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\begin{document}

\title{The Impact of Heart Team Discussion on Decision Making for Coronary
Revascularization in Patients with Complex Coronary Artery Disease}



\author[1]{Louise Kezerle}%
\author[2]{Eli Yohanan}%
\author[3]{Avshalom Cohen}%
\author[1]{Miri Merkin}%
\author[1]{Yaron Ishay}%
\author[1]{Jean Marc Weinstein}%
\author[1]{Carlos Cafri}%
\affil[1]{Soroka University Medical Center}%
\affil[2]{Ben-Gurion University of the Negev}%
\affil[3]{Clalit Health Services}%


\vspace{-1em}



  
  \date{May 23, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Background and aim: Revascularization guidelines support routine heart
team (HT) discussion of appropriate patients. The effect of HT on
decision making and clinical outcomes hasn't been explored. The aim of
our study is to investigate the impact of the HT on the mode and delay
to revascularization. Methods: We compared data from a prospective
cohort of consecutive patients with multivessel coronary artery disease
referred for HT discussion between 2016-2017 (HT group) with a historic
control group of patients matched according to clinical and angiographic
characteristics treated between 2005-2015 (No HT group). Results: There
were 93 patients in each group. The HT group and the No HT groups had a
similar rate of ACS as well as cardiovascular risk factors and
significant left ventricular (LV) dysfunction. No difference was
observed in the mean Society of Thoracic Surgery (STS) score (2.5\selectlanguage{ngerman}± 3 vs.
3 ±3 p=0.32) and the mean SYNTAX score was low and similar in both
groups (21±6 vs. 19±6 p=0.59). The treatment recommendations changed
greatly, with 63\% of patients being referred for coronary artery bypass
grafting (CABG) after HT discussion but only 23\% in the no HT group
(p\textless{}0.01). HT discussion led to a significant delay to PCI (8±5
vs. 1.8±4 days, p=0.02), while surgical revascularization times were not
affected. Conclusion: HT discussion in patients with multivessel CAD was
associated with an increased referral to CABG but led to a significant
delay in revascularization by angioplasty. The impact of these findings
on patient satisfaction and outcome should be further investigated.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\emph{}

\emph{INTRODUCTION}

Treatment based on multidisciplinary decision making is the cornerstone
of current patient-centered therapeutics in certain medical fields such
as oncology {[}1{]}. Recently, this approach has also been applied to
the field of coronary interventions. The decision-making process leading
to coronary revascularization is straightforward in many clinical and
angiographic settings, and recommendation for either percutaneous
coronary intervention (PCI) or coronary artery bypass graft surgery
(CABG) can be made in the catheterization laboratory immediately after
the diagnostic coronary angiogram. However, many patients presenting
with comorbidities or/and complex coronary anatomy may require a more
global assessment in order to choose the optimal revascularization
strategy.

The SYNTAX score was developed to grade the severity of coronary lesions
based on objective anatomical criteria {[}2{]}. This score was validated
in a cohort of stable coronary patients, and a higher score reflects
more complex disease and a greater risk for percutaneous interventions,
indicating a preference for CABG over PCI {[}3, 4{]}. This score,
however, being purely anatomical, still fails to describe the level of
risk and benefit to the specific patient, which comprise an intricate
interplay between demographic, clinical and anatomical characteristics.
These difficulties led to the understanding that the treatment of the
patient with multivessel or high risk coronary artery disease should be
individualized {[}5{]}. For this purpose, the 2010 European Society of
Cardiology (ESC) on coronary revascularization introduced the concept of
a Heart Team (HT), composed of cardiac surgeons, clinical cardiologists
and interventional cardiologists. {[}6{]} Nonetheless, this
recommendation is based on expert opinion and the impact of this
strategy on the decision making process and specially on clinical
outcomes has not been widely investigated.

Since 2015, the Soroka University Medical Center, a tertiary hospital in
Southern Israel has implemented an institutional protocol regarding
which patients should be brought for HT discussion. The main purpose of
this study is to examine the influence of the HT discussion on the
selection of the revascularization approach as well on the delay to
revascularization. Furthermore, we sought to evaluate the concordance
between the HT-recommended treatment of choice with the initial approach
suggested by the interventional cardiologist upon finishing the
diagnostic angiogram.

\emph{MATERIALS AND METHODS}

\textbf{2.1 Study Design and Population}

This study compared consecutive patients prospectively referred to HT
discussion in the Soroka University Medical Center from 2016 to 2017 (HT
Group) and a matched retrospective cohort of patients who underwent
coronary angiography between the years 2005 and 2015 (No HT Group).

The inclusion criteria for the registry were based on an institutional
protocol specifically designed for selecting patients for HT discussion.
In summary, patients were included if they presented with stable
coronary artery disease (CAD) or with stabilized acute coronary
syndromes (ACS), defined as hemodynamically stable patients, at least 48
hours since the last ischemic complaint, who were diagnosed with left
main (LM) and/or multivessel coronary disease with low SYNTAX score
(\textless{} 23) and low perioperative risk as assessed by the Society
of Thoracic Surgeons (STS) score (\textless{}4\%) {[}7{]}. Patients were
also included if presenting with single vessel disease considered high
risk for PCI due to left anterior descending (LAD) artery origin lesions
or complex bifurcation lesions of the proximal LAD. Patients with LM and
/or multivessel disease with an intermediate or high SYNTAX score
(\textgreater{} 23) were discussed by the HT if they were classified as
being of moderate or high perioperative risk (STS risk score
\textgreater{}4\%) or due to co-morbidities that could influence the
clinical outcome after cardiac surgery. Patients presenting with ST
elevation MI (STEMI) could be included if there were clinical and
electrocardiographic signs of reperfusion and/ or if the patient
presented in the evolved phase of STEMI and had been pain-free for at
least 48 hours before admission.

If a patient met the institutional criteria for HT discussion after the
diagnostic angiogram, the procedure was concluded, and the case brought
for discussion within 24 hours. The HT was composed of interventional
cardiologists, clinical cardiologists and cardiothoracic surgeons. A
member of the clinical team treating the patient was also present.
Afterwards, the treating physician presented the revascularization
strategy recommended by the HT to the patient and their family, along
with the advantages and disadvantages of both treatments. The patient
then made an informed decision whether to proceed with the HT
recommended therapy or to opt for the alternative, when feasible {[}8,
9{]}.

The retrospective cohort was composed of patients that underwent
coronary angiographies between the years 2005 and 2015 with matching
diagnosis and complexity of coronary disease, identified from our
institutional database. Angiographic data was individually reviewed by
an unbiased interventional cardiologist to unsure appropriate matching.

\textbf{2.2 Data analysis}

Demographic and clinical characteristics of the patients were analyzed.
The diagnosis at admission was divided in three categories: Stable
Angina, Unstable Angina and Myocardial Infarction (NSTEMI/evolved
STEMI). The angiographic characteristics were expressed as the number of
vessels with significant stenoses as well as the SYNTAX score {[}2{]}.
The perioperative risk was defined by the STS score {[}7{]}.

The primary outcomes for this study were the proportion of patients
referred to each revascularization modality in the HT and No HT groups
and the time to revascularization from the initial diagnostic coronary
angiography.

\textbf{2.3 Statistical Analysis}

The statistical analysis was performed using the SPSS version 21
program.~ Variables were presented as number and percentage or as mean \selectlanguage{ngerman}±
standard deviation for discrete and continuous variables respectively. A
two-sample t-test test was used for continuous data, and a \selectlanguage{greek}χ\selectlanguage{english}2 test for
categorical data. A two-sided p value less than o.o5 was considered
significant.

This study was approved by the Institutional Committee on Human Research
of our institution.

\emph{RESULTS} \textbf{}

The HT and the No HT groups included 93 patients each. The mean age was
66 \selectlanguage{ngerman}±12 years and the majority of patients in both groups were men
(65\%). There were no differences in the percentage of patients with
comorbidities and in other baseline clinical characteristics of both
groups except for a higher rate of previous PCI in the No HT group (47\%
vs. 26\%, p\textless{}0.05). The great majority of patients in both
groups presented with acute coronary syndromes (90\%) with a high
prevalence of NSTEMI or evolved STEMI patients (64\%). No differences
were observed in the complexity of the coronary artery disease according
either to the number of vessels with significant stenosis or the SYNTAX
Score. Significant three vessel disease or left main disease was seen in
75\% of the HT group and 80\% of the No HT group (p=0.49). Baseline
characteristics are presented in Table 1.

The mean SYNTAX score was similar between groups (19±6 in the No HT and
21±6 in the HT group, p=0.589) although there was a trend for a greater
percentage of patients with low SYNTAX scores in the No HT group (75.3\%
in the No HT and 59.6\% in the HT group p=0.06). The mean perioperative
risk according to the STS score was low and similar in both groups (3±2
vs. 3±3). Again, there was a trend for a higher percentage of patients
with intermediate and high STS scores in the No HT group, compared to
the HT group (22\% vs 8\% and 12\% vs 8\% respectively, p=0.052). (Table
2)

A significant difference in the modality of treatment chosen in each
period was observed. In cases treated without HT discussion, PCI was the
most frequent method of treatment, being employed in 69\% of cases.
During the HT period we observed a radical change in treatment
recommendations, with most patients being referred to CABG (63\%)
(Figure 1). This corresponds to a 174\% increase in the use of surgical
revascularization.

On the other hand, there was a significant increase in the time from
diagnostic angiography to revascularization in the HT group (8.5 ±4
days) in comparison with the No HT group (1.8 ± 5 days). (Table 3). When
examining this variable according to revascularization strategy, time to
CABG was similar in both the HT and No HT groups (7±8 vs 8±5, p=0.75)
but the time to PCI was substantially longer in the HT group compared to
the No HT group (0.39±2 vs 8±6 p\textless{}0.01).

\emph{DISCUSSION}

This study shows that the implementation of Heart Team discussion in the
decision-making process of patients with complex coronary artery disease
was associated with a profound change in the strategy for
revascularization characterized by an increased rate of CABG with a
reduction in the rate of PCI. Moreover, HT discussion was associated
with a significant delay in the time to PCI in comparison with patients
treated in earlier periods before the establishment of the HT.

The Heart Team has been recommended as standard care for patients with
complex CAD since the publication of the European and American
guidelines for myocardial revascularization in 2010 {[}6, 10{]}. This
recommendation, while intended to provide interdisciplinary sharing of
knowledge and experience in decision-making, is based solely on expert
opinion. As such, little is known about the impact of this approach on
rates of revascularization methods and on short and long-term outcomes
as well as immediate peri-procedural risks and potential benefits in
each individualized setting.

The main finding of our study was a significant change in the
revascularization modalities before and after HT implementation. In
fact, there was an increase in CABG recommendations from 23\% without HT
to 63\% in the HT group with a parallel decrease in the rate of PCI.
There are a few possible explanations for this substantial change:
first, the baseline characteristics of the patients was slightly
different. Despite individual matching, a trend for a lower STS score
was observed in the patients in the No HT group. This difference however
should have favored a surgical approach within this group, and these
were not the results that were noted.

In addition, the mean SYNTAX score and the proportion of patients with
intermediate or high SYNTAX scores was numerically higher in patients
discussed by the HT, although not statistically significant. This may
reflect the fact that the patients in the HT group had more complex
coronary anatomy hence being referred to surgery more often. In fact,
the past two decades have seen a myriad of trials {[}2, 11-16{]} seeking
to answer the question of which strategy provides better short and long
term outcomes for complex CAD while balancing patient satisfaction and
costs, mainly in the setting of stable disease. In summary, most trials
on multivessel disease show a survival advantage of CABG over PCI
according to anatomical complexity as assessed by the SYNTAX score,
while there are no clear benefits to either treatment when it comes to
isolated LM disease. Based on these findings, an intermediate or high
SYNTAX score is recognized by recent revascularization guidelines as a
class IA indication for CABG over PCI {[}4, 17{]}. Furthermore, the
FREEDOM randomized trial {[}18{]} compared CABG to PCI solely in
diabetic patients with multivessel disease and found reduced mortality
associated with the surgical approach. The accumulation of data on the
subject as well as updated guideline recommendations might have
influenced the change in revascularization strategies seen in our study
in the last few years. Supporting this observation is the fact that the
operator in the HT period between 2016 and 2017 recommended CABG in 57\%
of the cases whereas only 23\% of operators during the No HT period
(2005-2015) referred the patients for surgery.

Other factors such as personal tendencies and beliefs of the
cardiologists involved as well as financial or professional interests
that could influence the revascularization decision are neutralized by
the HT discussion leading to a change in treatment strategies. This
point was emphasized in a study by Abdulrahman \emph{et al} {[}19{]}
that described how HT recommendations changed according to which
professionals were present at the discussion.

Our findings are similar to recent reports in the literature. In 2016,
Bonzel \emph{et al} . {[}20{]} described that between 46-66\% of
patients discussed by the HT were referred to isolated CABG. They also
demonstrated that the patients referred to PCI had a low rate of need
for CABG during long term follow up with no increase in mortality after
2 years. Also, a possible intrinsic bias of the interventional
cardiologist in recommending PCI as a primary revascularization approach
was noticed in a study by Sanchez \emph{et al} {[}21{]} that used the HT
to review decisions on revascularization strategies based on SYNTAX and
STS scores and on Appropriate Use Criteria for coronary
revascularization. They found that 34.9\% out of 301 patients who had
undergone PCI in the past two years had an inappropriate or uncertain
indication for angioplasty as recommended by the HT.

Another important finding of the present study is that the decision to
bring the case to HT discussion was associated with a significant delay
in the performance of revascularization. Indeed, we observed a
significant increase in ''time to PCI'' from an average of 0.36 days to
8 days, while the time to CABG did not differ substantially. This was
most probably due to a limitation in institutional resources, but could
also occur in other hospitals should the HT approach be systematically
adopted. Taking into account that the population analyzed included 90\%
of patients with ACS, such a delay may be associated with potential
risks for this population. According to the European Society of
Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS)
guidelines on myocardial revascularization {[}6{]}, PCI or CABG should
be performed within 6 weeks after angiography for patients presenting
stable coronary disease and within 2 weeks for patients with a high-risk
coronary anatomy. For patients presenting with ACS the recommended time
frame for revascularization is shorter, based on adverse events that may
occur while on the waiting list for revascularization. Guidelines for
the management of patients with non-ST elevation acute coronary
syndromes (NSTE-ACS) {[}22{]} recommend an invasive strategy in moderate
to high-risk patients. The timing of the intervention in those patients
is dependent on the patient's baseline risk factors and extend up to 72
hours from initial presentation. The HT approach potentially promotes
delays in time to revascularization which was evident in the population
that was ultimately treated by PCI, in conflict with the aforementioned
recommendations. Multiple trials investigated and confirmed the value of
early revascularization in patients with NSTEMI (8), although the
clinical significance and major events rate during the waiting period
until revascularization after the HT have not been investigated. The
present study was not designed to examine such clinical outcomes, which
would be valuable data to be reported in follow up research.

Nevertheless, a 2018 single center {[}9{]} study of 1000 consecutive
patients concluded that the HT approach was feasible, with decision
making and treatment following within a short time after referral and
largely in accordance with clinical guidelines. This study however,
included mainly patients referred from a community setting and as such
the mean time to revascularization of 6 weeks was considered safe and
appropriate.

Our study has a number of limitations. First, this was an observational
study with a retrospective attempt of matching patients on the basis of
clinical and angiographic variables. Despite this attempt, numerical
differences in the number of patients with previous PCI, the complexity
of CAD and surgical risk were observed between groups. This potential
selection bias could explain differences in the choice of type of
revascularization between the two periods. Secondly, our sample size
might have been small to detect differences in characteristics between
the groups. Third, there was no long-term outcome follow up of the
patients treated with and without HT discussion. Further research into
the impact of HT discussions on clinical outcomes would be most
certainly welcome.

Nonetheless, this is to the best of our knowledge the first study to
analyze the change in revascularization policy associated with the
introduction of systematic, institutional HT discussions for complex
CAD.

\emph{CONCLUSION}

In conclusion, HT discussion for selection of the modality of
revascularization in patients with complex coronary artery disease is
associated with an increased rate of referral for CABG. This process is
associated with a significant delay in the time to revascularization by
PCI, which could pose potential risks for acute patients.

\emph{ACKNOWLEDGMENTS}

This study was conducted as part of the requirements for MD degree from
the Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion
University of the Negev.

\textbf{Author contributions}

Kezerle L -- Data collection, interpretation, drafting article

Yohanan E -- Data collection, data interpretation and drafting the
article

Cohen A -- Overview of data collection

Merkin M, Ishay Y, Weinstein JM -- critical revision of the article

Cafri C -- Study design, data analysis and statistics, approval of
article

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