Advent of TAVR heart team ushered in new era of collaborative care
Before the emergence of the heart team in transcatheter aortic valve repair, the collaboration of an interventionalist and cardiac surgeon for the treatment of a single patient with CVD was a decidedly less common occurrence in cardiology.
Although precursors for heart team existed in the field before TAVR — the 2009 SYNTAX trial evaluating PCI and CABG in complex CAD being a foremost example — it took the early TAVR trials, and a mandate from CMS, to establish the heart team as it is known today, according to Megan Coylewright, MD, MPH, vice chief of cardiology faculty development and director of the Structural Heart Program at Erlanger Health System in Tennessee.
“In addition to the SYNTAX trial and the multidisciplinary teams that were well established in oncology, the modern day heart team in valvular heart disease was the result of the PARTNER trials and the CoreValve and Evolut valve trials,” Coylewright told Healio. “During these trials, it was mandated that an interventional cardiologist and a cardiac surgeon meet with the patient and decide together, along with other experts including imaging specialists, which strategy might be best.”
CMS decided to follow the research protocol, Coylewright said, mandating the inclusion of an interventionalist and a cardiac surgeon in its national coverage determination. “So unlike in coronary disease,“ she said, “where we rarely now use a heart team to talk about the choice of PCI and CABG, we continue to meet as a heart team to talk about the treatment for aortic stenosis because of that mandate.”
Now, more than a decade since this mandate, Coylewright spoke with Healio about how the heart team operates in practice, sharing the logistics, advantages, challenges and more.
Healio: Can you take us through the preprocedure process of the heart team? What are the necessary steps to get every team member on the same page?
Coylewright: When a patient is diagnosed with severe aortic stenosis, they are required to see both a cardiac surgeon and an interventional cardiologist in the clinic. In most centers around the country, the patient and their family do not meet with those two individuals at the same time, which is primarily a scheduling and systems of care issue, although in a few high-volume centers they do. This is relevant to speak about because a critical member of the heart team is the patient, and listening to their values and preferences around the options presented to them by the heart team is an essential part of the shared decision-making process.
Consequently, preprocedure workup is complex and there are many moving parts, including those appointments with the physicians, a cardiac catheterization and a CT; the latter is required to understand not only whether a transcatheter valve will fit well but whether the index valve will set us up for success for a future valve should it be needed. We then bring all that information back to the patient in a way they can understand and listen to their goals and preferences, which shapes the decision and is the completion of that heart team approach in the preprocedure evaluation. So there is a lot of room to innovate in that area, to study new models of care and to think about how we can be sophisticated in levels of patient engagement.
Healio: What in your experiences has been the most significant advantage of working with your surgical colleagues on TAVR?
Coylewright: An advantage that comes first to mind is how professionally gratifying it is to work in a heart team and perform the procedures together. It is just so fun to have a colleague with a different skillset, perspective and experience, and collaborate on the same procedure together, working side by side for the best possible outcome for the patient. We do not get to do that a lot in medicine, and it is a privilege. I don’t know that we will always have that mandate in place, and without it, other forces, including available time, will make it harder for us to perform all the procedures together.
Healio: What is an important lesson you have gleaned from this multidisciplinary strategy?
Coylewright: Working together in a multidisciplinary team has strengthened both fields. As an example, when we started to study TAVR in intermediate-risk patients, the surgeons began to change the way they did their procedures. They started to put in larger valves so that the performance of the valve was better immediately, there was less patient-prosthesis mismatch and the patient was set up for success with a future valve. There is a misconception that we can just fix the tissue valve later. We do have some tricks to try to expand surgical valves that are smaller, but ideally the first valve is put in with the second valve in mind.
That change in behavior, putting in less 19 mm to 21 mm valves that are too small for another valve to fit inside in the future, was the direct result of this multidisciplinary team process and the constant feedback between the two experts.
Healio: What are some of the challenges that have arisen when working as a heart team? How have you handled them?
Coylewright: One of the biggest challenges is time and personnel. Preparing for a heart team meeting takes hours and hours of work, and it is not something that we are reimbursed for, necessarily. Most heart teams around the country have relied on help from an important role called the structural heart coordinator. Typically, this is a nurse or an advanced practice provider who keeps track of a long list of patients that are in the midst of workup for aortic stenosis, and then prepares presentations so that the heart team can sit down and rapidly review 10 to 15 complex patients and make recommendations together as a group based on the key medical pieces of information. The structural heart coordinator is a very challenging job and without it we can’t talk about patients in a coordinated way. The patients we see are really complex and often have a lot of comorbid conditions. There are a lot of procedural details that need to be reviewed, so one of the biggest challenges is time and resources for the heart team.
Recently, there have been articles published in Europe pleading with stakeholders to understand the importance of investing in the structural heart coordinator role and protecting time for the team members because it is so critical to optimal outcomes.
Healio: What happens when there is a difference in opinion in terms of the most optimal or appropriate treatment strategy for a given patient? How are these differing viewpoints settled?
Coylewright: Physicians involved in the care of patients with aortic stenosis want the best outcomes possible for their patients and sometimes it is not clear that there is one right answer. A healthy debate is important when there is a lack of clarity on what is the best option, and each member of the team brings a slightly different perspective, and that strengthens the decision-making and the understanding of the available options.
In addition, it is wise to think about the complexities of group decision-making, as literature has reported on the concept of groupthink. This is when you might have dominant voices that direct the way decision-making goes, and when there is not an active process of ‘going around the table’ to ensure all voices are heard. It is important that team members listen to one another and are humble about the complexity of this decision-making. Success takes many different perspectives; and working together and having inclusive, respectful working environments where people’s voices can be heard and the expertise shared is critical.
Healio: A 2021 Canadian study published in the Journal of the American Heart Association found a decline in the utilization of the heart team for TAVR candidates. Have you found this to be the case in your practice? What trends have you observed?
Coylewright: It is important to keep in mind that the heart team is needed in many areas of valvular heart disease. We now have transcatheter mitral programs and randomized controlled trials of patients who are low-to-intermediate risk for mitral valve repair receiving either transcatheter edge-to-edge repair or surgery. This requires a heart team to meet and discuss just like we do with the aortic valve. We also have that same process in the tricuspid space, although this is a new heart team with an HF physician front and center, and they play a key role in our functional mitral repair decisions as well. So we, as interventionalists in structural heart, are on many teams. Additionally, I also co-lead a neuro-cardio team for patent foramen ovale closure.
Regarding the 2021 paper, we all have to think about how best to use our time. There are some patients for whom there is little discussion needed about the best approach, particularly as it relates to patient goals and values. As an example, for patients older than 75 years with prior CABG who have iliofemoral arteries that are a great size for TAVR, there is not a lot of discussion from the patient, family or physicians about which strategy might be best. It will likely be TAVR. So there is good reason to be selective about the cases that really need the input from these varying members of a multidisciplinary team. And as things get busier and we have more choices to make, we will need our time to be spent on the cases that are most complex, and on time with patients and families because we have never had so many choices before and many of the options will impact quality of life over quantity of life; that is where we need to understand the patient’s perspective. Since we don’t have limitless time, it does make sense to focus on the spaces where that multidisciplinary team and shared decision-making process are needed most.
Healio: Last year, you senior authored a study published in PLOS ONE concerning preferences for patients with severe aortic stenosis. What did you and your team observe?
Coylewright: The study is one of the first larger studies that took patients who are experienced in the decision-making process for valve disease and asked them, “What are you hoping for?” The No. 1 thing that mattered to them was trust in their heart team, and we have not spent enough time understanding how we earn trust from our patients, particularly from diverse populations. This is one of our future challenges as a heart team: We need to continue to work to understand how to provide equitable access to aortic valve replacement because there are big disparities in care.
That research was helpful for me to understand that we have room to go in the heart team to figure out how best to include patients and families as we move forward.
References:
- Col NF, et al. PLoS One. 2022;doi:10.1371/journal.pone.0270209.
- Marcus G, et al. J Am Heart Assoc. 2021;doi:10.1161/JAHA.120.020741.
For more information:
Megan Coylewright, MD, MPH, can be reached at megan.coylewright@erlanger.org; Twitter: @mcoylewright.
Disclosures:
Coylewright reports receiving research grants from Edwards Lifesciences and Boston Scientific; honoraria for research work from Medtronic and Aquatec; and is the editor of CardioSmart.
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