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Page 2 of 16 Riojas et al. Vessel Plus 2024;8:6 https://dx.doi.org/10.20517/2574-1209.2023.122

candidates for ventricular assist devices or cardiac transplantation. Multidisciplinary teams are essential for
[6]
determining whether patients undergo surgical or transcatheter aortic valve and mitral valve replacement .
[7]
Some hospitals have “shock” teams to help determine how to manage patients in acute cardiogenic shock .
The pulmonary embolism response teams (PERT) decide how to manage patients with severely
symptomatic, large pulmonary emboli . Thus, the role of a single provider making a life-changing, complex
[8]
decision has evolved into multidisciplinary teams contributing information and analyzing data from
different perspectives to determine the optimal treatment pathway.

In coronary artery disease, there are primarily three treatment pathways: medical management,
percutaneous coronary intervention by an interventional cardiologist, or coronary artery bypass grafting by
a cardiac surgeon. Since most patients are seen by a primary cardiologist, this person has a large influence
on the referral pattern and decision making for their patients. Next, an interventional cardiologist may
perform a diagnostic coronary angiogram, and if there is significant coronary artery disease, he or she may
decide to perform an intervention without further discussion, also known as ad hoc PCI [9-14] . When a patient
is referred to a cardiac surgeon, the surgeon will review the coronary angiogram to determine possible
targets for bypass grafting and, at the time of surgery, will make a final decision on whether these targets are
suitable [15,16] . All of these are examples of individual decision making in coronary artery disease. There are
many instances where cardiologists and surgeons work in a collaborative atmosphere and may have
impromptu discussions on how best to manage certain patients . Many hospitals have now developed a
[9]
multidisciplinary heart team that presents, reviews, discusses, and collectively decides on the best evaluation
and treatment modality based on the data available [2,17-19] . Such heart teams utilize combined decision
making to determine the best treatment strategy for complex patients with coronary artery disease. This
narrative review will discuss data supporting the use of a heart team, how to implement a heart team, some
barriers to the heart team, and future considerations. A topic-based search of the Pubmed database was
performed using keywords such as “multidisciplinary team, heart team, complex coronary artery disease,
PCI, and CABG”.

A BRIEF HISTORY OF THE HEART TEAM
There is large variability in physician-made decisions for the management of CAD, raising concerns about
[2]
inappropriate revascularization . Some reports have shown the percentage of ad hoc PCI to be over 70% of
cases [12,13,20] . Many of these cases were in complex lesions including 2- or 3-vessel CAD, left main coronary
artery disease, and chronic total occlusions, in which some studies have shown better outcomes with CABG.
[10]
Thus, the major question is whether the optimal treatment modality was chosen . One study showed that
patients undergoing coronary angiography in hospitals with a higher PCI:CABG ratio had increased rates of
major adverse cardiac and cerebrovascular events (MACCE) and repeat revascularization 29. Additionally,
there was an increased hazard rate of MACCE, death, or MI if the patient had the index angiogram at a
hospital without CABG capability versus at a hospital with CABG capability. This raises the question of
whether there was an effective multidisciplinary discussion of the management of CAD in hospitals without
CABG capability. In contrast, multiple observational studies have demonstrated favorable and reproducible
outcomes when a Heart team was used in the evaluation of patients with coronary artery disease. The
earliest data were derived from studies comparing percutaneous transluminal coronary angioplasty (PTCA)
[21]
to CABG for revascularization. For example, the EAST , GABI , and BARI trials were randomized
[22]
[23]
controlled trials designed to compare CABG and PTCA. Patients had to meet criteria for both PTCA and
CABG and were evaluated by both cardiologists and surgeons. The BARI trial had very specific criteria for
the experience level and recent outcomes of the interventional cardiologists and surgeons . These trials
[24]
included nested registries along with randomized cohorts to evaluate physician or patient treatment
preferences versus patients in whom clinical equipoise was assumed . The registry patients demonstrated
[2]