Dr. William Wijns,
Interventionist William Wijns and surgeon Philippe Kolh support the concept of the heart team.
THE LEVEL OF CARE in medicine can be improved and made more consistent with the use of multidisciplinary teams to recommend the most optimal treatment. For example, pretreatment multidisciplinary discussion in tumour boards, introduced as early as the 1960s, has been shown to improve survival and to reduce hospital-variations in rates.
Multidisciplinary heart teams have been developed for the treatment of heart failure, congenital heart disease, aortic and mitral valve interventions, and myocardial revascularisation. The creation of a heart team, consisting of a clinical or non-invasive cardiologist, an interventional cardiologist and a cardiac surgeon, serves the purpose of a balanced multidisciplinary decision process. Additional input may be needed from general practitioners, anaesthesiologists, geriatricians, intensivists, or other specialists involved with the care of the patient (‘extended’ heart team).1In the field of myocardial revascularisation (MR), while decision-making for patients with acute indications or less complex CAD may be straightforward, European and American guidelines strongly advocate the implementation of heart team decisions for patients with stable and complex CAD as class of recommendation I (level of evidence C).2,3 Meetings of the heart team should be organised according to local needs: heart team discussions may be scheduled daily, weekly, or at various intervals, as suitable.
The benefit a heart team decision is convincingly presented throughout the literature. Interestingly, some studies have shown that re-discussing the same patients after one year leads to different discussions in about 25% of the cases.4 This underscores the fact that, in some CAD patients, both treatment modalities – PCI or CABG – might be appropriate. Also, including other clinical specialists into this conference might lead to a significant proportion of treatment recommendations other than MR (eg, medical therapy, heart transplantation, ventricular assist device, or valve surgery).
Despite being strongly recommended in the guidelines, the heart team concept has probably not been yet sufficiently implemented. As an example, the OECD (Organization for Economy Cooperation and Development) reports an average rate of 218 coronary revascularisation procedures per 100,000 population, with an average PCI proportion of 72% performed in 2013.5 There is, however, a high variation in these figures across countries, which may partly be the consequence of physician-related factors - and these have raised concerns about overuse, underuse and inappropriate selection of revascularisation.
Heart teams can initiate patient discussions using the treatment algorithms as outlined in the guidelines - however, as doctors, clinical decision making typically requires a more comprehensive understanding of the unique characteristics of the individual patient. For patient-focused care, each specialty needs to hear the other colleague’s viewpoint. When this fails to happen, we need to remain cognizant of the fact that it is the patient who ultimately loses from dysfunctional interactions - market share is not the issue. And remember that cardiologists and cardiac surgeons are on the same team – the Heart Team.
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