What is the role of a multidisciplinary heart team in procedure planning for coronary artery bypass grafting (CABG)?

Updated: Dec 04, 2019
  • Author: Rohit Shahani, MD, MS, MCh; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

The formation of a multidisciplinary heart team enables a balanced decision-making process (see Table 12 below). [27, 28] Clinicians should approach the informed consent process as an opportunity to enhance objective decision-making rather than solely as a legal requirement. It is vital to be aware that factors such as sex, race, availability, technical skills, local results, referral patterns, and patient preference may affect the decision-making process independent of clinical findings. [27]

Table 12. Multidisciplinary Decision Pathways, Patient Informed Consent, and Timing of Intervention [27] (Open Table in a new window)

 

 

Acute Coronary Syndrome 

 

Stable Multivessel Disease

Stable with Indication for Ad Hoc PCI

 

Shock

STEMI

NSTE-ACS

Other ACS

Multidisciplinary decision making

Not mandatory

Not mandatory

Not required for culprit lesion but required for nonculprit vessel(s)

Required

Required

According to predefined protocols

Informed consent

Oral witnessed informed consent or family consent if possible without delay

Oral witnessed informed consent may be sufficient unless written consent is legally required

Written informed consent* (if time permits)

Written informed consent*

Written informed consent*

Written informed consent*

Time to revascularization

Emergency: No delay

Emergency: No delay

Urgency: Within 24 h if possible and no later than 72 h

Urgency: Time constraints apply

Elective: No time constraints

Elective: No time constraints

Procedure

Proceed with intervention on basis of best evidence/ availability

Proceed with intervention on basis of best evidence/availability

Proceed with intervention on basis of best evidence/ availability; nonculprit lesions treated according to institutional protocol

Proceed with intervention on basis of best evidence/ availability; nonculprit lesions treated according to institutional protocol

Plan most appropriate intervention, allowing enough time from diagnostic catheterization to intervention

Proceed with intervention according to institutional protocol defined by local heart team

* May not apply to countries that legally do not ask for written informed consent, although European Society of Cardiology and European Association for Cardiothoracic Surgery strongly advocate documentation of patient consent for all revascularization procedures.

ACS = acute coronary syndrome; NSTE-ACS = non–ST-segment elevation acute coronary syndrome; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction.

Additional input from general practitioners, anesthesiologists, geriatricians, and intensivists may be needed.

Hospitals without a surgical cardiac unit or with interventional cardiologists working in an ambulatory setting should refer to standard evidence-based protocols devised in collaboration with expert interventional cardiologists and cardiac surgeons or should seek the opinions of these physicians for complex cases. Consensus on the best revascularization treatment should be documented. Standard protocols that are in accordance with current guidelines may be used to obviate individual case review of each diagnostic angiogram.

Ad hoc PCI is a therapeutic interventional procedure that is performed directly after the diagnostic procedure rather than during a different session. [27] Although it is convenient and often cost-effective, ad hoc PCI is not desirable for all cases; some patients may be in categories for which CABG is the most suitable choice. The anatomic criteria and clinical factors that determine whether a patient can or cannot be treated by means of ad-hoc PCI should be defined by institutional protocols designed by the heart team. [27]


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