As TAVI Turns 20, How Has the Heart Team Evolved?

Nearly two decades after the Heart Team first became entwined with transcatheter aortic valve procedures, cardiologists and surgeons today say these formalized discussions remain a pivotal part of patient care beyond aortic stenosis, yet they also point to plenty of room for improvement.

With roots in TAVI, which celebrated its 20th anniversary last month, the formalized Heart Team was borne out of the need for a patient to be seen by both an interventional cardiologist and a surgeon in order for the procedure to be reimbursed. Over the years, each hospital adapted the concept to meet its needs, with some planning weekly meetings to discuss cases, often bringing in other care team members and even the referring physicians and patient, as well.

{Aortic Valve Replacement: Can Choices Be Conveyed to Patients? VIDEO WILL APPEAR HERE}

More recent research indicated that, as processes have become more standardized, the Heart Team concept might be waning for TAVI, which is now available for patients at low-risk for surgery. But experts who collaborated on new UK recommendations say other complex areas of cardiovascular care like mitral and tricuspid valve disease and complex coronary disease, as well as endocarditis, also benefit from multidisciplinary discussions. They also home in on what has been working well and what might need adjusting in order to reach optimal care.

Senior writing committee author Simon Ray, MD (Manchester University Hospitals NHS Foundation Trust, England), told TCTMD the position paper, published last month in Heart, had two goals in mind.

If we're not trying to be aspirational in this document, there's little point in actually putting it out. Simon Ray

“First, we're trying to strengthen the Heart Team and the role of the Heart Team in decision-making and to emphasize that this is really important and has to be an absolutely central part of the care that any cardiac unit is delivering,” said Ray, past president of the British Cardiovascular Society (BCS). “And I suppose linked to that is that for those institutions and for those individuals who are perhaps a bit more skeptical, I think the real message is that the decision making has to be in the best interests of the patients and not in the best interest of any clinician or institution.”

Every clinician has their own “settled biases,” Ray continued. “We all like to think that what we do is a superior technique, but we just need to encourage everybody to take a little bit of a step back and look at what is the best treatment pathway for the individual patient that you've got in front of you, taking into account all the aspects of their pathology and their circumstances, and then make the very the best decision along those lines rather than necessarily what you as an individual can provide.”

New Guidance

The biggest change the Heart Team process has undergone in the past several years, at least in the UK, Ray said, is that while patients used to be referred by a cardiologist directly to a surgeon or interventional cardiologist, now patients are routed through a pathway in which they see and are discussed by both from the outset. “Now, I think the concept of the Heart Team is present in every interventional center to some degree,” he said. “It was more a philosophical change.”

Representatives from the BCS plus the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS), Association for Cardiothoracic Anaesthesia & Critical Care (ACTACC), British Heart Valve Society (BVHS), and British Cardiovascular Intervention Society (BCIS) all participated in the new document, which is an update the 2015 joint British Societies recommendations on multidisciplinary meetings (MDMs).

The document details best practices for discussions of myocardial revascularization, aortic valve disease, mitral and tricuspid valve disease, and endocarditis, including who should participate as well as what data should be presented at a minimum. It also defines the difference between the Heart Team and an MDM, with the latter being a structured, documented meeting of Heart Team members “convened for the purpose of reaching a consensus on the optimal management of a particular patient.”

Of note, for aortic stenosis patients in whom either TAVI or SAVR appears to be the best option, the paper recommends that only a quick summary of the patient be presented in the MDM, with full case reviews only being done for those in whom the benefits of two procedures appear equal or uncertain.

Ray said their new paper has already been criticized for being “unrealistic” in its suggestions for how multidisciplinary discussions and meetings should be run. “That's absolutely fair,” he said. “But I also think it misses the point a bit because if we're not trying to be aspirational in this document, there's little point in actually putting it out. What we're describing is what we think models should be aiming towards rather than necessarily what we can expect people to be doing tomorrow.”

Beyond the UK

In an editorial accompanying the paper, Brian Lindman, MD, and Kashish Goel, MBBS (Vanderbilt University Medical Center, Nashville, TN), outline several reasons for why some of the guidance it puts forth wouldn’t work in the United States. “Most patients in the USA would not be preemptively triaged to a ‘surgery clinic’ versus ‘TAVI clinic’; they would be seen in a joint clinic (or at least seen by valve experts from surgery and cardiology in separate clinics) to discuss the different options (risks vs benefits, knowns vs unknowns of each),” they write, adding that many low- and intermediate-risk patients will opt for TAVI following a shared decision-making process.

Also, the editorialists explain, patients with mitral and tricuspid disease are treated differently in the US than in the UK. British guidelines, for example, only recommend transcatheter edge-to-edge repair (TEER) for secondary MR if the patient is not suitable for surgery, while US guidelines favor TEER over surgery. “While an interventional cardiologist with experience in TEER may not be a core member of the Heart Team meeting for mitral and tricuspid valve disease in Britain, he or she would certainly be in the USA,” Lindman and Goel write.

Similarly, Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, NY), told TCTMD that the UK system of routing all patients through an MDM process will be hard to replicate in the US “where patients identify very strongly with their individual treating physicians.” Patient choice, while taken into consideration by the guidance document, is also incorporated differently, he said. “It's just the way that it's formalized might vary based upon institution to institution.”

Current Heart Team Practices

Certainly Heart Team practices differ according to institutional volume, expertise, and setting—academic or community. But all of the physicians who spoke with TCTMD for this story said their hospital or practice has some standard process in place for multidisciplinary discussion.

Kendra Grubb, MD (Emory University, Atlanta, GA), said that every patient that comes into their structural heart clinic is first seen by both an interventional cardiologist and a cardiac surgeon. “So they're seeing kind of a mini Heart Team even the first time they meet us,” she explained. Those patients’ cases are also presented at a weekly Monday morning meeting that usually lasts about 2 hours. “We review every case for the week that's already scheduled and make sure that there's consensus across the entire group, as well as we discuss in depth those patients who are more complex and may need additional studies or thought behind what is the best treatment,” she explained. “With TAVR being a mature technology, I don't think we need to necessarily do a deep dive on every single TAVR patient.”

Grubb said her team has also begun experimenting with an endocarditis team over the past 6 months. “We were struggling to get these patients through the system and out of the hospital,” she said. “They end up being admitted to the cardiac surgery service, but they have a tremendous amount of other medical issues. . . . It's just rethinking how the patients come through this system.”

With TAVR being a mature technology, I don't think we need to necessarily do a deep dive on every single TAVR patient. Kendra Grubb

Harindra Wijeysundera, MD, PhD (Sunnybrook Health Sciences Centre, Toronto, Canada), said his hospital holds a twice weekly, hour-long coronary Heart Team that discusses “all cases that fall in the gray zone or that should be surgical.” With 15-20 people usually in attendance, the meeting is co-chaired by an interventional cardiologist and a cardiac surgeon. “It's a fairly standard process—history is provided, imaging is reviewed, investigations are reviewed, discussions ensue, decision is documented and then circulated to the larger group,” he said. Ad hoc “huddles” are also done for emergent cases.

While most structural valve procedures are discussed in these twice-weekly meetings, TAVI cases are reviewed in a separate Heart Team rounds “just with the TAVI team, which is two nurse practitioners, four cardiologists, and two to three cardiac surgeons,” he explained. Mitral and tricuspid rounds happen biweekly, and while Sunnybrook also has an endocarditis team, it meets on an as-needed basis.

Aaron Kime, MD (Cardiac Surgery Associates, Elmhurst, IL), who works in a community hospital setting, told TCTMD that each of the two TAVI groups that rotate at the hospital he covers hold a weekly, 30- to 45-minute Heart Team meeting that includes him or another surgeon on-call.

Kime said he finds these meetings beneficial because “they take some of the bias out of the process. They certainly get the patients the best care as opposed to a patient seeing a cardiologist and just getting blindly routed for TAVR because that's the cardiologist's feeling or they end up in a surgeon's office and therefore, they go for surgery.”

Similarly, Adam Banks, MD (Presbyterian Heart Group, Albuquerque, NM), said his group holds an hour-long Wednesday afternoon meeting to discuss “a mix of aortic valve cases, mitral valve cases, sometimes just confusing endocarditis cases, and sometimes advanced heart failure cases.” Additionally, those involved in TAVI cases meet separately on Thursdays.

Compared with his experience while training at an academic institution, Banks said he’s noticed over the past 10 months in his current role that general cardiologists are included more in MDMs than he had seen before. “Part of that is that since, obviously, we have fewer people here, we're not as specialized,” he said. “We’re seeing a mix of patients, so I think those conferences almost become more important because you bring these patients that you may not have quite as much expertise in. So everybody can talk about them, make a good decision, and also at times . . . [decide which] patients need to be referred to other centers that have certain capabilities that we may not have.”

COVID’s Effects

While the Heart Team has evolved on its own, the COVID-19 pandemic altered the development of MDMs in specific ways.

“Our ability to have virtual meetings prior to February 2020 was just about zero,” Ray said. “And within the space of about a fortnight, everybody had Microsoft Teams.” Virtual meetings have had the added benefit of permitting clinicians from other institutions can dial in and contribute expertise, he noted.

The pandemic also strengthened the dialogue among cardiologists, surgeons, and intensivists in many institutions “simply because it imposed a really challenging set of realities on us,” he added. “I do hope that that will have a legacy.”

We’re seeing a mix of patients, so I think those conferences almost become more important because you bring these patients that you may not have quite as much expertise in. Adam Banks

Banks said that most of their Heart Team meetings are still virtual, although people are starting to want to go back to in-person discussions. Grubb said although they used Zoom prepandemic to connect three different hospitals, “more people utilize it now that we've come through COVID, because it allowed for more people to be involved without having to drive to a specific institution.”

Another big change for Grubb was an increased use of telehealth. “There's nothing that's going to, in my mind, be as good as face-to-face contact with the patient and their family—that patient-physician relationship I think is just so important—but knowing that our hospitals still had high numbers of COVID patients, having the ability to care for them via telehealth, at least for an initial visit and the early consultation helped us to be able to continue to care for these patients,” she said. “And now it’s just part of our system.”

Who’s Paying for This Time?

Back when the Heart Team concept was in its infancy, reimbursement for the time invested was a key concern. And in many parts of the world, that’s remained elusive. While the UK and Canada have healthcare systems that can better account for clinician time spent outside of patient visits, US physicians are not directly reimbursed for their time spent in MDMs. Some salaried physicians might be encouraged by their institution to participate, but others that are RVU-based might suffer an opportunity cost to attend.

Still, Ray said, “it would be absolutely wrong of me to pretend [the issue of reimbursement] has been universally solved in the UK. It hasn't.” But with increased recognition that MDMs are important for patient care and “absolutely essential” to the integrity of a good program, he added, “there has to be an expectation that all the key clinicians involved in the care of these patients have to have time set aside to take part in these meetings.”

Grubb said she is not paid for her time spent in Heart Team meetings directly, but that “we all think of it as just part of the patient's care,” even if most people would prefer to be reimbursed for it. As a salaried employee, Grubb said she’s “lucky” in that she can spend her time making sure patients get optimal care. “If I was RVU-based and every hour of my day I was expected to have RVUs and be very productive, I think my opinion would be very different,” she added.

Banks explained that though he doesn’t get any additional pay for attending Heart Team meetings, “it was pretty generous and showed that the hospital was committed to it that they were willing to block the clinic schedules.” He’s in a salaried position now, but after 2 years will be eligible for an RVU-based bonus. At that point, attending a Heart Team meeting might affect his bonus “a little bit [because] you're giving up an opportunity to make RVUs in clinic by giving up a couple patients, but it's pretty minimal. And I think everybody's been fine with that.”

Tension Between Surgeons, Cardiologists

In the early days of TAVI, tension simmered between interventional cardiologists, who were carving out something new with novel technology, and cardiac surgeons, worried that patients attracted to the idea of a less-invasive procedure might be exposed to something risky and lacking durability.

Asked whether any of that friction lingers, cardiac surgeon Gilbert Tang, MD (Mount Sinai Hospital, New York, NY), called it “a very complex question.”

“It really depends on the Heart Team's dynamics and the relationship between the cardiologist and the surgeon,” he said. “Some have been very collaborative, and some have been unfortunately less so.”

Today, he continued, cardiac surgeons are still threatened by lost volume not only due to novel procedures but also patient preference. “That can create potential animosity between the surgeon and the cardiologist,” Tang said, adding that surgeons ready to embrace the new technology can find it complementary to their surgical practice.

Kime said in his experience, Heart Team meetings are “pretty collegial.” Ultimately surgeons benefit from robust TAVI programs, he said, because “you serve as a magnet for the community, and the community refers patients, and not all of those people are appropriate TAVR candidates. There are a number of those people that end up having surgical aortic valve replacement.”

From his perspective, Ray said some tension remains, but it is “a lot less” than in the past. “I think that is because there is a growing recognition . . . that we can't be seen as two competing tribes here,” he explained. “We have to be seen as being part of an overall service for a disease entity.”

Newer-generation surgeons and cardiologists have “grown up with this process,” he continued, and are more likely to embrace it going forward.

The fact that the people who attend these rounds—and a lot of people attend them, every surgeon is there—means that they believe in the process. Harindra Wijeysundera

Banks, who graduated fellowship in 2021, has only noticed “very minimal” tension in both his community and academic realms. “Right now, we're just so busy with cardiac patients that, to me at least, there seems to be very little competition,” he said. “There might be some small disagreements about what the right thing is to do, and sometimes, honestly, it's just a situation where probably both options might be right for the patient. It's just a matter of making a decision.”

Grubb, who described herself as being protected by a “bit of a bubble,” said she hasn’t noticed any tension because all of the cardiac surgeons and interventional cardiologists who work in structural heart have carved out their own team. “We all win when a patient gets good care, and as long as we're all aligned with that, we don't have these ‘cardiac surgery versus cardiology’ problems,” she said.

She still hears rumblings of more animosity in community settings, where no clearly defined team with a common goal exists. “We really need to get away from that. We need to focus on the individual patient and what's going to be best for that patient,” she said. “When you have these defined Heart Teams, their results speak for themselves and that should encourage these programs that haven't gotten on board for that to press for a true Heart Team.”

At this point, Kirtane said he really doesn’t see too much friction between surgeons and cardiologists. Certain issues may escalate on social media, as it did with EXCEL, he added, but “that doesn't really happen in the hospitals. In the hospitals, these groups get along very, very well.”

Ultimately, “the fact that the people who attend these rounds—and a lot of people attend them, every surgeon is there—means that they believe in the process,” Wijeysundera said. “So is there disagreement? Absolutely. Is it rigorous at times? Yes, because these are grey cases and there isn't [always] an obvious answer. Is it respectful? Yes.”

Do We Need More Research?

More research into the concrete benefits of having a Heart Team might convince the remaining skeptics to participate, but at this point any future investigation into these processes will need to show effects on hard outcomes to be particularly actionable, experts say.

Another area in need of further study is into the patients who are evaluated by the Heart Team but never actually get an intervention, Tang said. “Maybe we need to form a Heart Team study and experience to learn: are we undertreating these patients? Are we overtreating these patients? Should more patients be more aggressively treated given their history? And if there are patients who are treated and had, let's say, adverse outcomes, should they have been medically managed like some of the cases we saw earlier in the TAVR days?”

Wijeysundera also agreed that specific endpoints need to be sought in order to effectively study the Heart Team. “If we're trying to link Heart Teams with hard outcomes, there are a lot of steps between what the Heart Team does and the outcome of a patient,” he said. “That may not be the most insightful type of research.”

However, he continued, studies “looking at organizational structure [and] how best to make teams work better” might be relevant to the evolution of these processes.

The lack of standardization between different Heart Teams also makes them hard to study, Grubb commented. “You're going have some small centers that have a great Heart Team and they do very good work. You're going to have other programs that say they have a Heart Team, but they really don't. And they may individually get very good results.”

For now, a guideline-based approach, like the one Ray and colleagues have published, “reinforces this Heart Team concept. I think that that's all we can hope for,” she added.

Future Directions

Looking ahead, Banks anticipates the need for more specific MDMs as the number of percutaneous therapies grows. “To some extent, that already happened in the academic setting where people are very specialized, and I think as more people are trained in this, you're going to have more specific focuses even outside academics.” At that point it would be reasonable to routinely include an even wider range of specialties, including family medicine and palliative care, he added.

Banks also would like to see community hospitals do better at communicating with physicians at academic facilities, not only to make it easier to access the full spectrum of patient options, but also to ease transfers and improve patient selection.

Both Kirtane and Wijeysundera pointed out that one of the biggest challenges going forward will be curtailing the number of meetings physicians attend, so that they can fit in all of their clinical work.

No matter how it's done, as long as the wide swath of opinions can be entertained and heard, then I do think that that's going to be in the patient's best interest. Ajay Kirtane

“In the context of busy clinical days, coverage of labs, and overlapping schedules, those things can be challenging,” Kirtane said. Having physicians rotate through these meetings might be a solution. “No matter how it's done, as long as the wide swath of opinions can be entertained and heard, then I do think that that's going to be in the patient's best interest.”

Tang urged more focus on patients’ individual circumstances in deciding what’s the best option for care. Family support and socioeconomics need to be considered, he said, when the Heart Team makes their recommendations.

The most important thing, said Grubb, may not be the structure or purview of the Heart Team, or how its reimbursed, but just having one in place.

“I worry about the centers that don't have a Heart Team at all,” she continued. “If this manuscript prompts people to look at their own Heart Teams and say we really need to have this where everybody has a voice, everybody has an opinion, we sit down and really discuss what is best for this patient, that's what the goal should be.”

Wijeysundera agreed, noting that the concept of quality care has evolved from something paternalistic to having patients be more actively involved. “Simply having a group of really engaged people. . . is not the sole ingredient to making this work,” he said, adding that the structure set out in the new UK document “is really very insightful and reflects what many of us have evolved to, but still continues to require evolution.”

For him, that’s the key takeaway from the document—“Every institution should look at their process and say: do we have a process? If you don't, that's a problem.”