Comparison of heart team vs interventional cardiologist recommendations for the treatment of patients with multivessel coronary artery disease

Abstract: Importance: Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown. Objective: To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease. Design, setting, and participants: In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center's database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020. Main outcomes and measures: The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist. Results: Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P < .001). When the heart team agreed with the original treatment decision, there was more agreement between the heart team interventional cardiologist and the original treating interventional cardiologist (138 of 163 cases [84.7%]) compared with when the heart team disagreed with the original treatment decision (14 of 71 cases [19.7%]); P < .001). Those with an original treatment of coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, 32 of 148 patients [22.3%], 32 of 71 patients [45.1%], and 6 of 15 patients [40.0%], respectively, received a different treatment recommendation from the heart team than the original treating interventional cardiologist; the difference across the 3 groups was statistically significant (P = .002). Conclusions and relevance: The heart team's recommended treatment for patients with multivessel coronary artery disease differed from that of the original treating interventional cardiologist in up to 30% of cases. This subset of cases was associated with a lower frequency of unanimous decisions within the heart team and less concordance between the interventional cardiologists; discordance was more frequent when percutaneous coronary intervention or medication therapy were considered. Further research is needed to evaluate whether heart team decisions are associated with improvements in outcomes and, if so, how to identify patients for whom the heart team approach would be beneficial

Gene profiling in enteroviral heart disease

The application of high-throughput genomical strategies and bioinformatical tools coupled with established molecular techniques allows researchers to gain new insights into the pathogenesis of infectious diseases. In humans, coxsackievirus B3 (CVB3) is the primary etiological agent of viral myocarditis, an inflammatory disease process involving the heart muscle. Specific therapy is currently unavailable. Viral myocarditis is a complex multiphasic infectious-inflammatory-reparative process. To address this temporal dimensionality, microarrays and non-array-based molecular techniques and histological and functional assays were used to further define enteroviral pathogenesis and its relation to heart failure. A re-analysed cDNA array-based dataset and an Affymetrix GeneChip®- based dataset from the murine heart during acute viremic, inflammatory and reparative stages were mined and compared. Global decreases in expression of metabolic and mitochondrial genes, increases in signalling, matrix and contractile protein genes, and distinctive patterns for genes in other functional groups are described. The transcript and protein profiles of heat shock protein 27, Muscle LIM protein and cathepsin L were confirmed using RT-PCR and immunohistochemistry, respectively. To focus on direct virus and host cell interactions, the transcriptional profile of CVB3-infected HeLa cells was investigated. Notably, increased expression of transcription factor c-fos downstream of extracellular signal-related kinase was found, a pathway our laboratory has previously shown to be important for virus replication and pathogenesis. The in vitro array experiment included a MEKl inhibitor treatment group. Commercial and in-house bioinformatical filtration, cluster analysis and visualization tools were used to determine potential gene targets downstream in the ERK pathway in the setting of CVB3 infection. Marked upregulation of oncogenes, serpins and matrix metalloproteinase genes, among others, were found in infected HeLa cells and in the heart. Together, our animal and cell culture array studies have contributed insight into host responses to enteroviral infections from which new testable hypotheses have been generated.Medicine, Faculty ofPathology and Laboratory Medicine, Department ofGraduat

Palliative Surgical Resection of an Extensive Metastatic Cardiac Myxofibrosarcoma

Herein, we report a rare case of metastatic secondary cardiac myxofibrosarcoma in a 33-year-old female patient. The tumor infiltrated the right lung and was extending into the heart via the right superior pulmonary vein. The patient who initially presented with a stroke was found to be at a high risk of recurrent embolic events and therefore was managed successfully surgically with a complex joint thoracic and cardiac tumor resection. This case illustrates that, in the setting of an extensive metastatic myxofibrosarcoma, an aggressive palliative surgical resection can be successfully performed to improve quality of life

Management and Prevention of Saphenous Vein Graft Failure: A Review

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