Building a Protected PCI Program: The Programmatic Approach

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 - University of Washington Medical Center heart team
University of Washington Medical Center heart team.

The University of Washington Medical Center in Seattle, already a major national referral center, has recently undergone a significant culture shift. The change began when Robb MacLellan, MD, joined as chief of cardiology of UW Medicine Regional Heart Center in 2011. He quickly identified interventional cardiology as an opportunity for growth. UW invested in resources. It recruited leading physicians and acquired leading edge technologies. And now, by the end of 2015, the 450-bed facility will have nearly tripled its traditional PCI volume and completed more than 400 structural heart cases.

Hear more from the team at University of Washington Medical Center, watch Episode 2: The Programmatic Approach to Teaching, Tactics & Techniques, from the series, Building a Protected PCI Program. 

And that’s just the beginning of the story behind the new day-to-day routine at this institution. The UW Medicine heart team—which has procedure volumes placing it at or near the top in the U.S. in echo, transplantation, atherectomy, LVAD and PCI for chronic total occlusion—has become a national training site for high-risk PCI with hemodynamic support. The cachement area of this academic medical center stretches across 23 percent of the geographic land mass of the U.S., and from sea to shining sea as a national referral base. Tough is their middle name when it comes to performing high-risk procedures others won’t—and passion is their game in teaching others to master and improve their skills, too.

UW also has left behind its erstwhile ivory-tower image to become a highly engaged member of the community. This has meant opening access so that any physician with a Washington State license can get temporary privileges for admitting and operating. That strong dedication to learning stretches across the state and around the globe. Practical, hands-on, in-depth, in-person, collaborative learning sits at the core of the program.  

Physicians “get to learn new devices, new techniques and new skill sets,” explains William Lombardi, MD, director of complex coronary artery disease therapies. The learning is done in a finely tuned environment of medical-staff, medico-legal and educational processes, he says, “so physicians can build practical skill sets, go back and be able to use them at their own center.”

A key technological leap facilitating the transformation came in the spring of this year when the FDA approved Abiomed’s Impella 2.5, a miniature temporary ventricular assist device, for use in elective and urgent high-risk PCI procedures. The approval, which expanded the device’s indications from its 2008 510(k) clearance now permits treatment of elective and urgent high risk PCI patients who are hemodynamically stable, but have severe coronary artery disease and depressed left ventricular ejection fraction. The approval comes in the wake of the PROTECT II study. This showed that patients supported—or, more precisely, protected—during PCI by Impella 2.5 had improved outcomes at 90 days. (Circulation: 2012 Oct 2;126(14):1717-27)

“What you have now is a hemodynamic-support tool allowing you to get that high-risk patient safely through the procedure he or she needs, which is complete revascularization,” says Lombardi. 

The device also allows the multidisciplinary heart team to closely collaborate around high-risk patients.

“There is a subset of patients who will benefit from high-tech intervention” involving not only interventional cardiologists but also cardiac surgeons, heart-failure experts, transplant specialists and numerous others, says Claudius Mahr, DO, the institution’s medical director of the mechanical circulatory support program and director of clinical integration at UW Regional Heart Center.

A culture of constant conversation

Cardiothoracic surgeon Jason Smith, MD, characterizes the culture change of collaboration he’s seen as part of a natural progression. “Over the last two years, we have really evolved a coronary team that is very similar to what we do for heart failure and transcatheter valve,” he says. “It is a constant conversation and collaborative evaluation between the high-risk PCI interventionalists and the cardiac surgery team. We are constantly sharing our expertise to come up with the best plan for the patient.”

The clinical trials showed that patients randomized to an Impella 2.5 received more out of their PCI, and the clinical improvements proved perdurable. Lombardi believes that’s because Protected PCI helps the