Clinical Characteristics and Outcomes of Patients With Complex Coronary Artery Disease Evaluated by a Multidisciplinary Heart Team

Background
The multidisciplinary ‘Heart Team’ (HT) approach for patients with complex coronary artery disease (CAD) carries a class I recommendation in current revascularization guidelines. However, contemporary data on clinical characteristics and outcomes of patients managed using the HT approach are limited.

Methods
From January 2015 to November 2018, 166 patients who were deemed high-risk for revascularization underwent HT consultation at a single tertiary/quaternary care center. All cases were reviewed by the HT comprised of interventional cardiologist(s), cardiac surgeon(s), general cardiologist(s), and additional specialists if needed. Data on demographics, comorbidities, clinical presentation, STS/SYNTAX scores, mode of revascularization, and in-hospital and 30-day outcomes were prospectively collected.

Results
Mean age was 70.0 ± 11.8 years and 73.5% were male. Prevalent comorbidities included diabetes (51.8%), peripheral artery disease (38.6%), cancer (24.1%), chronic obstructive lung disease (21.7%), end-stage renal disease on dialysis (13.3%), and chronic liver disease (6.6%). The most common presentation was NSTE-ACS (66.9%) and 67.5% had CCS class III-IV symptoms. The median left ventricular ejection fraction was 45% (IQR 32, 60). The median STS score was 3.9% (IQR 1.9, 8.0). With respect to coronary anatomic complexity, 40.4% of patients had left main disease, 71.1% had 3-vessel CAD, and 39.2% had a chronic total occlusion. The median SYNTAX score was 26 (IQR 20, 34). Of the 166 patients evaluated by the HT, 47.6% underwent PCI, 29.5% underwent CABG, and 20.5% received optimal medical therapy alone. At the higher cutpoints of STS and SYNTAX scores, PCI rates increased while CABG rates decreased. Among 129 patients who underwent revascularization, in-hospital mortality was 3.9%. Other in-hospital major adverse events included myocardial infarction (3.9%), stroke (2.3%), acute kidney injury requiring dialysis (3.9%), and transfusion (32.6%). Thirty-day post-procedure mortality was 4.8%.

Conclusions
Integrating a multidisciplinary HT into institutional practice is feasible and provides a structured, evidence-based approach to the evaluation and management of patients with complex CAD.