News
Although to many, the concept of Heart Teams, as examined in Mitchel L. Zoler’s article, "Heart teams inch into routine cardiac practice," seem novel, such collaborations were the norm at the dawn of cardiac surgery.
Beginning with the surgical approach to valvular and, later, coronary vascular surgery, the interaction between cardiac physiologists (as they were called then), coronary angiographers, and cardiac surgeons in deciding where and when to operate was often difficult and contentious. Cardiac surgery was a high-risk procedure, and the outcomes were uncertain. Over the last 50 years we have come a long way and much of what we do is almost commonplace, as frequently performed as a cholecystectomy or appendectomy and with similar risks. Over time, we have become casual with our decision-making process. Both cardiologists and cardiac surgeons have staked out their own therapeutic parameters. Specialty society guidelines have provided important boundaries within which we can and should operate.
At the same time, we continue to push the envelope to identify therapeutic targets and technologies. We have developed complex interventional and surgical procedures and have applied them to older and sicker patient populations. New technology has opened avenues of therapy that we could not have imagined at the inception of interventional cardiology and cardiac surgery.
The advanced interventional surgical approach now requires even greater interaction with more special players in both cardiology and surgery. Although the modern cardiology practice is built on everyday procedures that provide the platform on which we treat a variety of cardiac issues that commonly do not require ongoing group interactions, the new treatment options require a more interactive and collegial environment. It is in this domain that the Heart Team has an important role and has found success. It was re-initiated as a result of the development of the transcatheter aortic valve implantation, which requires close cardiology and surgical interaction. It has expanded as a team approach to the treatment choices in the care of patients with structural heart disease.
Definitions of the boundaries of the new therapies raise important economic and professional challenges. The Heart Team as currently organized provides the framework of that discourse. To some, it will represent an inconvenience and an obstruction to their individual professional performance: The requirement to participate in a structured interaction is just one more barrier to the daily performance of their skills. To others, it will provide an important process that will improve performance: It is an opportunity to coordinate the different skills required for the advance treatments and, more importantly, it represents a forum to educate not only the current participants but also the physician, nurses, and technicians for the future. The discussion and planning for the surgical approach for a particular patient provides a dynamic discussion of the therapeutic options and the important decisions about appropriateness of the procedure. This interactive learning process is critical to the interdisciplinary training of all present and future players.
The growth of cardiovascular therapy has led to the construction of large stand-alone units or sections within hospitals identified as heart centers or institutes. The creation of these facilities provides the professional structure and financial environment to create the Heart Team and answer some of the issues raised in the article in this issue. Initially devised as a combination of marketing and professional associations, they now can provide the educational and scientific structure of the Heart Team.
Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.