Dr. Seth Bilazarian’s Top Takeaways from TCT 2015
Dr. Seth Bilazarian, Vice President of Interventional Cardiology Programs at Abiomed, attended TCT 2015 and blogged about what he learned in a recent blog post. The Protected PCI blogging team also called him on the event's last day to learn more.
Benjamin: Hi, I'm Benjamin Hunting, and welcome to the Protected PCI Podcast. Today's topic is the top takeaways from TCT 2015. This event is the world's largest educational meeting specializing in interventional cardiovascular medicine. Joining us is Dr. Seth Bilazarian, Vice President of Interventional Cardiology Programs at Abiomed. Seth attended this meeting all week and is calling in on the last day to share his top takeaways.
Dr. Bilazarian, thank you for joining us today. I was hoping you could start out by telling us a bit about your new role at Abiomed, and what your expectations were for the week.
Seth: Well, I'm very new to the company. I had interventional call and my clinical responsibilities ended early in the morning on Friday at 4:00 AM and I assumed my new role at 9:00 AM with Abiomed as Vice President of Interventional Cardiology Programs and came to the TCT to begin my new role, which is evolving, but will be much about physician education and helping physicians and the company understand one another. That's my chief role as the first interventional cardiologist in the company.
Benjamin: And now that you've spent the week at TCT, what were your biggest takeaways from the event?
Seth: Well, TCT, I've been attending for many years, for almost all of my professional career I've been attending TCT. It is, as you said, the largest educational meeting, and there's enormous amounts of information in the coronary space, vascular space, structural disease space. But I would say that they seem to take a theme on each year. So in the last several years, the theme was really been mostly structural heart disease and trans-aortic valve replacement. But this year was noticeably different. There really was a shift, in my view, more towards an understanding of the importance of Protected PCI, and the critical nature of complex, high-risk, appropriate PCI patients, for the management of these patients. And there were many sessions and live cases about the best way to treat these patients, about populations that are really being under-served and under-evaluated, and under-treated. And really a call to action for physicians, and even for patients to understand the potential opportunities for treatment.
Benjamin: And how has this focus on Protected PCI impacted patients?
Seth: Well, one of the things that was brought up to begin with is that many of these patients are not even being recognized or evaluated. There's data that was presented by Ajay Kirtane from CRF group, that only about 25% of patients who are admitted with congestive heart failure are even evaluated for coronary disease in the first 90 days after their first hospitalization for congestive heart failure. So that's an example of very, very low rates of potential coronary heart disease contributions to heart failure. We know that heart failure's the number one admission for hospitalization, it's a huge economic burden, but it's also, of course, a huge burden on patients in terms of quality of life.
So there's really low levels of evaluation for patients with heart failure. Then on the other hand, we heard many cases of patients who were given a directive that they really should be in hospice because they had advanced coronary disease. But when they became associated with or contacted a center that was skilled in complex, high-risk PCI, they went from being a hospice patient to being a fully functional patient with an excellent quality of life. So in terms of range of shortcomings in the current management of treatment that I think there was a call to action, as I mentioned, and a desire to bring awareness to the interventional community. But of course for the larger community of clinical cardiologists, heart failure specialists, even patients. Of course, that's the great hope of this blog.
Benjamin: And do you see this awareness that was brought to the foreground at TCT spreading across the general medical community?
Seth: Well, the initiatives, I think, by both physician educators and groups like CRF that host TCT and, of course, physician educators and thought leaders around the world, is to bring a greater awareness to Protected PCI and the concept that complex, high-risk PCI patients are in need of treatment. So at this point, I think we're trying to bring that awareness forward. In terms of how we bring that awareness, I think it's a combination of both CME strategies, strategies of these large conferences, all the way down to local community hospital education programs. And Abiomed is taking a leading role as an industry sponsor of many of these efforts to bring greater awareness to both the physician community and the patients.
Benjamin: It sounds like Protected PCI has the potential to rewrite clinical practice in interventional cardiology.
Seth: Well, the anticipation is, like in any either diagnostic strategy or therapeutic strategy, that awareness is really the first step. One of the tenets we learn in medicine is that we can't consider the diagnosis if we don't think about it first. So the first effort, of course, is to get physicians who are caring for patients with heart failure, with anginal symptoms that are advanced, to think about an option that they may not have thought about previously. And I think that's the really significant thing that's going on.
We can sometimes use an exalted term like, "paradigm shift." I guess a lesser term would be just, be thinking many of the aspects of treatments for patients, like Chronic Total Occlusion care, Staged PCI, and incomplete revascularization, are all things that have largely been adopted as safe and appropriate, but are now really being rethought that they're perhaps not the best strategy, that we should be undertaking chronic total occlusions. We should do Staged PCI in patients, we should try not to completely revascularize them when they're in the cath lab, and that we should ultimately think seriously about, as much as possible, complete revascularization, which includes Chronic Total Occlusion. So I think that's really the first step. It's of course recognition and there's a lot more work to do after that in regard to training and other issues.
Benjamin: And do the training requirements present any particular challenges for the adoption of Protected PCI?
Seth: PCI involves physicians continuing to hone their skills and seek out opportunities to get better at complex interventional treatment strategies, whether that's using therapies such as rotational atherectomy for calcific disease, or advanced techniques for Chronic Total Occlusion. Which requires, really, a fair amount of commitment of attending chronic occlusion forces, and getting proctors, or attending opportunities to actually have hands-on opportunities to do these really advanced Chronic Total Occlusion therapies.
Benjamin: Do you think we're closing in on a universal understanding of what CHIP, or C-H-I-P, entails in the interventional cardiovascular community?
Seth: Well, I think that CHIP is a new concept, it's a concept that is evolving, it's a term that only recently has begun to be used. So CHIP stands for Complex High-risk PCI. The acronym is one that I think physicians are beginning to take note of. Of course, like many things, the definition is a little bit uncertain because what one physician might consider a high-risk or very complex PCI, another physician would consider to be not very high-risk, so the exact definition is in evolution. Of course, some of us know what those high-risk cases are, without any kind of question. For instance, a patient who has a last remaining vessel, who's surgically inoperable, who's having an intervention on that last-remaining vessel, I think no one would disagree, is a CHIP patient.
But other cases, a patient who has an ejection fraction of say, 35 or 40%, what we would consider a moderate left ventricular dysfunction, who may have a proximal LAD stenosis. That I think most people would also consider a high-risk case, but other physicians might say that that is a case that could be done without hemodynamic support. But then when we re-enter the possibility that a patient might have a calcific lesion, in the rotational atherectomy, for instance, that would then shift it back. So the definitions can be somewhat in evolution, and maybe operator-dependent, but I think that the concept is, is that it is one determinant of risk for patients. Ejection fraction being one, the second, the complexity of the lesions, and of course, the third, the patient characteristics. The patient's frailty, their renal status, their peripheral arterial disease status, and other issues can all contribute.
But one of them I think is substantial, is prior coronary bypass surgery. Patients who've had prior coronary bypass surgery are very high-risk for repeat operations. And they're at even greater risk if a repeat operation has to be taken in an emergency circumstance. I recall very well a surgeon that I refer to told me that, "We do reoperative bypass, we do emergency bypass, but we don't do emergency reoperative bypass." Which I think makes the point that these patients who've had prior bypass surgery and come to the catheterization labs for intervention, are really patients who are not going to do well and perhaps may not even be taken for emergency bypass if they do have a catastrophic circumstance in the laboratory. So we're offering these patients the maximum benefit for safety, working with dynamic support, are the ones that I found to be the most compelling ones at this conference. And I think physicians who are uncertain about adopting the Protected PCI approach should really think seriously about.
Benjamin: Do you have any advice for patients who might potentially benefit from Protected PCI, in terms of how they can find out more about the procedure?
Seth: So part of this Protected PCI website includes patient information, so that patients can become aware of this. And we're hopeful that over time, there'll be more and more centers, and more and more patient interest in, at least, exploring whether, after communicating with a physician and having a consultation, whether this approach is right for them.
Benjamin: You mentioned patient anecdotes. Were there any cases at TCT this year that really stood out in your mind with regards to how Protected PCI could've made a difference?
Seth: At the TCT meeting, the operators that have been performing CHIP cases, chronic total occlusion centers of excellence. And Protected PCI centers, shared cases in which patients were suffering with Class IV anginal or heart failure symptoms. Who were severely debilitated, could not leave home, and went on to actually resume really excellent qualities of life, with improvement in ejection fraction. And one really sad and compelling case, for me, was a case of a patient that was told that they should be on hospice care because their cardiac issues were so advanced and there were no therapeutic options, that they should really just be home with care for palliative type of treatment, and this patient had excellent angiographic results, and had an excellent restoration in life.
So that was really a very compelling story, in my mind, that patients should be really offered these options. Even if physicians don't have these skills themselves, they should really identify centers that they have confidence in, and that they have good relations with, that they can collaborate with to take care of these patients going forward.
Benjamin: Dr. Bilazarian, I'd like to thank you for taking the time to speak with us today. And for everyone listening, I'd like to invite you to visit the ProtectedPCI.com blog in order to learn more and subscribe to future podcasts. There'll be a link to the blog at the end of this podcast. Thank you for listening.
The Impella 2.5 system is a temporary (<6 hours) ventricular support device indicated for use during high risk percutaneous coronary interventions (PCI) performed in elective or urgent, hemodynamically stable patients with severe coronary artery disease and depressed left ventricular ejection fraction, when a heart team, including a cardiac surgeon, has determined high risk PCI is the appropriate therapeutic option. Use of the Impella 2.5 in these patients may prevent hemodynamic instability which can result from repeat episodes of reversible myocardial ischemia that occur during planned temporary coronary occlusions and may reduce peri- and post-procedural adverse events.
Protected PCI and use of the Impella 2.5 is not right for every patient. Patients may not be able to be treated with Impella if they have certain pre-existing conditions, which a cardiologist can determine, such as: severe narrowing of the heart valve, severe peripheral artery disease, clots in blood vessels, or a replacement heart valve or certain heart valve deficiencies. Additionally, use of Impella has been associated with risks, including, but not limited to valvular and vascular injury, bleeding, and limb ischemia in certain patients. Learn more about the Impella devices’ approved indications for use, as well as important safety and risk information at www.protectedpci.com/indications-use-safety-information/.