Talking Tall Rounds: Defining a New Era in Critical Care Cardiology

Podcast Transcript

Announcer:
Welcome to the Talking Tall Rounds Series, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic

Eric Roselli, MD:
Hello everyone and welcome to another episode of the Cleveland Clinic Heart, Vascular, Thoracic Institute, Talking Tall Rounds podcast. I'm Eric Roselli and I'm here with Venu Menon. It's really nice to talk to you, Venu, during the day when the sun is shining. Many times we're paging each other and calling each other's cellphone in the middle of the night to discuss all the really complex patients that come through your ICU, your critical care ICU. And I actually do enjoy those phone calls because they're always so fruitful. Our partnership with the way that we can take care of people and expedite care of them. But we have the pleasure to discuss the Tall Rounds event that occurred in March that was entitled, Defining a New Era in Critical Care Cardiology.

Venu Menon, MD:
Thanks, Eric. It's a real pleasure to be here on what's really an exciting subspeciality of cardiology that's emerging and I'm really interested in talking about this and engaging with our audience on this really important topic.

Eric Roselli, MD:
The Tall Rounds have been sort of pretty much standardized in their template. We always present a case and then we have a series of speakers from various specialties that just give a really nice sort of tight discussion about their perspective on a topic. In these podcasts, we go through some of that and then you'll get a chance, our listeners will get a chance to hear the audio from one of those. Before we get into sort of discussing and summarize some of those, why don't you tell us a little bit about how you got involved as a critical care specialist? I don't think I've ever asked you that.

Venu Menon, MD:
That's an interesting question. I distinctly remember my first day as an intern, I had every intention to be an oncologist. There was no doubt in my mind. And my first day as an intern, I was in the coronary intensive care unit and I had four admissions that night. One was a case of Chagas disease with multiple PVCs coming in with ventricular tachycardia.

Eric Roselli, MD:
Wow.

Venu Menon, MD:
There was a lady who had just been out on Long Island who came in with Lyme disease and complete heart block. There was an acute myocardial infarction with RV extension and there was a bread and butter heart failure admission. And a lady walked in the next morning who happened to be my attending, her name's Judith Hochman. She's gone on to do the SHOCK trial and the occluded artery trial. And we had so much fun those next three, four hours on rounds that any conviction I had about years of oncology disappeared right away and I was a cardiology critical care convert in just 24 hours. There goes any conviction that I have so I can be...

Eric Roselli, MD:
That's cool. That's so cool. I love that. You knew right away you wanted to take care of really sick patients and you were probably surprised to realize you had a couple people present with infectious diseases that presented in shock, didn't you?

Venu Menon, MD:
Correct. And you and I have seen that. We talk about infective endocarditis as this chronic problem with drug abuse and all the other things that are going on with intravascular access, but we actually see infectious endocarditis present as septic shock. We see infective endocarditis present as acute valvular hemodynamic instability. We see infective endocarditis as complete heart block and cardiac standstill needing resuscitation. Yeah, everything's critical care at the end, so there you go.

Eric Roselli, MD:
Right. Yeah. Well, I had the same sort of stimulus. I wanted to take care of sick people, the sickest people. And I remember when I was training, one of my general surgery mentors was like, "Oh Eric, you're going to just be sewing in circles taking coronary disease." It's only this tiny fraction of what we do. And it's all really right there every day in the critical care unit that you've done such a fine job of running. And in this Tall Rounds, we see an interesting case of a pretty young patient, Andrew Higgins, one of our trainees presents a 27 year old with structural valve deterioration and really fulminate minute kind of heart failure who comes in. And I think what's interesting about the case is it's not all the details, but the way that you guys really shepherd this patient who requires the input of so many different team members to come up with what eventually is the successful treatment and management.

Venu Menon, MD:
And that's the important part, Eric. In this first, in the 1990s, our whole trust in acute cardiac care was on coronary reperfusion. The challenge there was, how quickly do you open the artery? Is thrombolysis better than angioplasty? How do we get more reperfusion to people out there and have them survive an acute heart attack? But our successes in the 1990s and with primary angioplasty arriving, has really resulted in a completely different unit in 2000. Now we have the guy who survived two infarcs, had a dilated ventricle and is coming with a new insult. We have the person with end stage heart disease, whereas an ICD and has gone through an electrical storm and can survive. We have all the great work that you've done in acute aortic syndrome. This Marfan's patient who's had a reconstruction of the aorta over decades, now coming in with a new aneurysmal dilatation or a type A endo leak.

Venu Menon, MD:
In that setting, not only do they have an acute chronic sequelae of their heart condition, they also have sequelae in other organ systems. They're coming in with chronic ventilatory issues with COPD, they're in with renal failure, they're coming in with a prior malignancy with chemotherapy exposure and radiation injury. The whole focus of the reperfusion has changed into one where people have multiple issues, but the core into bringing them to CCU is a cardiac one, but you'd better respect these other conditions because otherwise they're not going home. And for that case from Andrew, the reason we brought it up was because it wasn't the cardiac condition, here was a kid who had chronic ventilation needs, malnutrition in that setting, the need to be transferred from hundreds of miles away to a quaternary institution. Just all the things that have made critical care cardiology what they are today. I thought it was a good summary of that. And I'm sure if the audience goes back and listens to it, they'll be engaged in what we're talking about.

Eric Roselli, MD:
Yeah, absolutely. I'm sure that your team probably we could call down to the unit right now and they could give us a half a dozen patients that would be great examples of that. Those challenges are what make it so fun, I'm sure. And another part of what's changed in that unit is the procedural portion, hasn't it? You have the little procedure room that you guys use all the time. Tell me about that.

Venu Menon, MD:
Yeah, that's been really great. And I think, one of the things is that someone thought about it long time ago. The thing is when I came into the Clinic, one of the best things about it was to have a procedure room within the ICU. In most institutions around the US, if you needed to put a pacemaker in, in the middle of the night or you needed someone to put an intriotic balloon pump, you would have to wheel them down to the cath lab. That's on another floor. You have this person being pushed around on a ventilator. It's the biggest pain one can endure and so as a result, people don't get procedures just because of how painful it is to move an unstable patient. To have the luxury of having a procedure room in the CCU, where you can do a pericardiocentesis, where you can put in an active pacemaking wiring, where you can quickly go and explore whether that the wire's not going up just because it's your peripheral vascular disease. It's been such a privilege.

Venu Menon, MD:
And it's also been so good for our patients that we can very quickly, how many times have you and I thought about, hey, we need to cannulate this guy on ECMO. Let's do it right here by the bedside in the procedure room. And you can imagine taking these people to remote units where people aren't used to the team, just doesn't work. And so the great thing for us has been in both our procedure rooms, we've had a 24/7/365 procedure nurse. And what's really great when you're a training institution and you have a procedure nurse, is that when young docs do procedures, this procedure nurse is not just a procedure nurse. This procedure nurse is conscience. This procedure nurse is telling that trainee, "Hey, have you thought about this wire? Have you thought about calling for help? This is not the way you do it. Look at sterile precautions." We've just been blessed by having that.

Venu Menon, MD:
And so the first year fellow in the clinic, as a cardiology fellow, all you do in your CCU month from morning to night is procedures. And you do procedures with the supervision of a critical care staff attending or someone like that. And so that's been really cool.

Eric Roselli, MD:
Yeah, it is cool. I remember as a trainee doing, it's like a mini operating room. I remember doing a pericardial window in there one time and as you said, cannulating. I think I took Mehdi Shishehbor through a chest tube or something when he was a resident. That's a really neat part of it. Part of our Tall Rounds, we get to hear you talk about the history of cardiac critical care. And I think that was really fantastic. And to our viewers, we encourage you to also log in and watch these talks. You get a complimentary CME with each of them Dr. Menon's presentation is fantastic. And then it's followed up, which I think is really relevant to what we were just talking about is a talk from Ran Lee, about the components of cardiac critical care training. That's a specialty that's come along. I'm going to ask you to speak about that, but I'm also going to say that at the end of our discussion here, we'll get to hear Ran Lee's, the audio from his presentation about this. This is really a rapidly growing subspecialty in cardiology, isn't it for you?

Venu Menon, MD:
It is, Eric. I think a lot of people become physicians because they want to become physicians and other people become surgeons. And what critical care cardiology does is it really integrates all the principles of internal medicine into everything that we love about time sensitive nature of cardiology and it melds it all together. We've really had significant interest in this area. And we were one of the first programs to recognize this and actually start a formal pathway to dual board certification in general cardiology, as well as cardiac critical care. Working with Neal Chaisson who's a program director for cardiac pulmonary critical care. This terrific one year fellowship where our general cardiology fellows were interested in this area, learn all about the ventilator, learn all about advanced airways, learn all about intubation, chest tubes, all the other things that we as cardiologists were really not trained to do when we initially began in critical care.

Venu Menon, MD:
And so this year really helps a physician take a look at the sick cardiac patient holistically, looking at other end organs, looking at really important issues like ventilator associated pneumonia and catheter associated urinary tract infection, things that you and I know are important, but we don't spend as much time because we're doing the things that we do. And so we really started this program way back and now we've had at least 10 or 11 folks graduate from this. They've gone on to publish in the literature. They've gone on to lead ICUs around the country. It's really been a pleasure to be at the vanguard of something like this. And this is here to stay.

Venu Menon, MD:
There is no doubt that in quaternary care ICUs that you and I have an in major institutions around the country, the future leadership in the CICU is going to be someone with this kind of a background, because one, it brings these other skills into the CCU and two, it lets the CCU is just a part of multiple ICUs in a large institution. And so it lets you talk the talk when you meet the people in neurocritical care, when you meet the people in surgical critical care, when you beat the people in MICU critical care.

Venu Menon, MD:
Many things are different, but many things about ICU care are common and can be standardized. And so this ability to be an ambassador from cardiology and cardiothoracic surgery to other ICUs is really important. And so this training program has been pivotal for us to train future leaders in this area and Ran is one of them. And I think listening to him, so Ran is special because he's done general cardiology, he's done a year of heart failure transplantation at Michigan and then he's done a year of cardiac critical care. He can understand, especially you and I can appreciate with all these temporary mechanical support devices who do you put a support device on? When do you put it? And do you understand the exit strategy or not? Because one of the most irresponsible things to do is to put support and not know how you're going to get out of the quagmire. And so people like Ran are really got to define this field and I'm hoping the audience listens to him and learns. And especially if young folks are in the audience, maybe they will consider doing cardiac critical care in the future.

Eric Roselli, MD:
Yeah, absolutely. If they are interested and I'm sure it's becoming increasingly competitive sort of position here, how do they apply for that?

Venu Menon, MD:
We are a handful of programs around the country and they're quite a few blossoming around as we speak. But what we've done is we think it's really important to be a spectacular cardiologist before getting into this. We usually take from within a very competent general cardiology fellowship program, someone who's interested in that area, but in the years when we don't have anyone from within the program, we take great folks from all over the country and they've come in here. And so we've had a number of folks from Canada come back and do it with us and go back home to Canada and head units like this. There's actually going to be a cardiac critical care. The critical care was not a match and this year coming up, the critical care is going to be in a match going forward.

Venu Menon, MD:
There's much more formalization into this in the years ahead. And so I do think that people need to think ahead, plan and do what they need to do, because there are some important questions. Is it important for you to do cardiology, heart failure, transplant and then critical care? Or do you do cardiology critical care and then heart failure transplant? There are all these nuances that you really need to think about. And then you and I know medical training is so many years, you're straight away committing yourself to seven or eight years of training here. And so you really need to have a passion to know this is what you want to do because otherwise, this is for someone who really knows that they belong in this kind of an acute environment where decision making needs to be quick and decisive.

Eric Roselli, MD:
Sure, but it's a one year fellowship and that kind of training will benefit you no matter kind of where you end up and what you end up doing.

Venu Menon, MD:
And what's great, Eric, is now we have cardiologists with this kind of background working with anesthetics in the post-cardiac ICU with cardiothoracic surgeons, because they understand this. And so we're really cross-pollinating these acute areas in cardiovascular care.

Eric Roselli, MD:
And I think you're absolutely right that the future of this is bright because there's a lot of forces beyond the things that we typically think of. There's economic forces. And as technology continues to advance and our treatment options get more and more complex, what that is going to mean is more and more centralization of complex cardiovascular care. And so there's going to be a need for people to sort of manage people and manage patients that require this complex care that's delivered in large central locations. And appropriate to what we have on the agenda, our next speaker was Damon Kralovic who runs our critical care transport service and he's going to talk to us about in that talk about how we'd get patients brought to us in our pretty broad reach. It's a couple hundred mile radius reach of our helicopters and even further with our other portions of our critical care, transplanting.

Venu Menon, MD:
And that was really important because, I think the one thing we did great as cardiologists in this country was deliver reperfusion to every American, regardless of their zip code. No matter whether you're in rural Minnesota or whether you're in suburb in New Jersey, if you have an ST elevation myocardial infarction today, you can expect an EMS to come to your house within 10 minutes, you can expect an EKG. You can expect have your artery open within 60 to 90 minutes. And so that's no longer even a quality benchmark. What we did was when you have that kind of a system, there are other conditions that may not be that time sensitive and time is, there's no question of distance, it's about time. We already had a really great STEMI system. We said, "Why don't we expand that to provide support to all these rural hospitals that get things like an acute aortic syndrome once or twice a year or a catastrophic abdominal aortic emergency?"

Venu Menon, MD:
And so this was a perfect set up that really helped. And Damon has done is create a transport system, whether it be by ground, whether it be by helicopter or even whether it be by a jet, sick people around the world, as long as we can think the transfer is safe and we've got them all the way from China to every country in the world to be here, we can send personnel, personnel who can take care of them during the transfer and do it safely and bring them through our ICUs. And I think that's a model that's really worked well for us, as you know, in acute aortic syndrome. Unlike STEMIs, most ERs, see two or three acute aortic syndromes a year. And so you need to be prepared when you see that to transfer it to some place where they can deal with this stuff. And so this has been a key component to delivering quality cardiovascular critical care.

Eric Roselli, MD:
Yeah. It's fantastic what they've done and even, it's Nurses Week. It's even a subspecialty in nursing. Those people are on that transport module, whatever it may be, wheels or wings, are basically a portable ICU station, isn't it? Transferring people on mechanical support?

Venu Menon, MD:
Think about it, Eric. That space in the back of the helicopter is really tight. To have a sick person in there with an intriotic balloon pump, you need to be a real professional to bring that over. And what we've been blessed with is most of the folks who are in these choppers are actually people you and I have worked with as nurses in our CCUs and in our cardiothoracic ICUs. These are people who know what downstream care looks like. They're just terrifically committed. With COVID and all of these things to go in there, this is like a war zone. You're going into an ER you've never been to, you have a guy there clutching his chest and having a type A dissection. You have no idea if there's a pericardial effusion or there's acute sphere AI and you're making a decision to fly that person 180 miles, 40 minutes to our ICU. That takes some doing.

Venu Menon, MD:
And I got kudos to what Damon has done with this critical care transfer group. In a unit ours, less than 10% of the actual patients in the ICU come from our own emergency room. 90% of these folks that we see are being flown in from remote corners of western Pennsylvania, Kentucky, West Virginia, the upper peninsula of Michigan. This is a large hinterland, but you have great, great impact when you can make these wonderful saves. And you know that better than most with acute aortic syndrome and how satisfying that is to take a young kid who didn't know they had a vascular Ehlers-Danlos and has an abdominal catastrophe or something like that and you save their life. That's really rewarding I can well imagine.

Eric Roselli, MD:
Yeah, no doubt. But it takes that entire team and for them to get those patients to us safely so we can provide definitive care is fantastic. And one of the areas where we've seen growth is once they get here, we have to image them. We have to understand exactly the details that we're we're dealing with, but now we've got technology to even get us some of those images before the patient arrives so we can really mobilize our team. And just that really important issue that you've talked about is the value of time. Our next speaker is Paul Cremer, who is one of our critical care specialists, one of our imaging specialists, one of our research. Paul's amazing. He does so many great things and he presents a really excellent talk.

enu Menon, MD:
Yeah. At the end of the day and this is why I think, like most things in life, you need to know what's going on. The diagnosis is key. You can get the blood pressure fixed and you can give blood, but you can't fix the patient ‘til you know what the problem is. And I think what's really changed and the most important thing I emphasize to a fellow is don't tell me what the blood pressure is, tell me what's causing it. Unless you know that you're in no man's land. And so I think what Paul does in his talk is really integrate how, not just being by the bedside, but how modern imaging in an ICU, whether it be something as simple as a portable echo or whether it be you're making a decision on viability in someone with an end state cardiomyopathy for targets and wanting to do bypass, imaging is key. We really get to know what the minefield looks like, where are the mines? How do we get across that minefield? And we need to plan it.

Venu Menon, MD:
Although this is time dependent, it doesn't mean you run in with your blinders on there into a battlefield just crying, going into war. You really need to have a multi-system having a plan. And so imaging is really, really key. And so what we've been blessed with Eric, is most of the folks who work in our ICU and we really believe that, have very strong imaging skills. I think it's really important for the person by the bedside, not to be a master, but to be able to look at primary imaging data and make implications.

Venu Menon, MD:
You do that all the time. You're a surgeon, but obviously when you look at the aorta, there are things that you see that even a good radiologist will not. And you need to be able to know when to believe that report and when to go back and say, "Hey, don't you think I need to do this this way, because I see the stuff here." And so that's the key of imaging, but I think imaging has improved so much over the last 10 to 15 years, both cross-sectionally and in terms of ultrasound that our ability to make these diagnoses very quickly has enhanced our ability and the promise to deliver care. That's been terrific.

Eric Roselli, MD:
Yeah, it is. It really is. We've got the modern software that allows us to do complex analyses in matters of seconds. We can analyze a 3D reconstruction of a CT scan that's been downloaded before the patient got here at the same time as you guys are doing a bedside echo to assess how that pathology is affecting the pathophysiology of what's going on and really refine our treatment plans on the spot with the whole team, sort of integrating all that information together, all in one central location. And a lot of times it is a dynamic situation and a patient may come in sick and then get sicker right in front of our eyes.

Venu Menon, MD:
I can see that from my situation working, let's say you had a type A dissection, most surgeons would go ahead and put a supracoronary graft in. Here you've got great imaging. You can see a degenerated descending thoracic aorta. You can see on imaging that this aorta is going to dilate over time. You say, "I'm not going to do one surgery and then go back four months later and do something else." You say, "I'm going to fix it right now." That is such a life-saving decision. And we wouldn't have been able to do that unless we had the kind of imaging that we have. I think imaging is key.

Eric Roselli, MD:
Yeah, no doubt about it. Paul does a nice job of reviewing all the different sort of, really different modes of imaging that we can have and how we integrate it into the decision making process. But sometimes when those patients turn on a hair, the decision is that we need to put them on mechanical circulatory support. And so then we hear from Shinya. Shinya Unai, who, I don't know if he sleeps a whole lot, but he certainly spends a lot of time in this place. But Shinya Unai who's been in your ICU quite often as one of our cardiac surgeons who just thrives on taking care of the sickest patients and coming up with novel solutions for them. He presents a nice discussion about the role of MCS.

Venu Menon, MD:
Yeah, I think, if you ask me what's changed in the ICU the most, it's our ability to develop, to provide reliable, durable, temporary support, because it's allowing us to bridge critically ill patients to a decision. We don't always have the answers, but then folks like Shinya put people on support, we are able to at least have the time to prevent end organ injury and recognize whether people are candidates for advanced therapies, durable VADs, give the ventricle a chance to recover. In the past, someone came in with end stage, even at a fulminant myocarditis, the ventricle might recover, but they had lung injury, they were on dialysis, they had other organ injury, the sequelae were lifelong. But this having the ability to put intelligent, rational ventricular specific mechanical support has revolutionized decision making in critical care cardiology. And Shinya does a terrific job in that lecture talking about how to do it and how to do it in a pragmatic, rational and economic fashion.

Eric Roselli, MD:
Right. It's not just ECMO anymore, is it?

Venu Menon, MD:
No it isn't. And it's obviously very ventricular specific disease, specific support.

Eric Roselli, MD:
Yeah. And the development of our shock team, which also sort of facilitates bringing together the players that are involved in those decisions. We've had separate Tall Rounds on that whole topic to delve into it. But again, critical care ICU, the cardiology critical care ICU is a place where teams come together and make complex decisions. And it really is a team of teams. And that's what we hear from Bjoern. Bjoern Toennes sort of steps back and gives us a nice discussion about this idea of collaboration, which is something that you and I having been here so long have always been a part of, but it's pretty cool to see how that's even become more seamless along the way.

Venu Menon, MD:
Completely agree. And I think, that's the wave of the future. And I think it's always been there, whether someone has a bypass surgery or an angioplasty or now at TAVR or a surgical approach, we've got to take a look at everything, both in the short term and in the long term. And I think in the past, we sometimes made decisions which were probably good for the patient at that point of time, but didn't make too much sense when you looked at the longitudinal journey of a patient over time. Having these different skillsets, having different eyes look at it, I really think you need to bring all the skills that you have by the bedside. And so I think a typical example is what we do with an aortic dissection.

Venu Menon, MD:
Whenever we have a aortic dissection come in, we have the luxury of time because the person is being flown in. But I think knowing that the person is coming in, having a critical care cardiologist there, along with a vascular surgeon, along with a cardiothoracic surgeon, along with someone like Paul Schoenhagen, who's reading the CT. You know when you see the patient that all the players who are at stake have a stake in that decision are there by the bedside, making a very meaningful decision, both in the short and longterm that's going to have tremendous impact on the patient. I think that's the key.

Eric Roselli, MD:
Yeah, it's interesting. As I look at it, in medical school now they have courses where they learn about professionalism. And basically they have business school classes that they learn in medical school, like how to communicate with each other and everything else. But you and I both remember a time when there were, even in this place where we do collaborate in a really amazing way, I remember some times when there were some awkward situations where the teams had to learn how to kind of come together and make decisions, but just to see how those interactions have evolved has been really neat.

Eric Roselli, MD:
I think one of the cool things that we did a while ago was when we came up with this idea about this sort of two to turn down. Where if we had a patient that we thought we weren't sure whether they should go to surgery or not or what the best treatment option was. And if there was some hesitancy from some individual staff member. By creating a policy so we could get beyond sort of that awkward discussion when there is some conflict about the decisions, by creating a policy where we've just all agreed to bring a third party in, has made those kinds of conversations a lot simpler, haven't it?

Venu Menon, MD:
I think the thing, Eric, that people think is that, we always talk about the glory cases that we save. But I think we know that of these 230, 240 admissions, I always tell my students and fellows, I shake somebody's hand every day who's not going to be alive the next day. And we have a 15, 24 people die there every month and we don't have solutions for everybody. This is a humbling business and you need to know what you can do and what you can't. And it's not all about the procedures. You also need palliative care. You need bioethics, you need neurology to prognosticate on brain function. This goes well beyond just you and me doing procedures and saving lives. This really goes to trying to provide a rational, dignified care at really vulnerable moments in patients' lives.

Venu Menon, MD:
And we don't always win. We do close the book knowing that we've left no stone unturned and we've respected the patient's and family's wishes, and we've done what we think is the best we can given our skills. I think that's I think a key message I'm hoping the younger folks also take away from this is that while we do have the latest and the greatest, ultimately medicine is a contact sport. You're in it not for virtual conversations, you're in it because you want to get your hands dirty. You want to meet these wonderful people at vulnerable portions of the life, help those who you can and then completely support patients and families through what's an endless nightmare for them.

Eric Roselli, MD:
No doubt. That's a really important part of our responsibility, is to provide them that sort of dignity when they're in those difficult and dark times. No matter how hard those times are, I've always been really pleasantly sort of surprised and just kind of profoundly impacted at the courage that people have. People from all different walks of life that we meet in those difficult situations are just so brave. And what they want is the autonomy and the understanding, even when we've realized that we've exhausted options and maybe what we're doing is futile and we're honest with those people and we're clear and we're transparent with them about things. They know. They know they're in a bad situation and they're so appreciative of that. I get a ton of really great thank you letters for people all the time for saving their lives, but the ones that touch me sometimes are the ones when someone's grateful for us having provided some compassion when we can.

Eric Roselli, MD:
That's a part of what happens in the ICU that, I know I don't want to bring us down in this podcast, but we got to talk about it because that's the real side of things and a real important part of it. And that's why it's kind of nice to have a whole team that works together because all of us that do this stuff, we get all that. And when we have those moments together, I think that kind of makes us stronger for sure. But those are numbers that get counted.

Eric Roselli, MD:
And the final speaker in our agenda on this topic is Penelope Rampersad, who's really amazing. You talk about someone who's had a multidisciplinary sort of training. She comes to our surgical ICU and helps us all the time as well. But just like anything we do in medicine, the only way if we know we're going to keep getting better at it is if we keep track of what we're doing. And she gives us a really nice review, some of the quality initiatives. Can you tell us a little about what she talked about?

Venu Menon, MD:
Yeah, and I think obviously you don't know how you're doing until you quantify and measure what you're doing. And I think there are a number of things that we can learn from other ICUs that are well established and haven't been validated in the CCU environment. And so Penny's our quality assurance director in the cardiac ICUs of the HVTI. And she does a terrific job talking about the various metrics, how you follow them, how you put things in place. And I think that's what's really important. At the end of the month, we've hopefully done a lot of things really well. There are other things that we can do better. And I think the key to getting better is to discuss in detail some of our failings and many of our successes and learn from what we did right. And then hopefully get better on what we did wrong and do it even better. And so Penny plays a key role in trying to make us be the best we can be in that situation.

Eric Roselli, MD:
We even quantify these days, the quality of the patient experience. That's got to be a really tough one to measure in the ICU setting, but it's as important as anything.

Venu Menon, MD:
Again, you said it's Nursing Week and so I just want to leave that with the fact that you and I walk into a patient's room and then we move on to the next one. The key person in that ICU is that bedside nurse and creating an environment where that bedside nurse knows he or she is in trouble, can ask for help, find that help in both nursing leadership, as well as in physician leadership to create that environment where people are not afraid to question, they're not afraid to express their anxiety, if that is what it is and get help is really, really important. And so I did want to raise that issue as we talked about the bedside experience.

Eric Roselli, MD:
Yeah. That's a great point. A guy who's married to a former ICU nurse, I totally can appreciate that. I'm glad you brought that up. There's no doubt about it. The nurses in those units are amazing, as well as the patient care techs and everybody else that runs through that place. We did have a little time for the panel discussion at the end of the Tall Rounds, which is also a great element to this symposium and the whole agenda. To our listeners, remember that you get complimentary CME when you sign in and watch the full video presentation with the slides and everything else. And we'll ask Dr. Menon to give a couple of closing words and then you'll be able to listen to the audio from Ran Lee's discussion about the components of cardiac critical care training. Venu, you want to close this out before we listen to Ran?

Venu Menon, MD:
Thanks Eric, again, this was a privilege to have this opportunity to speak to this audience. I'm must say that it's a great time in cardiac critical care, just because of what the advances in both cardiology and cardiothoracic surgery have done for these critically ill patients. The availability of the changes in structural heart disease, the changes in terms of procedures in endovascular intervention, the availability of temporary pumps and of support. All of these have created a degree of optimism in an area that was otherwise we just would not, could not help folks. And so I think in many ways, this is a spring time. It's never spring in Cleveland, but it's spring in the ICU in that there's opportunity and great improvement in outcomes to be had for these critically ill patients. And so on that optimistic note, Eric, thank you for having me on the show. I really enjoyed it.

Eric Roselli, MD:
Thanks Venu. I love your energy. I'll see you at the bedside. Thank you.

Venu Menon, MD:
See you again.

Ran Lee, MD:
I will be discussing the necessary components of cardiac critical care training for cardiologists. As mentioned before, the modern cardiac intensive care unit is evolving. With the advent of technological and device improvements as well as our aging population, we are seeing an increasing number of non-cardiac diagnoses as well as more diverse cardiac diagnoses beyond acute coronary syndromes.

Ran Lee, MD:
On the left here, you can see a paper from Jason Katz in 2016, published in JAC, looking at the overlap between medical ICU populations and cardiac ICU populations. And where we really intersect is in patient characteristics and resources with age, sex, disease, severity and mechanical ventilation, dialysis and vasoactive medications.

Ran Lee, MD:
On the right as a study from University of Virginia, back in 2017, published in JAC, looking at the diversity of cardiac diagnoses. Acute coronary syndrome only makes out about 25% of the cardiac diagnoses present over a year time span where you have sepsis, hypertensive crisis, brady arrhythmias, valvular heart disease and heart failure also making up a bulk of the cardiac diagnoses present. Acute kidney injury and acute respiratory failure made up of about a third of these patients over the span of a year.

Ran Lee, MD:
David Morrow in his scientific statement from 2012, really kind of defined what should be in a level one tertiary care center, coronary or cardiac ICU. Specifically speaking in monitoring, we should be able to have invasive hemodynamics, non-invasive hemodynamics, respiratory therapy, renal replacement, mechanical ventilation, 24/7 cardiothoracic surgery and interventional cardiology, as well as temporary mechanical circulatory support. The leadership and staffing should include cardiac intensivists, cardiologists and RN to patient ratios should be limited. With that, the American College of Cardiology set forth a training statement back in 2015, looking at what should we be doing to enhance our personnel? Specifically level three training, looking at completion of a one year clinical fellowship in critical care medicine within the department of cardiovascular medicine in conjunction, as well as the overlay and specifically the interval lapping with cardiothoracic ICUs.

Ran Lee, MD:
Level three training was evaluated and further expounded upon by Dr. Katz in 2016, looking at three different training modules, a standard dual certification pathway between separate fellowships in cardiology or critical care, a tailored dual certification where feasible trainees could undergo a one year critical care medicine training program or a dedicated program in critical care cardiology, specifically looking at a four year training program that streamlines the application and matching process.

Ran Lee, MD:
The key overall should be skill acquisition, defining competencies and trainings and enhancing leadership capabilities within cardiac intensive care. Graduates from the University of Pennsylvania program really expounded upon this further by looking at specific rotations, cardiothoracic ICU, medical ICU, junior CIC of attending, heart failure and procedural services, but also wanted to focus on year one, year two and year three opportunities to build to that if you were looking to create a program within your own institution.

Ran Lee, MD:
Here at Cleveland Clinic, we have a pattern one year rotation in medical ICU, coronary ICU, heart failure ICU, cardiothoracic ICUs neuro and several procedural rotations as well.

Ran Lee, MD:
The pathways of critical care cardiology to gain certification can be done in many different ways, either a one year critical care fellowship after cardiology or a two year critical care medicine fellowship before cardiology. In the ideal state, we should be able to develop subspecialty critical care cardiology with a cardiac intensive care program director and ACGME accreditation down the line.

Ran Lee, MD:
Our skillsets really should involve an amalgam of interventional critical care, heart failure, device managements, really looking at conditions such as cardiogenic shock, acute coronary syndromes, cardiac arrest management, but also incorporating critical care skills such as renal replacement, thoracenteses, airway management and bronchoscopy. And so here's where the intersection really lies between critical care and cardiology in terms of the tools that are necessary to be a truly adequate cardiac intensivist, vascular access, temporary durable mechanical support, cardiac arrest, cardiogenic shock, vascular procedures, but also a lot of focus on renal replacement, nutrition, ventilator and delirium management.

Ran Lee, MD:
Further training should also focus on an educational program that's robust and is multidisciplinary in nature and ability to review the up to date literature in critical care and also have supplemental educational opportunities on a nationwide scale. The ideal cardiac intensivist should be able to have appropriate training and competencies for mechanical support, advanced airway and ventilator management, training competencies in vascular access, training and competencies in perioperative management and management of multiorgan dysfunction and shock states.

Ran Lee, MD:
Thank you.

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