Practical Implementation of the Coronary Revascularization Heart Team

Abstract

Multidisciplinary decision making has been shown to be highly effective in various aspects of medicine, most notably with the concept of tumor boards and transplant committees. ,2The most updated guidelines for percutaneous coronary intervention (PCI), published jointly by the American College of Cardiology Foundation, American Heart Association, and the Society for Cardiovascular Angiography and Interventions, assign a class IC recommendation for the use of a collaborative Heart Team approach in the treatment of patients with complex coronary artery disease (CAD). 3 The guidelines assert that this recommendation is based on retrospective analyses showing that patients with complex CAD referred for revascularization based on a Heart Team consensus have improved mortality compared with patients merely assigned to a particular strategy in the context of their trial enrollment. Despite the suggestion of improved mortality in this retrospective comparison, the Heart Team approach has not been adopted widely in the current clinical practice of cardiovascular medicine. This multidisciplinary innovation remains in its infancy, and numerous questions remain about its practicality, feasibility, and efficacy.For several reasons, there remains significant variability in the care delivered to patients with complex CAD. 4 Numerous reports show that although differences in patient characteristics may explain some of the variability in revascularization decisions, much of this variance is physician driven, such as practicing in a fee-for-service model or high-risk anatomy for low-volume operators. 4,5 As emphasis grows on informed decision making and patient-centered care, a critical evaluation of these difficult questions will be essential to discovering whether there is a clinically meaningful effect of the Heart Team approach on patients with complex CAD.Although the longstanding use of tumor boards in the field of oncology represents a functioning model of interdisciplinary care on which the Heart Team may be based, it is critical to gather data on the types of patients who could be discussed in a Heart Team. Although the convening of tumor boards to provide prospective care in oncology is supported by the American College of Surgeons guidelines, recent data suggest that the use of tumor boards may have little impact on quality of care and survival across a large sample of patients in the Veterans Affairs Healthcare System. 6 Accordingly, if the Heart Team model of care is to be adopted, more evidence needs to be established in the literature on the details of how to implement such a system. Challenges in ImplementationSubstantial barriers do exist and have been identified previously. 7 The most significant barriers include the challenge of integrating multiple opinions into a final treatment decision systematically, engaging patients and families in decision making, communicating recommendations accurately and efficiently, and, finally, addressing the issue of remuneration for services. Also, time is a frequently cited li...

Safety and Efficacy of Implementing a Multidisciplinary Heart Team Approach for Revascularization in Patients With Complex Coronary Artery Disease

“…One of the initiatives of our newly established University of Pittsburgh Medical Center Heart and Vascular Institute (which includes cardiology, cardiac surgery, and vascular specialists) is to provide optimal evidence-based care for patients with cardiac disease. As a result, based on the merits of MHT in transcatheter aortic valve replacement programs, a previous investigation 13 was able to show successful novel implementation of an MHT for patients with complex CAD. In the present study, we further examined the safety and efficacy of this pilot program, specifically looking at midterm outcomes.…”

“…At a minimum, cardiac surgery and intervention cardiology were represented. Details of the MHT structure and its implementation have been described previously 13 and include detailed patient history, risk factors, frailty, review of coronary angiograms, and calculation of important risk scores, such as the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score and the Society of Thoracic Surgeons risk score for mortality and morbidity. 14 The MHT recommendation was adjudicated with the appropriateness for coronary revascularization based on the appropriate use criteria for revascularization and individual patient comorbidities.…”

“…Within this structured format, a previous report 13 demonstrated successful feasibility of implementing an MHT approach for patients with complex coronary disease. The aims of our present study are to demonstrate the safety and efficacy of the MHT approach for patients with complex CAD and to evaluate the midterm outcomes of these patients in an observational cohort study.…”

Predição do sucesso da cirurgia de revascularização miocárdica em pacientes com coronariopatia difusa: a contribuição do heart team

“…[17][18][19] . Essa decisão tomada em conjunto apresenta maior consistência que a de cada especialista isoladamente [18][19][20] .…”

“…, insuficiência cardíaca 17,18 e, mais recentemente, na decisão do tipo de tratamento -revascularização cirúrgica ou percutânea ou tratamento clínico -de pacientes com DAC avançada e/ou complexa [17][18][19][20]27 , pela primeira vez é estudado o papel do heart team na estratégia de tratamento cirúrgico em pacientes submetidos à revascularização miocárdica.…”