The Heart Team: Getting a Complete Picture
How specialists work together to keep your heart healthy
Interventional cardiology is a rapidly advancing field that offers minimally invasive treatment options for a variety of heart conditions. But the most effective care recognizes that every patient is an individual—what works for one person may not be the best strategy for another. The Heart Team concept was developed to encourage clinicians to collaborate and consider every option and help patients make informed choices about their care.
At a Glance
- The Heart Team is a patient-centric care model that brings different cardiac specialists together to review a case and provide their recommendations for the best treatment strategy.
- The team includes interventional cardiologists, cardiac surgeons, imaging specialists, and the patient’s general cardiologist. The final decision is always made by the patient and their caregivers.
- Because patients can learn about all of the options available to them, they can make a more informed decision—and clinicians can benefit from fresh perspectives and opinions from their peers.
- There are practical challenges for successfully and effectively using a Heart Team model, and its effectiveness can vary based on how it is implemented.
- Once used primarily for supporting transcatheter aortic valve replacement (TAVR), the Heart Team approach is being used for a growing list of treatments and new devices and to determine care options for additional heart conditions.
What Is a Heart Team?
The Heart Team is a collaborative model that allows multiple cardiac specialists—interventional cardiologists, cardiac surgeons, cardiovascular imaging specialists, and general cardiologists, among others—to review a patient’s condition together and offer their recommendations for treatment. By discussing the specifics of each case as a group, the specialists can thoroughly explore and vet the pros and cons of each treatment option.
This multidisciplinary approach has become an essential part of modern medicine. Coordinating care across different disciplines—or even within a specialty, such as cardiology—has been shown to provide the best outcomes. Tumor boards for cancer treatment and the formal coordination between heart failure and transplant teams are proven models that have become the standard.
The Heart Team is unique in that it encourages two highly specialized areas that are often perceived as competing—interventional cardiology and cardiac surgery—to work together. Many interventional procedures for valve and structural heart conditions are initially reserved for cases that are considered too high risk for surgery. But as interventional treatments become available to a wider population, a well-designed and coordinated Heart Team can help make sure that these two disciplines can complement each other effectively.
The concept was established to support early clinical trials for transcatheter valve replacement. “From a historical perspective, the Heart Team was really a new concept when early transcatheter aortic valve replacement (TAVR) trials were being conducted,” says Tamim Nazif, MD, an interventional cardiologist at Columbia. “To the credit of some of the early interventional and surgical pioneers working with TAVR, they recognized the value of taking a very intentional, deliberate approach. It helped make sure that every patient was seen and equally assessed in a patient-centered fashion by both the surgeon and the interventionalist.”
Exploring All Options
A Heart Team meeting brings experts together to discuss a patient’s case details. “At the Heart Team meeting, you sit down with everyone: all the doctors are present, and we review the patient's information together,” explains Dr. Nazif. “After we explore everything, we discuss the available options. We go through all the risks and benefits of each therapy. For complex cases, we might ask other doctors to weigh in. Is TAVR appropriate? Should we consider a mechanical valve? We discuss everything.”
Having a number of expert opinions can help form a consensus in difficult cases. “At an institution like Columbia, we're lucky to have several interventional cardiologists, several imaging experts, and several cardiothoracic surgeons—and all leading experts in their field,” says Dr. Nazif.
Once all the options have been considered, the team presents their recommendations to the patient. The patient’s general cardiologist may be included as well and can be an important part of the decision-making process. “We're seeing them at one point in time, while they may have a long relationship with their general cardiologist—so they often know the patient and their family very well,” notes Dr. Nazif. Patients may be brought in for a second visit if more information can help resolve questions that come up during the meeting.
But the final decision rests with the patient and their caregivers. “We let them know our conclusion, and explain how we made this determination,” says Dr. Nazif. “We explain the risks and the benefits, but we also ask the patient, What do you think? What do you want? Because the ultimate decision rests with the patient.”
Benefits of the Heart Team
The Heart Team helps keep the focus on the patient. “If you’re told that you could see one doctor or you could see a team of doctors—ideally together—and be offered their perspectives on what might be best for you—I think most patients would jump at that second opportunity,” says Dr. Nazif.
But the Heart Team offers benefits to the cardiologists, as well. As diagnostic technology and treatment continue to develop at a rapid pace, the Heart Team can help avoid a tunnel-vision approach to care, where specialists only advocate for their area of expertise. The different perspectives can lead to surprising results.
“In the beginning, I always assumed that as the interventional cardiologist, I would be arguing for TAVR and the surgeon would be arguing for surgery. But there have been many cases where I really felt strongly that the patient should have surgery, and the surgeon felt that the patient should have transcatheter therapy,” notes Dr. Nazif. “That can be kind of a neat experience: to sort of play devil's advocate and find yourself on the other side of the fence. It happens more frequently than you might imagine. And I really think that benefits the patient.”
What Are the Challenges?
Making the Heart Team approach work requires a lot of coordination, which can be a challenge for some organizations. “Here at Columbia, we actually have a clinic where we see the patients together at the same time,” says Dr. Nazif. “So you have a patient in a room and the doctors—both the interventional cardiologist and the cardiac surgeon together—go into the room and talk to the patient at the same time.”
That approach can be challenging for a number of reasons. “There are real difficulties in terms of coordinating busy schedules or for reimbursement structures,” says Dr. Nazif. “At Columbia, we've been able to idealize that process, but many organizations have struggled with that.”
And as with any collaboration, there’s always a risk of egos or territorial mindsets. A team approach is only effective if the members are able to communicate and work together. But a well-designed Heart Team maintains a patient-centered focus—and that benefits the institution as well. “Here at Columbia, all of our experts really work together on a collaborative basis, so it actually brings the fields closer,” notes Dr. Nazif. “And that ultimately serves everyone—the institution, the doctors, and most importantly, the patient.”
But for the Heart Team model to be most effective, it needs to be used consistently. “You won’t find a patient that has been offered TAVR that hasn't had the opportunity to speak with both the interventional cardiologist and the cardiac surgeon,” explains Dr. Nazif. “But there are certainly patients that are referred directly for surgical aortic valve replacement that don't have the opportunity to see an interventional cardiologist or to learn about TAVR.”
Patients can only make fully informed decisions about their care if they have the necessary information. “I think that it shouldn't just be high-risk patients or patients that are being considered for a transcatheter approach,” says Dr. Nazif. “It should be all patients with a given disease. I think it’s to the benefit of the patient to have the opportunity to hear from both doctors and have both perspectives.”
The Future of the Heart Team
As new treatments and devices become available, the Heart Team is evolving to meet those needs as well. “Even going back five years ago, a Heart Team meeting was basically a TAVR meeting,” notes Dr. Nazif. “Now, because of the different options that have become available, we're reviewing additional types of procedures, including mitral and tricuspid therapies. So while the concept started in TAVR, it has grown to accommodate different types of hybrid or percutaneous procedures.”
And that requires new perspectives from other specialties as well. Mitral valve issues, for example, may mean heart failure is also a factor. “We’ve added a second Heart Team meeting that includes a heart failure specialist,” explains Dr. Nazif. In addition, a heart patient with cancer or lung disease may require input from an oncologist or a pulmonologist. Expanding the team to include other specialties can help leverage the collective advances in these fields—and help make sure that the patient can get all the information they need.
Research on the effectiveness of the formal Heart Team approach and its impact on patient outcomes is growing. But initial data points to strong improvements in patient mortality, reduced rehospitalization, and high patient satisfaction.
As more information becomes available about the benefits of the Heart Team approach, the strategy may evolve into a more universal approach. “If we could have all patients with a given disease, such as aortic stenosis or mitral regurgitation, have the opportunity to see the Heart Team, I think that would be in the best interests of the patient,” says Dr. Nazif.