Clinical Impact of Heart Team Decisions for Patients With Complex Valvular Heart Disease: A Large, Single‐Center Experience

Abstract

Background A multidisciplinary approach might be pivotal for the management of patients with valvular heart disease (VHD), but clinical outcome data are lacking. Methods and Results At our institution, since 2014, internal guidelines recommended heart team consultations for patients with VHD. The clinical/echocardiographic characteristics, treatment recommendations, performed treatment, and early clinical outcomes of consecutive, hospitalized patients with VHD undergoing heart team evaluation were collected. Surgical risk was prospectively assessed by the EuroSCORE II and STS‐PROM. The primary end point of the study was early mortality. A total of 1004 patients with VHD with high clinical complexity (mean age, 75 years; mean EuroSCORE II, 9.4%; mean STS‐PROM, 5.6%; 48% ischemic heart disease; 29% chronic kidney disease, 9% oncologic/hematologic diseases) were enrolled. The heart team recommended an interventional treatment for 807 (80%) patients and conservative management for 197 (20%) patients. Management crossovers occurred in only 5% of patients. The recommended intervention was cardiac surgery for 230 (23%) patients, percutaneous treatment in 516 (51%) patients, and hybrid treatment in 61 (6%) patients. Early mortality occurred in 24 patients (2.4%) and was independently predicted by aortic stenosis, left ventricular ejection fraction, pulmonary artery systolic pressure, and conservative management recommendation. In patients referred to treatment, observed early mortality (1.7%) was significantly lower ( P <0.001) than expected on the bases of both the STS‐PROM (5.2%) and EuroSCORE II (9.7%). Conclusions Within the limitations of its single‐center and observational design, the present study suggests that heart team–based management of patients with complex VHD is feasible and allows referral to a wide spectrum of interventions with promising early clinical results.

Impact of severe valvular heart disease in adult congenital heart disease patients

“…As much as a quarter of patients presented at their first evaluation in our dedicated adult outpatient clinic with a severe valve dysfunction, that is expected to determine a major impact on the overall CHD hemodynamics. These patients were older, presented with more advanced NYHA functional class and more often had an underlying moderate or severe CHD, in line with recent studies reporting the increasing complexity of ACHD patients (1,(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). Moreover, patients with severe VHD were more prone to develop arrhythmias and more often required interventions/reinterventions, confirming previous observations (25)(26)(27).…”

“…From the above-mentioned database, we obtained the report of the first clinical outpatient evaluation that included complete medical history, vital signs, electrocardiogram (ECG), complete echocardiography. According to our institutional clinical pathway dedicated to ACHD patients ( 8 ), clinical assessment, ECG reading, and echocardiograms are directly performed and reported from experienced cardiologists specialized in the imaging and care of this patients’ population (FG, AD, and RL) and all patients that require an intervention are discussed in Heart Team, as previously described ( 9 ).…”

The multidisciplinary Heart Team approach for patients with cardiovascular disease: a step towards personalized medicine

“…Recently, some large studies demonstrated excellent outcomes of patients treated according to the Heart Team recommendations, 18,19 and some authors showed improved outcome of patients with CAD after the implementation of the multidisciplinary evaluation and a Heart Team program 20 . Nevertheless, previous studies focused only on CAD or HVD patients separately, so there is no information on the relative impact of the same Heart Team on different cardiac diseases 21–25 . As a consequence of available evidence, it can be assumed that the Heart Team approach is well tolerated, but it is not possible to determine whether this approach really induces a change in patient management and, if so, the magnitude of this change.…”

“…From a traditional face-to-face doctor–patient relationship, we have moved to a modern model in which the patient is now at the centre, with multiple specialists of equal importance sharing expertise and dedicated to the patient. The ‘team approach’ is therefore a reproducible model in every hospital and for every type of disease and specialty to identify the appropriate diagnosis and therapeutic strategy 16–21,25,26 …”

“…20 Nevertheless, previous studies focused only on CAD or HVD patients separately, so there is no information on the relative impact of the same Heart Team on different cardiac diseases. [21][22][23][24][25] As a consequence of available evidence, it can be assumed that the Heart Team approach is well tolerated, but it is not possible to determine whether this approach really induces a change in patient management and, if so, the magnitude of this change.…”