Rebecca T. Hahn, MD, FACC, FASE

Our Multi-Disciplinary Heart Team is composed of interventionalists, hybrid cardiac surgeons, cardiac anesthesiologists, clinical cardiologists, echocardiographers, research nurses, and nurse practitioners. For the procedure, the team also requires angioplasty assistants and dedicated nursing staff from the catheterization laboratory and operating rooms. The role and responsibilities of each team member is well defined, which helps reduce miscommunication and eliminate inefficiency. In addition, the team must be built on mutual respect and trust. Like any team, this trust has developed over the course of years and after much practice. It also works to a large extent because of insightful leadership and the resolute devotion of each member to the success of the program. Clear and frequent communication during every stage of this difficult procedure in very ill patients is essential.

Patient selection for transcatheter aortic valve replacement must be driven by the surgeon. According to the Placement of Aortic Transcatheter Valves (PARTNER) trial, Cohort B patients were considered inoperable due to coexisting conditions associated with a predicted probability of 50% or more of either death within 30 days after surgery or a serious irreversible condition. To more accurately assess this risk, an extensive evaluation by the clinical cardiologist, imaging experts, nurse, and nurse practitioner must be performed to identify and quantify these possible conditions. Newer risks such as frailty must also be quantified. The decision-making process presents certain dilemmas for the surgeon, who must consider his or her own operative mortality rates in order to make a realistic decision about inoperability. The surgeon relies on comprehensive discussions among all team members to help ensure the validity and reliability of the decision-making process.

The procedure itself is like a well-rehearsed, single act play on a very small stage. Although the primary operator is clearly identified at the outset, each member assisting with the procedure understands his or her role, as well the roles of his counterparts. All procedures at Columbia University are currently performed with general anesthesia and continuous transesophageal echocardiographic imaging. Following insertion of appropriate monitoring lines and induction of general anesthesia, the interventionalist gains femoral arterial access while the echocardiographer performs the initial images that will determine the appropriate size of transcatheter heart valve. These measurements include not only the aortic annulus but also characterization of the left ventricular outflow tract and mitral leaflets, the sinuses of Valsalva and sinotubular junction, and the location of the coronary artery ostia in relation to calcified cusps and annulus. Discussion between the interventionalists and echocardiographers ensues after full consideration of these measurements. Because both the balloon aortic valvuloplasty and the transcatheter heart valve deployment require ventricular pacing, there is frequently one member of the team assigned to the temporary pacemaker. We often joke about having a “pacing fellow”; however, the timing of the pacing run can significantly influence the outcome of the procedure, so no role is considered insignificant. During and following pacing, hemodynamics can change dramatically, and an experienced cardiac anesthesiologist must anticipate these changes without overreacting to changes that may be transient. Complications can occur at each stage of the procedure, and there is constant feedback from each team member in response to maneuvers and interventions. One of the most essential roles for continuous echocardiographic imaging is the rapid and accurate assessment of post-deployment valve position and function as well as all the etiology of any hemodynamic compromise. Following each case, the team constantly re-evaluates the procedure and refines the technique.

The Multi-Disciplinary Heart Team is a close-knit group not only because of the close proximity of each member during the procedure but because of the need to rely on one another for an optimal outcome. It is the only cardiac procedure in which all members of each discipline must be in the room throughout the case. Trust, respect and communication remain the key elements to reacting appropriately in challenging situations and for real-time crucial decision-making in these high-risk aortic stenosis patients. In moving forward with transcatheter treatment of valvular heart disease, the creation of these highly functioning multi-disciplinary heart teams is the key to a successful valvular heart disease program.