Establishing a Comprehensive Mitral Valve Program: Educating Patients and Referring Physicians

LEARNING OBJECTIVES

1.
Establish the key components necessary to market your program as a comprehensive mitral valve program
2.
Learn to build a focused outreach plan to optimize internal and external outreach efforts
3.
Learn to improve access to care through collaboration with the referral community

INTRODUCTION

In the past decade, structural heart programs have proven to be one of the largest areas of growth in the cardiovascular service line. This demand is due to both an aging population requiring complex treatment and technology enabling such patients to be treated. Mitral regurgitation (MR) is the most common form of heart valve disease in the United States, with a 10-fold increase in prevalence once patients reach 75 years of age. ^, Almost half of the patients who need and are eligible for a mitral valve intervention are not being identified and referred to a structural heart program; this potentially represents a large, unmet need. ^,

There are an increasing number of treatment options available for patients with mitral valve disease. In 2013, the first and only transcatheter mitral valve repair (TMVr) technology, the MitraClip (Abbott, Santa Clara, CA), received US Food and Drug Administration (FDA) approval and has pioneered the way forward for transcatheter mitral repair. The landscape for transcatheter edge-to-edge repair (TEER) widened following the FDA approval of the COAPT trial in 2018, as the indication was extended to include functional MR. COAPT demonstrated that TEER with MitraClip, in conjunction with guideline directed medical therapy, versus guideline directed medical therapy alone, in select heart failure patients with secondary MR improved survival, reduced heart failure related hospitalizations, reduced severity of MR, and provided symptomatic relief for this patient population.

Advanced surgical techniques, especially those related to mitral valve repair, in conjunction with ongoing transcatheter clinical trials for both mitral valve repair and replacement, require formal, multidisciplinary collaboration to determine appropriate care on a patient-by-patient basis. One of the challenges that programs face is the challenge of developing a growth strategy for their mitral valve program. The introduction of the first (TEER) therapy into many structural heart programs was often incorporated as a new “procedure” and not adopted and marketed as a part of a comprehensive valve “program.” Marketing a comprehensive mitral valve program may allow for the growth of all services offered by your team of experts to treat mitral valve disease. ^,

This chapter reviews the key components needed to create a comprehensive mitral valve program, how to build your plan prior to marketing your program, and strategies to execute hospital in-reach and community outreach initiatives. We provide examples on how to differentiate your program and create innovative ways to collaborate with referring physicians. Finally, we summarize the fundamental elements necessary to educate and engage patients in a program of this nature.

KEY COMPONENTS OF A COMPREHENSIVE MITRAL VALVE PROGRAM

The key components to building a comprehensive mitral valve program include: a cohesive team of key individuals with clearly defined roles, a multidisciplinary mitral valve clinic, and a mandatory, weekly, mitral valve team meeting. The first step is to ensure that you have a dedicated multidisciplinary team in place. A cornerstone of this endeavor is based on a collegial and collaborative partnership between the cardiac surgeon and the interventional cardiologist. Additional specialists on this team include a dedicated echocardiographer who specializes in structural imaging, a heart failure specialist with expertise in the treatment of heart failure and mitral valve disease, a dedicated structural heart valve coordinator (SHVC), and a dedicated cardiac anesthesia team.

The development of a multidisciplinary mitral valve clinic is essential for a comprehensive mitral valve program. A centralized evaluation location optimizes the patient process for thorough evaluation, proper diagnosis, and delivery of appropriate care by a team of experts. The goal of the comprehensive mitral valve clinic is to provide patient-centric care based on evidence-based medicine and advanced treatment options provided by the institution. The clinic team should consist of cardiac surgeons, interventional cardiologists, echocardiographers and imaging specialists, heart failure specialists, and other clinicians such as the SHVC, advanced practice providers, and patient educators.

A member of the physician team of experts should work with hospital administrators to lead, coordinate, and optimize the patient pathway through the valve clinic. For patients who have not had an initial screening transthoracic echocardiogram (TTE), a certain number of reserved slots, staffed with sonographers and imaging experts, should be available for initial evaluation and quantification of MR. The multidisciplinary mitral valve clinic should focus on shared decision-making best practices throughout the patient evaluation continuum, the appropriate intervention pathway, and follow up care.

It is important to institute a mandatory, weekly, multidisciplinary mitral valve meeting. All MR patients should be presented at this meeting to ensure a collaborative approach towards the appropriate mitral valve treatment pathway. This meeting is a case planning meeting, and all specifics needs related to pre-, intra-, and post-procedural patient care should be discussed. At the conclusion of the meeting, all equipment needed for the mitral valve intervention, as well as specific members of the multidisciplinary team and vendor availability, must be confirmed.

The Multidisciplinary Team

The Cardiac Surgeon

The role of the cardiac surgeon is imperative to the growth of the comprehensive mitral valve program. Offering complementary therapies to treat patients with mitral valve disease may provide growth to existing therapies offered at the institution. It is imperative for the surgeon to have a strong relationship with the interventional cardiologist in order to refer a patient for a transcatheter procedure and vice-versa. A hybrid team approach also creates new opportunities for the cardiac surgeon to acquire specific skillsets necessary to perform transcatheter procedures.

The Interventional Cardiologist

The role of the interventional cardiologist is to work with the multidisciplinary team to evaluate patients who are not surgical candidates for transcatheter options where the benefits outweigh the risks in certain patient candidates. The interventional cardiologist should be experienced in the treatment of mitral valve disease and have significant experience with the trans-septal technique. It is very important to develop a strong collaboration with the cardiac surgeon as it relates to patient evaluation, procedure planning, and intra-procedural success. A collaboration with the cardiac surgeon promotes dedication, motivation, and engagement in the team approach to treating mitral valve disease.

Structural Heart Valve Coordinator

The role of the SHVC is critical to the success and growth of any program. Many roles are included in the title of SHVC, such as (1) initial patient evaluation, (2) coordination of the patient pathway through the joint valve clinic, (3) arranging necessary testing for evaluation based on the type of procedure being considered, (4) guiding communication between patients and their family members, and (5) maintaining a constant mode of communication with the referring physician team. The SHVC presents the patient data at the multidisciplinary mitral meetings, collaborates within the industry for scheduling patient treatment, and collects required data for mandatory registry participation. Programmatic and outcome data are also captured, assessed, and reviewed by the SHVC to optimize efficiencies of the program. The data collected is utilized for demand planning that will determine additional headcount and additional resources necessary to optimize the overall efficiencies the program. Programmatic metrics should include patient volume, the number of days needed per month to treat patients coming into the valve center, appropriate utilization of staff and the delegation of responsibilities, and patient outcomes. This data can also be utilized to focus on the health economic impact to the institution with administration when looking at heart failure related admissions and length of stay.

Dedicated Structural Imaging

The cornerstone to any successful program is having dedicated structural imaging specialists. These imaging experts will develop and define a consistent algorithm and systematic approach to the patient screening and selection process within the institution. A well-defined investigation of the mitral valve will lead to appropriate acquisition of the images and measurements necessary to determine anatomic suitability for the specific treatment option for the patient. Having dedicated screening days built into the schedule will ensure optimization of capacity and reduce the time to treatment for patients. The individuals chosen to lead this charge are those that express interest in interventional echocardiography. They have a profound knowledge and skillset that incorporates three-dimensional echocardiography and multimodality imaging into planning and guiding structural heart disease interventions.

Heart Failure Specialist

The incorporation of a heart failure specialist as a part of the multidisciplinary team is essential to ensure that patients with heart failure and functional MR are appropriately managed on guideline directed medical therapy. The primary goal is to minimize late diagnosis and encourage early referrals to treat the heart failure population that suffers from functional MR. Another focus of the heart failure physician is to ensure that a frequent line of communication to referring physicians is instituted to standardize the adherence to guideline directed medical therapy and to evaluate all potential options available for advanced therapies for the patient with heart failure.

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