Is the Heart Team Concept Waning in TAVI?

Use of the TAVI heart team, defined as preprocedural consultations by a cardiac surgeon and an interventional cardiologist, has declined over the past decade in Canada, according to new administrative data. Notably, though, the procedural team still includes both specialists almost all of the time and treatment allocation didn’t seem to be affected by how patients were assessed.

The findings speak to the evolution of TAVI from a once-novel procedure intended for only inoperable patients or those at high-risk for surgery to one that today is commonly done for lower-risk patients, senior author Harindra Wijeysundera, MD, PhD (Sunnybrook Health Sciences Centre, Toronto, Canada), told TCTMD. “The fact that there is a cardiac surgeon and a cardiologist involved in every case, when we don't have a rule that there must be, speaks to the fact that there's a signal that collaboration is happening,” he said. “The fact that it looks like people have evolved to a point that they don't have to see a patient in person but trust their team, and [that] decisions are being made consistently over time, is also a positive statement.”

Wijeysundera stressed that the findings do not suggest that a heart team is no longer necessary, but rather show that practice has changed—certain patients are straightforward enough that both a surgeon and a cardiologist don’t need to spend the time to evaluate them individually.

Notably, while Canadian TAVI centers are required as a quality metric to staff both surgeons and cardiologists, these specialists are not mandated to participate in each case, as is the requirement for reimbursement in the United States.

The theme of collaboration doesn't have a set model. Harindra Wijeysundera

Commenting on the study for TCTMD, Thierry Mesana, MD, PhD (University of Ottawa Heart Institute, Canada), acknowledged that while there was once a perceived “turf war” between some surgeons and cardiologists when TAVI was first introduced, that has largely settled over time, especially with so many surgeons going for training in the transcatheter approach.

“I think it's probably better than what it was in the beginning, but I believe that there are still a lot of centers that are not really working in this heart team concept with the sprit that is ideal,” he said. “The best model is to have both of them working together, so you just eliminate the concept of war and competition. They just work together.”

Temporal Changes

For the study, published online this week in the Journal of the American Heart Association, Gil Marcus, MD (Sunnybrook Health Sciences Centre), Wijeysundera, and colleagues looked at billing data for 10,412 patients who were evaluated for TAVI in Ontario, Canada, between April 2012 and March 2019. Overall, 52.7% of patients were evaluated by both a surgeon and cardiologist preprocedure, with individual hospital rates ranging from 35.2% to 77.0%. A total of 5,747 patients ended up undergoing TAVI.

Heart team use declined from 69.9% in 2012 to 41.1% in 2018. On multivariate analysis, older patients (OR 0.97 per each year increase; 95% CI 0.96-0.97) and those with a greater burden of comorbidities were less likely to be evaluated by both specialists, likely because their cases were more straightforward, Wijeysundera said. Also, while larger hospitals were more likely to have a heart team in place (OR 1.12 for each increase of 50 beds; 95% CI 1.06-1.16), those with higher case volumes were less likely to use a heart team assessment (OR 0.81 per each increase of 100 TAVIs done; 95% CI 0.68-0.96).

The researchers noted a strong temporal impact, with patients in 2018 being 80% less likely to have a heart team approach than those in 2012 even after adjustment for baseline differences (OR 0.20; 95% CI 0.16-0.26).

Among the patients who underwent TAVI, 94.9% had both a cardiac surgeon and interventional cardiologist present during their procedure. Also, while patients who were assessed by a heart team were more likely to undergo an invasive approach—TAVI or surgery—there was no relationship identified between heart team use and treatment allocation even after adjustment (P = 0.93).

The heart team inevitably needs to shift as the procedure becomes more engrained in the field, write Marcus and colleagues. “We would argue that this does not reflect inappropriate care, as the allocation of treatments has not been impacted. Instead, it represents more efficient use of human resources to activate a heart team only in those cases where it is likely to impact care decisions.”

Changing Culture

“The heart team has become part of our culture, and that's great and that's important, but we mustn't be afraid to look at the evidence using scientific techniques to see: How can we improve? What has changed? And has it changed for the better or worse?” Wijeysundera said.

To argue in favor of greater or lesser heart team assessment is really dependent on clinical culture, he continued. “Our team consists of two cardiac surgeons who are TAVI trained and two interventional cardiologists who are TAVI trained, and every case is done by a combination of those two. We feel that it's critical for decision-making and it's critical for the procedure [as well as] ensuring that we have all of the people in the room to take care of essentially every contingency that could happen.”

Ultimately, “the theme of collaboration doesn't have a set model,” Wijeysundera said, and every institution is going to incorporate it differently.

Have both of them working together, so you just eliminate the concept of war and competition. Thierry Mesana

For Mesana, the main message is that “if you have aortic stenosis, [you have] to see a TAVI specialist—who can be a surgeon or a cardiologist. Both in any case are members of the heart team who discuss the strategies and the indications and the triage of this patient up front, but there is no need to see them in sequence or together.” This model only works for established centers, he noted, adding that new centers should have both a surgeon and a cardiologist working in tandem for every procedure.

The heart team concept is bigger, though, than simply the surgeon and the cardiologist, as it includes anesthesiologists, physical therapists, nutritional staff, and a variety of other players. At the end of the day, he stressed, this larger team approach is going to be the one that ensures the quality of care patients receive.