Heart Team Formation and Functions
Core Team Composition
A Heart Team must include at minimum three core specialists: a clinical/non-invasive cardiologist, an interventional cardiologist, and a cardiac surgeon, with this multidisciplinary approach receiving a Class 1 recommendation from both ACC/AHA and ESC guidelines for managing complex coronary artery disease. 1
Essential Core Members
- Clinical/non-invasive cardiologist – provides comprehensive cardiovascular assessment and coordinates medical management 1
- Interventional cardiologist – evaluates feasibility and appropriateness of percutaneous coronary intervention 1
- Cardiac surgeon – assesses surgical candidacy and CABG options 1
Additional Specialists (Case-Dependent)
- Anesthesiologist – evaluates surgical risk and ability to safely undergo general anesthesia 1
- Imaging specialists – provides detailed anatomical and functional cardiac assessment 1
- Primary care physician – contributes longitudinal patient knowledge and comorbidity management 1
- Palliative care, critical care specialists – for high-risk or end-stage disease patients 1
- Heart failure specialist nurses – serve as key coordinators between secondary and primary care 2
- Clinical pharmacists – provide medication optimization and titration support 2
Primary Functions
1. Treatment Decision-Making for Complex Cases
The Heart Team's primary function is collaborative treatment planning for patients with complex coronary disease where the optimal revascularization strategy is unclear, with observational studies demonstrating favorable outcomes and reproducible decisions. 1
Specific Clinical Scenarios Requiring Heart Team Evaluation:
- Unprotected left main disease 1
- Three-vessel coronary artery disease 1
- Two-vessel disease involving proximal LAD 1
- Single-vessel proximal LAD disease in diabetic patients 1
- Comorbid conditions impacting revascularization success 1
- Clinical or social situations affecting outcomes 1
2. Guideline Implementation and Standardization
The Heart Team improves adherence to evidence-based guidelines and reduces inappropriate revascularization, addressing the problem that only 53% of patients with CABG indications actually receive appropriate treatment 1. Multidisciplinary evaluation increases treatment conformity to clinical practice guidelines, as demonstrated in oncology models 1.
3. Risk Stratification and Interpretation
Heart Teams provide more accurate interpretation of clinical and anatomical risk scores (STS-PROM, SYNTAX scores) which have notable inter- and intra-observer variability when assessed by individual physicians. 1 The team collectively evaluates surgical risk, anatomical complexity, and local institutional expertise to guide appropriate management 3.
4. Shared Decision-Making with Patients
Decision-making must incorporate three key elements: (i) bidirectional knowledge transfer between physicians and patients, (ii) collaborative discussion, and (iii) reaching agreement that prioritizes patient preferences 1. Patients and their families should be integrated into the Heart Team process, which increases patient satisfaction and improves mental health scores 6 months post-procedure 1.
Secondary Functions
Enhanced Clinical Outcomes
- Reduced hospital variation in survival rates – similar to tumor board models 1
- Improved survival – pre-treatment multidisciplinary discussion associated with better outcomes 1
- Decreased inappropriate revascularization – addresses underutilization, overutilization, and misuse 1
Institutional Benefits
- Shared medico-legal responsibility – distributes accountability across team members 1
- Improved physician well-being – collegial discussion and peer acknowledgment enhance professional satisfaction 1
- Enhanced research enrollment – multidisciplinary teams increase clinical trial recruitment 1
- Quality monitoring – creates robust framework for outcomes tracking 1
Educational Function
Only 36% of Heart Teams currently emphasize education as a primary function, representing an underutilized opportunity 4. The systematic collegial discussion steers evolution of each specialist's expertise within the group setting 5.
Operational Framework
Meeting Structure and Frequency
Heart Teams should convene regularly with each case discussed in 5-10 minutes to maintain efficiency and physician engagement, as lower meeting frequency results in excessive caseloads that reduce motivation for active participation. 1, 6
Meeting models include:
- Daily to weekly scheduled meetings – for high-volume centers 1
- Ad hoc activation – for urgent cases or lower-volume centers 1
- Remote teleconference – for centers without on-site surgical departments, using WebEx or similar platforms 1
- Rapid activation protocols – for urgent or emergency clinical situations 1
Pre-Meeting Preparation
Research nurses or coordinators should gather necessary data and prepare risk score assessments displayed on plenary screens to avoid calculation errors through team feedback 1.
Decision-Making Principles
The Heart Team process must rest on collegiality, mutual respect, and commitment to excellence 1. However, hierarchy significantly impacts recommendations – when only the head of cardiovascular surgery was present, 83% of decisions favored CABG versus 54% when only the head of cardiology was present (p<0.0001), demonstrating that autocratic individuals can undermine true team discussion 7.
Common Pitfalls and How to Avoid Them
Hierarchical Dominance
The most significant threat to effective Heart Team function is hierarchical decision-making where the highest-ranking physician dominates without genuine team discussion. 1, 7 This results in treatment selection by rank rather than evidence. To mitigate: establish structured discussion protocols, ensure all voices are heard, and document rationale for decisions 1, 7.
Logistical Barriers
Scheduling constraints, resource limitations, and communication inefficiencies are recognized barriers 4. Solutions include establishing formal linkages through agreed local guidelines, shared electronic health records, and rapid access pathways to heart failure expertise 2.
Initial Team Dysfunction
Evidence suggests longer-working teams become more pleasant, interactive, and successful, meaning initial experiences may not be positive 1. Maintain the initiative despite early challenges, as it eventually leads to better treatment recommendations and personal wellbeing 1.
Incomplete Team Composition
Absence of necessary specialists compromises evaluation comprehensiveness 6. Ensure all relevant disciplines are present for each case type 6.
Evidence for Clinical Impact
Observational studies demonstrate that Heart Team decisions are reproducible and associated with good outcomes in complex coronary disease, though definitive randomized trial data showing direct patient benefit is lacking. 1 Indirect evidence from both cardiac and oncology fields strongly supports implementation 1. In lung cancer care, multidisciplinary evaluation increases resection rates, treatment rates, and guideline adherence 6.
The Heart Team approach addresses the critical problem that clinical judgment alone results in suboptimal treatment selection – when experienced cardiologists stated treatment preferences before randomization, patient survival was significantly different based on whether the preferred or alternative treatment was given 1.