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Page 10 of 16 Riojas et al. Vessel Plus 2024;8:6 https://dx.doi.org/10.20517/2574-1209.2023.122

attendings of these core specialties. Often, there are representatives from advanced practice providers from
the step-down ward and the Cardiovascular Surgical intensive care unit. There may be additional providers
from other specialties as warranted, such as ethics, infectious disease, radiology or other imaging experts,
pulmonary medicine, oncology, psychiatry, etc. There is often a list of patients to be discussed, or providers
may spontaneously present a new patient at their discretion. Although not required, a few slides are used to
present background information, and then there is a succinct presentation of relevant imaging, including
recent angiograms, echocardiograms, computed tomography scans, and cardiac MRI if available. The
discussion focuses on the main issues of debate or concern, with references to expert consensus or current
guidelines. The STS-PROM, SYNTAX II score, or other predictive scoring calculators are presented as
needed. Finally, the Heart team strives to achieve a consensus decision on the optimal treatment plan or
additional information or testing as needed. The referring provider will document this plan and supporting
information in the patient’s chart. Another unique facet of the Heart team conference is that providers may
subsequently provide follow-up information, including outcomes of the interventions performed. On a
routine basis, members will present patients who have undergone the recommended intervention and the
overall outcome. Here, we present examples of complex patients who were presented at our weekly
multidisciplinary heart team discussion.

Patient 1
A 58-year-old man with obesity and gastroesophageal reflux disease presented with angina and elevated
troponin and was transferred from another hospital. On coronary angiogram, he had multivessel CAD that
was not amenable to PCI; echocardiogram showed reduced biventricular function with left ventricular
ejection fraction (LVEF) of 15%-20%, and a cardiac MRI showed mostly viable myocardium. A CT chest
also demonstrated an ascending aortic aneurysm of 5 cm. This patient was presented to the Heart Team to
discuss options for treatment or intervention, centered around the discussion of whether he should go for
CABG versus heart transplant or durable left ventricular assist device (LVAD) implantation. He was deemed
not a good candidate for PCI. There were multiple suggestions, including medical management, off-pump
CABG, pump-assist CABG, on-pump CABG with temporary LVAD assist, and complete heart transplant/
LVAD workup prior to CABG in the event he is on prolonged mechanical support. Per Heart Team
[1]
recommendations and per 2021 ACC/AHA/SCAI guidelines for coronary revascularization based on
severe left main disease, he successfully underwent an on-pump one-vessel CABG, LIMA to LAD, as the
other vessels did not appear graftable. He also had an ascending aortic aneurysm replacement, and
placement of a temporary LVAD into the aorta for support after cardiopulmonary bypass.

Patient 2
A 75-year-old man with complex coronary artery disease, status post PCI to the RCA 13 years prior and PCI
to the left anterior descending and left circumflex in the setting of a STEMI 6 years prior, was presented to
2
the Heart Team. Additional past medical history included hypertension, obesity with a BMI of 38.9 kg/m ,
current smoker, and recent gastrointestinal bleeding after starting apixaban for thrombosis of the greater
saphenous vein. He presented with angina and further workup demonstrated an LVEF 40%-45%,
multivessel CAD, including in-stent restenosis of the proximal to mid LAD [Figure 3]. He had no
acceptable saphenous vein due to prior surgeries, and stenosis of the right subclavian artery. In this case, the
patient was presented for Heart Team discussion as he was seen as a high-risk patient due to obesity, limited
conduit, and current tobacco use. Stenosis of the proximal right subclavian artery precluded the use of the
in-situ RIMA, and there was concern that a free RIMA would not reach from the aorta to the PDA. There
was a discussion about optimal medical management versus intervention. One option was to use a free
RIMA as a T graft off the LIMA, but several surgeons agreed this was too risky for possible injury to the
LIMA. On the other hand, the PCI option was suboptimal as this would have required multiple overlapping
stents from the ostium to the mid LAD. After discussion with the Heart team, there was consensus that the