Quality Improvement and Outcomes

Building a Heart Team

Mitral valve therapies require a longitudinal, multidisciplinary approach for success. For an effective heart team approach, an institution should include the following members in its team ( Fig. 27.1 ):

• Cardiac surgeon with experience in mitral valve surgery

• Interventional/structural cardiologist

• Advanced heart failure cardiologist

• Cardiac imaging specialist

• Cardiac anesthesiologist

• Outpatient and inpatient team of advanced practice provider(s) and registered nurses

Each member of the team plays a key role in defining and ensuring implementation of the optimal mitral valve interventional process.

The cardiac surgeon has the greatest historical experience with mitral valve repair and replacement and is best equipped to properly risk stratify patients for surgery, ensuring both appropriate use and procedural success. Furthermore, current and future transcatheter techniques may still require surgical expertise, especially when alternative and/or transapical access are required. The Society for Thoracic Surgeons already has national benchmarks for surgeons to follow, some of which are described later in this chapter. These benchmarks can be used to determine their suitability for heart team involvement.

The interventional and/or structural cardiologist is most knowledgeable in catheter-based interventions and works alongside the cardiac surgeon to deliver the required therapy. They should be proficient in interpretation of intracardiac hemodynamics and shunts, obtaining large-bore access, performing transseptal puncture, and closing iatrogenic atrial septal defects in addition to the core skills required of an interventionalist. Their expertise is required for diagnostic hemodynamic assessment, procedural success, preprocedural optimization with percutaneous coronary intervention or ethanol septal ablations, as well as complication bailout including atrial septal defect (ASD) closure, device retrieval with snare catheters, and pericardiocentesis. Minimal procedure requirements for the structural cardiologist have started to emerge and are discussed later in the chapter.

An advanced heart failure specialist is not only an important member of the heart valve team but often the gatekeeper for referrals. In addition to establishing a longitudinal relationship with the patient’s valve journey, the heart failure specialist assists in risk stratification and optimization of medical management prior the procedure. This component of care is crucial, especially when determining appropriate use for secondary mitral regurgitation in light of findings of both the cardiovascular outcomes assessment of the MitraClip percutaneous therapy for heart failure patients with functional mitral regurgitation (COAPT) and percutaneous repair with the MitraClip device for severe functional/secondary mitral regurgitation (MITRA-FR) trials where the differences in outcomes are in part related to differences in optimization of goal-directed medical therapy. Postprocedurally, the heart failure specialist will assist in left atrial or ventricular unloading and further optimize filling pressures and biventricular function.

Mitral valve therapies require cardiac imaging during evaluation and treatment. By extension, an expert cardiac imager is integral for success. This role can be filled by either a cardiologist or cardiac anesthesiologist with interest and knowledge of mitral valve anatomy and catheter based structural heart procedures. Prior to some procedures, cardiac CT is performed to define the mitral valve anatomy as it relates to the heart, and to determine risk for complications such as left ventricular outflow tract obstruction. Calling upon this expertise is of paramount importance to avoid complications. During the procedure, the operator relies on the cardiac imager to guide several portions of the procedure. As such, the imager must be facile with specific training in the various procedures and specifics such as delineating the interatrial septum for optimal septal puncture as well as the ability to rapidly shift between views, such as what is required during evaluation of the mitral valve leaflets during transcatheter edge-to-edge repair (TEER) clip deployment. The cardiac imager should be facile in obtaining and interpreting three-dimensional (3D) views of the mitral valve and characterizing mitral gradients in real-time.

The cardiac anesthesiologist, in addition to performing transesophageal echocardiography, ensures adequate hemodynamic support before, during, and after the case. Because these procedures are often performed in high-risk patients with reduced cardiac reserve, their role in maintaining patient stability before and after the procedure is emphasized. In addition, cardiac anesthesiologists play an important role when assessing procedural outcomes by employing blood conservation strategies, early extubation protocols, and pain management particularly in patients with reduced pulmonary reserve.

Advanced practice providers play a variety of roles in procedural planning, execution, and follow-up, working both in the inpatient and outpatient setting. They are integral in performing pre- and postprocedural visits (often 30-day and 1-year follow-ups), updating registry data as required, communicating with patient families to address their concerns, overseeing the completion of diagnostic testing, tending to inpatient consults, and triage urgent cases and more. One or more advanced practice provider (APP) is often required to fill these roles and are recommended for best practice in optimizing structural heart programs.