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Description of a Heart Team approach to coronary revascularization and its beneficial long-term effect on clinical events after PCI

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Abstract

Objective and background

We present a first description of a Heart Team (HT)-guided approach to coronary revascularization and its long-term effect on clinical events after percutaneous coronary intervention (PCI). The HT approach is a structured process to decide for coronary bypass grafting (CABG), PCI or conservative therapy in ad hoc situations as well as in HT conferences. As a hypothesis, during the long-term course after a PCI performed according to HT rules, a low number of late revascularizations, especially CABGs, are expected (F-PCI study).

Methods

In this monocentric study, the HT approach to an all-comer population was first analyzed and described in general with the help of a database. Next the use of a HT approach was described for a more homogeneous subgroup with newly detected CAD (1.CAD). Those patients in whom the HT decision was PCI (which was a 1.PCI) were then studied with the help of questionnaires for clinical events during a very long-term follow-up. Events were CABG, PCI, diagnostic catheterization (DCath) and death.

Results

A significant number of patients were presented to HT conferences: 22 % out of all 11,174 catheterizations, 24 % out of all 7867 CAD cases and 35 % out of 3408 1.CAD cases. Most of these patients had multi-vessel disease (MVD). Conference decisions were isolated CABG in 46–66 %, PCI in 10–14 %, valvular surgery in 9–16 %, HTx in 10–21 % (Endstage heart failure candidates for surgery) and conservative therapy (Medical or no therapy, additional diagnostic procedures or no adherence to recommended therapy) in 2–3 %. However, most PCIs, ad hoc and elective, were performed under Heart Team rules, but without conference. During follow-up of 1.PCI patients (Kaplan–Meier analysis), CABG occurred in only 15 % of patients, PCI in 37 % and DCath in 65 %; mortality of any course was 51 %. Mortalities were similar in one-vessel disease and in a population of the same year, matched for age and sex (p < 0.057), but mortality was higher in 1.PCI patients with MVD (p < 0.001). Beyond 2 years, Kaplan–Meier curves were linear.

Conclusion

The structured Heart Team approach is an effective tool for ad hoc and conference-based clinical decision-making with a sustained clinical benefit. This is demonstrated in low late CABG (and PCI) rates after a 1.PCI, without elevated mortality. The all-comer population supports the universal value of these data. Stable annual event rates late after PCI suggest a conversion to stable CAD. Heart Team conferences are also important tools in cases of valvular and end-stage heart disease.

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Acknowledgments

We thank Gerhard Strupp, M.D., Gerhard Schreiner, M.D., Bernd Plappert, M.D. and Michael Conze, M.D., for performing catheterizations, Christine Thomas BBA, Brigitte Kohlman, Sandra Bär and Sabrina Fritsch for technical assistance and Steffen Schneider, Ph.D., IHF GmbH Institut für Herzinfarktforschung, Ludwigshafen, for statistical assistance.

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Authors and Affiliations

  1. Medical Clinic I, Cardio-Thoracic Center, Klinikum Fulda, Pacelliallee 4, 36043, Fulda, Germany

    Tassilo Bonzel & Volker Schächinger

  2. Clinic for Cardiothoracic Surgery, Cardio-Thoracic Center, Klinikum Fulda, Fulda, Germany

    Hilmar Dörge

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  1. Tassilo Bonzel
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Correspondence to Tassilo Bonzel.

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The study has been approved by the Ethical Committee of the Hesse State Chamber of Physicians (Landesärztekammer Hessen) and is therefore in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

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All authors declare that they have no potential conflict of interest.

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For the Fulda F-PCI project.

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Bonzel, T., Schächinger, V. & Dörge, H. Description of a Heart Team approach to coronary revascularization and its beneficial long-term effect on clinical events after PCI. Clin Res Cardiol 105, 388–400 (2016). https://doi.org/10.1007/s00392-015-0932-2

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