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No "i" in Heart Team: incentivizing multidisciplinary care in cardiovascular medicine.

The landmark Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, comparing drug-eluting stents with coronary bypass surgery in patients with complex coronary artery disease, was published in 2009.1 Although the trial continues to provide valuable insights regarding selection of coronary revascularization procedures, a particular aspect of its protocol has also generated considerable attention: the “Heart Team.” Although not the first to suggest it, the Heart Team concept was recently popularized by the SYNTAX investigators in their attempt to accommodate an “all-comers” design, streamlining the process for patient selection that had burdened coronary revascularization trials in the past. Instead of using an exhaustive list of explicit inclusion and exclusion criteria, the study protocol simply required that, for the most part, a cardiac surgeon and an interventional cardiologist came together in consensus about the appropriateness of enrolling a patient.

Although the idea of using Heart Teams in this manner did not originate with the SYNTAX trial, the special emphasis placed on it by the investigators was unique and identified as such, even early on, by editorialists and prominent clinicians.2,3 As a result, the notion of encouraging multidisciplinary care in cardiovascular medicine, exemplified by the Heart Team concept, has gained increasing traction in the context of a broad range of procedures that encompass coronary revascularization, transcatheter aortic valve replacement (TAVR), and other complex endovascular interventions. It is widely discussed in the published literature, highlighted at scientific conferences, and, most prominently, incorporated into professional society guidelines. In recent guidelines for coronary revascularization, for example, use of a Heart Team is a class I recommendation during the decision-making process for patients with complex coronary artery disease.4,5

So, what exactly is a Heart Team? In the SYNTAX trial, the idea simply referred to the requirement that, at …