October 31, 2008

VA Med Center’s cardiac surgery program growing

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Jorge Balaguer, M.D., left, with patient Henry Derryl. (photo by Neil Brake)

VA Med Center’s cardiac surgery program growing

The cardiac surgery program at the Nashville Veterans Affairs Medical Center recently reached a milestone, with 500 cardiac surgery cases since 2005.

A comparison in volume drives home just how far the cardiac surgery program has come in a short time. In 2007, surgeons performed 141 cardiac operations. This number represents an increase of almost 90 percent when compared to the volume in 2004. The division expects to perform 170 cases in 2008.

Although the VA is physically adjacent to Vanderbilt Medical Center, the federal government owns and operates it as a separate entity. However, its success depends on strong support from Vanderbilt.

“Our Veteran's program is extremely important to Vanderbilt Heart & Vascular Institute,” said John Byrne, M.D., chair of the Department of Cardiac Surgery at Vanderbilt. “We are one team. While the Vanderbilt surgeons occasionally attend at the VA and assist with specialized operations, the VA program serves as a reservoir for talent that Vanderbilt can call upon from time to time.”

When Byrne became chair of the department in 2004, he made a commitment to VA leadership to support its cardiac surgery program, which was in need of a chief. He immediately thought of Jorge Balaguer, M.D., his friend and colleague from Brigham and Women's.

“Shortly after accepting the position here I knew there was one person who could lead the VA program,” Byrne said.

Balaguer accepted and became chief of cardiac surgery at the VA in 2005.

“The program was coming out of a difficult transition. I thought that despite the issues, the battles were winnable. I felt we had the ingredients to have a winning team,” Balaguer said.

Balaguer, assistant professor of Cardiac Surgery, directed early intervention programs toward reorganizing the cardiac surgery team inside and outside the operating room. Cardiac surgeons, cardiac anesthesiologists, cardiologists, perfusionists, nurses, the surgical intensive care nurses, residents and fellows all became part of the VA team.

“Team approach to patient care became the signature of the cardiac surgery program,” Balaguer said.

In order to increase volume, the team took on complex procedures such as re-operations, aortic root replacements and aortic arch replacements. Stephen Ball, M.D., contributed his expertise in off-pump coronary artery bypass.

Cardiac surgeons Mike Petracek, M.D., and Tarek Absi, M.D., pioneered the minimally invasive mitral valve surgery program at the VA.

“I believe our program is the only VA in the nation that offers this type of minimally invasive valve surgery,” Balaguer said. “It is technically very demanding and very risky, but we've had tremendous results.”

The Continuous Improvement in Cardiac Surgery Program analyzes data from all 44 cardiac surgery programs in the VA system, including risk stratification and risk-adjusted outcomes. The Nashville VA Medical Center had the lowest three-year average O/E ratio for mortality in the VA system: 0.4.

At the heart of the VA program is excellent customer service. Balaguer oversaw the reorganization of the surgical intensive care and step-down units with revised protocols, care maps and order sets. A multi-disciplinary approach to patient care became known as the “VA Way.”

The VA cardiac surgery program works in close collaboration with cardiology. Together, they decide how best to treat a patient — whether it is medically or surgically. Byrne was instrumental in establishing this “hybrid” approach to patient care.

“Our collaborative working relationship with cardiology and the formation of the Vanderbilt Heart pavilion is our single most important achievement. Without this team approach, none of the things we have achieved at Vanderbilt or at the VA would have been possible,” Byrne said.