Benoy Shah MD Profile picture
Oct 14, 2021 21 tweets 13 min read Read on X
#EACTS2021
Heart Team - does it still exist?

A very interesting session this morning - a 🧵
#EACTS2021
Dr Alfieri reminded us that medicine has a long history of collaboration between different specialties and areas of science/engineering

He gave the example of Lowell Edwards (engineer) & Albert Starr (surgeon) to create the ball-in-cage valve - same for Bjork-Shiley
#EACTS2021

Why do we have a Heart Team?

Dr Alfieri highlighted this can broadly be divided into these three categories. I really like this...
#EACTS2021

He used ischaemic cardiomyopathy as a great example of increasing complexity of the disease...and thus the wide number of skill sets required
#EACTS2021

This is the 3rd dimension - increasing array of therapeutic options for patients. He highlighted the multitude of options for aortic & mitral valve interventions available today
#EACTS2021

Are there potential downsides to this approach? Yes.

I really liked this SWOT analysis (Strengths; Weaknesses; Opportunities; Threats) that he presented
#EACTS2021

Next was a presentation by former ESC President and multi-modality cardiac imager Dr Jeroen Bax, who discussed the role and place of the Heart Team in the guidelines
#EACTS2021

Who is in the heart team? Lots of people!
#EACTS2021

Dr Bax explained the changes between the 2017 & 2021 ESC guidelines on VHD...explaining the reasons for including Heart Team discussions - usually for the most complex cases or ones in which several treatment options exist
#EACTS2021

A great flowchart showing the flow of care between networks

Last year, the @BrHeartValveSoc produced its Blueprint which discussed the importance of network-based care. Not all hospitals / centres have all options and expertise - and they don't all need to!
#EACTS2021

A great question - does *every* patient need to be discussed by the Heart Team, even where the decision is clear?

Dr Bax was clear the answer is NO - the Heart Team should be reserved for more complex cases. I agree. Most Heart Teams would not have time to do this
#EACTS2021

Next talk from Dr Hendrik Treede on potential threats to the Heart Team approach - especially cost
#EACTS2021

Then a very interesting talk (for me!) on whether imaging still leads to best decisions for patients - pleased to hear early on a resounding Yes from Dr Unbehaun!
#EACTS2021

As minimally invasive and transcatheter procedures have increased, so has the need for 3D imaging to plan successful procedures
#EACTS2021

Love these slides. Not only can imaging tell you if the procedure can be done, but also how hard it might be and what precautions might be needed.

Indeed, TAVI or TMVI without high quality imaging are impossible!

@AusamiAbbas
#EACTS2021

Great example relating to V-in-V TAVI...imaging can tell you likelihood of coronary obstruction and thus whether the #BASILICA technique will be required

True!
#EACTS2021

Final talk by @PeymanSardari on Education in Cardiac Surgery and the role of the Heart Team

Great first slide. Everyone loves Santa...but Santa does not exist...same for the Heart Team! 😆
#EACTS2021

Over 70 transcatheter devices on the market; none suitable for all patients...and no Dr can be expert in all of these...so, have to select the right device for the right patient to be done by right operator(s) in the right centre...and that'll need a Heart Team
#EACTS2021

Important points on this slide

Patient CoI referred to patients having done internet searches & coming to clinic with treatment plans already in place

It's a delicate balance; we should encourage patient empowerment and increasing their knowledge
#EACTS2021

"A successful episode of patient care is more than just them surviving the operation"

Dr Sardari Nia invited all to join the Heart Team Academy - a global effort to advance the field

Very true
#EACTS2021

What a superb final slide...love this!

Great session...hope you enjoyed this thread...more later!

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More from @dr_benoy_n_shah

Oct 30
Deep dive on #EARLYTAVR from ##TCT2024

Lots already said & discussed

It takes time to read the paper, read the supplementary appendix, analyse the results, think about them etc!

Some thoughts...🧵 Image
On Sunday I wrote a thread about asymptomatic severe AS and what we knew already from RECOVERY & AVATAR RCTs and what the guidelines currently advocate

Here's the 🧵 in case you missed it

EARLY TAVR
Asymptomatic severe AS patients recruited between March '17 - Dec '21

75 sites across 🇺🇲 and 🇨🇦

Asymptomatic status confirmed by negative treadmill test in 90.6%
(Remaining 9.4% unable to do test, relied on detailed physician history)

That's a good % that did ETT 👏
Read 29 tweets
Oct 27
Tomorrow - Oct 28th - we learn the results of 3 landmark randomised studies in patients with aortic stenosis (AS)

Results of EARLY-TAVR, EVOLVED & TAVR UNLOAD will be unveiled at #TCT2024 in a Joint LBCT Session with #NEJM

These could well be practice-changing studies...

A 🧵 Image
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#TCT2024
The first 2 RCTS - EARLY TAVR & EVOLVED - concern the management of asymptomatic severe aortic stenosis (ASAS for this 🧵)

Currently, ASAS (with normal LV function) is not a Class I indication for valve intervention in either 🇪🇺 or 🇺🇲 VHD guidelines Image
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##TCT2024
There have been 2 RCTs of early intervention (surgery) vs routine care, aka 'watchful waiting'

It's worth reminding ourselves briefly of these studies, as the background is important in understanding EARLY TAVR in the right context
Read 21 tweets
Mar 17
*Mitral valve assessment by TTE*

Transthoracic echocardiography (TTE), when performed with care and diligence, can reveal a lot about the valve. TOE isn't necessary in all cases to determine leaflet pathology.

A worked example below:
In the PLAX view, you can assess the scallops of the leaflets

In a true PLAX view with aortic valve clearly visible, you mostly see the A2-P2 interface. Here, you can see a clear & large prolapse of the posterior leaflet
If you tilt upwards towards the PLAX RV outflow (pulmonary valve) view you see mostly the A1-P1 interface

Here, you can see the valve looks slightly different & no prolapse is seen
Read 17 tweets
Feb 29
Good teaching case for Fellows from a recent emergency scan

Happy heart or unhappy heart?

What can you deduce from these spectral Doppler traces of mitral (left) and tricuspid regurgitation (right)?

#echofirst #cardiotwitter #ACCFIT
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Lots of excellent replies. A lot of information to glean from 'just' the CW Doppler traces

The ECG is broad and with a pacing spike just before the QRS complex...so a pacemaker is in situ

MR trace: faint, not severe MR by jet density

But look at the MR Vmax, not even 4m/s!

1/
MR Vmax is normally 5-6m/s in normal LV function.

If the Vmax is a low as this, it either reflects a weak LV, or very high left atrial pressure...or both. It's often both

So the MR CW Doppler suggests:

a) significant LV dysfunction
b) non-severe MR

2/
Read 5 tweets
Dec 16, 2023
As we approach the end of 2023, what was the most important paper you read this year?

Mine wasn't in cardiology

I think this went under the radar a little, but it shouldn't have...the impact of private equity (PE) takeovers in healthcare

An end-of-year 🧵
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Before going further, we should clarify what PE actually is. Now, I am NOT a financial expert at all, but here goes...!

PE is essentially the investment of capital (equity) into a private (non-public listed) company or business. Read this for more 👇🏽

hbr.org/2007/09/the-st…
PE has garnered a reputation for huge profits as they typically buy into a company, aggressively ⬇️ costs whilst ⬆️ profit margins, leverage debt if needed, and then sell, often at a large profit

Does this matter when it comes to delivering healthcare services?
Read 15 tweets
Oct 11, 2023
Sixty years ago this month - October 1963 - US cardiologist Dr Robert Bruce published a paper detailing his efforts to devise a multi-stage treadmill test

Little did he know this would go on to become the Bruce protocol the most widely used for exercise testing

A thread...
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Prior to this, 'stress testing' to evaluate cardiac function was performed using the Masters 2-step technique, first described in 1935. This crude but simple test involved repeated steps up & down over 90 seconds

sciencedirect.com/science/articl…
Bruce, amongst others, recognized the limitations of this test & set about developing an exercise treadmill test

His initial work focused upon a single stage protocol, but he soon realized this wasn't stressing fitter patients enough & the test was taking too long!

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Read 12 tweets

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