Clinical Editor's Corner Live: Left Main PCI in Interventional Labs Without On-Site Surgery

When is high risk too high? Listen in as Dr. Morton Kern and his expert colleagues review the complexity of left main intervention in a lab without on-site surgery in this 30-minute discussion, or read the transcript below.

Dr. Kern's original article can be found in Cath Lab Digest's March 2023 issue: Left Main PCI in Interventional Labs Without On-Site Surgery: When is High Risk Too High?

 

 

 

 

 

 

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The following transcript has been lightly edited for clarity.

Welcome to Cath Lab Digest’s “Clinical Editor's Corner Live” with Dr. Morton Kern. I'm managing editor Rebecca Kapur. Today, Dr. Kern and guests Kirk Garratt, Michael Lim, Arnold Seto, Bonnie Weiner, and Chris White discuss left main PCI in interventional labs without on-site surgery. Thank you for joining us.

Morton Kern, MD:

Welcome to Cath Lab Digest Live. I have some distinguished panelists to address our topic today, which is left main percutaneous coronary intervention (LM PCI) in laboratories with no on-site surgery, the subject of a recent editor's page, and also the subject of a Society for Cardiovascular Angiography and Interventions (SCAI) consensus document, chaired by Cindy Grines and Arnold Seto. Today, I have Arnold Seto, Mike Lim, Chris White, Kirk Garratt, and Bonnie Weiner talking to us — experts that often contribute to our editor’s page and I am grateful for them. So let me just start right in.

When is the risk of performing procedures in a lab with no surgery backup too high? And all of us seniors in this discussion have been talking about this problem, I would say, for our entire career, because as soon as people got off the ground, they said, "Well, I want to do this in an outpatient setting" or "I want to do this in my own personal laboratory."

Now, here is the kind of the index case that caused Arnold and I to get a little bit uncomfortable. And this was a 57-year-old guy came in with a chest pain syndrome, progressive over a couple of weeks.

Typical as you know, some minor electrocardiogram (EKG) changes, no enzymes. Our first set of angiograms showed this ulcerated, very unattractive, ugly left main, some left anterior descending (LAD) disease, modest. The right coronary artery (RCA) was totally occluded. And so, we chewed on it for a little bit. The guy was stable enough to be transferred, but there were questions. One, do we put a balloon pump in? Two, if we can't get emergency transfer, how long do we keep him? Three, why can we not get emergency transfer, because all the hospitals had full beds because of the COVID population? And three, should we just attempt this on site and not worry about surgery backup? He is what I would consider at pretty high risk anatomically. Clinically, I don't know what his left ventricle (LV) was, but it was probably 45% ejection fraction. Let me just leave this patient in your hospital and if you don't have onsite surgery, what do you do? And all of you have commented [in the original Clinical Editor’s Corner in Cath Lab Digest], but I wanted to hear it again.

Chris White, MD:

In the New Orleans region, we call it the South Shore region, South of Lake Pontchartrain, we have four hospitals. We have the academic medical center, and then we have three community hospitals all within 10 to 15 minutes drive. Those three hospitals all have cath labs without surgical backup. We offer surgical backup at the hub. We routinely have followed the SCAI guideline for no on-site surgery backup as how we determine what cases can be done in those community labs and what needs to transferred. That has not posed a problem until now, when you mentioned the COVID surge. But I will tell you that the premium nursing charges that we are facing from registry nurses and travel nurses have led us to stop reducing our nursing staffing so that we have many unstaffed beds at the medical center. That leads to a lot of transfer delays and really complicates things, because I'm not sure a transfer delay makes this an attractive procedure for a community lab. I'm concerned if I can't get him in anyway, if I do this procedure and he gets sick, I still can't get him in, right?

Morton Kern, MD:

Sure.

Chris White, MD:

I don't know that I would want to poke a skunk with a stick. I don't know that I would take a stable patient and do something to make him unstable. If he was unstable, that would be a different kettle of fish. Stopping a heart attack is different than what you've posed for this patient. But I don't think that the lack of an easy transfer bed should be used as an excuse for escalating the complexity of a procedure performed without backup, even with the aids that Arnold mentioned, because those aids we know are not effective. I mean, they're not going to save a life, particularly a balloon pump. Balloon pumps have failed at every turn they've been tested. So relying on those, if I got a big dissection down the distal left main and into both branches, I would worry about getting that guy from my cath lab at the medical center to surgery safely. We all know that that's dicey, but bringing someone from 10 minutes away would be even worse. And I would have trouble supporting that.

Morton Kern, MD:

So let me ask Kirk, I'll just make it around. So Kirk, what would you do if I said to you, you have this patient, same artery, same everything, he's in your lab, you dissect it and you have to go to surgery. Is surgery going to save his life? I mean, it's 45 minutes to get to the OR, I'll bet. What do you say to that guy? Says, you're no better off than not having surgery at all if you're going to have to fix this percutaneously anyway.

Kirk N. Garratt, MD, MSc:

Well, I share Chris's thoughts on that. It's hard enough to get a patient, unstable with a dissected left main, safely from our own cath lab to the OR. In my facility, it literally is across the hall to a cardiac operating room. So that's hard. And now, you're going to package in a transfer from a center that maybe you're located just 10 minutes away, but your estimate of 45 minutes to get that patient to OR I would say is wildly optimistic. That's an hour and a half to two-hour procedure to move a patient safely. Because you have to do so much work upstream to try to create a stable platform for the movement. And then there's the kind of unwinding of all that in the operating room and that all has to be done safely. It just takes time to do it. So I agree with Chris, I wouldn't poke at this either. Now, if it was an unstable patient and you didn't have an option, well, then you accept that that comes with all the liabilities or attendant to the fact that you don't have the ability to move that patient quickly to another hospital.

Morton Kern, MD:

So do we really need surgery backup at all? We just need transfer to a higher level of care.

Kirk N. Garratt, MD, MSc:

I'm just going to jump into it. I guess, if you're saying, "Oh no, this doesn't look that bad. I can do this in my ASC, it's only 10 minutes to the hospital." How about it? I don't think surgical backup is really terribly important for you. If you dissect the heck out of that thing, I'm not going to probably bail you out.

Morton Kern, MD:

Arnold, did you want to jump in there?

Arnold H. Seto, MD, MPA:

Yeah. On the expert consensus document, we did quote one study and probably the only study that's been published, it was from a German center, which noted that the delay to cardiac surgery when you had cardiac surgery backup in-house was two hours like Kirk said, right across the hall. If you don't have cardiac surgery backup at your hospital, it'd be five hours. So, these numbers need to be kept in mind. It really emphasizes how we need to rely first on our rescue capabilities and support capabilities with Impella (Abiomed) and bedside extracorporeal membrane oxygenation (ECMO) if you have them, even as we are moving on to transferring a patient.

Now, the guideline that the experts consensus document quoted is that the risk of cardiac surgery is equal regardless of whether you have backup or not. However, this shouldn't tell people that you should be doing left mains at noncardiac surgery hospitals. You should look at your facility, your transfer capability, your support capabilities, and adjust accordingly. We came from the perspective that many of these hospitals have lost cardiac surgery backup recently. Some of these facilities have had a lot of experience and support, and well-staffed cath labs, and those facilities we thought were adequately capable of supporting such high-risk cases.

Chris White, MD:

Arnold, I don't agree that you can conflate an Impella with bedside ECMO.

Arnold H. Seto, MD, MPA:

Sure.

Chris White, MD:

Those aren't the same thing.

Arnold H. Seto, MD, MPA:

Of course.

Chris White, MD:

We can argue about whether Impella works at all.

Morton Kern, MD:

Cut me to the quick, Chris.

Chris White, MD:

Yeah, it's just a pain point. I doubt that many of your community sites without backup surgery have the capability for cath lab ECMO. We do, right. So my point to you is, if my surgeon's not going to open the chest on the table (which we've done), the ability to put somebody on ECMO does stabilize them quite significantly while we get to surgery. I wouldn't accept that all surgeries are two-hour delays. We all know that some are longer, but many are shorter depending upon the urgency of going to surgery. Our ability to get backup surgery has atrophied as we've gotten so very good at not having a lot of disasters. Mort and Bonnie, Kurt, probably remember balloon angioplasty days when we were in the operating room, not very infrequently with the perfusion balloon from Richard Stack. I mean, those were days we used the OR and that skill became good. Now, we're so darn talented with stenting that I can't remember the last time we crashed into the OR. We go to the OR more for cath diagnostic disasters than we do from interventional disasters.

Morton Kern, MD:

Chris, that's great. That's a great answer. I didn't mean to interrupt you, but...

Chris White, MD:

That's okay.

Morton Kern, MD:

Bonnie, so we hardly ever go to the OR, believe it or not, and we pride ourselves on hopefully making good patient selections that we don't start going into trouble at the front end. And therefore, we won't get into as much trouble at the back, we send them infrequently. The things that take your patients to the OR are what? Is it dissection? We try and manage it. Is it perforation? Is it ripping an aorta? What do you go to the OR for?

Bonnie Weiner, MD:

Yeah. I mean, perforation is still an issue, I think. Again, not frequent, but as we do more complex lesions and complex patients with a lot of calcification and things like that. There's an itch there that I think is important, that I think contributes to the rare patient. I agree with Chris, it's rare that the patient goes to the OR. We'd like to think that we have good judgment in terms of patient selection, but bad things happen even in the right circumstances. And again, Rotablator (Boston Scientific) or burrs getting stuck, stents coming off balloons, which again, infrequent in the current technology, but it happens. And it happens in the settings of, again, these complicated lesions, heavily calcified, Rotablators, other debunking type or lesion prep approaches. I don't think we're perfect. I think things happen, guide catheters dissect, GuideLiners (Teleflex) dissect. I mean, there's an-

Morton Kern, MD:

Oh, come on.

Bonnie Weiner, MD:

... observation.

Morton Kern, MD:

Never had a problem.

Bonnie Weiner, MD:

We try and dig ourselves out of a hole that maybe particularly in settings where not only the skills of the operators, but the skills of the team around them may not be at the same level as it is in our main facilities.

Morton Kern, MD:

Okay, Bonnie, that is exactly one of the points I wanted to get to and I appreciate that. So Mike, my lab can do a lot of things, but my recovery area cannot. So I'm a little reluctant to be putting in an Impella when it can't get cared for in the post cath setting. And I know Chris doesn't believe in Impella, but we actually put one in a while ago and it worked. But what's your thought on this disparity between your resources in the lab and your resources out of the lab and then your resources at your referral center? Do we need surgery at all? I mean, can I get by without it among other things?

Michael J. Lim, MD:

I mean, it's a series of questions, so thanks. The points to this instance in the conversation are great and ones that folks should pay attention to. Do we need surgery? Yes, we need surgery. I think trying to stand alone without surgery is fraught with problems, even if it's one in a very high number of cases. Part of the case selection is at least an operatory discussion with surgeons and other folks, which has been advocated by all the societies. The heart team approach of, "Hey, what is the best thing for this patient?" Chris's point from the very beginning here, this is a stable patient and poking a wire or a backup guide catheter into this left main is a decision that has significant repercussions. There should be thought about it. Next, you asked about sort of different levels. I think your point is it's not just the skill of the interventional operator, which is key here. The skill and the expertise and the experience of the folks in the room with the interventional operator, as well as what the capacity is within the hospital. Chris and Kirk talked about significant nursing shortages, which are very real and it's not just nursing shortages. Even if you have nurses, they're not necessarily experienced or skilled, taken care of and doing the things that we need them to do. So you can be as successful as possible as the operator. But if the team around you isn't at your level, the patient isn't well taken care of.

Morton Kern, MD:

Yeah, I agree. Now Chris, you said nursing shortages critical and we have all seen it here and staffing the lab has been a super challenge over the last year. What are you doing to get around this?

Chris White, MD:

We're building a nursing school. We just finished construction on a building. We have seriously taken the pipeline by the throat. We've just finished our construction project in conjunction with one of the local universities. So we've built the Ochsner Nursing School, so we will have a pipeline for us. In the short term what we're doing is praying that our competitors in the region also cannot stand this expense. All without collusion because obviously that's illegal, but we're hoping that everyone doesn't pay these premium nursing fees that will bring nurses back down to level.

Bonnie Weiner, MD:

Chris and Mort, one of the things that I've seen a lot of conversation about recently in terms of nursing staff is virtual nursing. And that to me is kind of counterintuitive and I'm looking at people's faces on this call and they're saying, "What are you talking about?" And the conversation from nursing administrators has been on both sides of this and just wondering whether anybody has any experience with that or any thoughts on it?

Morton Kern, MD:

Bonnie, could you give me the short version? What is a virtual nurse?

Bonnie Weiner, MD:

Well, that's a really good question, Mort. What some facilities are doing are saying, "Okay, I can use a less experienced, less skilled person and have a more senior nurse available virtually for that person."

Michael J. Lim, MD:

Well, certainly there's been virtual ICU care by physicians, so they'll build rooms which are connected to all of the monitors as well as a camera within the room and physicians who will watch over that as critical care physicians have been kind of in short supply for a while. Bonnie bringing forward a concept of having more experience. Nurses also can be housed to be able to look after multiple ICUs in different places. I guess, the other thing I would add would be Abiomed and Chris's favorite Impella device is connected to the home base and they can also monitor the hemodynamics off of the Abiomed pump. The nurses or anybody in the ICU frequently calls that 1-800 number and that's how patients are taken care of, sends anything else. And so, Bonnie brings forward a great point, there's a lot of virtual or remote...

Bonnie Weiner, MD:

Yeah, I don't want to sound old here, but there's something about actually seeing the patient and putting-

Morton Kern, MD:

Oh, Bonnie, geez. Maybe on my stethoscope years ago.

Bonnie Weiner, MD:

I know. What can I tell you, Mort.

Morton Kern, MD:

I know. Hey, so I'm waiting for artificial intelligence (AI) to come in, take over, do all the notes, write the chart in entries and let me bill for it. Is that going to happen? Is AI going to come into your system and take over Kurt? You got AI working?

Kirk N. Garratt, MD, MSc:

Well, we do, but not quite that way. We're leveraging some stuff that I can talk about in a sec, but I did want to make one more comment about the virtual nursing board, if that's okay.

Morton Kern, MD:

Sure.

Kirk N. Garratt, MD, MSc:

So virtual nursing at our place is being used to support both home visitation platform and our care video platform. We're using it to help monitor outpatient compliance with medications in specific populations. Right now, we're deep into it through an agency called Story Health based in San Francisco for the management of our heart failure patients. We're about to launch that in hypertension management and we're also using virtual nursing to support our hospital care at home line of work. Now, that's different than having a virtual nurse in the hospital, but what it does is it allows you to then reassign the warm bodies into the acute facility. It creates less pressure to have them out in the field because you can centralize that work and it does have a favorable impact on the workforce. I just wanted to-

Chris White, MD:

What it doesn't recognize, Kirk, is the reason for that disparity is nurses don't want to be in the acute care setting. They want to be in the home and you can't find enough nurses that want to come back.

Kirk N. Garratt, MD, MSc:

We've had to-

Bonnie Weiner, MD:

Absolutely.

Kirk N. Garratt, MD, MSc:

Chris and I tell you, I wrote more about it. Some of the stuff we've had to do is pretty hard to stomach man. We're through the worst of it now, at least at our place we are. But boy, for a period of time there, we were paying nurses salaries that anesthesiologists would've been happy with. It was pretty amazing.

Chris White, MD:

Let me just throw this in, Arnold's doing virtual patient visits as other clinicians are. I don't do that, but Arnold's doing it. And a lot of our fellows are doing virtual physician, we call them VVC, video voice calls to the patients, they like it and that's almost virtual, but it's certainly remote. Arnold, should we keep that up?

Arnold H. Seto, MD, MPA:

Yeah, I mean at the Veterans Affairs (VA), obviously we are limited by both clinic space and clinic nursing. Having the physicians directly call the patients, the advantage of having Medicare cover telehealth and extend that coverage for another two years, it's been very helpful for both us and in the community. So I think it's here to stay and hopefully Medicare continues to support telehealth.

Bonnie Weiner, MD:

But I think we have to be careful.

Morton Kern, MD:

Go ahead, Bonnie.

Bonnie Weiner, MD:

...about outpatient visits and remote monitoring and stable patient and infrastructure for that compared to a hospitalized patient that by definition have gotten sicker and sicker as we've transitioned so much care to an outpatient setting.

Morton Kern, MD:

Excellent.

Michael J. Lim, MD:

That's kind of the point. I guess, in both folds there's been rapid increase in abilities in technologies, Dr. Grines’ and Seto's piece from the SCAI expert consensus quotes low rates of complications amongst more complex patients, and suggest that we can do them in more settings and maybe without surgery backup. But is that really the best for all patients? We have a bunch of operators which are decreasing in their annual volumes. What is the measure of operator expertise, virtual care and all this? In our virtual talk right now, we would've never done five years ago, but these are great platforms. Finding and fitting the right stuff for the right patient, matching that up is no different than what Chris and Bonnie referred to as what happened a long time ago. But I think the niche is to still try to put what is our goal? What are we trying to achieve here? Rather than just trying to plug in things because we have the capability or because it's easy or we don't have seemingly another easy solution.

Chris White, MD:

Mort, I would just add that I see telehealth as additive, not replacement.

Morton Kern, MD:

Got it.

Chris White, MD:

Arnold has described using his tele visits because they couldn't do capacity. We have enough capacity, but we use telehealth to even reach further out to the patient. We can screen initial visits. We have general cardiology, we have subspecialty cardiology, somebody wants a visit. We can use telehealth in order to triage that patient into the heart failure group or the electrophysiology (EP) group or maybe general cardiology. It makes us much more efficient and the hidden benefit is we monetize the telephone time. You used to spend your time on the telephone talking to people for free. Now, I drop RVUs and charges because I monetized my telehealth time.

Morton Kern, MD:

I think that is an excellent observation and I hadn't really thought of it that way. So we've got about four minutes left. I just want to kind of summarize and go back to where we started. Are we better now than we were five years ago? Do we know more now than we did five years ago with regard to doing outpatient or not outpatient, PCI with no on-site surgery? I look at this image of this left main and there would be nothing in the world that would make me do that without having some protection. I just don't have the courage. Maybe Paul Teirstein does. I know if I show this to him, he'd say, "What's a big deal? We just do a chronic total occlusion (CTO) over the right. We do bifurcation kissing stents on the left and if he's got a low ejection fraction (EF), I throw an in Impella and then I support him. And why are you being such a baby?" He says to me, "You got an acute case of crybaby eyes." And I say, "No. I just don't want to do that."

Chris White, MD:

Yeah. I would never let anybody shame me into doing something stupid.

Morton Kern, MD:

Oh, hell no.

Chris White, MD:

And I think treating this without surgical backup is absolutely stupid.

Morton Kern, MD:

So would I get into trouble in a standard of care argument since we now have any-

Chris White, MD:

I don't testify against you.

Morton Kern, MD:

You would, I know. So I think with the consensus statement, I can see that people need to be kind of following the rules. If they don't and get into trouble, then they are challenging that standard of care.

Chris White, MD:

I think that consensus statement is a little bit of a stretch.

Morton Kern, MD:

Say again?

Chris White, MD:

A stretch. I think we got out a little bit in front of ourselves because to answer your question, I don't think we know anything more today about PCI without on-site surgery than we knew 10 years ago. The studies have all been done a long time ago and none of them included this patient. So I don't think we know a lot more that today than we did. I think the assumption by many that these assist devices are effective is uncertain, right? I mean, certainly there's help. The question is how much help? Is it adequate help? It's not ECMO. So again, every time I've been in a trial that looked at a balloon pump or I remember 25 years ago, we put people on fem bypass. It didn't work for shock. People still die.

Morton Kern, MD:

So, I agree with you Chris. We got a whole different discussion coming up about why all of our shock studies are a wash between the two types of support or three types of support. And I think part of it is the level at which we deliver the care when they enroll in the study, how sick they are, what their potential... It's a whole thing. I want to come back to it and on a future editor's page, we will.

 

Michael J. Lim, MD:

The final thing here, I think everybody said the same thing, but I want to emphasize it. We utilize surgical backup and send patients to the OR very infrequently, but when we need it, man, it's the disaster. Kirk brought up it might be two hours. Chris talked about the value of ECMO. I mean, I think that we shouldn't just take for granted the concept that we have surgical backup, whether it's in our own building or whether it has to be transferred. I think we need to think about as cath lab directors and leaders to talk about what are we doing? We need to talk about what CPR and resuscitation is when we get in trouble on the cath lab table.

If that means that we got to put an ECMO on the table and that's part of the CPR routine, then that's the standard, which means we got to get all the equipment there, which also means we got to run through rehearsals and drills so that all of the people there when it happens once every several years, everybody knows what to do. And this doesn't happen in the current cath lab. Never really has. But I think this kind of discussion that we've had, I would say to me that's the take home point is, we need to be better prepared to take sure that these patients survive their catastrophes.

Morton Kern, MD:

Good. Well, you just preempted my editor's page from February 2023, which is on the article about survival of CPR patients in our various cath labs. I don't want to get into it today because we're out of time. I want to say thank you very much to Chris and Mike and Bonnie and Kurt and Arnold, who I'm going to see in a few minutes anyway. I hope you'll join me again for a Cath lab Digest Editor's Page Zoom. I hope somebody hears us talk about it and get some information that'll help their system. So thank you very much.

Chris White, MD:

Thank you, Mort.

Kirk N. Garratt, MD, MSc:

Great time.

Bonnie Weiner, MD:

Thanks, Mort.

Michael J. Lim, MD:

Thank you guys.

Morton Kern, MD:

You're welcome.

Arnold H. Seto, MD, MPA:

Thank you all.

Rebecca Kapur:

Our thanks to Dr. Kern and guests, Kirk Garratt, Michael Lim, Arnold Seto, Bonnie Wiener, and Chris White. And thank you for joining us. Find more from Dr. Kern on cathlabdigest.com.