The Heart Valve Team case study

During the Heart Team meeting, it is essential that the necessary specialties are present to discuss all facets of treatment, either through a surgical or transcatheter approach. In this case, as recommended by the VARC-2 criteria, there are representatives from the surgical, interventional and clinical cardiology departments, as well as an anaesthesiologist, imaging specialist. Furthermore, the Heart Team depicted here has a leader that structurally gathers all information to be presented.

Discover this example of the dynamics of the Heart Valve Team and how it works in daily practice.

Case example by Prof. Franz-Josef Neumann and the group of the Herzzentrum Bad Krozingen, Bad Krozingen, Germany

Operators: Dr. Heinz Joachim Büttner, Dr. Michael Gick

The first step to allow appropriate decision-making should be that all information regarding the patient is available and presented: age, symptomatic status, co-existing cardiovascular conditions, and additional risk factors, with, to summarise, the predicted risk of mortality estimated using the STS score. A coronary angiogram is available to assess whether the patient has coronary artery disease. Echocardiography and MSCT are required to evaluate the severity of AS and calcifications, assess the left ventricular function, allow valve sizing, and provide information about potential access sites.

After presentation of the case, it is discussed whether a TAVI would be an option for the patient, considering a number of factors including the size of the valve. The surgeon is consulted about whether this patient is a candidate for surgery. Consensus was reached quickly in this case as the surgeon considered this patient to be too high risk to undergo AVR. In this particular case, the surgeon considers the patient to be too high risk based on the age, left ventricular ejection fraction, and comorbidities of the patient. This may differ on an institutional level or even per surgeon, and no strict cut-off of risk scores should be used as risk estimation with scores, since these are often inaccurate in individual cases.

The decision how to proceed with TAVI was thereafter decided by the interventional cardiologists. In-depth planning already took place, discussing which access site will be used based on the size, tortuosity and calcification of the aorta and peripheral vessels, and how the vessels will be closed post-implantation. An important message from this video is that, apart from the cardiologists and surgeons, different specialties are involved with the selection of the best treatment strategy for the patient, including an anaesthesiologist and imaging specialists, which does not always relate to the decision between AVR and TAVI, but also to the execution of the procedure.

Conclusion

One important aspect of the Heart Team meeting is not shown here. After a Heart Team meeting, it is crucial that the patient is correctly informed about the decision, following three key points:

  • Knowledge transfer, in which it is equally important that the physician provides information to the patient and the patient to the physician,
  • Discussion, and
  • Reaching an agreement on which treatment strategy will be performed.

Additional reading

  1. Multimodality imaging for valvular interventions: the eyes of the valve team
  2. To learn who and what are the key components of a transcatheter valve team and how the team is formed, consult the PCR London Valve session: Creating a transcatheter team
  3. The role of the heart team in complicated transcatheter aortic valve implantation: a 7-year single-centre experience