Multidisciplinary Heart Team Research Articles

Improving Cardiovascular Workforce Competencies in Cardio-Obstetrics: Current Challenges and Future Directions.

Maternal mortality in the United States is the highest among all developed nations, partly because of the increased prevalence of cardiovascular disease in pregnancy and beyond. There is growing recognition that specialists involved in caring for obstetric patients with cardiovascular disease need training in the new discipline of cardio‐obstetrics. Training can include integrated formal cardio‐obstetrics curricula in general cardiovascular disease training programs, and developing and disseminating joint cardiac and obstetric societal guidelines. Other efforts to help strengthen the cardio‐obstetric field include increased collaborations and advocacy efforts between stakeholder organizations, development of US‐based registries, and widespread establishment of multidisciplinary pregnancy heart teams. In this review, we present the current challenges in creating a cardio‐obstetrics community, present the growing need for education and training of cardiovascular disease practitioners skilled in the care of obstetric patients, and identify potential solutions and future efforts to improve cardiovascular care of this high‐risk patient population.

Transcatheter Aortic Valve Replacement in the Coronavirus Disease 2019 (COVID-19) Era.

Transcatheter Aortic Valve Replacement in the Coronavirus Disease 2019 (COVID-19) Era.

Multidisciplinary Heart Team Approach for Complex Coronary Artery Disease: Single Center Clinical Presentation.

BackgroundThe Heart Team approach is ascribed a Class I recommendation in contemporary guidelines for revascularization of complex coronary artery disease. However, limited data are available regarding the decision‐making and outcomes of patients based on this strategy.Methods and ResultsOne hundred sixty‐six high‐risk coronary artery disease patients underwent Heart Team evaluation at a single institution between January 2015 and November 2018. We prospectively collected data on demographics, symptoms, Society of Thoracic Surgeons Predicted Risk of Mortality/Synergy Between PCI with Taxus and Cardiac Surgery (STS‐PROM/SYNTAX) scores, mode of revascularization, and outcomes. Mean age was 70.0 years; 122 (73.5%) patients were male. Prevalent comorbidities included diabetes mellitus (51.8%), peripheral artery disease (38.6%), atrial fibrillation (27.1%), end‐stage renal disease on dialysis (13.3%), and chronic obstructive pulmonary disease (21.7%). Eighty‐seven (52.4%) patients had New York Heart Association III‐IV and 112 (67.5%) had Canadian Cardiovascular Society III‐IV symptomatology. Sixty‐seven (40.4%) patients had left main and 118 (71.1%) had 3‐vessel coronary artery disease. The median STS‐PROM was 3.6% (interquartile range 1.9, 8.0) and SYNTAX score was 26 (interquartile range 20, 34). The median number of physicians per Heart Team meeting was 6 (interquartile range 5, 8). Seventy‐nine (47.6%) and 49 (29.5%) patients underwent percutaneous coronary intervention and coronary artery bypass grafting, respectively. With increasing STS‐PROM (low, intermediate, high operative risk), coronary artery bypass graft was performed less often (47.9%, 18.5%, 15.2%) and optimal medical therapy was recommended more often (11.3%, 18.5%, 30.3%). There were no trends in recommendation for coronary artery bypass graft, percutaneous coronary intervention, or optimal medical therapy by SYNTAX score tertiles. In‐hospital and 30‐day mortality was 3.9% and 4.8%, respectively.ConclusionsIntegrating a multidisciplinary Heart Team into institutional practice is feasible and provides a formalized approach to evaluating complex coronary artery disease patients. The comprehensive assessment of surgical, anatomical, and other risk scores using a decision aid may guide appropriate, evidence‐based management within this team‐based construct.

Outcomes of Patients with Chronic Thromboembolic Pulmonary Hypertension Risk Stratified by a Dedicated Heart Team to Receive Pulmonary Endarectomy or Balloon Pulmonary Angiogiplasty

Chronic thromboembolic pulmonary hypertension (CTEPH) is progressive condition characterised by fibro-thrombotic obstruction of pulmonary arteries, and is associated with significant mortality. Given techniques are evolving, there is still considerable variation in the literature regarding surgical and interventional outcomes. This study aims to determine outcomes for CTEPH patients undergoing pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) in specialist pulmonary hypertension unit with treatment modality determined by a multi-disciplinary heart team. This is a retrospective cohort study of all patients undergoing PEA or BPA between 2002 and June 2018. A team of experienced cardiologists, surgeons and interventional radiologists made decisions regarding treatment modality. Both haemodynamic, clinical and procedural outcomes were measured, and comparison was made between treatment groups. Only patients who had available pre- and post intervention right heart catheter data were included in the haemodynamic analysis. A total of 92 patients were included between the PEA group (n=65, age 58 ± 16, m=32, f= 33) and BPA group (n=27, age 65 ± 17, m=15, F=12). For haemodynamic outcomes, a total 52 patients (42 PEA, 10 BPA) were included. There were statistically significant improvements in pulmonary vascular resistance (PVR), mean pulmonary artery pressure (mPAP), mean right atrial pressure and cardiac index. Though the reductions in mPAP (PEA 21 mmHg vs. BPA12.5 mmHg) and PVR (PEA 527 ± 350 dyn.s.cm-5 vs. BPA 304 dyn.s.cm-5) were more marked in the PEA group, there was no statistically significant difference between the groups. There were two deaths (3%) post PEA and one death (3.7%) encountered post-BPA. We conclude, that with careful patient selection and experienced proceduralists, there is significant improvement in haemodynamic outcomes with both surgery and intervention, and an acceptable complication profile.

Evaluation of mode of birth in pregnant women with heart disease

ObjectiveMaternal heart disease (HD) complicates 1–4 % of pregnancies and is associated with adverse maternal and fetal outcomes. Although vaginal birth is generally recommended in the guidelines, cesarean section (CS) rates in women with HD are often high. Aim of the present study was to evaluate mode of birth and pregnancy outcomes in women with HD in a tertiary care hospital in the Netherlands. Study designThe study population consisted of 128 consecutive pregnancies in 99 women with HD, managed by a pregnancy heart team between 2012–2017 and ending in births after 24 weeks’ gestation. Pregnancy risk was assessed per modified World Health Organization class. Mode of birth (planned and performed) and maternal and fetal complications (cardiovascular events, postpartum hemorrhage, prematurity, small for gestational age and death) were assessed for each pregnancy. ResultsPregnancy risk was classified as modified World Health Organization class I in 23 %, class II in 50 %, class III in 21 % and class IV in 6% of pregnancies. Planned mode of birth was vaginal in 114 pregnancies (89 %) and CS in 14 (11 %; nine for obstetric and five for cardiac indication). An unplanned CS was performed in 18 pregnancies (16 %; 16 for obstetric and two for cardiac indications). Overall mode of birth was vaginal in 75 % and CS in 25 %. Twelve cardiovascular events occurred in eight pregnancies (6 %), postpartum hemorrhage in nine (7 %) and small for gestational age in 14 (11 %). No maternal or fetal deaths occurred. ConclusionsFindings of this study indicate that – given that pregnancies are managed and mode of birth is meticulously planned by a multidisciplinary pregnancy heart team – vaginal birth is a suitable option for women with HD.

Transapical transcatheter aortic valve implantation for predominant aortic regurgitation with a self-expandable valve.

BackgroundTranscatheter aortic valve implantation (TAVI) has become the gold standard for high-risk severe aortic stenosis. However, the experience of treating aortic regurgitation (AR) with this technology is still limited. Previously, we have demonstrated excellent 1-year outcomes of transapical TAVI with J-ValveTM (JieCheng Medical Technology Co., Ltd., Suzhou, China) in treating predominant AR, while the mid-term outcomes up to 4 years have never been reported.MethodsTransapical TAVI with J-ValveTM to treat predominant AR was performed in 47 patients in Zhongshan Hospital from May 2014 through October 2018. Procedural and clinical outcomes with follow-up up to 4 years were analyzed using Valve Academic Research Consortium-2 criteria (VARC-2).ResultsAll patients (age 73.7±7.9 years) were considered to be prohibitive or high-risk for surgical aortic valve replacement (SAVR) (logistic European System for Cardiac Operative Risk Evaluation, 21.1% to 44.4%; mean, 24.3%±5.1%) after evaluated by a multidisciplinary heart team. Transapical implantations were successful in all patients. The clinical outcomes of the entire cohort in the latest follow-up (371 to 1,968 days, median 574 days) included all-cause mortality (6.4%), disabling stroke (2.3%), new permanent pacemaker (6.8%) and valve-related re-intervention (0). Paravalvular leak (PVL) was rate as none or trace in 37 of 44 and mild in 7 of 44 patients at the latest follow-up. Mean transvalvular gradient was favorable after valve implantation during follow-up at 9.3±2.5 mmHg.ConclusionsThis study revealed that, transapical TAVI with J-ValveTM for treating AR has encouraging mid-term outcomes, and the advantages at one year demonstrated in previous study can be maintained through 4 years.

Review of alternative access in transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) has surpassed surgical aortic valve replacement (SAVR) as the most common treatment strategy for severe symptomatic aortic stenosis over the past decade. As TAVR technology has continued to advance, it has been expanded from being an option only for extreme risk patients to now being the preferred option for the majority of patients with severe aortic stenosis. Recent trials have shown that TAVR is superior or non-inferior to SAVR even in patients at low surgical risk. One limitation of TAVR is the need for large bore vascular access. This has improved over time with smaller sheath sizes and improved delivery systems, but is still a significant issue in a patient population that often has many comorbidities including peripheral arterial disease. Early in the TAVR experience the only option for alternative access was transapical access, which has consistently been linked to increased procedural complications and worsened clinical outcomes. However, in recent years several centers have demonstrated the safety and efficacy of several alternative access strategies including transaxillary, transcarotid, transcaval, and direct aortic. There are no randomized data comparing these strategies, so access site approach is chosen by the multidisciplinary heart team based on patient anatomy and site expertise. We will review the current data in alternative access that in our view supports prioritizing a transaxillary or transcarotid strategy. In addition, we will describe our center's pre-procedural planning, peri-procedural approach, and propose an algorithm for alternative access.

P862 A conservative strategy for a frequently fatal post-myocardial infarction mechanical complication

Abstract A 88-year-old female was admitted for an anterior ST-segment elevation myocardial infarction (STEMI). Patient had a history of intermittent chest pain for 2 days with worsening on the day of admission. Electrocardiogram (ECG) at admission showed ST-segment elevation on leads from V2 to V6 and leads DI and aVL. Initial observation on the emergency department was described as unremarkable apart from the chest pain. Aspirin and Ticagrelor loading doses were administered and patient underwent emergent coronary angiography, which showed left anterior descendent artery occlusion after the emergence of second diagonal branch. Coronary angioplasty of this lesion was tried, with a total of 3 drug-eluted stents implantation but with no success as in the end there was no reflow of the artery. Patient was then admitted on cardiac intensive care unit, and on observation at that time there was a remarking holosystolic murmur. Transthoracic echocardiogram showed (apart from left ventricle systolic disfunction with akinesia of the apical segments as well as middle segments of the interventricular septum (IVS) and anterior wall) an apical IVS defect with a left to right shunt with a gradient of around 50mmHg evaluated by Doppler, and no signs of right ventricle overload. Case was promptly discussed with cardiothoracic surgery and it was decided that she was not a candidate to urgent surgical intervention. Patient had an initial evolution in Killip class II, and remained hemodynamically stable for the rest of the admission, having no signs of heart failure on discharge at 17 days later. Serial ETTs during admission and at discharge were similar to the evaluation performed at admission. In the meanwhile, during admission, case was discussed in multidisciplinary heart team with cardiothoracic surgery and interventional cardiology. Given the favourable evolution and comorbidities and frailty of the patient it was decided to adopt a conservative strategy with medical follow-up, only considering intervention if there was worsening of heart failure. Until now, with 4 months follow-up, patient remains in New York Heart Association (NYHA) functional class I. Discussion Post-myocardial infarction ventricular septal defect (VSD) is a complication that, regardless of the treatment strategy has a high mortality rate, especially when patient presents in cardiogenic shock. However, when patient is stable and especially when comorbidities imposes a high interventional risk medical treatment can be an option. So far, this is a successful case of a medically managed post-myocardial infarction VSD. Abstract P862 Figure. Ventricular Septal Defect

The Best Approach for Patients with Stable Coronary Disease: The Importance of a Multidisciplinary Heart Team.

Background: A multidisciplinary Heart Team (HT) is nowadays considered to be of great importance for a complete and accurate assessment of patients with stable coronary disease (CAD). This study evaluates the role of the HT approach in the selection of best therapeutic strategies for patients with stable CAD. Methods: The study included 200 patients with stable coronary artery disease. The weekly HT meetings consisted of open discussion taking into consideration the latest recommended therapies. HT outcome options included medical therapy (MT), percutaneous coronary intervention (PCI), or surgical intervention (CABG). Following HT implementation, the 1-, 3-, and 6-month outcomes in addition to the distribution of baseline characteristics were assessed. Results: The following HT strategies were implemented: PCI - 46%, CABG - 10% and MT - 44% of patients. Patients selected for surgical treatment were more likely to have multi-vessel coronary disease (p=0.011). The survival rates at 6 months according to HT strategy were 96.8% for PCI, 95% for CABG, and 94.2% for MT. Conclusions: The HT multidisciplinary decision is mandatory for optimal patient care and can prevent specialty biases. Tertiary care institutions should develop and implement interdisciplinary protocols for common CAD cases.

144 Outcomes of Patients With Chronic Thromboembolic Pulmonary Hypertension Risk Stratified by a Dedicated Heart Team to Receive Pulmonary Endarectomy or Balloon Pulmonary Angiogiplasty

Chronic thromboembolic pulmonary hypertension (CTEPH) is progressive condition characterised by fibro-thrombotic obstruction of pulmonary arteries, and is associated with significant mortality. To determine outcomes for CTEPH patients undergoing pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) in specialist pulmonary hypertension unit with treatment modality determined by a multidisciplinary heart team. This is a retrospective cohort study of all patients undergoing PEA or BPA between 2002 and June 2018. A team of experienced cardiologists, surgeons and interventional radiologists made decisions regarding treatment modality. Both haemodynamic, clinical and procedural outcomes were measured, and comparison was made between treatment groups. Only patients who had available pre- and post intervention right heart catheter data were included in the haemodynamic analysis. A total of 92 patients were included between the PEA group (n=65, age 58±16, m=32, f=33) and BPA group (n=27, age 65±17, m=15, F=12). For haemodynamic outcomes, a total 52 patients (42 PEA, 10 BPA) were included. There were statistically significant improvements in pulmonary vascular resistance (PVR), mean pulmonary artery pressure (mPAP), mean right atrial pressure and cardiac index. Though the reductions in mPAP (PEA 21 mmHg vs BPA12.5 mmHg) and PVR (PEA 527±350 dyn.s.cm-5 vs BPA 304 dyn.s.cm-5) were more marked in the PEA group, there was no statistically significant difference between the groups. There were two deaths (3%) post PEA and one death (3.7%) encountered post-BPA. This is the first centre in Australia to offer PEA and BPA, and the results capture the program. We conclude, that with careful patient selection and experienced proceduralists, there is significant improvement in haemodynamic outcomes with both surgery and intervention, and an acceptable complication profile.

480 Successful anticoagulation treatment of an ascending aortic thrombus associated with myocardial infarction and systemic embolism

Abstract Background The ascending aorta is an uncommon site for non-infective mural thrombus. The detection of such a thrombus is of particular importance, given the risk of systemic and coronary embolisation. We present a case of a 60-year-old female with an ascending aortic thrombus complicated by non-ST-elevation myocardial infarction (NSTEMI), and associated systemic embolism in the form of renal and splenic infarcts. Case Report A 60-year-old female was admitted to a local secondary hospital with a 4-day history of crampy abdominal pain and intermittent bilateral arm pain associated with nausea and vomiting. Past medical history included known hypertrophic cardiomyopathy, gastroesophageal reflux disease, carpal tunnel syndrome, hepatic steatosis, but no known thrombophilia or coronary artery disease. Computer tomography (CT) scan of the abdomen revealed subacute infarction of the right kidney and spleen in keeping with a thrombo-embolic event. A CT pulmonary angiogram revealed a small pulmonary embolus in the right lower lobe. Troponin I level was elevated at 11 mg/L (normal <0.04 mg/L). She was treated with aspirin, clopidogrel and therapeutic enoxaparin for a NSTEMI, and transferred to a metropolitan tertiary centre for ongoing investigation. A transthoracic echocardiogram performed showed known hypertrophic cardiomyopathy, but negative for intracardiac shunting via bubble study. Coronary angiography revealed an acutely occluded distal left anterior descending (LAD) artery with no collaterals, and mild irregularities in all other coronary arteries. A transoesophageal echocardiogram performed to exclude any intracardiac sources of emboli showed a pedunculated and mobile non-calcific mass measuring 1.0cm X 0.5cm in the posterior aspect of the ascending aorta, associated with atheroma in the aortic arch. A laboratory workup for antiphospholipid syndrome, antithrombin III, protein S and protein C deficiency were negative. After discussion with the multidisciplinary Heart team, the consensus was that the aortic mass was likely thrombus formation relating to erosion of aortic atheroma. It was hypothesised that this may have resulted in distal embolisation to the left kidney and spleen, and possibly also caused embolisation to the LAD artery, although the cause of the pulmonary embolism was still unknown. The patient was then discharged on rivaroxaban and aspirin. A repeat transoesophageal echocardiogram was performed 4 months after discharge to assess the ascending aortic mass. It showed complete resolution of the mass in the ascending aorta, with no change in any other cardiac structures. Discussion Although thrombus formation is uncommon in the ascending aorta, certain conditions, such as pregnancy and thrombophilia increase its risk. Several case reports of ascending aortic thrombus were found in the literature, but this will be the first to report complete resolution with treatment using a direct oral anticoagulant. Abstract 480 Figure. Ascending Aortic Thrombus + Resolution

Hemodynamic and Imaging Assessment of Transcatheter Aortic Valve Replacement with the Inovare® Proseal using Multislice Computed Tomography.

ObjectiveTo evaluate the hemodynamic performance (i.e., gradients and paravalvular leakage [PVL]) of the new and experimental Braile Inovare® Proseal. Additionally, we aimed to assess pre and postoperatively the aortic annulus and the transcatheter prosthesis using multislice computed tomography (MSCT).MethodsPatients were selected by a multidisciplinary heart team and referred for transcatheter aortic valve replacement (TAVR). MSCT was performed before and after surgery. Measurements of the aortic valve and prosthesis were conducted and correlated with the valve gradient and residual PVL.ResultsTwenty-one patients were selected for the protocol. Patients had a mean age of 79 years and 38% of them were of female sex. The mean EuroSCORE II value was 12.5%±10.8. Mean gradient was reduced from 45.8±11.04 mmHg to 5.59±2.61 mmHg and there were no instances of PVL worse than mild. There were no cases of coronary obstruction or procedural death. Circularity was present in all prostheses evaluated. Circularity indexes for the prostheses were: inflow 0.05±0.03, middle third 0.04±0.02, and outflow 0.04±0.02 (P=0.08). The mean distance between the prosthesis and the left and right coronary ostia were 14.8 mm±3.3 and 17.3 mm±3, respectively. Oversizing was appropriate with a mean of 22.14%±6%.ConclusionBraile Inovare® Proseal transcatheter device has demonstrated low gradients with low rates of PVL. Oversizing by annular measurements was adequate. MSCT was adequate to evaluate device sizing and has demonstrated preserved expansibility and circularity in the evaluated cases.

Severe Mitral Annular Calcification and Mitral Valve Surgery: An Algorithmic Approach to Management

The management of mitral valve dysfunction in the setting of substantial mitral annular calcification (MAC) remains controversial and is one of the most challenging problems in mitral valve surgery. The physiopathology of severe MAC is related to a combination of progressive, degenerative and active calcium deposition in the annulus that is often multifactorial, but largely attributable to aging and chronic disease conditions. Given the fact that overall life expectancy in the elderly population are increasing, it is imperative to understand contemporary and future therapeutic options since this MAC is likely going to be a frequent problem faced by the next generation of cardiac surgeons. This review provides a relevant synthesis of existing literature and aims to assess the efficacy of existing therapeutic choices for patients with mitral valve dysfunction and 'big' MAC with a goal of minimizing postoperative complications (e.g. left ventricular outflow tract obstruction, prosthetic paravalvular leak, valve embolization, and stroke) that can be achieved via a multidisciplinary heart team approach.

Impact of lung diseases in patients undergoing on transaortic compared with transfemoral TAVI

Lung diseases are associated with higher mortality on patients undergoing on Tanscatheter aortic-valve implantation (TAVI). Impact of lung diseases are poorly investigated on alternative access. His study aim to compare 30-day and 1-year mortality after transaortic (TA) or transfemoral (TF) TAVI on patients with chronic lung diseases. All patients with symptomatic aortic stenosis were consecutively included between January 2012 and January 2016. Spirometry was performed and interpreted by a pneumologyst. Pulmonary diseases were defined according based on spirometric results. The allocation strategy for SAVR or TAVI, the way, the valve selection, was at the discretion of our local multidisciplinary Heart Team. Clinical follow-up was performed by clinical visit or phone consultation. The primary end point was the death from any cause after TAVI. A total of 164 patients were analysed. Comparing 82 TA to 82 TF patients mortality was similar at 30 day (RR = 1.24 (0.52–2.92) P = 0.692). Mortality rates after 1 year was also similar (RR = 1.35 (0.76–2.42), P = 0.308). There was no impact in lenght of hospitalisation (TF: n = 7.2 ± 2 days, TA n = 8 ± 3.3 days P = 0.108) ( Fig. 1 ). In patients undergoing on TAVI, these results suggest that compared with the TF in TA approach lung diseases do not impact mortality. Access selection should not be impact by a lung dieases.

450 Balloon Aortic Valvuloplasty Alone Compared to Medical Therapy is Associated With Improved Long-Term Survival in Patients With Severe Aortic Stenosis

The role of balloon aortic valvuloplasty (BAV) has been questioned in an era of transcatheter aortic valve implantation (TAVI). Whether BAV alone is associated with improved outcomes when compared to medical management of patients with severe aortic stenosis (AS) is unclear. We assessed consecutive patients with echocardiographic evidence of severe AS between 2015-19. Patients were grouped according to the management instituted as determined by the multidisciplinary Heart Team decision; either BAV or medical management. The primary outcome was long-term all-cause mortality. Among the 187 patients with severe AS, 139 (74.3%) underwent medical management while 48 (25.7%) underwent BAV. Patients undergoing BAV were older (81.7 vs 85.8 years, p=0.01) and more likely to be female (33.3% vs 18.6%, p=0.02). No differences in individual covariates of the STS-PROM score or functional characteristics including living/mobility status or cognitive impairment were noted. 77(41.6%) deaths occurred over the study period. Patients treated with BAV had a significantly lower chance of death compared to those managed medically (HR 0.46, 95% CI 0.25-0.86, figure), even after adjustment for significant univariate clinical and functional predictors. In severe AS, BAV was independently associated with lower mortality when compared to medical therapy despite being performed in older patients. Due to limitations in access to TAVI, studies are warranted to assess whether BAV as opposed to medical therapy, can reduce wait-list mortality.

What is new in the 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy?

Summary of key elements of the new 2018 European Society of Cardiology (ESC) guidelines for the management of cardiovascular diseases during pregnancyCardiovascular diseases during pregnancy are the most common causes of pregnancy-associated mortality.Vaginal delivery is the preferred mode of birth in the majority of pregnancies.It is recommended that patients with modified World Health Organization (mWHO) class IV risk are counselled against pregnancy.Patients carrying mWHO II–III, III, and class IV risks should undergo prepregnancy counselling by a multidisciplinary pregnancy heart team to determine a delivery plan and define postpartum care.Specific medications should not be principally withheld in pregnancy but the risk-benefit ratio should be carefully evaluated prior to administration.Beta blockers are recommended during and after pregnancy for congenital long QT syndrome and catecholaminergic polymorphic ventricular tachycardia.Low molecular weight heparin is the ideal substance for prophylaxis and treatment of venous thromboembolism in pregnancy under weekly monitoring of anti-factor Xa activity.

TCT-454 Characteristics and Outcomes of Patients Who Are Denied From a Percutaneous Edge-to-Edge Mitral Valve Repair After Being Referred to a Transcatheter Mitral Valve Program: Impact of a Dedicated Multidisciplinary Mitral Heart Team Approach

TCT-454 Characteristics and Outcomes of Patients Who Are Denied From a Percutaneous Edge-to-Edge Mitral Valve Repair After Being Referred to a Transcatheter Mitral Valve Program: Impact of a Dedicated Multidisciplinary Mitral Heart Team Approach

A multidisciplinary approach in determining of prevalence of coronary artery disease and treatment strategies in patients with pathology of the aorta and peripheral arteries

The treatment of coronary artery disease (CAD) in patients with combined pathology of peripheral arteries who are to perform endovascular or surgical interventions is a difficult task. The most important issues are the adequate diagnostics of artery systems’ lesions, determining the most optimal strategy and stages of treatment. This makes a multidisciplinary approach with the involvement of various specialists the most optimal.Aim. Based on multidisciplinary approach, to determine the prevalence of CAD and treatment strategy in patients with lesions of the aorta and peripheral arteries.8Material and methods. The study included 693 patients with pathology of the aorta and peripheral arteries: 171 (32,5%) were female, and 522 (75,3%) were male. The age of patients ranged from 29 to 93 years, an average — 67,2+8,8 years. Also 32,5% of patients (n=223) were older than 71 years. Cardiac complaints were present only in 203 (29,3%) patients, while 490 (70,7%) were asymptomatic. The majority of 693 patients had an isolated lesion of the internal carotid artery (ICA) (n=196, 28,3%), a combined lesion of the ICA and lower limb arteries (n=93, 13,4%), a combined lesion of the iliac and superficial femoral arteries (n=70, 10,1%) and femoral arteries lesions (n=60, 8,6%).Results. Finally, 554 (79,9%) of 693 patients had lesions of at least one coronary artery more than 50%, while 368 (66,4%) of them were clinically asymptomatic. By the decision of the multidisciplinary heart team, 316 (57,0%) patients underwent myocardial revascularization operations: 21 (6,7%) — coronary artery bypass grafting and 295 (50,3%) — percutaneous coronary intervention. Surgical and endovascular operations for pathology of the aorta and peripheral arteries were performed in 486 (70,1%) of 693 patients. Unlike with 260 (53,5%) patients, in 226 (46,5%) patients, in addition to vascular surgery, myocardial revascularization was performed. As a result of 923 (564 endovascular and 359 surgical) operations performed in 580 patients at the hospital stage, 3 (0,51%) of them had a fatal outcome. In other 2 (0,56%) cases, there was stroke: in one case after ICA prosthetics, in the other case — thrombosis of the ICA after the carotid endarterectomy. Acute myocardial infarction at the hospital stage was not detected in any of the patients.Conclusion. In 79,9% of patients with atherosclerosis of the aorta and peripheral arteries, at least one coronary artery lesion of more than 50% is detected. In 66,4% of patients with pathology of the aorta and peripheral arteries and with lesions of the coronary arteries of more than 50%, there are no cardiac complaints. In 45,6% of patients hospitalized with a diagnosis of atherosclerotic lesions of the aorta and peripheral arteries, myocardial revascularization is required. A multidisciplinary approach is an effective and safe treatment strategy for patients with pathology of the aorta and peripheral arteries of atherosclerotic origin and concomitant CAD.

Impact of Hierarchy on Multidisciplinary Heart-Team Recommendations in Patients with Isolated Multivessel Coronary Artery Disease.

Background: The Heart Team (HT) discussion has been incorporated in the current guidelines for myocardial revascularization in order to optimize treatment decisions for patients with multivessel coronary disease (MVD). There are no data in the literature, whether hierarchical issues do have an impact on HT decisions. We aimed to analyze the therapeutic recommendations of the multidisciplinary “Heart Team” (HT) for coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) if: (a) The head of cardiovascular surgery (HOS) and the head of cardiology (HOC) were present during the HT meeting, (b) both directors were absent, (c) only HOS or HOC was present. Methods: Retrospective analysis of all HT discussions between 2012 and 2015 in patients with isolated MVD (without any other cardiac problems requiring surgery). Results: During the study period, we analyzed 209 HT discussions in patients with isolated MVD. If neither HOS nor HOC was present at the HT discussion, the therapeutic recommendation was in 69% CABG and 31% PCI. If HOS and HOC were present in 77% CABG and 23% PCI was recommended (p = 0.34). If only HOS was present therapeutic recommendation was in 83% CABG and 17% PCI, and if only HOC was present the recommendation was in 54% CABG and 46% PCI (p < 0.0001). This difference did not attenuate during the study period. Conclusions: The hierarchy of the participating physicians significantly impacts treatment recommendations of a multidisciplinary HT in patients with isolated MVD. This impact did not attenuate after several years of Heart Team interaction.

Multidisciplinary transcatheter aortic valve replacement heart team programme improves mortality in aortic stenosis

ObjectivesTo analyse the effect of the implementation of a transcatheter aortic valve replacement (TAVR) and multidisciplinary heart team programme on mortality in severe aortic stenosis (AS).MethodsA retrospective, observational cohort study...