Multidisciplinary Heart Team Approach for Complex Coronary Artery Disease: Single Center Clinical Presentation

Abstract

Background The Heart Team approach is ascribed a Class I recommendation in contemporary guidelines for revascularization of complex coronary artery disease. However, limited data are available regarding the decision‐making and outcomes of patients based on this strategy. Methods and Results One hundred sixty‐six high‐risk coronary artery disease patients underwent Heart Team evaluation at a single institution between January 2015 and November 2018. We prospectively collected data on demographics, symptoms, Society of Thoracic Surgeons Predicted Risk of Mortality/Synergy Between PCI with Taxus and Cardiac Surgery ( STS ‐ PROM / SYNTAX ) scores, mode of revascularization, and outcomes. Mean age was 70.0 years; 122 (73.5%) patients were male. Prevalent comorbidities included diabetes mellitus (51.8%), peripheral artery disease (38.6%), atrial fibrillation (27.1%), end‐stage renal disease on dialysis (13.3%), and chronic obstructive pulmonary disease (21.7%). Eighty‐seven (52.4%) patients had New York Heart Association III ‐ IV and 112 (67.5%) had Canadian Cardiovascular Society III ‐ IV symptomatology. Sixty‐seven (40.4%) patients had left main and 118 (71.1%) had 3‐vessel coronary artery disease. The median STS ‐ PROM was 3.6% (interquartile range 1.9, 8.0) and SYNTAX score was 26 (interquartile range 20, 34). The median number of physicians per Heart Team meeting was 6 (interquartile range 5, 8). Seventy‐nine (47.6%) and 49 (29.5%) patients underwent percutaneous coronary intervention and coronary artery bypass grafting, respectively. With increasing STS ‐ PROM (low, intermediate, high operative risk), coronary artery bypass graft was performed less often (47.9%, 18.5%, 15.2%) and optimal medical therapy was recommended more often (11.3%, 18.5%, 30.3%). There were no trends in recommendation for coronary artery bypass graft, percutaneous coronary intervention, or optimal medical therapy by SYNTAX score tertiles. In‐hospital and 30‐day mortality was 3.9% and 4.8%, respectively. Conclusions Integrating a multidisciplinary Heart Team into institutional practice is feasible and provides a formalized approach to evaluating complex coronary artery disease patients. The comprehensive assessment of surgical, anatomical, and other risk scores using a decision aid may guide appropriate, evidence‐based management within this team‐based construct.

SCAI position statement on optimal percutaneous coronary interventional therapy for complex coronary artery disease

“…[15][16][17] Recent evidence further shows that utilizing a structured heart team form and a formal interventional cardiology consultative service can improve the operation of a CAD heart team. 18 Therefore, the use of the CAD heart team is encouraged for guiding revascularization decision-making for patients with complex CAD.…”

“…26 This score, which can be used in conjunction with a multidisciplinary heart team approach, may provide a highly evidence-based approach to determine the relative merits of PCI, CABG, hybrid strategies, or medical therapy in patients with multivessel disease. 18 Patients with multivessel or LM coronary disease declined for car- 3.3.3 | Acute coronary syndromes PCI reduces morbidity and mortality in acute coronary syndromes (ACS), in patients with or without ST-segment elevation. 28,29 Minimizing the time to reperfusion is critical in STEMI and requires coordinated transfer systems and early activation of the cardiac catheterization laboratory.…”

“…Moreover, a heart team approach may provide better outcomes, as suggested by favorable outcomes in the registry arms of randomized controlled trials and routine clinical practice 15‐17 . Recent evidence further shows that utilizing a structured heart team form and a formal interventional cardiology consultative service can improve the operation of a CAD heart team 18 . Therefore, the use of the CAD heart team is encouraged for guiding revascularization decision‐making for patients with complex CAD.…”

“…The SYNTAX II score was created to help define the optimal revascularization strategy (CABG vs. PCI) for individual patients based on coronary anatomy and select comorbidities 26 . This score, which can be used in conjunction with a multidisciplinary heart team approach, may provide a highly evidence‐based approach to determine the relative merits of PCI, CABG, hybrid strategies, or medical therapy in patients with multivessel disease 18 …”

An economic evaluation of an advanced video conferencing system for cardiac multidisciplinary team meetings

“…Although this is retrospective data, it highlights that remote MDT’s can be highly effective. The number and type of cases discussed in the remote MDT was similar to other cardiac networks 8–10 …”