The Heart Team: Where did it Come from and Where is it Going (2019)

The Heart Team concept arose during a time when Interventional Cardiology (IC) and Cardiovascular Surgery (CVS) were grappling with and exploring competitive revascularization strategies in patients with chronic coronary artery disease (CAD). That dyad construct of IC and CVS was fundamentally important in the planning, implementation, and performance of the iconic SYNTAX Trial which was developed during a time when there were strongly held opinions about the two competing strategies of care. To address the competing issue, potential patients with chronic multi-vessel disease had to be suitable for complete revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG).1Serruys PW Morice MC Kappetein AP et al.Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.N Engl J Med. 2009; 360 (doi:10.1056/NEJMoa0804626.): 961-972Google Scholar The basis of that dialogue was joint meetings between IC and CVS to review each individual case – the patient demographics, functional imaging, and angiographic studies. In ideal situations, both IC and CVS would consult together with the patient. This co-evaluation optimized patient education and decision-making. The model was the forerunner of today’s health-care system that is patient-centred, team-based, and integrated. Without equipoise in identifying patients who might be suitable for randomization, the SYNTAX trial would never have been able to be completed. Without such a trial, revascularization strategies would not have developed a sound, scientific basis for decision-making. As a result of the SYNTAX initiative, the concept of a Heart Team became fully embodied in professional societal guidelines and is now an important component for reimbursement. Although the Heart Team required consensus between interventional cardiology and cardiovascular surgery2Fihn SD Blankenship JC Alexander KP et al.2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, society for cardiovascular angiography and interventions, and society of thoracic surgeons.Circulation. 2014; 130 (doi:10.1161/CIR.0000000000000095.): 1749-1767Google Scholar,3Neumann FJ Sousa-Uva M Ahlsson A et al.2018 ESC/EACTS guidelines on myocardial revascularization.EuroIntervention. 2019; 14 (doi:10.4244/EIJY19M01_01.): 1435-1534Google Scholar and has now been widely used, site-specific implementation and infrastructure varies. Despite this, the goal of direct focused meetings of the stakeholders involved concentrating on issues of specific patients which lead to consensus recommendations remains the ideal. The clinical appeal and perceived success of the Heart Team resulted in its application to other disease states, most recently and prominently, in transcatheter aortic valve replacement (TAVR).4Baumgartner H Falk V Bax JJ et al.2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38 (doi:10.1093/eurheartj/ehx391.): 2739-2791Google Scholar,5Nishimura RA Otto CM Bonow RO et al.2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.J Am Coll Cardiol. 2017; 70 (doi:10.1016/j.jacc.2017.03.011.): 252-289Google Scholar Specifics of its early application in that arena were slightly different, although again, both IC and CVS were the dominant players. As previously mentioned, specific implementation was variable and left to the individual institutions. In contrast to the background of the SYNTAX trial where there were two competitive strategies to be studied, both of which were felt to be potentially equivalent, there were differences in the field of aortic valve disease. These differences related to the fact that there was only one clearly established treatment for symptomatic severe aortic valve stenosis, namely surgical aortic valve replacement (SAVR). There was, however, another new technology, TAVR, which was still in development and testing, but was being enthusiastically embraced, initially, for patients felt to be either inoperable or at high risk for SAVR. Discussions for the Heart Team then revolved around the question of whether the specific patient at hand was deemed a SAVR candidate by the CV surgeon. If the patient was deemed inoperable or prohibitively high risk for the standard of care, then the Heart Team could render an opinion about whether vascular access with large bore catheters could be accomplished safely and whether the valvular anatomy appeared suitable for TAVR. In that case, the patient was presented with TAVR as the only option. Conversations by the Heart Team in that specific scenario with the patient included the potential for severe procedural complications and whether there was the possibility of surgical bailout if such occurred. As data accrued, the conversation for the Heart Team changed and now included the issue of comparability between two techniques: SAVR and TAVR. During this time, the definition of the Heart Team changed as it was no longer just comprised of IC and CVS and was expanded to other important stakeholders in the process of care. Throughout this time, as the conversation was changing, the make-up of the Heart Team also evolved from the core of an IC and CVS to now include structural imaging specialists, patient advocates, health-care teams, general cardiology, nursing staff, and, at times, geriatricians. The dialogue in this setting was the risk/benefit ratio of either procedure for the specific patient at hand. Along with this, the target population changed from high-risk/inoperable to intermediate risk and then to low-risk patients. With more data from clinical experience and randomized clinical trials (RCTs), the conversation has continued to evolve to the stage where, in selected patients at intermediate and even low risk for SAVR, that TAVR and SAVR are now considered to be comparable. TAVR being the less invasive option lends it to the dominant strategy which likely will be recommended unless contraindicated.6Bavaria JE Tommaso CL Brindis RG et al.2018 AATS/ACC/SCAI/STS expert consensus systems of care document: operator and institutional recommendations and requirements for transcatheter aortic valve replacement: a joint report of the American Association for thoracic surgery, American College of Cardiology, society for cardiovascular angiography and Interventions, and society of thoracic surgeons.J Am Coll Cardiol. 2019; 73 (doi:10.1016/j.jacc.2018.07.002.): 340-374Google Scholar, 7Mack MJ Leon MB Thourani VH et al.Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380 (doi:10.1056/NEJMoa1814052.): 1695-1705Google Scholar, 8Popma JJ Deeb GM Yakubov SJ et al.Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.N Engl J Med. 2019; 380 (doi:10.1056/NEJMoa1816885.): 1706-1715Google Scholar The CV surgeon will remain an integral part of the team and part of the procedure as per the professional guidelines, FDA IFU (Instructions for Use), and CMS. However, the strategy will have shifted from equipoise to TAVR unless not feasible. The details of the specific patient will continue to be central. If the patient has bicuspid valve disease with aortopathy, is young (e.g., <60–65), has significant CAD, or other anatomic constraints (e.g., left ventricular outflow calcification, other valvular dysfunction such as severe mitral or tricuspid regurgitation), then conventional SAVR will still be an important alternative. In that case, the conversation will typically revolve around considerations of durability as well as differences between a mechanical or biologic valve. The next phase of the Heart Team integration will be complex, involving all of the expanded team, but now to include input from palliative care. Palliative care has been important in clinical practice as an increasing number of patients with advanced disease are seen in many different areas of cardiovascular disease including heart failure. The specific role depends on the individual institution: in some institutions a specific Palliative Care Service may be involved which is centered on exploring issues with the patient and family about care options focusing on the quality of life and sometimes hospice care. In other institutions, the general cardiovascular physician may serve in that role. The focus of the palliative care aspect of the Heart Team involves identification of patients who are felt to be “Cohort C,” namely those in whom the risks of either TAVR or SAVR outweigh any intermediate or longer term benefit that might accrue from intervention. In these cases, there will be additional items to consider. If the patient risk is related to comorbidities, then other specialties will be needed. Alternatively, if the symptoms of heart failure or debilitating dyspnea are related to the degree of left ventricular dysfunction or potentially concomitant pulmonary abnormalities, there will need to be consideration as to whether there will be improvement in symptoms if TAVR is recommended. In this clinical setting, the Heart Team will need to have discussions about the role of balloon valvuloplasty. Depending on the symptomatic improvement from the procedure, the decision of TAVR suitability may need further consideration. The economics of the Heart Team approach are important. Initially, the Heart Team approach in TAVR was mandated to include evaluation by two Cardiac Surgeons as well as IC. That has subsequently been decreased to having only one surgeon involved in evaluation. As TAVR becomes the standard of care for the treatment of aortic stenosis, that may further evolve to include discussions of which patients should not undergo TAVR. The concept of a Heart Team continues to be applied to other arenas including left atrial appendage occlusion, atrial fibrillation9Kirchhof P Benussi S Kotecha D et al.2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS.Eur J Cardiothorac Surg. 2016; 50 (doi:10.1093/ejcts/ezw313.): e1-e88Google Scholar, as well as structural heart diseases such as mitral and tricuspid valvular disease. In the setting of atrial fibrillation, the term “integrated care” has been applied with cooperation of multiple stakeholders including cardiologists, cardiac surgeons, stroke specialists, and electrophysiologists. It will also be applied to other areas where the advantages and disadvantages of complementary or competitive procedures are available. While the Heart Team approach makes intuitive sense, it includes extra time and certain inefficiencies. Although now codified in professional societal documents, details of its implementation are typically left up to the individual institution. In its optimal form, it includes face to face, routine scheduled meetings of the stakeholders involved with a specific patient. During this time, the relevant clinical and imaging data are reviewed and then consensus reached about patient suitability for either SAVR or TAVR or conservative medical therapy. In patients in whom TAVR is considered, the imaging information must be available to decide about potential access approach as well as the specific type and size of the device to be implanted. Although this is optimal, there is great variability in its implementation. Similar to shared decision-making, the Heart Team effect is potentially important; but, its impact may be hard to quantify. From the patient care standpoint, shared decision-making has been tested scientifically and has been found to improve patient awareness of options; however, it remains controversial and its exact implementation continues to evolve.10Coylewright M, O’Neill E, Sherman A, et al. The learning curve for shared decision making with an encounter decision aid for symptomatic aortic stenosis: a mixed methods study of the heart team. 2019.Google Scholar The Heart Team, on the other hand, is often upstream from shared decision-making and has not been similarly subjected to testing. Although now embodied in the professional societal guidelines, it is uniformly accorded Level of Evidence C. One goal has been to bring the Heart Team to a more collaborative approach between IC and CV Surgery. In that regard, it has been extremely successful. Nationally, the field of TAVR has been dominated by RCTs in which there were co-principal investigators: IC and CV Surgery. This relationship has been fundamental. As a result, training programs have now changed so that surgeons and interventional cardiologists undergo some aspects of training together such as development of percutaneous vascular access skills for the CV surgeons. Another metric might be seen in publications reflecting more collaborative work; for example, the major publications and randomized trials have all included both IC and CV surgeons as co-principal investigators.6Bavaria JE Tommaso CL Brindis RG et al.2018 AATS/ACC/SCAI/STS expert consensus systems of care document: operator and institutional recommendations and requirements for transcatheter aortic valve replacement: a joint report of the American Association for thoracic surgery, American College of Cardiology, society for cardiovascular angiography and Interventions, and society of thoracic surgeons.J Am Coll Cardiol. 2019; 73 (doi:10.1016/j.jacc.2018.07.002.): 340-374Google Scholar, 7Mack MJ Leon MB Thourani VH et al.Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380 (doi:10.1056/NEJMoa1814052.): 1695-1705Google Scholar, 8Popma JJ Deeb GM Yakubov SJ et al.Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.N Engl J Med. 2019; 380 (doi:10.1056/NEJMoa1816885.): 1706-1715Google Scholar As the future of less invasive approaches to the field of cardiovascular disease continues to expand, training programs of the future should become more focused and efficient. The CV surgeons have already put into place a strategy for decreasing the length of training to become certified in Thoracic Cardiovascular Surgery which shortened the general surgical training period. In the future, professional societies might focus on developing programs which would result in the training of a hybrid individual specifically trained and focused on specific aspects of disease such as coronary artery or the expanding field of structural heart disease. Such hybrid programs would improve the expertise of individuals coming from either IC or CV surgery programs. The future will also include increasing collaboration with industry and regulatory agencies as partners with device development, testing, and final approval. Dr. Holmes and Dr. Greason report no conflict of interest. Dr. Brown reported no conflict of interest. Dr. Mack is a Co-PI of Partner trial of Edwards Lifesciences, Co-PI of COAPT trial of Abbott, and study chair of Apollo trial of Medtronic.