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Riojas et al. Vessel Plus 2024;8:6 https://dx.doi.org/10.20517/2574-1209.2023.122 Page 9 of 16

[7]
as indicated . Similarly, a rapid response, multidisciplinary team to treat patients with pulmonary emboli
[8]
[49]
has been developed at Vanderbilt and Massachusetts General Hospital . A 24-h hotline is used to activate
the pulmonary embolism response team (PERT), which includes specialists from emergency medicine,
interventional cardiology, cardiac surgery, vascular surgery, pulmonology and critical care, and hematology.
These teams for acute patients allowed expedited decision making based on approved algorithms and
protocols.

Another concern is whether all relevant patients are discussed in the heart team conference. It may be
difficult to determine whether all relevant patients are actually captured within such multidisciplinary
conferences. For example, are there patients with clinical equipoise who preferentially undergo certain
treatments at certain institutions? One group presented every patient with a new diagnosis of CAD in a
[50]
heart team meeting . Approximately 65% of patients were discussed ad hoc, and of those, 63% went on to
PCI. On the other hand, 35% were discussed in the weekly Heart team meeting, and of these, approximately
87% went on to have surgery. Although this “all-comer” approach may ensure equity in patient selection, it
can also be a large commitment of resources. Another approach may be to only present patients deemed
high risk for PCI . This approach reportedly had good participation of not only cardiologists and cardiac
[29]
surgeons, but also other specialists whose involvement was not required. This limited approach to patient
selection may have greater physician participation, but may inadvertently exclude patients with clinical
equipoise, and raises the concern that maybe more patients should be presented in the heart team
meetings . Thus, the best approach may be to identify those patients who could be equally treated with
[51]
[52]
either PCI or CABG, which was the approach of Patterson et al. . However, even in this study, one
limitation per the authors was that the determination of clinical equipoise was subjective and dependent on
the referring physician.

As with many conferences, time is a major limiting factor for busy clinicians. There are also limitations to
finding the most convenient time for multiple clinicians. There is also time required for preparation, and
time that could potentially be used for clinical, educational, or research purposes . Creating consistency
[17]
will lead to participants prioritizing attendance at the meetings. There should be respect for everyone’s time,
and discussions should be focused on pertinent issues. Some may view the time as a lost chance to generate
clinical revenue or complete other clinical tasks. However, one study of multidisciplinary teams showed that
multidisciplinary team evaluation of breast cancer patients resulted in an overall cost reduction to patient
care . Medical record documentation in the patient chart as a consult or progress note generates
[53]
reimbursement and may encourage participation for some. This can be facilitated by the involvement of
administrative staff in the multidisciplinary meetings to review coding practices and to ensure accuracy and
optimize billing .
[42]
THE HEART TEAM OF JOHNS HOPKINS MEDICINE
Johns Hopkins Hospital is a major academic health center that performs a high volume of diagnostic
cardiac catheterizations, percutaneous interventions, and cardiac surgery procedures yearly. At Johns
Hopkins Hospital, there are two workflows to activate the Heart team. The most common pathway is the
weekly Heart team discussion, which focuses on elective outpatient referrals. However, the Shock (acute
heart) team activation via phone may be used when a decision is needed within 6-12 h and is for acutely ill
inpatients, most of whom are in one of the intensive care units. Previously, elective meetings were held in
person in a conference room, but now, the meetings are held via a web interface with HIPAA compliance.
Multiple cardiology, interventional cardiology, intensivists, and cardiac surgery attendings are in
attendance, as well as training fellows from general cardiology, interventional cardiology, cardiology critical
care unit, and cardiac surgery. There is a minimum of one senior and often additional other junior