Heart Teams in coronary artery disease

Abstract

The concept of the Heart Team consisting of at least a cardiac surgeon and an interventional cardiologist in guiding decision-making on the optimal revascularization modality in patients with complex coronary artery disease has had a relatively short history. Prior to the publication of the landmark randomized SYNTAX trial in 2009, decision-making between coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) in patients with complex coronary artery disease was very much at the discretion of the interventional cardiologist, who acted as the ‘gatekeeper’. Such an approach appropriately drew heavy criticism from cardiac surgeons and the cardiology community alike, since patients with complex coronary artery disease were being denied evidence-based surgical revascularization, and undergoing the then non-evidenced-based practice of multivessel PCI. The SYNTAX trial was designed to overcome the historical limitations of the trial data comparing CABG with PCI, by incorporating an all-comers design, in which practically no patient was refused entry. Notably, SYNTAX represented the largest assessment of revascularization with CABG or PCI in subjects with complex coronary artery disease, and aimed to supply a body of evidence to support the then rapidly expanding practice of multivessel PCI. Since publication of the SYNTAX trial, it is noteworthy that the Heart Team approach is advocated in both European and US revascularization guidelines, with the Heart Team given a class I recommendation. The role of the heart team in the management of complex coronary artery disease and the use of clinical tools to aid this process are fully explored in this chapter.