything wrong with the valve. Maybe it's where it's housed. So this is a cat scan of a patient with an aortic season in the Arctic and aortic root aneurysm. So his thesis is aortic valve. But this this is aortic root. So the route has dilated so that the valve itself is okay. The leaflets itself themselves air okay, but the aorta around it is disease. So in these patients, often times we can save the living valve. So this is called the valve sparing replacement so took. All the diseased aorta is taken out. This is the background to graph. This is a healthy native aortic valve rezone inside of the tube graft. So I show you this to show you that healthy valves, whether they're mitral valves, aortic valves, can often times be saved. And that's what we try to dio. Lastly, I go over, um, hypertrophic cardiomyopathy. So this is a pretty classic echo of patient with hypertrophic cardiomyopathy. So, um, here's the aortic valve. Here's a basil septal bulge right under the aortic valve, which is not only causing turbulence under the aortic valve, but it's actually pulling that mitral leaflet in and causing it to leak. So, um, it's, um, muscle in a place that's too thick, and it's causing essentially to valve problems. So what we can do is, uh, instead of having to replace any valves is take that muscle out. So this is what this is what it looks like, what we do. So this is the ascending aorta. This is the aortic valve. This is the aortic valve pulled away. This is the muscle under the aortic valve. So the basil septum and this is the anterior early for the mitral valve. So what we do is just excised this muscle, and it's usually in the 3 to 6 g of muscle. So it's not a lot. It's just in a bad place. And as you can see here, with a lot of that muscle taken out, the outflow tract looks much wider. This is what it looks like live so this is through the inside of it. So the end of cardio is down on that green towel. This is shaved Muslims. You could see we end up going pretty deep down into the ventricle. So it's, you know, three centimeters down into the ventricle on four centimeters across. So about 3 g of muscle in a good, uh, three by four centimeters each way. So what we can do as well is to make sure that we can check our work in the O. R. So a lot of times, these patients, um, have a dynamic obstruction. So they do okay if they're sitting, if they're walking, sometimes even light exercise. But when they really start to go is when they obstruct when they start to get their heart rate up, so we'll give you a little stress test. So this is the inter operative T right? Afterwards, So this looks great. So the outflow tracts wide open no further, um, turbulence in the output track, the mitral valves not leaking. So then we give him a little debuted. I mean, to get his heart rate going and, uh, his heart beating a little harder. And we get this same result, so he's gonna be fine, it at lower heart rates. But once he starts toe really exert himself, he'll get, uh, symptoms again. So What we can do for these people is go back on bypass, take a little bit mawr and do it again. So here we went back. Took a little bit more muscle, Aziz, you could see even in this stress, Tate with beauty mean in a low blood pressure thing out. Foot tract is wide open and the must end of valves not leaking. So, um, we can tell people when they leave the o. R that they got a very good result and should be fine to live a very active lifestyle. So in summary, coronary artery bypass remains the super common, safe and durable operation to improve survival and symptoms. Many options exist to repair and replace disease valves, both both surgically and trans. Catheter and relieving. Obstruction, release relieves valve pathology and symptoms in patients with hypertrophic cardiomyopathy. Thanks again for joining. All right, Well, thank you, Bobby. Thank you. Lives. Those talks were outstanding. Really enjoyed them myself. And I hope everybody else did as well. I'm sure you did. So thank you. Um, got lots of good questions that have been popping up here. And just a reminder for folks. Toe put questions under the Q and a tab at the bottom of your zoom screen. If you'd like us to answer any questions. Um, you know the first few questions I think were directed towards Dr Liz TUI about prevention. So let's maybe I'll combine the first two for you. The first two would be one person asking about having been on Staten for many years. Is there a benefit to calcium scoring? If you've already been on a staten and then, uh, combined that, I guess with the second part, which is a patient who was 69 years old with a 75 scoring the led in a total score of 1 25. You know, how severe is that? So if you could come start with those two, please. I think you're on mute. Little Sorry. You think I'd have that figured out by December? I'm sorry about that, guys. Um, so regarding the patient who is already on a statin whether or not to repeat a calcium score generally, we don't repeat it unless it would, in some way impact clinical management. It's not well known what happens to the calcium score with statin treatment. Some studies show that the actual burden of calcification might increase as plaques stabilize and become safer plaque. So, in general, if someone's honest at and I is pretty rare instances for when you might want to repeat that to the question of what does a calcium score of 75 the lady and the total score of 1 25 mean? Um, Zoom was convenient because I got a little warning about that question coming. So I was able to pull up the calculator that we used to estimate. What does that risk mean? Um, we've seen anybody can Google Mesa calculator, calcium calculator and then put the patient's age and the score and how that how that score compares to other people their age. So it really it depends on if this individual is a man or a woman. If it was a female age 69 these total score of 1 25 would put her at the 77th percentile, meaning that she has more coronary calcification, then 76% of women her age. So ah, higher risk score and would be appropriate for statins. Whereas if it was a 69 year old man that would place him at the 49th percentile, so he would really be average. And as a you know, in that patient provider discussion, you can decide. Okay, Well, heart disease is my greatest health threat. Maybe I still want to go on the stand and just simply because I do have plaque, even though I'm average. But it's not as high of a risk or as it would be for a woman of the same age and the score of 75 the lady that tells us a little bit about where the plaque is located. But, um, that's harder to predict. In general, scores over 100 is thought to be a greater likelihood that a plaque might be obstructive, meaning restricting flow. But that's not guaranteed. Some plaques can protrude outwards. Others protrudes inwards to have flow limitation. So that really is variable. Excellent. Thanks, Lis on board. Appreciate all the questions coming through. We almost probably have more than we'll be able to answer here, but maybe I'll throw on to Dr Stephan here. Eso Bobby, if you do Amazing the left atrial appendage legation when you stop on a regulation for a fib and do you do a follow up tea and any certain interval like 45 days, Um, or do you just stop it? A certain timeline. So post op patients are still very at risk for a fib in the first 8 to 12 weeks. So if I do any sort of ablation on them, I tell them, Usually I can almost guarantee you you'll be in a fib at some point in the next 8 to 12 weeks. So they end up on anti coagulation that long, and then we send them to their E p or cardiologists usually and have them do a monitor to see whether or not at work, as you saw. You know, it works in 60% of people that had a fit, but there's still a good percentage of people that don't go back permanently to a Sinus rhythm. So, um, really important to not just stop anticoagulants shin and see what things look like after about three months? Perfect. Thanks. Very, um, again, Sorry. As I keep kind of doubling up here with questions when you're getting a lot of interesting questions here about calcium scoring. So maybe hit you with a two part question again um, you know, the first part is, you know what? What age do you consider calcium scoring? If there's a strong family history of heart disease? And then the second question relates to, you know, the PCSK nine inhibitors and you sort of apply those similarly to statins. And people are standing intolerant, meaning if they're, you know, high risk or would be qualified for a Staten. What happened to be standing intolerant or using them basically is equivalent substitutes for So the age where the council scores well validated is in those over age 45. Uh, that being said, the cholesterol treatment guidelines are applicable people age 40 and above. So I think it's a very helpful score in people 40 or older, rare cases and people in their upper thirties. If there's really a marked family history, albeit again, if they're really, truly is a marked family history and they have high cholesterol, you're probably just gonna want to treat them regardless. So, generally, somewhere between the order of like 40 to 45 as a starting age for PCSK nine inhibitors, um, that's where it gets tricky. Uh, in general at this time, they are approved in those who have clinical cardiovascular disease or those with familial hypercholesterolemia, and not yet in those who are standing intolerant but have a high lifetime risk. That may change as pricing changes over the years. I mean right now, a big piece of that is that the PCSK nine inhibitors are extremely expensive. So if the question I think you said it was someone with diabetes and moderate risk, um, generally, after exhausting Staten strategies, then we would most next. Consider a Zeta might, since it is generic and you just don't get a robust LDL lowering. But it is well demonstrated to have benefit on top of statin therapy from the Approve It trial. So it's pretty rare Thio then go to pieces canines for primary prevention. You could consider a calcium score, and if this cousin score was really high over 400 significantly higher, maybe you could convince someone's insurance that that has similar clinical risk to cardiovascular disease and they might approve it. But to date, that's been challenging, I think, because of the cost of the medications. Yeah, I think that's well said. There's a lot of promise with some of those trials and how they've performed. But just not enough data relate to support with guidelines and with insurance companies and many instances. So that's perfect. Thanks, Lis. All right, Dr Stefan, I'll hit you with a two part question here just to be a little bit fair on great questions again. So thanks everybody for so many questions. Um, you know, a two part question about it first is how often you repeat and echo after a tissue valve, and then the second piece, they're just, you know, some of the common observations and complications you've seen after Tavern, you're so repeating the echo. So everybody in the O. R gets on intra op echo after, sir, are you know, once we're done putting the valve and so we know if there's any concerns and typically if there is, we take care of them right there. So we know Interop whether or not there's any concerns, if there's not usually will get one at about three months just to make sure and then, um, every year after that is typical. Every once in a while, there's some weird, and you're following them a little bit more closely. But typically one kind of in the three month range than every year. Tavern complications. So, of course, anything that can go wrong will go wrong. So start with the access. So, you know, everybody gets a full body cat scans. So you have a sense of what their extremities they're gonna be like if they're at, you know, if they're small, if they're calcified, if you're gonna have problems dealing with those, um, deploying the valve since you're not excising the old valve and usually you're ballooning up a new valve, sometimes the conduction system can get temporarily or permanently damaged. So pacemakers air common catastrophic complications are rare. Um, things that require open surgery are rare in the, you know, emergent open surgery are rare in the 1% range. It happens. Um, our experience and our preoperative imaging have really helped get that to be quite low. Excellent. Thanks, Bobby. And, uh, we do have an audio questions. So, Christian, I don't know if you can connect the audio here and we'll try and listen in on audio question. Give it a girl. Let's see. Looks like they may have changed their mind, so Okay, no problem. Thank you. Why don't we just maybe do one more quick question here for each of our presenters tonight. So, Liz, if I guess Sorry, another two part question. Forgive me. Uh, the first is, you know, if you're taking calcium supplements, does that affect your calcium? Score your your coronary artery disease. And then secondly, you know, we know from big trials that stands reduced the risk of an acute coronary syndrome. Does it seem to change the type of severity of a CS that you've seen and you repeat that last part? Does it seem to change the type of severity of a C s? Yeah. Sorry. Seeing you know, when people come in, is it a less severe heart attack? Are Do we have any data on that which I personally don't know that we dio Yeah. I don't know the answer to that one. Answer the second part first. I'm not sure I We certainly know that the incidence of heart disease has gone down the risk of major cardiovascular events that it's gone down. Whether the severity changes. I don't know, I guess would be that there is good data that statins improve peri operative risk. So, you know, there's something about the plaque stabilization effect of Staten. So but I don't know and then to the first question about calcium supplements. But also there's not a lot of great data about. There is some speculation that excessive calcium intake that's not in our foods doesn't have the same cold factors to get into the bones and make strong bones like we want. And instead you could have vascular deposition of calcium calcification. So in my patients, I generally try to encourage them to increase their dietary intake of calcium because there's vitamin K to what's called the cool factor that helps the calcification get where it's supposed to go. And accepting those who also may have osteopenia or osteoporosis. Where there, endocrinologist or primary provider might say that they need calcium supplementation. And we just don't have great data, that which, which is worse in terms of benefit versus risk? I don't know market. You have an extra comment on that, too. I think there's debate about that in our cardiology community. Yeah, absolutely. In the comment, I was gonna make us around that other part of the question, which is, you know, we don't necessarily know about the severity of a C s or the you know, the type of a CS per se. But, you know, one study I'd refer people to, if they haven't looked at it, is the Scott Heart trial. There was a recent trial is probably a year and a half ago, now in New England Journal that looked at really the five year outcomes essentially of early detection of plaque with, you know, cat scanning similar to the concept of calcium scoring. And this was the first time, really, that an imaging study was shown to impact outcomes when they found plaque earlier, over the course of five years, not just with statins but with statins and lifestyle, you know, activity guidelines and potentially early, appropriate coronary intervention. They showed a statistically significant improvement in the heart attack rates and mortality by identifying black early so that that's a really powerful study of people. Haven't looked at that Scott hard trial. Um, great questions. Everyone and one final one here for Dr Steffen eso. Bobby um, do use aspirin with a Zanuck regulation for mechanical valves. Post operatively. Typically, everybody goes on a low dose aspirin on Ben Coumadin, But yeah, typically Everybody's on a low dose. Aspirin. Excellent. All right, well, thanks again, everyone. So much for joining us. Thanks to Dr Lewis to a doctor, Bobby Stephan, for your presentations, which are wonderful for all of our attendees. Again, we've got the CMI code, so please feel free to scan that or follow the surveymonkey link on your screen to access that. So thanks again for your time. Please, Everyone stay healthy. Stay safe and happy holidays. And certainly I know we're all looking forward to 2021. So thank you so much. Have a great