Debate Continues on Use of Heart Teams for High-Risk Patients with Heart Valve Disease
San Francisco, CA—Unlike the old heart team model, which often placed the geriatrician between the patient and the other members of the team, the ideal modern model should place the patient at the center of a circle consisting of the surgeon, interventional cardiologist, pulmonologist, anesthesiologist and geriatrician, argued A. Pieter Kappetein, MD, PhD, of the Erasmus University Medical Center in Rotterdam, The Netherlands, in a flash debate at TCT 2013.
In arguing against the heart team concept for decision-making, Ganesh Manoharan, MBBch, MD, said the heart team ideal is rarely implemented in real life. “There are zero data to suggest that the heart team as perceived today saves lives, and there are zero data to suggest the heart team improves patient selection or outcomes,” Manoharan said.
Heart teams are essential
Some common objections to employing a heart team model are that it is time consuming; there are already trials and guidelines to be followed; and the heart team’s deliberations may cause a delay in treatment. Kappetein dispelled those notions by pointing out the multiple interpretations that are needed in making valvular heart disease treatment decisions.
Regarding cost, Kappetein noted that in his hospital, decisions made by the heart team can lead to significant savings.
For example if the heart team comes to the conclusion that medical therapy is preferred over TAVR in one of every 30 patients, and if one in every 20 patients receives surgical AVR instead of TAVR, this leads to a total annual savings of €730,000 per year.
Heart teams are less than ideal
According to the ACCF/AATS/SCAI/STS expert consensus document on TAVR, the ideal heart team would include the patient’s primary cardiologist, a cardiac surgeon, an interventional cardiologist, an echocardiographer, imaging specialists, a cardiac anesthesiologist, a nurse practitioner and cardiac rehabilitation specialists. Manoharan said an actual heart team meeting usually consists of a meeting in a cath lab between one cardiologist and one surgeon in between cases; there is no record of the meeting; no anesthesiologist is present, and the surgeon assumes the role of “Gatekeeper.”
“I believe the heart team should not be used as a regulatory tick-box but as a true forum for open, frank discussion on patient care and for continued learning,” Manoharan said. In the argument between protectionism and patient safety, he reiterated, “I want to make sure the right thing happens.”
Kappetein is on the clinical trials steering committee for Abbott Vascular, Boston Scientific and Medtronic CardioVascular.
Manoharan reports no relevant conflicts of interest.