Heart Team Approach: Still a Work in Progress

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 - Robbin Cohen, MD
Robbin Cohen, MD

The heart team approach is transforming how cardiovascular specialists and staff interact and provide patient care, but it also poses challenges in daily practice.

The evolution of complex algorithms for cardiac care, combined with the introduction of potentially disruptive therapeutic technology, has resulted in a new and expanded definition of the “heart team.” Individually led silos separating cardiology, cardiac surgery, intensive care medicine, nursing, ancillary care and administration have given way to a more collaborative patient care model based on diagnostic and therapeutic guidelines and focused on quality.  This shift has required not only a structural reorganization in the way we deliver patient care, but also a shift in attitude and direction in leadership, teamwork, communication and patient education.

The multidisciplinary heart team concept has existed for decades in heart transplant and ventricular assist device programs. It more recently was popularized for the treatment of coronary artery disease by studies such as the SYNTAX trial, where input from an interventional cardiologist and a cardiac surgeon were required to determine suitability for enrollment in the trial (N Engl J Med 2009;360:961-972). This allowed for collaboration between physicians who offer different interventional approaches for the same disease to determine the best treatment for individual patients. 

In Europe, this approach has been expanded such that guidelines on myocardial revascularization include input from noninvasive cardiologists, and in some instances, primary care physicians, intensivists, and anesthesiologists (Eur Heart J 2010;31:2501-1555; Circ Cardiovasc Qual Outcomes 2012;[5]:410-415). The Centers for Medicare & Medicaid Services embraced this concept, mandating that patients undergoing transcatheter aortic valve replacement (TAVR) be evaluated and cared for by a multidisciplinary heart team.

The shared decision-making concept of the heart team would seem to offer advantages to both physicians and their patients, the sum of which should result in improved clinical care and better outcomes. This is especially true when it comes to developing care plans for patients with more complicated clinical issues.

However, applying the multidisciplinary concept to daily clinical practice can be logistically challenging. Surgeons, cardiologists and other personnel may have trouble finding the time to attend regularly scheduled heart team conferences. It also is not clear if and how they should be compensated for this time. If multidisciplinary clinical conferences are not held frequently enough, the decision-making process can delay therapy, which becomes clinically inefficient, not to mention frustrating to patients and their families. Furthermore, organizing clinical conferences and collecting patient data and imaging studies is a time-consuming process that requires clinical coordinators and administrative support. These resources require a large financial commitment from hospitals.  

For many hospitals, the heart team successfully exists as a “virtual” program consisting of physicians, physician assistants, coordinators, nurses, operating room and cath lab teams and other hospital personnel. They function under an umbrella of collaboration and professionalism, and the system is extremely patient focused.   

The heart team approach will continue to evolve as the need to combine our skills continues to increase. The actual form of the ideal heart team in daily practice, its logistics, organization, and financial structure, have yet to be determined. The good news is that cardiologists, cardiac surgeons and others can look forward to working together in a more collaborative role for a long time.

Dr. Cohen is a cardiothoracic surgeon at the University of Southern California in Los Angeles and chair of the Workforce on Media Relations and Communications for the Society of Thoracic Surgeons.