The current state of the multidisciplinary heart team approach: a systematic review

Summary

The heart team (HT) approach, recommended for managing cardiovascular diseases, emphasizes multidisciplinary collaboration. Despite its potential benefits, evidence on its effectiveness and implementation is varied and sparse. This review assesses the HT approach’s impact on patient outcomes and care delivery in cardiovascular care. A systematic review was conducted across MEDLINE, EMBASE, PubMed, Cochrane and Google Scholar up to July 2023, focusing on studies that implemented an HT approach in coronary and heart valve disease management. Exclusion criteria included non-human studies, case reports and studies not focusing on HT outcomes. From 6270 identified articles, 20 met the inclusion criteria. These studies demonstrated significant variability in HT composition and organization, coupled with a lack of standardized metrics for evaluating clinical outcomes and the impact of the HT. Significant variability was observed in HT composition, with 13 of the 20 studies did not utilize structured templates, those that did demonstrated more consistent decision-making. In mitral valve interventions, HTs were linked to reduced in-hospital mortality and improved long-term survival (5-year survival probability of 0.74 vs 0.70, P = 0.04). In aortic valve interventions, 80% of patients underwent tailored valve procedures following HT evaluation. The HT approach in cardiovascular care demonstrates improved patient outcomes, particularly in specialized interventions for mitral and aortic valve diseases and coronary artery disease management. Despite these positive findings, the variability in HT implementation and the need for standardized outcome metrics call for further advances to optimize this collaborative care model.

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INTRODUCTION

Cardiovascular diseases represent a global burden with increasing prevalence expected in the near future due to the population’s ageing and the steady rise of risk factors such as hypertension, diabetes and obesity [1]. Among the various treatment modalities, cardiac surgery and transcatheter interventions have been pivotal in the advancement of therapeutic outcomes. However, the complexity and diversity of cardiac pathology, coupled with the rapid evolution of diagnostic and therapeutic techniques, have created a paradigm shift in patient management—the concept of the heart team (HT) approach [2].

Traditionally, the treatment of cardiovascvular disease has been approached through the lens of individual specialities, with cardiologists primarily responsible for medical therapy and interventional procedures, and cardiac surgeons leading surgical interventions. While these specialists have made significant contributions to the field, the complex and multifaceted nature of cardiac conditions often necessitates a more collaborative and integrated approach.

The HT approach, inspired by the successful outcomes seen in other disease models such as oncology, has emerged as a novel strategy in cardiovascular care. The HT was first introduced by SYNTAX Trial [2] and later embedded as Class I recommendation by the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA) in their 2012 guidelines for coronary artery disease management [3]. This approach was later extended to the management of valvular heart disease (VHD) in the 2014 ACCF/AHA guidelines [4], emphasizing the importance of a multidisciplinary team in decision-making processes for patients with severe symptomatic VHD. The European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) have also endorsed this approach in their 2017 guidelines [5].

The HT typically comprises cardiologists, cardiac surgeons, imaging specialists and anaesthesiologists and often includes other healthcare professionals such as nurses, physiotherapists and social workers. This heterogeneity fosters a comprehensive assessment of the patient, leading to an individualized treatment plan tailored to optimize the patient’s clinical outcome and quality of life. The HT approach also facilitates the implementation of advanced therapies, such as transcatheter aortic valve implantation (TAVI) and transcatheter mitral valve repair [6]. These procedures require careful patient selection, procedural planning and post-procedural management, all of which can be effectively addressed by a multidisciplinary team.

Yet, despite these guidelines, there remains a need for strong evidence supporting the superiority of the HT approach over traditional care models in the management of cardiovascular diseases. As highlighted in our recent survey, there are wide variabilities in the conduct, format, documentation, type of patients, decision-making and auditing processes of HTs worldwide [7]. The variability in HT adoption stems from differing healthcare systems, institutional resources and professional dynamics. Factors such as team composition, meeting frequency and decision-making processes vary significantly across institutions. In some settings, HT meetings are held weekly with multidisciplinary specialists, while in others, they occur on an ad hoc basis or are inconsistently implemented. In some cases, the HT process is entirely bypassed, which highlights a significant inconsistency in adoption rates. Moreover, disparities in resource allocation, such as the availability of structured templates for decision-making or the inclusion of imaging specialists, further contribute to these inconsistencies.

Transitioning to an HT mandates a move from conventional hierarchies to a more collaborative decision-making model, requiring clear communication, consistent commitment to cross-disciplinary collaboration and a supportive institutional foundation. Additionally, scalability, particularly in settings with limited resources, remains a concern [7].

This systematic review seeks to evaluate and collate existing scientific data on the multidisciplinary HT approach’s role, effectiveness and challenges in cardiovascular care. It explores published studies on team composition, meeting formats and documentation practices and investigates the decision-making processes for inclusiveness and effectiveness. The review also examines the metrics and outcomes used to assess the HT approach’s impact. This comprehensive analysis aims to provide a nuanced and unbiased perspective, highlighting potential advantages, limitations and areas requiring further research to optimize patient outcomes and streamline care delivery.

METHODS

Literature search strategy

A systematic review was conducted in accordance with the Cochrane Collaboration published guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). MEDLINE, EMBASE, PubMed, Cochrane and Google Scholar were searched for original articles from inception to July 2023. The search terms used were as follows: (Multidisciplinary team or Interdisciplinary Team) and [cardiac or cardiology or cardiac surgery or cardiothoracic surgery or coronary revascularization or mitral valve or aortic valve or tricuspid valve or coronary artery disease or coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI)]. Further articles were identified through the use of the ‘related articles’ function on MEDLINE and a manual search of the reference lists of articles found through the original search. The only limits used were the English language and the prespecified time frame.

Study inclusion and exclusion criteria

All original articles published from inception to July 2023 included reporting the implementation of an HT approach for the management of coronary and heart valve disease. Studies were excluded if (i) inconsistencies in the data impeded extraction of data, (ii) the study was a review, case reports, preclinical study or abstract from a meeting, (iii) the study did not include human participants or had <10 participants, (iv) the study focused on transplantation or mechanical circulatory support, thoracic surgery, congenital cardiac surgery procedures and infective endocarditis. By following the aforementioned criteria, 3 reviewers (T.A., P.S.N. and A.A.R.) independently selected articles for further assessment following title and abstract review. Potentially eligible studies were then retrieved for full-text assessment.

Data extraction and critical appraisal of evidence

All full texts of retrieved articles were read and reviewed by 3 authors (T.A., P.S.N. and A.A.R.) and a unanimous decision made regarding inclusion or exclusion of studies. When there was disagreement, the final decision was made by the senior author (P.S.N.), the following data were extracted: study characteristics, HT characteristics, population number, methods and main outcomes. A data extraction table for this review was developed and included the selected studies. Data extraction was performed by 2 review authors (A.A.R. and T.A.) The correctness of the tabulated data was validated by a third author (P.S.N.).

Risk of bias analysis

The risk of bias in the selected articles was evaluated by 2 independent reviewers (A.A.R. and T.A.) using an adapted Cochrane Collaboration risk of bias tool (Fig. 1). The methodological quality of the studies was assessed based of domains of RoB 2.0: deviation from intended intervention, missing outcome data, measurement of outcome and selective reporting, classified as low risk of bias, some concerns or high risk of bias.

RESULTS

Study selection

The literature search identified 6270 articles, of which 4819 were screened following the removal of duplicates and 236 were full-text reviewed and assessed in accordance with the inclusion and exclusion criteria. Following critical appraisal, a total of 20 studies [8–27] were included in this review. Figure 2 illustrates the entire study selection process. A summary of the studies collected and their respective designs, HT characteristics, as well as the main reported outcomes are found in Tables 1 and 2.

Heart team structure

HT structures and details about their design are found in Tables 3 and 4.

• Composition: A total of 16 studies specified the exact number of specialty doctors involved in cardiac care. Of these, 6 studies reported the presence of more than 2 cardiologists and cardiothoracic surgeons. Eight specifically reported the inclusion of other specialties outside of cardiology and cardiothoracic/cardiac surgery. These specialties varied and included anaesthesiology, echocardiography, heart failure specialists, electrophysiologists, imaging specialists, geriatricians, clinical nurse consultants, respiratory physicians, radiologists, cardiac anaesthetists, vascular surgeons, cardiovascular intensivists and TAVI nurse coordinators. One study by Sardari Nia et al. proposed directly involving patients in the HT meeting.

• Meeting frequency: The data from the 20 studies reveal that the meeting frequency of HTs is predominantly weekly, with 11 out of the 20 studies reporting a weekly schedule. Daily meetings are reported in 3 studies, biweekly to monthly meetings are held as per 2 studies, and 1 study mentions meetings upon request. The remaining 3 studies did not specify the meeting frequency.

• Structured discussions: The use of structured templates and risk scores in HT meetings varies among the studies. Structured templates for patient discussion are explicitly mentioned including custom-made forms, electronic forms integrating guidelines, proformas, structured online case presentations, a ‘CAD Heart Team Decision Aid’ and templates that include risk stratification. Surprisingly, in our review, a majority of studies (13 out of 20) did not specify the use of such structured templates. Risk scores were commonly used for patient assessment, particularly the SYNTAX score in 5 studies, EuroSCORE II in 9 studies, STS-PROM in 4 studies and New York Heart Association (NYHA) classification in 3 studies.

Impact of the heart team on clinical outcomes

Among all 20 studies [8–27], a great heterogeneity and variability were present in the reported outcomes, with a lack of consistency in the objective and methodology of the studies attempting to assess the impact of the HT approach on clinical outcomes.

Mitral valve team

In our systematic review, 5 studies delved into the effects of the HT on mitral valve-related outcomes. Heuts et al. [10] highlighted a dedicated approach that achieved a 100% repair rate for degenerative mitral valves. Collaborative surgical planning with a multidisciplinary team led to enhanced repair rates, especially for degenerative valve disease patients. Külling et al. [12] linked the team approach to reduced in-hospital mortality rates for MitraClip procedures and observed high 4-year survival rates for various repair methods. Sardari Nia et al. [13] showed that dedicated mitral valve HT referrals led to a higher 5-year survival probability compared to general HT referrals.

Aortic valve

Our systematic review highlighted 9 key studies examining the HT’s role in aortic valve interventions. Dubois et al. [15] reported that after HT evaluations, 80% of patients underwent tailored valve procedures with positive outcomes. Bonzel et al. [8] highlighted that only a small portion of patients with severe degenerative aortic valve stenosis were not recommended an intervention, underscoring the HT’s thorough evaluation. Thyregod et al. [17] observed a high intervention rate with TAVI recipients typically being older with more complex health histories. Jones et al. [18] found that the introduction of TAVI programs correlated with reduced mortality. Jonik et al. [22] reported improved outcomes and quality of life post-TAVI or SAVR (Surgical Aortic Valve Replacement), significantly outperforming optimal medical therapy alone. Porterie et al. [20] reported lower in-hospital mortality and fewer complications in patients managed by the HT. The HT group had significantly lower in-hospital mortality, reduced risks of complications and demonstrated equivalent long-term survival rates and readmissions for cardiovascular reasons.

Coronary artery disease

In our systematic review, 6 studies illuminated the HT’s pivotal role in coronary artery disease (CAD) interventions. Domingues et al. [9] highlighted the detailed approach of the HT, noting that additional investigations were requested in 29.2% of cases prior to making definitive treatment recommendations. Patterson et al. [27] delved into survival rates, finding no significant difference in outcomes for patients undergoing CABG versus those who chose PCI post-HT discussions, with a 3-year survival rate mentioned. Abdulrahman et al. offered insights into the decision-making dynamics, revealing that choices between CABG or PCI often mirrored the existing hierarchy within the team. The potential of seamlessly integrating a multidisciplinary HT into standard institutional practice, especially for challenging CAD cases, was articulated by Young et al. [24] A particularly revealing observation came from Tsang et al. [23], where the HT’s treatment recommendations diverged from the initial suggestions of interventional cardiologists in 30.3% of the cases.

Contrasting general heart team and dedicated heart team

In the study by Sardari Nia et al. [13], patients referred to a dedicated mitral valve HT were contrasted with those referred to a general HT. Notably, the dedicated HT patients demonstrated superior 5-year survival probabilities and diminished adjusted relative risk of mortality. Adhering to the HT’s recommendations further curtailed the relative risk of mortality. The study by Jones et al. [18] assessed the influence of a TAVI-dedicated program’s introduction. It was observed that a TAVI program was associated with a mortality benefit for patients with severe aortic stenosis, irrespective of the broadened access to intervention. This mortality benefit was maintained even after accounting for the implementation of aortic valve intervention.

DISCUSSION

Our systematic review aligns with previous survey findings, highlighting a persistent lack of structured implementation of the HT concept in managing cardiovascular disease (Figs 3 and 4). Despite widespread acknowledgement of its importance for complex patient care, significant variability exists in team composition, meeting conduct and decision-making processes across institutions. While the overall quality of the evidence remains heterogeneous, the systematic review data highlight the effectiveness of dedicated HTs in both CAD, mitral and aortic valve disease management, with significant improvements in repair rates, survival probabilities and reduced mortality risks. Nevertheless, the lack in consistency of reported outcomes remains an important shortfall of this approach. While the HT model has been widely acknowledged as essential for managing complex cases, variability in its implementation is influenced by the resources, manpower and financial constraints of individual institutions. Each HT must adapt to the unique context of its healthcare setting, ensuring that decisions are ultimately centred around patient care rather than institutional capabilities.

The structure and functioning of the heart team based on the literature

Our systematic review has revealed a significant discrepancy between the theoretical framework of the HT concept and its practical application. Despite clear recommendations from scientific societies such as the American College of Cardiology (ACC), the AHA, the ESC and EACTS regarding the use of a collaborative HT approach as a class I indication in the management of cardiovascular disease [3–5], our findings indicate that there is still significant room for improvement in its implementation and optimization. Our work underscored the ubiquity of at least 1 interventional cardiologists, 1 cardiac surgeon and 1 non-interventional cardiologist. However, the inclusion of other pivotal members, such anaesthetists, radiologists and patients, emphasizes the breadth and depth that a well-structured HT can bring to patient care. In line with the findings of our recent survey [7], most studies were found not to conform with recent guidelines, with the majority of studies not conforming to the recommended composition that includes a clinical cardiologist, interventional cardiologist, cardiac surgeon, imaging specialist and cardiovascular anaesthesiologist.

One of the cornerstones of the HT approach is its systematic deliberation of cases. While the frequency of meetings varied across studies, the significance of regular and comprehensive interactions was evident. Further insights from a study by Imran Hamid et al. [7] revealed that over 90% of respondents from various European institutions reported the presence of an HT. The study highlighted significant variability in the real-world practice of HTs across Europe. Fifty-five percent of these respondents held weekly HT meetings, with 73% being conducted face-to-face. This frequency and mode of interaction underscore the value of direct, regular communication in optimizing patient care.

Surprisingly, our review revealed that a majority of studies did not specify the use of structured templates. The importance of structured templates was evident in the findings of Imran Hamid et al. [7], where marked variability in documentation processes was observed. This omission might indicate an underutilization or underreporting of these essential tools. The use of structured templates, such as custom-made electronic forms or specific proformas, can enhance clarity, ensure consistency and streamline deliberations.

The integration of risk scores, such as SYNTAX and STS-PROM [28–30], further exemplifies the systematic nature of the HT approach. These scores provide objective data, aiding the team in assessing the complexity of coronary artery disease or predicting the risks associated with particular surgical procedures. Surprisingly, Imran Hamid et al. [7] noted that 67% of respondents did not calculate the SYNTAX score for coronary artery disease patients, highlighting potential gaps in systematic assessments. Their usage aligns with the ethos of the HT approach—evidence-based, comprehensive and patient-centric care. While it is acknowledged that different regions, such as the USA and Europe, have established preferences for certain risk scores—STS-PROM in the USA and EuroSCORE II in Europe—this diversity should not be viewed as a barrier to improving patient care. Instead, it provides an opportunity for cross-regional learning and the potential to integrate multiple risk scores into a more flexible and comprehensive framework.

This diversity reflects the unique healthcare environments in which these scores are used, but it does not preclude future efforts to harmonize risk stratification methods across regions. By adopting a flexible approach tailored to institutional needs, while remaining open to the benefits of alternative scoring systems, the HT model can continue to evolve and improve outcomes for patients. Ultimately, the goal should be to optimize the use of risk scores based on the best available evidence, ensuring that each institution employs the tools most appropriate for their patient population while fostering continuous improvement and consistency in decision-making across different settings (Figure 3).

The role of multidisciplinary heart teams in improving patient outcomes

The findings from the reviewed studies underscore the critical role of HTs in improving patient outcomes for CAD, mitral and aortic valve diseases. One of the cardinal attributes of HTs is their intricate and thorough patient evaluation mechanism. For instance, Domingues et al. [9] discovered that additional investigations were solicited for a significant 35% of patients. When juxtaposed with the findings of Abdulrahman et al. [26], which showcased the efficacy and favourable outcomes of HT decisions in complex coronary cases, it becomes evident that such a meticulous evaluation paves the way for optimal patient care.

The collective wisdom of the HTs also fosters an adaptive and dynamic treatment strategy. Tsang et al. [23] illuminated this facet, noting that the HT’s collective decision-making process deviated from the initial treatment plan for nearly a third (30.3%) of aortic stenosis patients. Such adaptability not only showcases the team’s commitment to customizing care but also their agility in pivoting based on evolving patient data.

The efficacy of medical interventions is ultimately measured by their clinical outcomes, and the role of HTs is crucial in this regard. Evidence from Porterie et al. [20] underscores this point, demonstrating a significant decrease in in-hospital mortality for patients managed by an HT. Complementing this, research from Heuts et al. [10] and Jimenez et al. [11] further corroborates the practical advantages of the HT model, showcasing its contribution to improved treatment decisions and patient outcomes.

Comparison between dedicated mitral valve heart team and general heart team

Reflecting on the data, it is noteworthy to observe that patients managed by a dedicated mitral valve HT exhibit superior outcomes compared to those managed by a general HT. In the research by Sardari Nia et al. [13], it was discernible that the patients under the dedicated HT’s care had better 5-year survival probabilities and lower adjusted relative risks of mortality.

The research demonstrates a statistically significant improvement in patient outcomes for those treated by a dedicated mitral valve HT, with a 5-year survival rate of 0.74, compared to 0.70 for patients treated by a general HT [95% confidence interval (CI) 0.66–0.74; P = 0.040]. A crucial finding is the adjusted relative risk of mortality, which was 29% lower for patients referred to the dedicated HT compared to the general HT (hazard ratio 0.71, 95% CI 0.54–0.95; P = 0.019). This comparative analysis unveils the significant advantage of a dedicated HT in managing mitral valve diseases. It suggests that a more focused and specialized team, possessing specific expertise and understanding of a particular disease entity, can yield better results in patient management.

Specialization improves communication and decision-making, focusing on the most effective interventions for better patient outcomes. This raises the question of whether specialized teams for other heart diseases could enhance care. However, the risk of fragmented care and increased costs from over-specialization suggests a balanced approach, combining specialized and generalist teams, is vital for patient-focused care.

How to provide structure to the heart team?

Having a well-defined structure, complete with designated roles and responsibilities for each team member, creates a framework within which the team operates. This is crucial as it eliminates ambiguity, enhances coordination and ensures that every aspect of patient care is adequately addressed.

• Defined roles and responsibilities: ensures clarity, reduces ambiguity and promotes coordination.

• Robust communication channels: essential for ensuring effective collaboration and timely information sharing among team members.

• Decision-making protocols: decisions should be systematic, based on evidence, clinical guidelines and patient preferences. Avoid reducing decisions to mere opinions.

• Evaluation protocols: implement methods to integrate available evidence and assess treatment risks and benefits.

• Patient-centric approach: prioritize patient preferences and values in the decision-making process.

• Leverage technology: use shared electronic health records for better coordination. Incorporate decision support tools to align with the latest evidence and guidelines.

Limitations of the field and the study

While dedicated HTs show promise in improving patient outcomes, several limitations should be acknowledged. The available evidence is largely based on single-centre, retrospective studies with small patient populations, which limits the ability to detect significant outcome differences. Additionally, the structure and function of HTs vary widely across institutions and countries. These differences are often inherent to the healthcare context, reflecting variations in resources, team composition and decision-making processes. Such variability is a natural consequence of differing healthcare systems and local practices, which affects how HTs operate and influences their efficacy in managing complex cardiovascular cases.

Moreover, there are no randomized controlled trials directly comparing dedicated HTs to general HTs, further complicating efforts to draw definitive conclusions about their relative effectiveness. The diversity of heart diseases, patient characteristics and treatment options across studies also makes it challenging to attribute improvements solely to the HT model.

Another important limitation is the lack of standardized metrics for evaluating clinical outcomes and the impact of HTs. The absence of such metrics makes cross-study comparisons difficult, introducing inconsistencies in outcome reporting. Additionally, potential delays in decision-making, biases in team recommendations and the possibility of bypassing thorough evaluations in routine cases highlight the need for more systematic approaches. Standardized protocols and quality audits would help address these issues, enabling HTs to deliver more consistent and effective patient care, while recognizing that some degree of variability is unavoidable due to the specific contexts in which these teams operate.

CONCLUSION

The review highlights the HTs crucial role in cardiovascular care, pointing out significant variations in their makeup and operation. Inspired by oncology's success, HTs offer a model for collaborative patient management. The impact of HTs varies but shows positive trends, especially in mitral valve interventions with better repair rates and survival, aortic valve strategies tailored for better outcomes and nuanced coronary disease management. Despite these successes, challenges such as variability in HT structure—often inherent to the differing healthcare contexts across institutions and countries—and the lack of conclusive evidence from randomized controlled trials call for greater standardization and further study.

While some degree of variability is unavoidable due to the differences in resources, team composition and healthcare systems, the development of standardized protocols and outcome metrics could help optimize HT implementation and improve the comparability of results across studies. The balance between specialized and comprehensive care remains critical. As the healthcare field moves towards more collaborative, integrated and patient-focused care, there is a growing need for a model that combines specialized expertise with a comprehensive, standardized approach to maximize patient outcomes.

FUNDING

None.

Conflict of interest: Peyman Sardari Nia has a consultancy agreement with Neochord Inc, Edwards Lifesciences, Medtronic, Abbott and Fuijfilm medical and is the inventor of MV simulators that are commercialized through his start-up (Simurghy). Jindra Vainer has a consultancy contract with Cardiac Dimensions Inc. The other authors report no conflicts of interest.

DATA AVAILABILITY

The data that support the findings of this study are available from the corresponding author (P.SN), upon reasonable request.

Author contributions

Arian Arjomandi Rad: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Supervision; Validation; Writing—original draft; Writing—review & editing. Sebastian Streukens: Conceptualization; Investigation; Methodology; Validation; Visualization; Writing—review & editing. Jindra Vainer: Data curation; Investigation; Methodology; Validation; Visualization; Writing—review & editing. Thanos Athanasiou: Data curation; Investigation; Methodology; Supervision; Validation; Visualization; Writing—review & editing. Jos Maessen: Conceptualization; Data curation; Formal analysis; Methodology; Supervision; Visualization; Writing—review & editing. Peyman Sardari Nia: Conceptualization; Data curation; Investigation; Methodology; Project administration; Supervision; Validation; Writing—original draft; Writing—review & editing

Reviewer information

European Journal of Cardio-Thoracic Surgery thanks Alexander Wahba, Carlos A. Mestres, Tomislav Kopjar and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.

REFERENCES

ABBREVIATIONS

ABBREVIATIONS
 
• ACC

  American College of Cardiology

 
• ACCF

  American College of Cardiology Foundation

 
• AHA

  American Heart Association

 
• CABG

  Coronary artery bypass grafting

 
• CAD

  Coronary artery disease

 
• CI

  Confidence interval

 
• EACTS

  European Association for Cardio-Thoracic Surgery

 
• ESC

  European Society of Cardiology

 
• HT

  Heart team

 
• NYHA

  New York Heart Association

 
• PCI

  Percutaneous coronary intervention

 
• TAVI

  Transcatheter aortic valve implantation

 
• VHD

  Valvular heart disease