"It’s time to bury the old PCI vs. CABG battle of the past," said Dr. Williams. If cardiologists and surgeons don’t work together, "it’s not good for them or for patients. When you work together, it’s mutually beneficial, and most importantly it’s better for patients."
What’s next for revascularization heart teams?
Have heart teams for revascularization become the standard of care, is there consensus on when they should be used, and do most U.S. interventionalists and cardiac surgeons already belong to a heart team? The short answer to all three questions is maybe.
"Heart teams may be the standard of care at many [U.S.] institutions, but I can’t speak for all. At Brigham and Women’s, it is our standard of care for patients with complicated CAD," said Dr. O’Gara. Right now "heart teams are the aspiration, but I’m not sure it is the standard. But it was a class I recommendation that had unanimous consensus behind it.
Dr. Patrick T. O'Gara
"The ACC has focused on education to proselytize the value of this approach," said Dr. O’Gara, who is currently ACC vice president. The results of the SYNTAX trial established the expectation that among patients with multivessel disease, there would be a discussion before surgeons, interventionalists, and the patient about the optimal [revascularization] approach. But aside from the educational aspect on the benefit of doing this I’m not aware of any regulatory agency that is embedding heart teams in, say, a performance metric," the better to solidify their role in practice.
Most surgeons and cardiologists fall back on calling for a heart team for any patients with "complex" coronary disease, generally defined as patients with left main disease or triple-vessel advanced coronary disease. Those were the categories of coronary disease for which PCI’s use was deemed "uncertain" by the revascularization appropriate-use criteria established last year by the ACC, STS, and several other cardiology and surgical groups (J. Am. Coll. Cardiol. 2012;59:857-81).
"I wouldn’t say that for revascularization using heart teams is the standard of care, but it’s being used in more and more places," said Dr. Weaver. A heart team "is not for every case; it takes time, and in most cases it probably won’t change the decision. But certainly for complex cases it should be routine. At many centers it is routine – but for a small subset of patients," said Dr. Weaver. "The ACC can help define what is a complex case and help convince payers that this is useful and that we need to reward this behavior as an incentive."
In general, cardiologists and surgeons likely feel little urgency to become part of revascularization heart teams, if for no other reason than most of them probably believe they are already part of one.
"I would not be surprised if most American cardiologists and surgeons feel that they are already on a heart team. They feel: ‘I practice at a place with a surgeon, or with a cardiologist – we’re a team.’ I don’t think that anyone in private practice loses sleep because they think they are not on a heart team," said Dr. Nallamothu.
But there is probably a need for a more systematic application of heart teams to appropriate cases, a clearer definition of appropriate cases, and increased leadership from professional societies to accomplish these goals, according to at least some experts.
"I wouldn’t say that societies have fallen short, but there is a lot of work to do. It’s a huge challenge, and these groups could definitely lead going forward," said Dr. Sundt.
"Societies need to take the lead on defining optimal care" and the collaborative approach to revascularization, said Dr. May. The collaborative discussions that the ACC and STS have had about TAVR is "a model" for future collaborations on revascularization and other areas of multidisciplinary cardiac care, such as mitral valve replacement.
"In the long term, I think there will be more integration of interventional cardiology and cardiac surgery, with more overlap of the procedures they use," predicted Dr. Nallamothu. As that happens, "we’ll also see more team discussions about complex revascularization cases."
Dr. Nallamothu, Dr. May, Dr. Block, Dr. Gardner, Dr. Williams, Dr. Sundt, Dr. Weaver, and Dr. O’Gara all said that they had no relevant financial disclosures.
m.zoler@elsevier.com
On Twitter @mitchelzoler