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Beyond calling the play: How a heart team should work
I completed my fellowship and started my first job in 2013. It was nice to finally be able to make independent decisions, but there were situations when the right answer was not initially clear, particularly in patients whose angiogram indicated disease that potentially required surgery.
Reluctant to be too aggressive, too passive or too independent, I would call a cardiothoracic surgeon and share the story of the patient on the table. More often than not, the surgeon would say, “Well, you’re there right now” or “Go ahead and fix.” So I would. It wasn’t long before I felt I was asking for permission rather than getting a real “heart team” consultation.
Scott M. Lilly
The meaning of heart team came up recently during our combined cardiology-cardiothoracic surgery conference. We were reviewing a case that involved a cardiac arrest in a patient with obstructive distal left main and right CAD, along with severe chronic obstructive pulmonary disease. A surgeon had been consulted; when risk of prolonged intubation was raised (40% based on the Society of Thoracic Surgeons score), he quickly declined surgery. In my opinion, this case was a particularly effective example of a joint approach. It was markedly different from simply calling a cardiothoracic surgeon to the cath lab, or asking for a remote review of the films.
So, how should a heart team work? Here are a few suggestions from our conference:
- The term heart team should become part of our common vocabulary — a buzzword — and it should indicate the need for a collaborative discussion about patient options.
- Whenever possible, both the cardiologist and the cardiothoracic surgeon should share their assessment and recommendations with the patient (and family) in person and at the same time.
- Consultations should include objective (guidelines, SYNTAX, STS, EuroSCORE) and subjective (frailty, rehabilitation potential) data to foster meaningful discussion and real patient-centered care.
- Shared decision-making should mean shared accountability, including in public reporting. It would be ideal if the heart team were reported as a whole, rather than separately in the cardiac cath lab and cardiothoracic surgical department.
What the heart team means and how it is comprised differ between individuals and between institutions. Establishing uniformity in heart team processes could provide an opportunity to learn about efficiencies and inefficiencies, and make achieving our goals less taxing on an already pressed schedule.
How does the heart team work at your institution? Is it a formal or informal process?
References:
Head SJ. Eur Heart J. 2013;34:2510-2518.
Holmes DR. J Am Coll Cardiol. 2013;61:903-907.