Page 12 - Journal of Structural Heart Disease - Volume 1 Issue 1

Original Research Article
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decision-making, and post-procedural care. A cohesive team minimizes fragmentation in decision- making and improves coordination and delivery of care. It is crucial for patient safety, which is vital given that a substantial portion of this population may be frail and/or have multiple co-morbidities.
Structure and Challenges of a MDT
At the core of a multidisciplinary team lay a partner- ship between interventional cardiologists and cardio- thoracic surgeons. However, as outlined by the 2012 ACC/STS consensus statement on TAVR, a complete heart team should also include others: a non-invasive cardiologist, imaging specialists (echocardiography, CT, MRI), cardiothoracic anesthesiologist, nurse prac- titioner, and cardiac rehabilitation specialists [6]. It must be noted that when dealing with congenital or acquired structural disease, for example, ASD/VSD, a strong relationship with pediatric interventional car- diologist is advantageous. The heart team must also extend beyond the individual physicians who form it and reflect a broader cooperation between cardi- ology and surgery divisions. Incorporating several members from each division strengthens the MDT by expanding the clinical input available for the de- cision-making process, as well as improving the flow and availability of care to the patients. Importantly, the opinion of a second surgeon regarding the oper- ability of a candidate is often required for enrollment in several existing TAVR protocols.
Specifically for MitraClip, the heart team must in- clude a cardiologist and cardiothoracic surgeon both experienced in mitral valve disease and treatment. The surgeon can lend expertise as to suitable mitral valve anatomy but also importantly assess patient frailty, an important criterion for patient selection. The use of 3D echocardiography in addition to stan- dard 2D and Doppler imaging is vital in assessing mi- tral valve anatomy and pathology and thus suitability for MitraClip. This highlights the importance of hav- ing an experienced echocardiographer not only as a member of the MDT but also present during proce- dure to help guide deployment.
The primary challenge to a MDT is having effective communication and coordination between the dif- ferent providers each with a busy clinical schedule. Fundamental to overcoming this hurdle and vital to
the success of the MDT is a network of support staff including clinical and research coordinators. The clin- ical coordinator is a key member of the MDT who can serve as a pivot point through which the evaluation of a patient can be planned and executed. They can compile diagnostic results and facilitate the flow of information between the different members of the heart team. Because many patients are outside refer- rals, the coordinator can spearhead the gathering re- sults from any previous diagnostic evaluation. Finally, as many devices and procedures are still in the inves- tigational phase, the research coordinators are neces- sary to the enrollment of patients in ongoing studies or registries.
An MDT Model
While the ACC/STS consensus statement outlines the composition of a MDT, there exists no blueprint for organizing a team that will be cohesive and effec- tive. Individual structural heart programs must adapt their model within the unique environments of their academic center. Below is a summary of our experi- ence in applying the MDT approach to valvular heart disease (TAVR, MitraClip).
Outpatient Evaluation
Patients referred with complex valvular heart dis- ease are seen in a weekly comprehensive valve clinic that brings together elements from cardiology and cardiothoracic surgery. Prior to being scheduled for consultation, the patient’s available information is re- viewed and any additional required diagnostic test- ing (e.g., transthoracic echocardiography, pulmonary function testing, CT) is scheduled for the day of their appointment day if possible. Additionally, the patient meets with any pertinent research coordinators and undergoes any needed ancillary studies (blood draw, frailty testing, etc.). This maximizes the amount of pertinent information available to the clinical team allowing a more precise evaluation and fruitful dis- cussion with the patient. Once the patient has been seen, the history and physical as well as all available objective data (echocardiography, coronary angio- gram, CT, etc.) are reviewed as a team. Therapeutic options are discussed and any additionally needed
Structural Heart Disease, May 2015
Volume 1, Issue 1: 5-8