Comprehensive heart teams are rewriting the rules of patient care
Over the past decade, more and more cardiology patients have been treated by a multidisciplinary heart team. Use of the heart team approach for shared decision-making (SDM) on how to best treat and care for patients is a Class I recommendation in both the U.S. and European guidelines.[1,2]
The idea behind such an approach is to have multiple stakeholders in a patient's care meet and discuss the patient and determine the best possible way to care for them. The concept originally started to gain momentum when surgeons and interventional cardiologists were brought together to select patients during transcatheter aortic valve replacement (TAVR) trials; once specialists saw just how effective it could be, it only grew more and mor ein popularity.
The multidisciplinary team concept was originally created to select which patients were best suited for TAVR or open heart valve replacement surgery to help eliminate biases between surgeons and interventional cardiologists. These teams also often involve a cardiac imager, a nurse and a patient navigator at a minimum. They discuss the patient's health and possible next steps, similar to a tumor board. The team also pre-plans the case and work as a team during the live case. The hallmarks of the heart team include collaboration and the sharing of opinions and expertise in group decision making.
How to build a structural heart team
Many heart teams are created to deal with complex patient cases, as in structural heart programs. As TAVR continues to gain market share (about 84% of the market in 2022), more hospitals are adding structural heart teams. This takes commitment from the department and the hospital administration, explained Charles Davidson, MD, clinical chief of cardiology and medical director of the Bluhm Cardiovascular Institute and a professor of medicine at Northwestern University.
"This has to be something that hospital, physicians and administrators really want to take on, because it is going to require building a team around the program," Davidson said. "It is going to be an investment in time and finances to build a high-quality program."
You need to find a cardiac surgeon and interventional cardiologist who are willing to work together for the common goal of how top best meet the patient's needs, he added. They may decide that surgery is the best option, for example, or they may go with a catheter-based procedure or medical therapy.
"Those people have to be able to work together in lockstep and be able to discuss things in an open forum and decide what is best for that patient, because it is not one-size-fits-all," Davidson explained.
Beyond the cardiologists, Davidson said that other critical members of any structural heart team are radiologists and cardiac imagers, for the CT and MRI, and an echocardiographer who can perform live transesophageal echocardiogram (TEE) imaging in the cath lab or hybrid OR. Beyond that, the team also should include nurses, research coordinators if involved in trials, schedulers, and clinic operations.
"All of that is needed from the day the patient calls in to set up an appointment to procedure time, because there are a lot of touches that occur there, and they need to occur efficiently to build a strong program," Davidson said.
At Northwestern, these teams also include patient navigators who act as liaisons between the patient and their caregivers. This frees up the clinical staff to care for patients rather than making calls, scheduling and doing a lot of leg work.
"We learned early on we don't want to have the nurses doing all the scheduling for the patient's imaging tests ... I want people to work at the top of their license, so I want nurses taking care of patients and I want physicians doing their patient care work. I don't want them involved in a lot of the logistics that take up so much of their time," Davidson explained.
He also pointed out that these teams rely heavily on nurse practitioners, starting with the intake of the patient all the way through to post-procedure follow-ups.
Davidson outlined 4 basics of what hospitals need to consider starting a new structural heart program:
1. Champion interventional cardiologists and cardiac surgeons who can work together as a team and share decision making for what is best for the patient.
2. Interventional imagers who can work as a key part of the team for pre-procedural evaluations and guide imaging during procedures. This is usually a dedicated interventional echocardiographer. Imagers who can review pre-planning CT for measurements and assessments of anatomy are also key.
3. A support team that includes nurses trained in TAVR, patient navigators and other support staff to coordinate scheduling and guide the patient through their care journey. This helps coordinate all of the moving parts and frees up the physicians and other clinicians to concentrate on procedures and clinical decision making rather than the large amount of non-clinical work involved.
4. A hybrid cath lab that is rated for open surgical procedures is ideal. This is in case there is need for conversion to open procedures or surgical access for transapical or other alternative access routes. The larger rooms are also needed for the addition of extra staff and equipment for peri-procedural imaging, anesthesia and additional tables for prep and staging.
Davidson's structural heart team has been involved in TAVR since the start of U.S. trials for these devices more than 15 years ago. The Northwestern program has now expanded to transcatheter repair and replacement of all four valves in the heart, as well as other types of structural heart interventions, and is seen as a leader in this space.
Northwestern Medicine also expanded access to TAVR and other interventions to its satellite suburban hospitals as the health system expanded over the past decade, purchasing several other hospitals in the Chicago region. These hospitals refer the more complex cases to the Bluhm Cardiovascular Institute in downtown Chicago.
Example of an interventional echocardiographer manipulating a transesophageal echo (TEE) probe to help guide a structural heart procedure. Communication between the interventional imager and the interventional cardiologists is key to understanding what is seen in the images. Image courtesy of GE Healthcare
Interventional imaging requirements for a heart team
Cardiac imaging specialists are very important to the success of structural heart teams, especially with intraprocedural guidance of TEE.
"You really need a dedicated interventional echocardiographer who can help during structural heart procedures. They need to be specialized. We have 18 echocardiographers, but really only two of them do interventional echo. They are critical to the procedures, because otherwise I cannot see what I am doing," Davidson said.
He said TAVR cases today now largely use transthoracic echo, but TEE is still essential for growing numbers of mitral and tricuspid procedures. These imagers play a key role in decision making in those cases so it is important that they have a seat in the heart team meetings.
"The interventional imager is now a very integral part of the heart team, and it is not just the intraprocedural guidance anymore, it is really the entire pathway of the patient," Rebecca T. Hahn, MD, a professor of medicine at Columbia University Irving Medical Center and director of interventional echocardiography at the Columbia Structural Heart and Valve Center, said. "The imager is the one who is actually guiding the procedure, so it becomes and essential part of the team and an integral part for technical success of these devices," she said.
Imaging also plays a key role in none-structural heart decision making, and all the people interviewed said they should be included on other patient care teams. The heart team concept is already implemented at many centers for heart failure, coronary artery revascularization and high-risk pregnancy.
Building a cardiology department-wide heart team approach to care
The new Institute for Cardiovascular Health in Austin, Texas, hopes to build a world-class cardiology program using a department-wide heart team approach. The cardiac center is a collaboration between Ascension Texas and the University of Texas at Austin and its Dell Medical School.
"Despite the enormous amount of money we spend on in this country on cardiovascular disease, there are some pretty sobering statistics," said Charles D. Fraser, Jr., MD, the institute's executive director. "Life expectancy for males is actually down the past couple of years, cardiovascular disease is still the number one killer in our country, yet we spend more and more and more and the United States does not compare favorably if we look at our peers around the world. So there is no question that the proposition of how we do business needs a shake-up."
Instead of doing the same thing hospitals have always done, Fraser said he and his team decided to build on the success of the collaborative heart team approach and make it a universal approach to all cardiac patients.
"What we are building is a fully integrated program where we coalesced all the elements of cardiovascular care, administration, facilities, research personnel, and educational programs all in one place," he explained. "We wanted to get everyone on the same team and stating a common vision and then working cohesively to feed that vision."
These pieces of the puzzle all existed before, but there was not an entity to combine these elements, so cardiac care took place in disparate silos where there were not always easy handoffs in care, or one physician did not have all the information on another aspect of the patient's care.
"We already started doing this at Dell Children's Hospital, and I have never worked at a place where every patient, every single day, is reviewed by the entirety of the heart program. And every member of the team had someone valuable to contribute to the proposition. It also provides a basis for everyone to better understand the care continuum," Fraser said.
Outside of the patients in the hospital, he said this approach should be considered for the life-long care of a patient. As a cardiovascular surgeon, he said he meets some patients when they are a fetus and has followed many of them for decades through their continued need for cardiac care.
Heart team concept moving to the rest of cardiovascular medicine
The collaboration of heart teams forged by TAVR were found to benefit patients, improve outcomes and help in care transitions. That model is now being adopted across some cardiology departments as a standard of care. This care team concept is now used across some cardiology departments today because of the improvement in care delivery seen with TAVR patients. Similar multidisciplinary acute care teams also have evolved out of the heart team idea for stroke teams, pulmonary embolism response teams (PERT), aortic dissection and aneurism care teams and heart failure care teams.
Beaumont Hospital was an early adopter of the PERT team concept, which includes in includes team members from interventional radiology, interventional cardiology, radiology and neurology, explained Terry Bowers, MD, director of vascular medicine at Beaumont, and national co-chair of the Pulmonary Embolism Research Collaborative (PERC). He said there is now a national trend toward creating PE response teams that include cardiology.
"More and more hospitals are coming together and saying we are partners in this," Bowers said. "In regards to interventional radiology and interventional cardiology, it's not one discipline's disease that needs to be hand selected for them only. At our institution, we have a cohesive team that spans from cardiology, radiology and emergency medicine, and we all play an integral role in in the team."
Bowers said this has improved care, reducing the historical mortality rate of between 8%-14% for intermediate and high-risk PE patients, down to 1.3% in-hospital mortality, and 1.6% discharged mortality at 30 days.
"We have a PERT interventional call now, that has a correlation to the STEMI call, and frankly we see as many pulmonary embolism escalation cases now as we do STEMI cases coming through the door," Bowers explained.
The recent landmark BEST-CLI trial at the 2022 American Heart Association (AHA) meeting compared surgery vs. interventional revasculaization in critical limb ischemia patients and used a heart team approach, with close collaboration between vascular surgeons and interventional radiologists and cardiologists. The principle investigators of the trial said it is likely that vascular team approach will see wider adoption in the years ahead.
Is TAVR's greatest legacy the development of the heart team?
TAVR pioneer and cardiac surgeon Michael Mack, MD, chairman of the cardiovascular service line at Baylor, Scott, White Health, believes that TAVR has led to a paradigm shift in how cardiac patients are treated. But, he added, the even bigger legacy of TAVR is the creation of the heart team approach.
"As big as a game-changer as TAVR has been, I think the heart team concept might be an even bigger legacy that has happened out of all of this," Mack said. "I don't know who named the PARTNER Trial, but they were prophetic in a way. It's such a great name, because that is the way things have developed."
Indeed, heart teams are now seen in all aspects of cardiology, from complex cardiac surgeries to state-of-the-art interventional procedures.
Links to Sources for Building and Maintaining a Heart Team:
The Truly Functional Heart Team: The Devil Is in the Details — Journal of the American Heart Association
The Heart Team: Getting a Complete Picture - Columbia University Department of Medicine
Collaborative Cardiac Care: A Comprehensive Heart Team Approach to Multiple Severe Vascular Conditions – Journal of the American College of Cardiology
Making Heart Team Discussions Work – Structural Heart Journal of the Heart Team
Purposeful Interprofessional Team Intervention Improves Relational Coordination Among Advanced Heart Failure Care Teams – Journal of Interprofessional Care
The Heart Team Expands – Structural Heart Journal of the Heart Team
Getting the best from the Heart Team: guidance for cardiac multidisciplinary meetings, Guideline or consensus statement - Heart, British Medical Journal
Approaches to the Role of The Heart Team in Therapeutic Decision Making for Heart Valve Disease – Structural Heart Journal of the Heart Team
Comparison of Heart Team vs Interventional Cardiologist Recommendations for the Treatment of Patients With Multivessel Coronary Artery Disease – Journal of the American Medical Association
The Heart Team: Where did it Come from and Where is it Going – Structural Heart Journal of the Heart Team
The Impact of a Dedicated Chronic Total Occlusion PCI Program on Heart Team Decision Making – Journal of Invasive Cardiology
Creating a Multidisciplinary Pregnancy Heart Team - Current Treatment Options in Cardiovascular Medicine
Multidisciplinary Heart Team Approach for Complex Coronary Artery Disease: Single Center Clinical Presentation – Journal of the American Heart Association
Teamwork and Speed Bumps – Structural Heart Journal of the Heart Team
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com