An “evolution” of heart care services

The renewed emphasis on a team approach for the evaluation of some heart patients is in the early stages at Cape Cod Hospital. Known as the “Heart Team Approach,” it places the patient and their family at the center, with various specialists and the patient’s general cardiologist meeting on complex cases to formally discuss the best treatment options.

“It’s a collaborative relationship so patients are involved in the decision-making process and have the benefits of all the different minds getting together to decide the best approach to the patient’s care,” said Cardiac Surgeon Saqib Masroor, MD, who is leading the re-energized Heart Team effort along with Interventional Cardiologist Alanna Coolong, MD.

“You have all the different treatment options discussed in an objective manner, with evidence-based, guideline-supported therapy. That’s the highest quality care you can expect anywhere,” he said.

Dr. Masroor, who is chief of Cardiac Surgery at Cape Cod Hospital (CCH) and is affiliated with Beth Israel Lahey Health in Boston, arrived at CCH last year. He led the development of similar heart team programs at his previous hospital, University of Toledo Medical Center in Toledo, OH, and before that he was part of the team that helped renew the Heart Team approach at University of Miami Hospital and Clinics in Miami, FL. Having the opportunity to participate in the new version of the Heart Team program at CCH was one of the things that appealed to him about coming to Cape Cod Hospital. The other attraction was the quality of the physicians and staff, he said.

“We have a lot of experts, we just need to bring them together,” he said. “We don’t lack talent, we lack a platform where they can come together and discuss cases.”

A Patient-Centered Approach

Dr. Coolong said the new program is a re-commitment to an approach that has been part of the American College of Cardiology guidelines since 2011 and has been in place at Cape Cod Hospital for at least that long.

“Our heart team approach has been re-energized,” she said.

A team approach is best-practice medicine for cardiac programs, especially in communities like Cape Cod, said Dr. Coolong, who is the director of the Cardiac Catheterization Lab at CCH.

“Most of our patients are elderly and have multiple co-morbidities, and most patients, in general, have more than one treatment option,” she said. “So, it’s always this kind of ongoing dialogue amongst the members of the Heart Team, trying to hone in on what’s the best way to take care of them.”

She said the approach presents a cohesive message to the patient about their diagnosis and the treatment options available to them, which can cut down on the amount of stress the patient may be feeling.

“When you have multiple treating physicians coming in, meeting with the patients and giving them different messages about what they’re going to have done in terms of a procedure, it can be very anxiety-producing for the patient. It can generate a lot of confusion,” Dr. Coolong said. By meeting collaboratively and discussing a case before presenting the treatment options to a patient, the Heart Team is able to remove some of that anxiety, she said.

Building On Success

Cape Cod Hospital has been recognized nationally multiple times over the past few years for its Cardiac Services. In February, the program was confirmed as one of the top hospitals in the U.S. for cardiovascular care in the newly published 2023 U.S. News & World Report “Best Hospitals” guidebook by the American College of Cardiology (ACC).

CCH was selected for the guidebook for its “commitment to optimizing patient care and outcomes, and for continuous quality improvement of its cardiovascular services by implementing high standards of evidence-based care and protocols for its patients.”

The hospital cardiac program was also recently named a Blue Distinction® Center for Cardiac Care designation by Blue Cross Blue Shield of Massachusetts, as part of the Blue Distinction Specialty Care program.

The new, more formal Heart Team approach seeks to build on the high-quality care that has been a part of Cape Cod Hospital Cardiovascular Services for so long, said Cape Cod Healthcare President and CEO Michael Lauf.

“It’s evolution,” he said. “We’re certainly appreciative of everyone that’s helped us get to this point, but with any journey, you have to evolve, grow, improve. Like anything, changes need to occur, opportunities need to be pursued. This is the next iteration of our commitment to our community.”

Heart Team History

The Heart Team concept was first integrated into the European Society of Cardiology revascularization (a procedure that restores blood flow in blocked arteries or veins) in 2010. The American College of Cardiology adopted it in its guidelines in 2011 and updated the guidelines in 2021.

“In patients being considered for coronary revascularization for whom the optimal treatment strategy is unclear, a multidisciplinary Heart Team approach is recommended,” the Joint Committee on Clinical Practice Guidelines report by the American College of Cardiology/American Heart Association reported in its 2021 Guidelines for Coronary Artery Revascularization. “Treatment discussions should be patient centered, incorporate patient preferences and goals, and include shared decision-making.”

As a 2019 article in the journal Future Medicine noted, heart teams can be productive or counterproductive. “The difference depends on personal or professional issues and the extent of shared goals and good understanding among the team members about the rules of engagement in a medical consultation forum,” wrote article authors Ran Kornowski and Guy Witberg.

The new program at CCH, as spear-headed by Dr. Masroor, reflects a re-commitment to a collaborative approach to patient care, Dr. Coolong noted.

“It was there, but I think it’s been strengthened,” she said.

Team Conferences

Cardiac Imaging Specialist Tendoh Timoh, MD, FACC, said the new Heart Team program is similar to the tumor board multi-disciplinary reviews that are currently done in oncology. It helps patients and clinicians navigate the complexities of cardiac issues in a cohesive way, he said.

When a patient is hospitalized for a heart issue, typically they will need either interventional (catheterization), or cardiac surgery, he said. The two surgical teams “have to be constantly talking to each other about each patient” in order to arrive at the best treatment option, he said. “No one can be siloed,” he added. “We want to do it in a collaborative manner.”

Sometimes there are easy decisions about how to handle a case, but often the decision-making is “not that black and white,” said Dr. Masroor. The more complicated cases need to be discussed with all of the stakeholders, including the patients, he said.

Dr. Masroor plans to begin the Heart Team conference in the next few months with virtual meetings where the various specialists and the patient’s general cardiologist gather to review the patient’s treatment options. This group would include all of the physicians that would be involved in the patient’s care, he said.

“Sometimes it may be surgery, sometimes a stent, and sometimes a combination of both,” he said. “A patient would be referred from a community cardiologist to the hospital team and there would be a consultation as to how to best treat them.”

Older, More Complex Patients

As patients get older, they not only have more complex cardiac disease, but other medical illnesses that make their care more challenging, said CCH Hospital Cardiologist Karl Stajduhar, MD, FACC. “The traditional options one might have of either surgery or catheter intervention, or medicines, is a much more complicated picture now,” he said.

Hospital cardiologists, who are assigned to patients when they are admitted to Cardiac Services at the hospital, make a concerted effort to get all participants in a patient’s care at the table to have their recommendations and evaluations considered, he said. “As our experience with this has matured, we realize the complexity of the patients and the interventions require this kind of approach."

“Currently, it’s a much more shuttle consultation, meaning that if one of the patients was on my service who had significant valve disease, I am talking with the surgeon, I’m talking with the interventional cardiologist, I’m talking with the outpatient providers. So that’s being done, but not in a more rigorous and formalized fashion. That’s what we’re hoping to establish (with the Heart Team).”

Having a forum to figure out what the range of options are for patient management is vital, Dr. Stajduhar said.

“Matching up those recommendations to the skillsets we have here at Cape Cod Hospital, figuring out when a person should be referred to another center that may have specialized care on one of the other techniques we may not have here. I think all of those things will improve patient care and hopefully integrate the inpatient and outpatient part of things, and minimize the actual hospital stays where patients are away from their families and their lives,” he said.

Bringing in Community Cardiologists

Making sure each clinician’s voice is weighed equally is a big part of the re-energized Heart Team Approach, said Dr. Coolong.

“Dr. Masroor has really kind of embraced this idea that everyone is included in the discussion and that we’re all kind of on the same page and speaking with the patient,” she said.

Dr. Masroor has been visiting with the cardiologists in the community to describe the vision for the program and get their feedback. “They’re very excited because it’s their patients and they want to have a say in how their patients are managed,” he said.

Falmouth Cardiologist David Rancourt, DO, MPH, FACC, said he believes the new approach will enhance patient outcomes and experience.

“From a community cardiologist standpoint, when we have need of higher level of care (for a patient), whether it’s consultations with electrophysiology, interventional cardiology, cardiothoracic surgery; having an open discussion with and about the patient is ideal,” he said.

A patient’s cardiologist brings to the table a longer history with the patient, he said. “I can give (the team) an understanding of who the patient is, what we’re hoping to accomplish together,” he said.

Cardiologist Elissa Thompson, MD, who practices in Hyannis and Chatham, said having more experts consulting about a case is always beneficial for patients.

“It’s such a boon for our patients to have this kind of collaboration,” she said. “It just provides so many layers of protection for the patient. It shows intention to the patient and for the patient.”

Dr. Thompson reiterated the fact that the general cardiologist brings a critical voice to the discussion because they know the patient and all the variables that may go into their treatment plan.

“It’s incredibly important to understand that no one really wants to have bypass surgery, but, if they’re going to live longer and more healthfully because of the durability and appropriateness of that procedure, for example, then it’s important to have a voice defending that and making sure that the patient is the focus of the conversation, always,” she said.

Not every cardiac case needs to undergo a formal team review, Dr. Masroor said.

“There’s sometimes some easy decisions, but many times patients have complex medical conditions and issues and the decision-making is not that black and white,” he said. “Those need to be discussed with all the stakeholders, including the patients.”

Dr. Coolong agreed.

“There is a subset of patients where everyone would agree that the patient should receive a certain type of therapy,” she said, such as a patient who is a clear candidate for a stent or valve replacement. “There’s another group of patients that are complicated and require a more thoughtful approach based on a Heart Team discussion with all the involved players to try and determine what might be best for the patient. And obviously, the patient drives that whole process,” she said.

New Advances Arriving at CCH

The cardiac team at Cape Cod Hospital, which also includes electrophysiologists, physician assistants, technicians and the nursing staff in the OR, catheterization lab and on the cardiac patient unit at the hospital, provide top-quality care, said Dr. Masroor. Most of the latest cardiac procedures are currently being done at the hospital, he said.

“We did three aortic dissections (cases where the inner layer of the aorta separates from the deeper layers and is at risk of rupturing) just in December. That is one of the most high-risk procedures that is done in heart surgery, and they’ve all done well and gone home in five to six days,” he said.

Dr. Masroor and his OR team have also done several pacemaker lead extractions, a complicated procedure because the older leads get scarred and are not easy to remove. Endograph procedures in which a graft is inserted in a weakened aorta without making an incision were recently started at the hospital, as well, he said. Prior to that, patients would have to go to an off-Cape institution to have the procedures done.

On the horizon for cardiac surgery are hybrid revascularizations using robotic techniques, Dr. Masroor reported. He is proficient in robotic-assisted bypass surgery and is in the process of training assistants in order to get the program up and running at CCH. Robotic-assisted bypass surgery offers faster healing times because there is no bone cutting involved. There is less bleeding and fewer limitations on exercise, Dr. Masroor added.

“For a select group of patients, it’s a very good option,” he said.

Patients for whom robotic-assisted surgery would be an option include those who have one or two heart blockages that cannot be stented, people already at high risk for having non-healing chest bone incisions, older patients for whom cracking the chest open would not be advisable, and younger patients who don’t want to be out of work as long.

“We’re just laying the groundwork for a program that’s more modern and aggressive with the new technologies,” he said.