JACC: ADVANCES VOL. -, NO.

-, 2023
ª 2023 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN

COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER

THE CC BY LICENSE (http://creativecommons.org/licenses/by/4.0/).

EXPERT PANEL

The Multidisciplinary Heart Team in

Cardiovascular Medicine
Current Role and Future Challenges

Wayne B. Batchelor, MD, MHS,a Saif Anwaruddin, MD,b Dee Wang, MD,c Elizabeth M. Perpetua, DNP,d,e
Ashok Krishnaswami, MD, MAS,f,g Poonam Velugapudi, MD,h Janet F. Wyman, DNP,i David Fullerton, MD,j
Patricia Keegan, DNP,k Alistair Phillips, MD,l Laura Ross, PA-C,m Brij Maini, MD,n Gwen Bernacki, MD, MHSA,o,p
Gurusher S. Panjrath, MD,q James Lee, MD,c Jeffrey B. Geske, MD,r Fred Welt, MD,s Prashanth D. Thakker, MD,t
Anita Deswal, MD, MPH,u Ki Park,v Michael J. Mack, MD,w Martin Leon, MD,x Sandra Lewis, MD,y David Holmes, MDz

ABSTRACT

Cardiovascular multidisciplinary heart teams (MDHTs) have evolved significantly over the past decade. These teams play
a central role in the treatment of a wide array of cardiovascular diseases affecting interventional cardiology, cardiac
surgery, interventional imaging, advanced heart failure, adult congenital heart disease, cardio-oncology, and cardio-
obstetrics. To meet the specific needs of both patients and heart programs, the composition and function of cardio-
vascular MDHTs have had to adapt and evolve. Although lessons have been learned from multidisciplinary cancer care,
best practices for the operation of cardiovascular MDHTs have yet to be defined, and the evidence base supporting their
effectiveness is limited. This expert panel review discusses the history and evolution of cardiovascular MDHTs, their
composition and role in treating patients across a broad spectrum of disciplines, basic tenets for successful operation, and
the future challenges facing them. (JACC Adv 2023;-:100160) © 2023 The Authors. Published by Elsevier on behalf of
the American College of Cardiology Foundation. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

From the aACC Interventional Cardiology Section Leadership Council, Inova Heart and Vascular Institute, Falls Church, Virginia,
USA; bDivision of Cardiology, ACC Interventional Section Leadership Council, St. Vincent Hospital, Worcester, Massachusetts,
USA; cACC Cardiovascular Imaging Section Leadership Council, Center for Structural Heart Disease, Henry Ford Hospital, Detroit,
Michigan, USA; dACC Cardiovascular Team Section Leadership Council, Empath Health Services, Seattle, Washington, USA;
e
Seattle Pacific University, School of Health Sciences and School of Nursing, Seattle, Washington, USA; fDivision of Cardiology,
ACC Geriatric Cardiology Section Leadership Council, Kaiser Permanente San Jose Medical Center, San Jose, California, USA;
g
Division of Geriatrics, Stanford University School of Medicine, Stanford, California, USA; hDivision of Cardiology, ACC Early
Career Professionals Section Leadership Council, University of Nebraska Medical Center, Omaha, Nebraska, USA; iACC Cardio-
vascular Team Section Leadership Council, Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan,
USA; jDivision of Cardiothoracic Surgery, Department of Surgery, ACC Cardiac Surgery Team Section Leadership Council, Uni-
versity of Colorado School of Medicine, Aurora, Colorado, USA; kDivision of Cardiology, ACC Cardiovascular Team Section
Leadership Council, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA;
l
ACC Cardiac Surgery Team Section Leadership Council, The Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland,
m
Ohio, USA; ACC Interventional Cardiology Section Leadership Council, Park Nicollet Heart and Vascular Center, St. Louis Park,
Massachusetts, USA; nCharles E. Schmidt College of Medicine, Florida Atlantic University, Delray Medical Center, Delray Beach,
Florida, USA; oCardiovascular Division, Department of Medicine, ACC Geriatric Section Leadership Council, Cambia Palliative Care
Center of Excellence, University of Washington, Seattle, Washington, USA; pVeterans Administration of Puget Sound, University
of Washington School of Medicine, Seattle, Washington, USA; qACC Heart Failure and Transplant Section Leadership Council,
George Washington University School of Medicine and Health Sciences, Washington, DC, USA; rDepartment of Cardiovascular
Medicine, ACC Cardiovascular Imaging Section Leadership Council, Mayo Clinic, Rochester, Minnesota, USA; sDivision of Car-
diovascular Medicine, ACC Interventional Cardiology Leadership Council, University of Utah Health Sciences Center, Salt Lake
City, Utah, USA; tCardiovascular Division, Department of Medicine, ACC Fellows in Training Section Leadership Council, Wash-
ington University, Saint Louis, Missouri, USA; uDivision of Internal Medicine, Department of Cardiology, ACC Cardio-Oncology

ISSN 2772-963X https://doi.org/10.1016/j.jacadv.2022.100160

2 Batchelor et al JACC: ADVANCES, VOL. -, NO. -, 2023
Evolution of the Multidisciplinary Heart Team in Cardiovascular Medicine - 2023:100160

ABBREVIATIONS BRIEF HISTORY OF THE

AND ACRONYMS HIGHLIGHTS
MULTIDISCIPLINARY HEART TEAM

The MDHT team plays a central role in the
ACHD = adult congenital heart
disease
Driven by a need to bring together multiple treatment of a broad array of complex
specialists to render highly individualized diseases across multiple cardiovascular
AS = aortic stenosis
treatment protocols, cancer care and solid medicine subspecialties.
CABG = coronary artery bypass
graft surgery organ transplantation programs have used

There is no widely accepted standard on
CAD = coronary artery disease
multidisciplinary teams for decades. 1,2 In
the composition and function of cardio-
fact, multidisciplinary team care is now
TAVR = transcatheter aortic
vascular MDHTs and the processes for
valve replacement widely accepted as the preferred model for
rendering treatment decisions.
VHD = valvular heart disease many cancer treatments. 1 The use of a
multidisciplinary heart team (MDHT) in car-
Key principles exist for the effective
diovascular medicine has origins in clinical trials operationalization of the MDHT.
comparing myocardial revascularization strategies for

MDHTs must adapt to the specific needs
coronary artery disease (CAD)3-6 and subsequent
of the patient and changing landscape of
studies evaluating transcatheter aortic valve
cardiovascular therapies.
replacement (TAVR) for aortic stenosis (AS)7,8 which
required discussion among a cardiac surgeon, inter-
Further research is required to determine
ventional cardiologist, and interventional imaging best practices for cardiovascular MDHTs
physician. In these circumstances, the primary and their impact on team efficiency and
objective of the MDHT was to form consensus on satisfaction and patient outcomes.
treatment decisions in complex patients for whom
both surgical and percutaneous interventions were
available, each with its own corresponding risks and and for patients with left main and multivessel CAD
benefits. who are being considered for PCI or CABG.10-12 These
The use of a cardiovascular MDHT was first applied recommendations have been further codified by the
in the SYNTAX (Synergy Between PCI with Taxus and Centers for Medicare & Medicaid Services (CMS) Na-
Cardiac Surgery) trial, in which a cardiac surgeon and tional Coverage Decisions for TAVR and transcatheter
interventional cardiologist were required to docu- mitral valve edge-to-edge repair, for which MDHT
ment clinical equipoise between coronary artery evaluation has become a requirement for pay-
bypass graft surgery (CABG) and percutaneous coro- ment.13,14 Beyond myocardial revascularization de-
nary intervention (PCI).5 Official clinical endorsement cisions (PCI vs CABG) and VHD, there are multiple
of the MDHT was later issued by the 2014 European other fields of cardiovascular medicine that depend
Society of Cardiology/European Association for on MDHT input, including advanced heart failure
Cardio-thoracic Surgery revascularization guidelines, (HF) and cardiac transplantation, adult congenital
which put forth a Class IC recommendation for MDHT heart disease (ACHD), cardio-oncology, cardio-ob-
assessment in patients for whom decision-making stetrics, and geriatric cardiology. Therefore, contem-
was complex and/or not covered by an institutional porary MDHTs must continually adapt to the
protocol.9 Since then, the MDHT has received Class I changing needs and increasing number of patients
recommendations in both the United States and Eu- considered for advanced therapies that span broad
ropean guidelines for valvular heart disease (VHD) cardiovascular disciplines.

Leadership Council, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; vDivision of Cardiovascular
Medicine, ACC Interventional Cardiology Section Leadership Council, University of Florida College of Medicine, Malcom Randall
VA Medical Center, Gainesville, Florida, USA; wDivision of Cardiothoracic Surgery, Department of Surgery, ACC Cardiac Surgery
Team Section Leadership Council, Baylor Scott and White Health, Dallas, Texas, USA; xDivision of Cardiology, Department of
Medicine, ACC Leon Center Leadership Council, Columbia University Irving Medical Center, New York, New York, USA; yACC
Section Steering Committee, Legacy Medical Group Cardiology, Portland, Oregon, USA; and the zDepartment of Cardiovascular
Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Michael Landzberg, MD, served as Guest Editor and Guest Editor-in-Chief for this paper.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the Author Center.

Manuscript received August 23, 2022; accepted October 17, 2022.

JACC: ADVANCES, VOL. -, NO. -, 2023 Batchelor et al 3
- 2023:100160 Evolution of the Multidisciplinary Heart Team in Cardiovascular Medicine

F I G U R E 1 Key Principles for the Effective Operation of the MDHT and its Core Responsibilities

MDHT ¼ multidisciplinary heart team; QI ¼ quality improvement.

COMPOSITION AND STRUCTURE OF THE MDHT members (ie, pulmonary medicine specialists,
vascular medicine/surgical specialists, neurologists,
Although there is no universally accepted structure nephrologists, and others) may provide valuable
for the cardiovascular MDHT, our conceptual frame- input. Although this construct of MDHT structure and
work of the MDHT places the patient at the top, aided composition (Central Illustration) provides a useful
by a team of health care professionals who work conceptual framework, there is no widely accepted
collaboratively throughout the patient’s continuum standard, as MDHTs may vary both within and across
of care (Central Illustration). Core team members are cardiovascular subspecialties, and the distinction
typically comprised of the key health care personnel between core and extended team members is some-
involved in the routine evaluation and treatment of what arbitrary. However structured, successful
the patient during various phases of care. Involve- MDHTs must possess the collective expertise neces-
ment of the patient’s family and/or close friend(s) sary to manage a wide range of complex disease
may add perspective, empower the patient, enhance scenarios and flexible enough to adjust to the unique
informed consent, and improve overall patient satis- needs of the individual patient.
faction.15 Given that treatment decisions require a
firm understanding of procedural risks and benefits, CONTEMPORARY ROLE OF THE MDHT IN
quality of life/functional status, patient expectations, CLINICAL PRACTICE
and health values, this additional input is often
essential, especially in older adults with frailty and/or Although best known for their role in VHD, cardio-
cognitive impairment. Depending on the clinical vascular MDHTs are routinely used in a wide range of
scenario and phase of care, other extended MDHT clinical scenarios. To follow is a discussion of how
4 Batchelor et al JACC: ADVANCES, VOL. -, NO. -, 2023
Evolution of the Multidisciplinary Heart Team in Cardiovascular Medicine - 2023:100160

C E NT R AL IL L U STR AT IO N Conceptual Framework for the MDHT

Batchelor WB, et al. JACC Adv. 2023;-(-):100160.

The figure depicts the relationships between the key entities involved in the multidisciplinary care of patients with complex cardiovascular disease. Typical members of
the core and extended teams and responsibilities of hospital administration are shown. The arrows highlight the relationships and communication that exist between
these entities. Tier 2 program multidisciplinary heart teams (MDHTs) may share the same internal components as a tier 1 program. The Central Illustration was
completed through a collaboration of Devon Stuart (Devon Medical Art) and Mary Kate Wright (MK Illustrations).

MDHTs play an important role in: 1) VHD; 2) interpretation of multimodality cardiac imaging and
myocardial revascularization decisions (PCI vs invasive hemodynamics are often necessary for the
CABG); 3) advanced HF and cardiac transplantation; evaluation of patients with complex VHD. In this
4) ACHD; 5) cardio-oncology; 6) cardio-obstetrics; and setting, optimal interpretation of cardiac imaging
7) geriatric cardiology. Clinical case examples that data often requires input from a structural heart
illustrate the role of the MDHT in these scenarios are interventional imaging physician. For patients in
presented in Table 1. need of valve repair or replacement, the MDHT must
formulate a recommendation for either transcatheter
ROLE OF THE MDHT IN EVALUATING PATIENTS WITH or surgical intervention. This process should take into
VHD. As previously mentioned, the MDHT has account individual patient preferences and health
become firmly embedded in the care of the VHD pa- values through the use of shared decision-making17
tient. The roles of the MDHT in this setting are to while satisfying the CMS criteria of being “reason-
evaluate the patient’s severity of disease, determine able and necessary”, which are required
which, if any, interventions are appropriate, and to for payment.11,16
discuss the risks, benefits, and alternatives of avail- TAVR, the most frequently performed VHD pro-
able treatment options with the patient. 11,16 Thorough cedure, is currently approved for low-, intermediate-,
assessment of patients’ symptoms and accurate and high-risk patients with AS. Therefore, it is
JACC: ADVANCES, VOL. -, NO. -, 2023 Batchelor et al 5
- 2023:100160 Evolution of the Multidisciplinary Heart Team in Cardiovascular Medicine

T A B L E 1 Case Examples Depicting the Role of MDHT

Recommended MDHT
Case Examples Treatment Options Members Key MDHT Functions

A 78-y-old frail woman with type II DM who walks PCI vs CABG vs Med Rx CC, IC, CTS, APC, GM, 1. Assess medications, frailty, nutritional status, physical &
with a cane and presents with a non-STEMI, 3V Neph cognitive functioning
CAD (Syntax score 32), acute on chronic stage III 2. Anatomic suitability for CABG vs PCI
CKD, LVEF 40%, and “forgetfulness” 3. SDM: CABG vs PCI vs Med Rx
4. Prevent/treat ARF before and after intervention
A 64-y-old man with symptomatic, severe Sievers I TAVR vs SAVR IC, CTS, ACI, APC, 1. Assess COPD severity and optimize Rx
bicuspid AS, COPD, LVEF 45%, and an ascending PMS 2. Assess bicuspid AV and raphe calcification, annulus size, and
thoracic aorta diameter of 4.4 cm who “prefers” LVOT calcification.
TAVR. 3. TAVR vs SAVR  repair of TAA
4. TAVR: delineate long-term follow-up for TAA
A 52-y-old man with a history of remote mantle Mitral TEER vs Surgical IC, EP, CTS, ACI, HFC, 1. Optimize GDMT and consider CRT-D
radiation for Hodgkin’s disease who presents MVr/MVR vs TMVR vs APC, Hem 2. Determine MR etiology (primary vs secondary) and reassess
with acute HF, LBBB, LVEF 30%, Med Rx severity after optimal GDMT and CRT-D
thrombocytopenia, and severe MR due to 3. Assess suitability for TEER vs surgical MVr/MVR vs TMVR
annular dilatation and mild P2 posterior leaflet (within clinical study)
mitral valve prolapse. 4. Determine cause of thrombocytopenia
5. SDM: decision on above MR therapies
An 81-y-old man with a history of treated multiple TAVR vs Med Rx vs HFC, IC, ACI, 1. Assess medications, frailty, nutritional status, physical &
myeloma, primary (AL) cardiac amyloidosis, Hospice care CTS, GM, APC, cognitive functioning
LVEF 30%, peripheral neuropathy, stage IV CKD Hem, PC, Neph 2. Assess prognosis of MM/amyloidosis
and chronic NYHA III-IV HFrEF who presents 3. Determine medical futility of TAVR (“Cohort C” patient?)
with acute HF and LFLG gradient AS with AVA 4. Determine severity of LFLG AS
1.0 cm2. CFS is 5. 5. SDM: Med Rx vs TAVR vs hospice care
A 63-y-old woman with a history of dilated CM Cardiac Tx vs TEER vs HFC, IC, CTS, ACI, 1. Assess hemodynamics and need for inotropes, vasopressors,
(LVEDD 68 mm), CRT-D, severe secondary MR, LVAD vs Med Rx APC, Neph, GI and/or MCS
and LVEF 25%, presenting with prolonged 2. Assess renal and hepatic function
hypotension, ARF, recurrent hospitalization, 3. Assess suitability for TEER
jaundice, and elevated transaminases 4. SDM: TEER vs LVAD vs cardiac Tx
A 31-y-old woman presenting G1P0 at 15 wks of Pregnancy termination vs IC, CTS, CC, ACI, 1. SDM: continuation of pregnancy vs termination
gestation with severe rheumatic MS (MVA medical Rx vs BMV card-obst, MFM 2. Determine anatomic suitability for BMV
1.0 cm2), moderate MR, PASP 65 mm Hg. NYHA 3. Careful 3rd trimester and postpartum surveillance for HF.
II.
A 28-y-old male with hypoplastic left heart Fontan revision with ACHD team, HF, CTS, 1. Assess RVEF with cardiac MRI
syndrome and 3 prior cardiac surgeries: Maze and valve repair CA, SW, PC, 2. Assess liver function/cardiac cirrhosis
Norwood, bi-directional Glenn and lateral tunnel vs cardiac Tx psychologist 3. Assess renal function
Fontan. Presents with increasing fatigue, 4. Assess for protein losing enteropathy
exertional dyspnea, and palpitations associated 5. Assess suitability for redo cardiac surgery
with worsening RV systolic function, moderately 6. SDM: redo cardiac surgery vs Tx
severe TR, and intermittent AF. 7. Weigh short- and long-term outcomes
A 70-y-old woman with history of carcinoid Surgical valve Card-Onc, HFC, CTS, 1. Assess frailty, physical and cognitive functioning, and
syndrome presents with worsening fatigue, replacement IC, CA, nutritional status
lower extremity swelling, abdominal bloating, (TV þ PV) vs oncologist, ACI 2. Determine extent of extracardiac carcinoid
stage III CKD, severe tricuspid regurgitation, palliative/hospice care PC, Neph 3. Assess severity of right HF
moderate tricuspid stenosis and severe 4. SDM: surgical valve replacements vs Med Rx vs hospice care
pulmonic regurgitation associated with right HF.

ACHD ¼ adult congenital heart disease; ACI ¼ advanced cardiac interventional imaging physician; AF ¼ atrial fibrillation; AL ¼ amyloid light chain; APC ¼ advanced practice clinician; ARF ¼ acute renal failure;
AS ¼ aortic stenosis; AVA ¼ aortic valve area; BMV ¼ balloon mitral valvuloplasty; CA ¼ cardiac anesthesiologist; CABG ¼ coronary artery bypass graft; CAD ¼ coronary artery disease; Card-Obst ¼ cardio-
obstetrics; Card-Onc ¼ cardio-oncologist; CC ¼ clinical cardiologist; CFS ¼ clinical frailty scale; CKD ¼ chronic kidney disease; CM ¼ cardiomyopathy; COPD ¼ chronic obstructive pulmonary disease;
CRT-D ¼ cardiac resynchronization therapy defibrillator; CTS ¼ cardiothoracic surgery; DM ¼ diabetes mellitus; Endo ¼ endocrinologist; EP ¼ cardiac electrophysiologist; GDMT ¼ guideline directed medical
therapy; GI ¼ gastroenterologist; GM ¼ geriatric medicine specialist; Hem ¼ hematology; HFC ¼ heart failure cardiologist; HFrEF ¼ heart failure with reduced ejection fraction; IC ¼ interventional
cardiologist; LBBB ¼ left bundle branch block; LFLG ¼ low flow low gradient; LVAD ¼ left ventricular assist device; LVEF ¼ left ventricular ejection fraction; LVOT ¼ left ventricular outflow tract;
MCS ¼ mechanical circulatory support; MDHT ¼ multidisciplinary heart team; MFM ¼ maternal fetal medicine specialist; MM ¼ multiple myeloma; MR ¼ mitral regurgitation; MRI ¼ magnetic resonance
imaging; MV ¼ multivessel; MVR ¼ mitral valve replacement; MVr ¼ mitral valve repair; Neph ¼ nephrologist; non-STEMI ¼ non-ST-segment elevation myocardial infarction; NYHA ¼ New York Heart
Association; PASP ¼ pulmonary arterial systolic pressure; PC ¼ palliative care specialist; PCI ¼ percutaneous coronary intervention; PMS ¼ pulmonary medicine specialist; PV ¼ pulmonic valve; RV ¼ right
ventricle; SAVR ¼ surgical aortic valve replacement; SDM ¼ shared decision-making; SW ¼ social worker; TAA ¼ thoracic aortic aneurysm; TAVR ¼ transcatheter aortic valve replacement;
TEER ¼ transcatheter mitral valve edge-to-edge repair; TMVR ¼ transcatheter mitral valve replacement; TR ¼ tricuspid regurgitation; TV ¼ tricuspid valve; Tx ¼ transplant.

important for the MDHT to render treatment de- palliative care specialists play an important role in
cisions across a broad spectrum of patient age, sur- this setting. The American College of Cardiology
gical risk, and anatomic scenarios (ie, patients with (ACC) has a useful decision aid that can help patients
bicuspid disease, aortic root enlargement, and/or make informed decisions on surgical AVR vs TAVR.
concomitant CAD). The MDHT must also identify Similar concepts underpin MDHT decision-making in
older “Cohort C” TAVR candidates who may be too the care of patients with mitral, tricuspid, and pul-
irreversibly compromised for AVR and better suited monic diseases.11 In the process of rendering treat-
18
for hospice care. Consultative geriatric and/or ment decisions, the lifelong management of the VHD
6 Batchelor et al JACC: ADVANCES, VOL. -, NO. -, 2023
Evolution of the Multidisciplinary Heart Team in Cardiovascular Medicine - 2023:100160

patient must be carefully considered, including de- For reviews of patients with high-risk complex
vice durability and the feasibility and safety of future CAD, core members of the MDHT typically include
procedures. those directly involved in deciding on and performing
Core team members of the MDHT for VHDs typi- coronary revascularization procedures (ie, interven-
cally include interventional cardiologists, cardiac tional cardiologists, cardiac surgeons, cardiac anes-
surgeons, structural heart interventional imaging thesiologists, and APCs). However, extended team
physicians, and advanced practice clinicians members (ie, geriatric, palliative care, and/or HF
(APCs). 8,11 Although several other health care pro- specialists) may be necessary to provide additional
fessionals may play key roles prior to, during, and/or input prior to or following revascularization. In-
after the hospital phase of care (ie, referring physi- stitutions involved in the routine care of these com-
cians, consulting cardiologists, cardiac anesthesiolo- plex patients may define specific operators
gists, medical and/or surgical subspecialists, nurses, (interventional cardiologists and cardiac surgeons)
cardiac catheterization laboratory and operating who are proficient in performing technically chal-
room staff, pharmacists, and clinical research co- lenging, high-risk coronary revascularization pro-
ordinators), they are often not part of the core team.11 cedures. A fully operational complex CAD MDHT
Specific case examples of how the MDHT plays a role should provide formal review of cases by a team that
in the care of the VHD patient are presented in at least includes both interventional cardiologists and
Table 1. cardiac surgeons.22 Pertinent clinical information,
ROLE OF THE MDHT IN MYOCARDIAL REVASCULARIZATION including symptoms, medical/surgical history, labo-
DECISIONS (PCI VS CABG). With the prevalence of CAD ratory findings, noninvasive testing (transthoracic
increasing in the United States, cardiologists are echocardiography, stress test), and invasive data
seeing more patients with complex multivessel (right and left heart catheterization, coronary angio-
disease, including left main and/or triple vessel gram), is best captured on a case report form that may
disease.19 Treatment decisions for these patients be used during MDHT meetings to communicate
must consider a wide range of patient ages, pertinent information and facilitate final treatment
comorbidities, procedural risks, and personal pref- recommendations.22 Thus far, the widespread use of
erences. Technical advances and improved operator the MDHT in this setting has not been achieved, with
experience have made PCI a feasible option for a recent report from a large academic medical center
more high-risk patients with multivessel and/or left showing that only 3% of potential patients were
main CAD, many of whom are at too high risk for referred for MDHT review. 22 Specific case examples
CABG due to their advanced age or comorbidities. for which the MDHT may help determine the optimal
The 2021 ACC/American Heart Association/Society management of high-risk patients with complex CAD
for Cardiovascular Angiography and Interventions are shown in Table 1.
coronary revascularization guidelines provide evi- ROLE OF THE MDHT IN ADVANCED HF AND CARDIAC
dence-based treatment recommendations for pa- TRANSPLANTATION. Despite the advances in phar-
tients with multivessel CAD and emphasize the macological and device-based therapies, the out-
importance of MDHT input. 20 However, the evi- comes of patients with advanced HF remain poor. 23
dence base underpinning these treatment recom- With treatment options becoming increasingly com-
mendations stem from clinical trials comparing plex, multidisciplinary team-based care is necessary
CABG to PCI that have generally excluded patients to deliver effective therapies across the spectrum of
with severe comorbidities and marked frailty. It is HF patients. Multidisciplinary HF care has been
in the space of uncertainty and clinical equipoise shown to improve the overall quality of care, patient
between PCI and CABG that the MDHT has its engagement, and medication safety, while reducing
greatest value. 21 When rendering revascularization the duration and frequency of recurrent HF hospi-
recommendations for such patients, careful consid- talizations.24-27 The recently published ACC/Amer-
eration of age, the technical barriers to CABG or PCI ican Heart Association/Heart Failure Society of
(vascular access/peripheral arterial disease, porce- America HF guidelines endorse multidisciplinary care
lain aorta, or hostile chest), and comorbidities (ie, to assist in the transition from the inpatient to
severe chronic lung, kidney, or liver disease, active outpatient setting and to reduce the risk of rehospi-
cancer, depressed left or right ventricular function, talization; recommendations that also apply to pa-
severe concomitant valvular disease, prior cardiac tients receiving heart transplantation and left
surgeries, cognitive impairment, and nutritional ventricular assist devices. 28 Regulatory agencies and
status) is paramount.20 payers, including the Organ Procurement and
JACC: ADVANCES, VOL. -, NO. -, 2023 Batchelor et al 7
- 2023:100160 Evolution of the Multidisciplinary Heart Team in Cardiovascular Medicine

Transplantation Network, The Joint Commission, and outcomes, and safety of ACHD patients. Two levels of
CMS, have mandated a multidisciplinary team programs were identified: care centers and compre-
approach for the evaluation and care of advanced HF hensive care centers. The former work with the latter
patients undergoing left ventricular assist device more advanced centers as satellite programs.
placement or heart transplant surgery. 29 Currently, there are 43 accredited CHD programs in
In the past decade, there have been significant the United States; the MDHT is a critical component
advances in pharmacologic, transcatheter, and sur- in each of these programs. Core members of the ACHD
gical therapies for HF. Although several new thera- MDHT often include ACHD medical directors, cardiac
pies have become commercially available, not all surgeons (with specialized training in CHD), inter-
have been included in the most recent treatment ventional cardiologists, electrophysiologists, HF spe-
guidelines.28 Therefore, MDHT input is often neces- cialists, cardiac anesthesiologists, APCs, ACHD
sary to provide insight into when and how to deploy nurses, and social workers. To adequately address the
the most up-to-date and effective advanced thera- complex needs of ACHD patients, the MDHT should
pies, while recognizing medical futility. The core also have access to reproductive medicine services,
members of the MDHT for advanced HF patients advanced imaging, and treatment for pulmonary
typically include advanced HF cardiologists, APCs, arterial hypertension, thereby drawing pulmonary
pharmacists, nurses, and HF program coordinators. medicine, obstetrics and gynecology, and imaging
Extended MDHT members may include critical care specialists into the extended team. In putting forth
physicians, cardiac surgeons, physical therapists, the final treatment recommendations, it is important
palliative care specialists, nephrologists, endocrinol- for the MDHT to consider the lifelong treatment plan
ogists, pulmonologists, social workers, dieticians, for ACHD patients and follow their long-term out-
transplant and/or left ventricular assist device comes. Specific examples in which the MDHT plays a
nurses, infectious disease specialists, and psycholo- role in the care of patients with ACHD are presented
gists. Team member input varies depending on the in Table 1.
clinical setting (ambulatory vs hospital), specific ROLE OF THE MDHT IN CARDIO-ONCOLOGY. Car-
needs and social circumstances of the patient, and diovascular disease and cancer share common risk
local expertise. The recent emergence of effective factors, including older age, health behaviors, and
treatments for infiltrative cardiomyopathies, such as comorbidities, which help explain their frequent
cardiac amyloid and sarcoid, has placed further coexistence.31 Certain cancer therapies and malig-
emphasis on the MDHT as treatment often requires nancies, themselves, play an etiologic role in the
input from a variety of health care providers (ie, development and progression of cardiovascular dis-
cardiologists, advanced cardiac imaging physicians, eases. This has led to the need for cardiovascular
pharmacists, geneticists, pulmonologists, and endo- professionals specifically trained to manage patients
crinologists). The rapidly expanding fields of struc- with active cancer and cancer survivors with existing
tural and device-based HF therapies also require cardiovascular disease, under the umbrella of cardio-
effective care coordination between HF specialists, oncology. Cardio-oncologists have expertise in
interventional cardiologists, cardiac surgeons, inter- providing comprehensive care to patients with co-
ventional imaging physicians, and intensivists. When existing heart disease and cancer and in preventing
rendering treatment plans, the multidisciplinary HF and treating the cardiovascular complications of
team must incorporate patient preferences and health cancer and cancer therapies, with an aim to improve
values while striving to reduce health care dispar- patient prognosis and limit interruptions in can-
ities. 30 Specific case examples illustrating the role of cer therapy.
the MDHT in treating patients with advanced HF are Cardio-oncology requires multidisciplinary coop-
shown in Table 1. eration among cardiology, hematology-oncology
ROLE OF THE MDHT IN ACHD. Patients with major teams, and a variety of other disciplines. Cardiolo-
CHD defects often require specialized health care for gists, oncologists, and APCs form the primary core
the entirety of their lives. Historically, care for these members of cardio-oncology MDHTs, and pharma-
patients has tended to be disjointed, typified by cists play a key role in helping form cardiac and
multiple individual providers delivering care from oncologic treatment plans with the aim of minimizing
within silos, resulting in fractured care. In 2017, the the risk of drug-drug interactions, QTc prolongation,
Adult Congenital Heart Association launched an bleeding, and thromboembolism. However, the
accreditation system that defined the resources, staff, composition of the MDHT and timing of cardiac pro-
and processes necessary for the optimal care, clinical cedures may vary according to the stage of cancer,
8 Batchelor et al JACC: ADVANCES, VOL. -, NO. -, 2023
Evolution of the Multidisciplinary Heart Team in Cardiovascular Medicine - 2023:100160

timing and nature of cancer therapy, and the urgency require close monitoring and MDHT care during the
for, and need of, cardiac intervention. For example, stages of pregnancy.
patients with carcinoid VHD typically require a MDHT The prenatal cardio-obstetric evaluation typically
comprised of cardiologists, cardiothoracic surgeons, includes a thorough review of the patient’s past
cardiac anesthesiologists, and medical oncologists to medical history, prior cardiovascular procedures,
evaluate the patient’s cardiovascular and functional medication history and need for adjustment during
status, extent of extracardiac carcinoid disease, and pregnancy, and exercise stress testing in patients
to guide the use of somatostatin analogues before, with asymptomatic VHD. 38 Genetic counseling may
during, and after surgery to prevent perioperative be indicated in patients with heritable conditions
carcinoid crisis. 32,33 such as aortopathies. Evaluation from a cardiac sur-
The International Cardiac Tumor Board serves as geon and/or an interventional cardiologist on the
an example of an effective multidisciplinary work- MDHT is warranted in patients with severe VHD to
ing model designed to serve an uncommon group of determine which, if any, intervention is indicated
cardiovascular malignancies.34 This tumor board has preemptively to avoid decompensation during preg-
shared leadership and collaboration from cardiac nancy. Multidisciplinary care may also be warranted
surgery, medical oncology, cardiology, radiation prior to conception for risk assessment and consid-
oncology, imaging, and pathology across several eration of preconception interventions.
institutions in the United States, Canada, and The goal of the cardio-obstetrics MDHT is to
Europe. Monthly hybrid virtual and onsite tumor maximize both maternal and fetal health. Therefore,
board meetings are coordinated by APCs, and the a unique challenge facing the MDHT is to formulate
board is set up for case presentation, discussion, recommendations that are not only patient-centered
and referral to tertiary oncologic and surgical in- but also consider fetal/neonatal health. Expansion
stitutions. This quaternary care model serves mul- of the MDHT to include specialists in maternal fetal
tiple institutions across several countries and fits medicine and neonatology is often required to assess
into the conceptual framework of the MDHT illus- fetal risk relative to gestational age. Because cardiac
trated in Figure 1. A case example of how the MDHT surgery during pregnancy is associated with an
plays a role in the care of cardio-oncology patients increased risk of fetal loss, percutaneous trans-
is presented in Table 1. catheter therapies are often preferred when feasible
and effective.39 However, the effects of ionizing ra-
ROLE OF THE MDHT IN CARDIO-OBSTETRICS. The
diation on the unborn fetus need to be taken into
United States is the only industrialized nation facing
consideration, and efforts should be made to mini-
increasing maternal mortality, for which cardiovas-
mize radiation exposure to both mother and fetus
cular disease is the leading cause, and Black and
during these procedures. Case examples illustrating
Hispanic mothers are affected disproportionately.35,36
the role of the MDHT in cardio-obstetrics are pre-
The hemodynamic changes during pregnancy,
sented in Table 1.
including increases in heart rate and cardiac output,
may exacerbate preexisting CVD conditions.37 Car- ROLE OF THE MDHT IN GERIATRIC CARDIOLOGY.
diovascular diseases that occur preconception, during The U.S. population is rapidly aging. In the year 2034,
pregnancy, or in the peripartum phase may require older adults (age 65þ years) are projected to
the expertise of an MDHT. Examples of chronic car- outnumber children (<18 years old). 40 Aging is often
diovascular diseases that significantly impact preg- accompanied by changes in physical and cognitive
nancy include stable CAD, VHD (ie, mitral and AS in function, frailty, sarcopenia, multimorbidity,
particular), and cardiomyopathies (ie, peripartum increased risk of falls, disturbances in urinary func-
cardiomyopathy). Several urgent cardiovascular sce- tion, and reduced life expectancy.41,42 Because the
narios, including acute myocardial infarction result- majority of older TAVR patients have sarcopenia43
ing from spontaneous coronary artery dissection, and more than a quarter continue to have function-
hemodynamic compromise from VHD in the third ally limiting symptoms after valve replacement,
trimester and postpartum phases, and cardiogenic geriatric consultation may be useful in selected pa-
shock secondary to peripartum or other cardiomyop- tients, either preceding or following TAVR. Treatment
athies, may present abruptly and require emergent decisions in older frail adults require that health care
care. Patients with aortopathies, including those professionals, patients, families, and caregivers come
associated with a bicuspid aortic valve disease, also to a clear understanding of a patient’s baseline status,
JACC: ADVANCES, VOL. -, NO. -, 2023 Batchelor et al 9
- 2023:100160 Evolution of the Multidisciplinary Heart Team in Cardiovascular Medicine

procedural risks vs benefits, personal preferences, implementation of an MDHT.52 In the SYNTAX III
health values, and prognosis, both with and without REVOLUTION Trial, the MDHT was firmly rooted into
intervention.11,16,44 The 2020 ACC Expert Consensus the clinical trial design itself, playing a central role in
Decision Pathway for TAVR calls for the routine pre- evaluating the value of coronary computed tomog-
TAVR assessment of frailty, disability, physical and raphy angiography compared with conventional
cognitive function, and procedural futility.11 Patients angiography in the management of multivessel
with baseline major impairment within these do- CAD. 53 These findings, from predominantly observa-
mains should be referred for comprehensive geriatric tional studies, reveal an association between MDHT
evaluation.45 A detailed geriatric evaluation helps the care and improved patient outcomes but fall short of
MDHT understand the degree to which an older frail proving causality.
patient may achieve enough improvement in symp- It should also be recognized that MDHT evaluation
toms, functional status, quality of life, and/or sur- itself may create challenges, including the potential
vival to justify procedural risks. In older adult for discordant recommendations.54 When the care of
patients with HF, interdisciplinary geriatric care has 237 patients with multivessel CAD was independently
been associated with improved quality of life and reviewed by 8 different blinded heart teams, discor-
spiritual well-being, and reduced anxiety and dant treatment recommendations were observed in
depression.46 During the COVID-19 pandemic, the nearly a third.54 Greater discordance was noted for
expansion of digital health (telehealth, telemedicine, patients treated with PCI and medical management
mobile health, and remote patient monitoring), than for those treated with CABG. This is important
internet access, and cellular technologies have pro- because discordant recommendations may cause
vided further opportunity to enhance care and confusion in patients and/or erode trust. In summary,
improve health outcomes for older adults.47 Case although the MDHT has become firmly embedded in
examples of how the MDHT plays a role in the comprehensive heart programs across the United
management of the older adult with cardiovascular States, the evidence supporting its use is based on
disease are presented in Table 1. observational studies. Therefore, future investigation
is needed to elucidate what, if any, benefit is
WHAT IS THE EVIDENCE IN SUPPORT OF
conferred by MDHT care on patients (ie, clinical out-
THE MDHT?
comes, quality of life, patient satisfaction) and the
heart team itself (ie, team member engagement and
Despite the routine use of the MDHT in clinical
satisfaction, team efficiency, agreement/discordance,
practice, its effectiveness in improving patient out-
and productivity).
comes has been poorly studied. The evidence un-
derpinning its Class I recommendation has been OPERATIONALIZING THE MDHT
based solely on nonrandomized, observational
studies and consensus opinion (Level of Evidence: The core responsibilities of the MDHT are to: 1) gather
C).11,48 The use of a multidisciplinary team has been team member input and feedback; 2) establish the
associated with improved survival in patients with final MDHT treatment plan; 3) ensure effective
invasive breast cancer.49 Reductions in variability of communication between MDHT, patients, and pro-
care, adherence to standardized protocols, and viders; 4) review program metrics (procedural vol-
multidisciplinary expertise are posited reasons for umes and clinical outcomes/quality improvement
benefit in that setting. A systematic overview of 7 processes); 5) review program billing, coding, and
randomized controlled trials reporting the impact of finances; 6) track research site performance; and
acute care multidisciplinary team intervention on 7) ensure that team members are kept up to date with
hospitalized older patients showed reductions in treatment guidelines and/or other relevant de-
emergency department readmission rates, mortality, velopments in the field (Figure 1). We believe there
and functional decline.50 In the realm of cardiovas- are 7 key principles for the effective operation of the
cular disease, the registry of Emory Angioplasty vs cardiovascular MDHT (Figure 1), several of which have
Surgery Trial demonstrated that the final coronary been promulgated by the National Academy of Sci-
revascularization strategy agreed upon by the MDHT ences. 55 Defining the independent roles and duties of
produced better survival than that noted in the ran- each team member is critical, and there should be
domized trial cohort. 51 A recent retrospective analysis clarity around who is responsible for presenting cases
of 3,399 patients undergoing TAVR in a South during MDHT meetings. We recommend that the
Australian tertiary care center reported a 20% reduc- meeting agenda and all pertinent patient clinical data
tion in 5-year risk-adjusted mortality following the be circulated to MDHT members prior to the meeting
10 Batchelor et al JACC: ADVANCES, VOL. -, NO. -, 2023
Evolution of the Multidisciplinary Heart Team in Cardiovascular Medicine - 2023:100160

and available throughout the meeting. Routine use of low-volume programs. Still, the key principles and
a standardized case report to collect key data ele- goals of MDHT meetings (Figure 1) should be adhered
ments may be useful. The hospital administration to, regardless of clinical setting.
should help support the MDHT by managing infra- Many programs may not have the collective expe-
structure, staffing, coding/billing, resource alloca- rience and medical subspecialization to address the
tion, and marketing/advertising of the program broad array of complex clinical scenarios. In this
(Central Illustration).11 Regularly scheduled MDHT setting, there may be value in forming a partnership
meetings are necessary to gather team members, re- with a larger more experienced high-volume tier 1
view clinical data, reach consensus, and finalize program (Central Illustration). This may be accom-
treatment recommendations. Weekly meetings are modated through videoconferencing for case pre-
generally sufficient for this purpose, although sentations and electronic sharing of imaging data.
meeting frequency will vary depending on clinical Such a relationship may help triage complex patients
case load and member availability. Meetings, either to the more advanced tier 1 program, while building
in-person and/or virtual (ie, video conferencing), may experience and expertise in the tier 2 center. Such
also serve to review program metrics, procedural networks of care may also afford patients access to
outcomes, accuracy of documentation, coding and more advanced treatment options than otherwise
billing, clinical research protocols, and referral net- available in their local community. In this setting,
works. We also recommend that MDHTs engage in effective communication, both among clinicians and
regularly scheduled morbidity and mortality confer- between clinicians and patients, is paramount.
ences, from which quality-improvement initiatives Keeping the patient fully informed and central to the
may be recognized and launched, and patient care process helps ensure shared decision-making.16,57
56
processes and safety reviewed. Although there is no Another pervasive challenge for MDHTs is to reduce
widely accepted standard on how MDHTs render de- health care disparities related to race, gender,
cisions, consensus opinion is often used. We recom- ethnicity, age, rurality, and social determinants of
mend that each MDHT establish a process for making health such that they do not prevent patients who are
decisions, dealing with disagreement, and commu- in need of care from accessing and receiving it.58 An
nicating with patients and referring providers. understanding of the demographics of the patients
cared for within the MDHT relative to the surround-
CHALLENGES FACING THE MDHT
ing community may provide insights into these dis-
parities, allowing for interventions to minimize
There are several challenges with incorporating and
treatment gaps.36,58 Currently, substantial variability
maintaining a MDHT. First, the need for patients to be
exists in the composition and operation of MDHTs
seen by several specialists and undergo multiple
across the United States and other countries. Similar
diagnostic tests places significant physical, psycho-
to the multidisciplinary organ transplantation and
logical, and financial burdens on patients and care-
cancer care models, the MDHT paradigm could
givers. The scheduling challenges associated with
benefit from greater standardization of staffing
bringing together various team members on a regular
models, implementation guidelines, training oppor-
basis represent another limitation. Many MDHTs
tunities, and measurement of outcomes. Finally,
convene weekly clinics, where patients with specific
there exists no reimbursement structure from payors
cardiovascular conditions are seen by all relevant
that assigns monetary value to the time providers
subspecialists during the same visit. The benefits of
spend engaged in MDHT meetings and other patient
this paradigm include patient convenience and the
care-related activities.
potential for more rapid decision-making. However,
logistics may be problematic, and efficiency is not STUDY LIMITATIONS
optimal. Premeeting discussions among team mem-
bers can help address specific clinical questions prior The ideas and recommendations put forth in this
to the official meeting, thereby improving meeting perspective are from the views and opinions of the
flow and efficiency. A team member (or members), authors. Our goal is to put forth a conceptual frame-
often the program coordinator, should be tasked with work for the MDHT and its contemporary role in
setting the meeting agenda and collecting, orga- treating patients across a broad range of cardiovas-
nizing, and presenting relevant clinical information. cular disciplines and clinical scenarios. This review
Adequate hospital resources and meeting space are does not describe the various instruments that may
needed; however, the resources available in a large be used to measure successful functioning of MDHTs.
academic institution may not be present in smaller, For this, the reader should refer to literature from
JACC: ADVANCES, VOL. -, NO. -, 2023 Batchelor et al 11
- 2023:100160 Evolution of the Multidisciplinary Heart Team in Cardiovascular Medicine

multidisciplinary cancer teams.59 Given the lack of successful delivery of cardiovascular care well into
experimental evidence underpinning our claims on the foreseeable future.
the optimal composition, structure, and functioning
of cardiovascular MDHTs, the recommendations and ACKNOWLEDGMENTS The authors wish to thank

opinions put forth are based on expert opinion and a Devon Stuart for her assistant in creating the Central
limited number of observational studies. Illustration. The authors also thank Abby Cestoni
from the American College of Cardiology for her help
CONCLUSIONS with the production of this article.

The MDHT plays a central role in contemporary care FUNDING SUPPORT AND AUTHOR DISCLOSURES
models for a wide range of cardiovascular diseases.
The value of the MDHT lies in its ability to transcend Dr Batchelor has received institutional research grant support from

the limitations of established care guidelines by Abbott and Boston Scientific; and is a consultant for Abbott, Med-
tronic, Edwards, V-Wave Medical, and Boston Scientific. Dr Anwar-
providing the most up-to-date and informed treat-
uddin is a consultant/proctor/advisory board member at Medtronic;
ment recommendations for complex individual pa- proctor at Edwards; on the steering committee of Boston Scientific;
tients through the consolidation of multiple team on the advisory board of OpSens; and has equity in East End Medical.
Dr Wang is a consultant at Edwards Lifesciences, Boston Scientific,
member inputs. The major challenges facing the
Abbott, and Neochord; and has received institutional research grant
MDHT include the increasing number of clinical sce- support from Boston scientific. Dr Velugapudi is on the Speakers
narios that require its input, a lack of widespread Bureau of Abiomed and Opsens; and is on the advisory board of
subspecialty expertise, time constraints of team Women’s Health Initiative. Ms Wyman is a consultant at Edwards
Lifesciences and Boston Scientific. Ms Perpetua is a consultant at
members, and a lack of reimbursement structure that
Abbott and Edwards; and is on the advisory board of Abbott. Dr Maini
assigns value to provider time engaged in MDHT ac- has equity in East End Medical; is on the advisory board of Boston
tivities. Although MDHT care has become routine in Scientific, Abbott, and Medtronic; is on the Speakers Bureau of Boston
the treatment of patients with complex CAD, VHD, Scientific, Abbott, and Medtronic; and has received proctorship
honoraria from Boston Scientific, Abbott, and Medtronic. Dr Mack is a
and ACHD and in the fields of cardio-obstetrics, car-
co-principal investigator/study chair (no renumeration) for Abbott,
dio-oncology, and geriatric cardiology, there remains Edwards Lifesciences, and Medtronic. Dr Leon is on the advisory
a lack of experimental data confirming improved pa- board (no renumeration) of Abbott, BSC, MDT, Edwards, Gore, and

tient outcomes. Therefore, future investigations are Venus Medtech. All other authors have reported that they have no
relationships relevant to the contents of this paper to disclose.
needed to define: 1) best practices for MDHTs; 2)
which disease scenarios benefit most from their
input; and 3) to what extent MDHT care improves the ADDRESS FOR CORRESPONDENCE: Dr Wayne B.
effectiveness of treatment decision-making, team Batchelor, Director, Interventional Heart Program,
member efficiency/satisfaction, and ultimately pa- Inova Health System, Inova Heart and Vascular
tient outcomes. Notwithstanding these limitations, Institute, 3300 Gallows Road, Falls Church, Virginia
the MDHT will remain a critical component for the 22042, USA. E-mail: [email protected].

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