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increased 3-year survival in the EAST registry and increased 7-year survival in the BARI trial, suggesting
that selection of treatment after discussion with a cardiologist, cardiac surgeon, and patient yields better
outcomes compared to randomization.

CLINICAL EVIDENCE SUPPORTING A HEART TEAM
Since then, data has accumulated regarding the efficacy of a heart team. In 2012, Chu et al. at the University
of Pittsburgh Medical Center formed a multidisciplinary heart team to discuss patients with complex
coronary artery disease [3,18] . In this pilot study, 180 patients were included, and 36% underwent PCI, 48%
CABG only, 2% hybrid approach, and 14% medical therapy alone. The 30-day mortality was 8% for the PCI
group, 1% for the CABG-only group, and 12% for the medical management-only group . This was one of
[3]
the first pilot prospective cohort studies, and the authors concluded that implementation of a Heart team is
feasible, safe, and efficacious . Several other observational studies of complex coronary artery disease also
[3]
showed better adherence to guideline recommendations and appropriateness of intervention when a heart
team was utilized [4,19] .

[25]
Even after the initial published recommendations for a heart team in 2010 , there still was a lack of
randomized data regarding the benefits of a heart team discussion or involvement in patient care.
Yamasaki et al., retrospectively reviewed their clinical outcomes 2 years before and 2 years after
implementation of a heart team . Notably, the PCI:CABG ratio decreased after the implementation of the
[26]
heart team. A multivariable analysis demonstrated that the number of MACCE was reduced with the heart
team approach. Further, after propensity score matching, the heart team approach was independently
associated with reduced MACCE.

A retrospective review of the Critical Care Cardiology Trials Network registry evaluated the use of Shock
teams in cardiac intensive care units between 2019 and 2021. Patients in cardiogenic shock treated at
hospitals with shock teams had shorter median ICU length of stay and less mechanical ventilation. In this
study, the presence of a shock team was independently associated with lower ICU mortality (adjusted
OR 0.72; 95%CI: 0.55-0.94, P = 0.016) .
[27]

Although the above data suggest improved long-term outcomes and improved adherence to current
guidelines when a heart team is utilized, there is no randomized controlled trial evaluating the outcomes of
a heart team versus no heart team discussion of patients with CAD.

GUIDELINES SUPPORTING THE USE OF A HEART TEAM
Whereas there may be no perfect method for making recommendations for the treatment of coronary artery
disease, the medical community should work towards creating a bias-free decision-making process. The
“Heart team” is not a novel concept, and in fact, it has been trialed at many major institutions [5,17,18,28,29] . The
concept of the heart team approach was developed in the context of randomized controlled trials comparing
PCI with CABG. In these trials, the Heart team would ensure that patients were equally suitable for
randomization to either PCI or CABG [30,31] . Following these studies, it became evident that the use of a
collaborative heart team could help in decision making between providers and patients . Additionally,
[2]
there have been previous reports about the inappropriate use of PCI or CABG with marked differences in
European countries . Thus, the 2010 ECS/EACTS Guidelines for myocardial revascularization made a
[10]
Class 1 recommendation based on Level C evidence for the use of a Heart team to guide institutional
protocols and discuss complex patients on an individual basis . These recommendations have been
[25]
promoted in the 2012 ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT , and 2014 and 2018 ECS/
[32]
EACTS guidelines [11,33,34] . The most recent guidelines to recommend the use of a multidisciplinary Heart