Thank you so much for the kind invitation, Mauricio. And I'm going to talk a little bit about the importance of the heart team for coronary revascularization with specific mention of the current guidelines. As Mauricio mentioned, I don't have any financial relationships and my only disclosure is that I'm a cardiac surgeon. We're going to be talking about the 2021 ACC AHA Sky Guidelines that just came out last year. And the current guideline recommendation is at the top of the screen. The use of a heart team is now a class of recommendation one, level of evidence B non-randomized. And it's in patients for whom the optimal treatment strategy is unclear. A heart team approach that includes representatives from interventional cardiology, cardiac surgery and clinical cardiology is recommended to improve patient outcomes. And on this slide, I have the past recommendation from the American Heart Association in the middle, which was a 1C in 2011. And then the European guidelines from 2018, a heart team approach is actually a 1C recommendation. When we think about patients with coronary artery disease and types of revascularization, these are some of the things that we think about. And it is a little bit bent towards the surgeon point of view in terms of thinking about conduit, whether it be arterial or venous and the stenosis, but certainly the patient's comorbidities weigh in very heavily. We often will calculate the society of thoracic surgeons predicted risk of mortality. We'll take into consideration the acuity of the patient and was there an acute coronary syndrome, if they're going to be adherent to medications and what the consequences will be if the revascularization strategy fails. I would say clinically in my institution, we don't do the syntax score regularly, but we do consider anatomy, completeness of revascularization, perceived lifespan, and myocardial viability. But what's also important about the new guidelines is the involvement of the patient in decision making. And what about the patient, again, complex anatomy involving the left main. And here we can see a left main trifurcation with occlusion of the CERC and diffuse disease in the LAD. And on the far right, a reminder that many of these patients come to us with reduced left ventricular ejection fraction already. And so these are some of the factors that are in the current guidelines for consideration by the HEART team. And I've highlighted with the underlying text under the guiding principle, it's typically for patients with complex disease, multiple comorbid conditions that may impact the success of the revascularization strategy, and also other clinical or social situations, such as medication adherence. And those are listed here in detail, not only the anatomy, the multiple comorbidities that may weigh into a decision, particularly if someone has a calcified aorta that will not permit a cross clamp or aortic cannulation, procedural factors, is it technically possible to do PCI, and other patient factors that come into play. Because every patient is, after all, unique. This is a nice diagram that Tom Metkus did for this article that sort of lists on the left the different situations where a HEART team may be involved. Left main disease, complex disease, as I said, multiple comorbidities, including diabetes, peripheral artery disease, unique clinical scenarios or other problems, or procedural issues. And in the middle, he's listed multiple people who may be in a HEART team discussion, and it may be different or defined differently at different institutions. Importantly in the circle, the patient preferences and wishes and expectations, and then the risks and benefits of each, including the risks and benefits of doing nothing or only medical therapy, and then treatment decision, and what's important is also outcome assessment. Much of the data supporting a HEART team approach is retrospective data and not randomized. This is from an article by Pat O'Gara and colleagues, where they talk about the use of a HEART team and how it began originally in trials such as the Syntax and the Partner Trials, where cardiologists and surgeons got together to discuss enrollment for patients in these trials. And it's sort of, for those of us that trained in cardiothoracic surgery, it's similar to what would be a tumor board, where we discuss complex patients with a multidisciplinary group, and patients now tend to be more demanding, and they really want transparency about the different options, and they're much more educated. So these are some of the recommendations they made to utilize clear and common definitions of what a HEART team is, and what the roles of the members are, and then gather the metrics on outcomes. I think that will be very important going forward, is that we have good data and more outcomes data to support the use of the HEART team, and then also clinician outcomes and metrics for the health system. This is another table from that same paper, where they evaluated different outcomes that could be measured at your institution. If you want to have a HEART team, you could look at the desired outcome of improved knowledge by doing a survey. You could do the percentage of patients who have shared decision making, or what the decisions are of your HEART team, etc. This is a summary on a slide that Tom Metkus kindly shared with me, of a study that they looked at about 170 patients that had a HEART team discussion. You can see on the top right, they looked at medical therapy in blue, PCI in red, and CABG in green. At the top, if the STS score went up from 4% to greater than 8%, you could see CABG in green went down. However, when they looked at calculation of syntax score by the HEART team, there's really no difference between the different syntax scores. And so Dr. Metkus stresses the importance of collegiality also at our own institution and mutual respect when we have our HEART team discussions, and that we need to try to have consensus, and that we can parlay this into being a quality assessment for our institution. Here's the graph that he made for Johns Hopkins, where we have a HEART team discussion either at the clinic setting, say for a TAVR clinic, or in the ward, or a HAL line, which is where a clinician can call in from an outside hospital and get an opinion over the phone. So at our institution, we have a weekly meeting on Friday mornings. It's about an hour. We always have interventional cardiology, non-interventional cardiology, and surgeons in the group, and a variety of other people. It's also a very good educational hour for fellows who are learning how to make decisions. We can activate it via phone or at the bedside, and we come up with treatment decisions. This is the form that we use to fill out with each HEART team discussion. What are the results of the studies? What were the opinions? And currently, we do it via Zoom, and it can be ad hoc and spontaneous. We typically do calculate the STS predicted risk of mortality, and we often will bring patients to this meeting if the treatment decision is unclear. They may have unique or difficult anatomy. We look at echoes. We look at caths, obviously. They may have unique diseases, and we may involve ethics or infectious disease or oncology, and sometimes there is just brainstorming going on, and some of the topics that come up and the options that come up are things, frankly, that I may never have even heard of. It's kind of like you get a bunch of smart people together, and you really get an education yourself. We often, it's a benefit to the patient because we often have a rapid decision after the meeting, and then we can go back to the patient and the family at the bedside and say, a group of experts evaluated your anatomy, and this is the consensus from the group of experts what we think would be the best treatment, but ultimately, as we mentioned before, patient decision-making is also very important. And these are some of the benefits of our team that were listed in these papers, and if you look at the table one at the bottom from the Ogera paper, they have potential benefits not only to the patient but the clinician and the health system, improving knowledge, greater satisfaction in the clinicians, which is something I hadn't even thought of as a benefit of our team, improved quality of life for the patient, and then, of course, greater adherence to guidelines, lowering readmission rates, shorter length of stay, faster time to decision and lower cost could all be outcomes that we could measure using a heart team. So I thank you for your attention. This is a slide that is from the European guidelines that helps determine sometimes in our heart team discussion where patients may be more appropriate for CABG, for example, if they have a contraindication or lack of adherence to DAPT or high syntax score or severe calcified lesions and where they would be more favored to PCI. Thank you so much for the opportunity to talk to you about the importance of a heart team discussion for our patients.

heart team

coronary revascularization

patient outcomes

decision-making

retrospective data