<v ->Brain-Heart Team or Heart-Brain Team.</v> Ours is a Brain-Heart Team, y'all come first. I'm Megan Coylewright and this is Megan Stevens. She is our expert stroke neurologist at Erlanger Hospital System. And she's gonna do the bulk of the talking but we are the Brain-Heart Team and we meet monthly and we'll talk a little bit about the nuts and bolts of how we do that. But in all the presentations, how do you pick patients? I ask Dr. Stevens. That's how I pick patients. Sometimes I pick 'em a little early and she calls me and says "No." And then I call the patient back. The guidelines that we recently wrote together, it was such a great experience combining neurology and cardiology and the patient voice. So you'll, if you read these guidelines, they're very different. They acknowledge for the first time that we may not be the sole authority on all things, particularly when the data is not so strong. Although Dr. Thaler has really pushed us forward. So we have three cases to highlight how we work together as a Brain-Heart Team. So we meet Thursday mornings at 7:30 to 8:00 on a Zoom call. And you have to have two champions. One is the cardiologist and one is the neurologist. But then we invite all of our friends to join us and our first goal is improving patient outcomes for patients like this. A patient who presents with migraines. And the question of PFO closure, that's our first goal is picking the right patient. But after COVID, our second goal has been staff retention. And we've found that when we engage our APPs, our nurse coordinators, our other neurologists who are doing stroke care on the inpatient side, but not necessarily seeing the follow up on the outpatient side, it really leads to a feeling of professional satisfaction an esprit de corps. We're all in this together. We're sharing new data, new information. Most of the time it's just Dr. Stevens teaching me. I'm asking her really basic questions and she gives me different lectures and little mini lectures which help my whole team understand. So there's a key component of education and program building on our calls together. And sometimes we meet in person but it is hard to fit it in all the other meetings. So it's important to have that commitment. This first case is a 47 year old woman who came in with a history of migraines. And our guidelines suggest when it comes to migraines in PFO closure if they have debilitating migraines and Dr. Stevens has done everything with her and her team to help resolve that pain. And they still have pain and they understand the risks and benefits closure could potentially be beneficial. Not TIA though as much as migraines. This study actually the patient had a TTE and a TEE and they suggested that she had a PFO because she had what was called negative contrast, meaning they give the saline bubbles and it never quite fills next to the septums you see that line there, how there's black and there's none of the bubbles going across. That doesn't mean there's a PFO there. It means that we never filled that area well enough because we're injecting through an IV in the arm and the blood flow through a PFO comes from the leg. I agree with Dr. Thaler, you've gotta get a TEE but sometimes you have to put an IV in the foot. Isn't that confusing? And sometimes you have to bring them to the lab. So for this patient, I said, "I don't even know that you have a PFO." And once Dr. Stevens got ahold of her, she felt better anyway. So sometimes it's really getting the patients to the right care. Even as your team members around you are telling you that they want you to go forward with closure. I'm gonna ask Dr. Stevens to come up and share the next two cases. Start thinking about your patients 'cause then we'll open it up for discussion for your questions. <v ->So this next case really illustrates</v> one of the Brain-Heart Team goals of consistent messaging. So this is a 38 year old man who had acute onset of nystagmus. He immediately knew something was wrong. He's a personal trainer, so he is very familiar with how his body should be functioning. And so he went to an outside hospital and was quickly evaluated and the workup was extensive while he was there. It did not reveal much beyond this mid-brain stroke on the right side. The rest of the MRI was clean there was no small vessel disease on the flare and his blood vessels, there's a picture over there. They were clean just as that shows there with the arch, not all views, but the vertebral arteries they were all clean, no evidence of dissection, occlusion, stenosis, atherosclerosis, just clean. His hypercoagulable panel was negative. He had a UDS that was negative. He did not have any past medical history and he did have a PFO. It was considered small TEE confirmed and the cardiologist that was working with him in the hospital really wanted to push for closure during the hospitalization. But the patient was really uncomfortable with that. And so he sought a second opinion with the brain heart team at Erlanger. First working with Dr. Coylewright. And this is a video, feel free to chime in. <v Coylewright>Yeah let me walk through this.</v> So the patient had a very small shunt on their echo and I just wanted to point out that again echo is really limited depending upon how much the patient valsalvas what is the pressure difference between the right side and the left side? So what you're looking at here is an intracardiac echo image and at the very top of the screen is the right atrium. And then you see the line, horizontal, that's the the septum. And then a line straight down. That's a stiff wire and it's tenting open what is actually a very large PFO but it looks small on the initial imaging. And if we'll go to the next slide there, Dr. Stevens, you can see the big space that is present. Just really when he valsalvas. This is a weightlifter. I mean his arms were like as big as Megan and I. He was a really big dude and he kept asking when he could go back to the gym. So he was definitely valsalving a lot. And let's go to the next slide. So that's a Gore septal cardioform occluder. But just to highlight that sometimes the ultrasound can be misleading. We could not get these images from the outside hospital. So it was a very, it was many, many visits with Dr. Stevens and I. But the reason that he stayed with us this was actually over the course of probably three months of decision making and we ended up in the exact same place that the cardiologist wanted him to be at the outside hospital. But the patient was comfortable with the decision making by that time. And that's why he came to us was for that collaboration between Dr. Stevens and I saw both of us several times and I think that's some of it's important to make the right diagnosis and get the device in perfectly. But some of it is just to hold patients in care in that process. And one of the things that Dr. Stevens, I wanted you to talk about, was all of the extra counseling you go through for lifestyle modification, prevention. And there's just another added layer of taking care of patients after their stroke. <v Stevens>Absolutely, so the patient</v> really needed to be certain that there was nothing else that we could do to lower his stroke risk beyond doing something that was invasive. And so one of the things that was beneficial in this patient was to really kind of walk through the nuts and bolts of the workup as I was doing before with you looking at those blood vessel pictures together looking at the brain MRI together and acknowledging that a small mid-brain stroke could without the other supporting documentation that was negative be a small vessel stroke it could have been a large artery stroke but he did not have the risk factors and he didn't have the evidence on imaging. And so again, when you have consistency of messaging then you can build trust and that really helps build access to care. So in this next case the goal that really is illustrated would be that we have to have shared decision making when we are discussing these patients on the Brain-Heart Team which does include the patient and their family. So this was a woman who I actually met when she was in her mid 60s, but she had a history of strokes that began in her 50s. And at the time she did have a PFO that was identified but the timing was such that we didn't really have the preponderance of evidence for supporting PFO closure. So it really wasn't a discussed option. And then unfortunately she moved and then the next place she moved to she was trying to establish care with a neurologist. And unfortunately she had some episodes of old stroke deficits coming back in the setting of stressors, which as neurologists we know is recrudescence and can happen. But it got mislabeled because they didn't know her as conversion disorder. And so unfortunately the stigma of that diagnosis likely stuck with her because the notes don't really show any attention was given to lowering her stroke risk. So she ended up moving and this time to the Chattanooga area and she established with me after she had a TIA and got another workup. And so we could see that on her brain MRI she had some areas of stroke that were involving multiple vascular territories. And if you wanna jump in with this one. <v Coylewright>As opposed to case number two</v> this was a very large shunt seen on TTE. So her story's just so painful to hear because it's not subtle. <v Stevens>So we reviewed together</v> through the shared decision-making process that if she had been offered PFO closure at the time that she first presented she would've been a great candidate. If you took into account the rope score as well as the Pascal classification she would've been a probable patient. And so that's where the benefit is greatest. But as time moved on, she got older and she had more events and so her rope score lowered but she still fell within the criteria of being a possible PFO attributed stroke even though she was now older. <v Coylewright>So this is intracardiac echo imaging</v> showing her not just the large shunt, but also an atrial septal aneurysm. You can see it bouncing next to that stiff wire. This is still frames of the Gore cardioformm occluder. And that's a picture of the device in her heart with the ICE camera looking at it. And these procedures take like 30 minutes and they go home later that day. It's not the procedure that's the tough decision, it's really about holding that patient in care making sure we're making the right diagnosis and meeting them where they are. So Dr. Stevens, I'll have you kind of just provide concluding statements to our segment and then we have a few minutes for patients to share difficult cases. <v Stevens>Yes, absolutely.</v> So in this case, it was challenging because we had a patient who actually by that point really by age, didn't fit within the meta-analysis criteria for being that type of patient that you would feel really comfortable maybe initially with offering PFO closure. But in sorting through the history and the data and having discussions with Dr.Coylewright and the patient and her family we all agreed to move forward with PFO closure which was ultimately what in hearing from them they would've wanted to begin with many years ago. (audience clapping)

Brain-Heart Team approach

neurology

cardiology

patient care

collaboration