EDITORIAL
European Heart Journal (2014) 35, 66–68
doi:10.1093/eurheartj/ehs466
Venn diagrams in cardiovascular disease:
the Heart Team concept
David R. Holmes Jr1,*, Friedrich Mohr 2, Christian W. Hamm 3 and Michael J. Mack 4
1
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN, USA, 2Herzzentrum Universitaet Leipzig, Klinik fur Herzchirurgie, Leipzig, Germany;
Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany; 4Division of Cardiothoracic Surgery, The Heart Hospital, Plano, TX, USA
3
Online publish-ahead-of-print 11 January 2013
----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Heart valve † Percutaneous † Professional affairs † Cardiology † Cardiac surgery
Venn diagrams are illustrations composed of overlapping circles
that demonstrate the relations between finite collections of
things1 and are most useful in defining areas of commonality
among different aggregations. Originally described by John Venn
in the 1880s to teach elementary set theory, these diagrams are
most often used to illustrate set relationships in such fields as
probability, statistics and computer science.
Venn diagrams can also be useful for understanding the roles of
various stakeholders in the management of cardiovascular disease
from its diagnosis through its treatment. As the field progresses,
the area of overlap of the cardiovascular disease Venn diagram
continues to expand. This is evident in many aspects of cardiovascular disease management, including individual diagnosticians and
treatment specialists, diseases, technologies, institutions, payers
and regulators. Despite a movement towards convergence in
areas of disease management, however, professional societies
remain in their individual silos. This article explores whether
Venn diagrams of professional societies, which traditionally had
little overlap or mutual engagement, should continue to converge
until they merge into one.
The well-recognized concept of atherosclerosis as a disease that
affects all vascular beds has focused therapeutic strategies on the
coexistence, for example, of coronary artery disease and peripheral arterial disease in the same patient. Whereas in the past
there was a tendency to treat an acute coronary syndrome as an
isolated event in a patient, attention now focuses on the fact
that other manifestations of the disease, such as peripheral arterial
disease and cerebral vascular disease, are likely to be present in this
patient as well, and the involvement of these other vascular beds
may affect treatment strategies. Thus, the evolution of the
understanding about atherosclerosis has stimulated physicians
and surgeons who focus on these different vascular beds to strategize together about the treatment of this patient.
Another example of multi-stakeholder involvement, overlap and
convergence involves the diagnosis of cardiovascular disease using
non-invasive imaging. In the past, echocardiography, nuclear echocardiography and non-invasive radiographic techniques such as
magnetic resonance imaging and computed tomography occupied
separate silos, and the specific test ordered for a patient generally
matched the expertize of the physician who ordered it. For
example, echocardiographers were more apt to recommend
echocardio- graphic imaging techniques for functional assessment.
More recently, imaging specialists have converged for training, certification and practise, and more often than not, the choice of the
imaging technique now focuses on obtaining the optimal imaging
test, irrespective of the imaging specialists’ areas of expertize.
The overlap of the Venn diagrams for interventional cardiology
and cardiovascular surgery has grown larger since the promulgation of the multidisciplinary Heart Team concept. Specialty teambased care is not a concept new to medicine; for example,
Tumour Boards make multispecialty disease management decisions
in oncology2,3. The use of the specific term ‘Heart Team’ is more
recent and was only incorporated in guidelines subsequent to the
presentation of the results of the pivotal SYNTAX trial4. SYNTAX
evaluated the two randomized strategies of coronary bypass graft
surgery and percutaneous coronary intervention in patients with
complex multivessel or left main coronary artery disease. Working
together, a team composed of a surgeon, an interventional cardiologist a primary cardiologist, and the patient agreed upon the optimal
revascularization strategy5,6.
* Corresponding author. Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA. Tel: +1-507-2555846; Fax: +1-507-2552550, E-mail: [email protected]
(D.R. Holmes).
Co-published in The Annals of Thoracic Surgery, European Journal of Cardio-Thoracic Surgery, and European Heart Journal. Copyright & 2013 by The Society of Thoracic
Surgeons; published with permission by the European Association for Cardio-Thoracic Surgery and the European Society of Cardiology. For permissions please
email: [email protected]
Editorial
This Heart Team approach has been codified in the European
Society of Cardiology/European Association for Cardio-Thoracic
Surgery (ESC/EACTS) guidelines on Myocardial Revascularization,
which recommend that patients with complex coronary artery
disease be seen by a Heart Team, which includes cardiovascular
surgeons and interventional cardiologists7. Using a Heart Team approach is a Class I-C recommendation of the 2011 ACC/AHA guidelines for Coronary Artery Bypass Graft Surgery8. This concept has
also been employed in the field of structural heart disease, specifically aortic stenosis and transcatheter aortic valve replacement
(TAVR)9,10. In this setting, the Venn diagrams of cardiovascular surgeons and interventional cardiologists coalesce to form the core of
the team responsible for planning and implementing the chosen
strategy for aortic valve replacement. This convergence has now
been mandated for reimbursement by federal regulatory agencies.
Although there are practical institutional implementation issues, increasingly collaboration will be demanded by societal imperatives
to optimize patient care.
Yet another example of the convergence of distinct elements in
cardiovascular disease is the development of common service lines
or heart hospitals, wherein all cardiovascular specialists (surgeons,
cardiologists, vascular radiologists, cardiac anaesthesiologists, cardiovascular nurses among others) are combined under one umbrella either physically or conceptually. The Heart and Vascular
Institute at the Cleveland Clinic is a high-profile example of such
a convergence. A European milestone example for such collaboration for many decades between surgeons and cardiologists under
one roof is the Thoraxcenter Rotterdam. Meanwhile, several
cardiac centres were established across the USA and Europe
copying the initial models. There is a clear advantage to an
organ-oriented medical approach that uses the collective wisdom
of various specialties and, analogous to Tumour Boards in patients
with cancer, identifies and recommends the optimal course of
therapy for patients with heart disease.
67
This background of increasing convergence among cardiovascular disciplines contrasts starkly with our silo-bound professional societies: American College of Cardiology (ACC), American Heart
Association (AHA), The Society of Thoracic Surgeons (STS),
American Association for Thoracic Surgery (AATS), The Society
for Cardiovascular Angiography and Interventions (SCAI), American Society of Echocardiography (ASE) and American Society of
Nuclear Cardiology (ASNC), or respectively in Europe, the ESC
and EACTS. Each silo touches the others competitively, sometimes
antagonistically, and at other times, collaboratively. Each silo has
many similar discrete components—executive committees; volunteer and paid staff; advocacy, scientific, educational and regulatory
groups, to name but a few. In addition, the core mission of each silo
may be very similar (Fig. 1). While each professional society serves
its core constituency well, there are many disadvantages to such a
situation, including overlapping efforts that are inefficient; conflicting aims that confuse patients, payers and regulators alike; and diffusion of efforts to obtain increasingly scarce industry and
government funding. Other disadvantages specific to cardiology
and cardiovascular surgery are these: competing outpatient registries (e.g. ACC and AHA); confusing messaging for procedural reimbursement (e.g. carotid stenting); redundant grants for
disease-specific approaches (e.g. Heart Rhythm Society, ACC,
STS for atrial fibrillation) and a plethora of requirements for credentialing and certification (e.g. ASE and ASNC).
The walls of silos can be broken through, however, and it is our
position that it is in everyone’s best interest —most of all the
patients we serve—to do so. STS and ACC have begun an unprecedented collaboration with federal regulatory and reimbursement
agencies and industry around TAVR, addressing its optimal utilization and developing a national registry, educational programmes,
requirements for credentialing and metrics for procedural performance10,11. Such an effort should involve close collaboration
and communication at all levels (Fig. 2). A similar collaboration
Figure 1 At the present time, for patients with coronary artery disease, the professional silos of cardiology and cardio-thoracic surgery often
do not overlap, despite the fact that the underlying missions have great similarity. Merging of these Venn diagrams either administratively or as
part of a Heart Team could substantially improve patient education and care.
68
Editorial
We fully appreciate the obstacles, barriers and concerns regarding self-interest and loss of autonomy that naturally arise with such
a disruptive and far-reaching proposal, but they are not insurmountable. We recognize that this cannot be done immediately
in one bold move. We present this as a vision of the gradual convergence of Venn diagrams until we are all one circle.
The theme of the recently concluded German Society for Thoracic and Cardiovascular Surgery annual meeting was ‘ein Herz, ein
Team (one heart, one team)’. Together, we propose ‘one heart,
one team, one society’.
Conflict of interest: none declared.
Figure 2 The development of a TAVR Heart Team and blending the disciplines of cardiology and cardio-thoracic surgery will
enhance optimal patient selection, procedural performance and
outcome.
was initiated in Germany in 2010 when both the German Society
of Cardiology and the German Society for Thoracic and Cardiovascular Surgery started a registry that collects all procedural and
follow-up data on conventional and catheter-based aortic valve
replacements. The two societies also have written joint position
papers on TAVR and are designing crossprofessional training programmes and certifications.
There have been several examples of close relationships
between surgery and cardiology: among others, these include the
fact that the third president of the American College of Cardiology, Robert Glover (from 1953–54), was a surgeon from
Philadelphia. The current convergence of ACC and STS represents
a continued example of what could be obtained by very close
collaboration among the professional societies. The similar collaboration between the German cardiology and cardiac surgery
societies is a parallel example in Europe. One could imagine a
single professional society, perhaps a global cardiovascular
society, which would include all segments of the cardiovascular
team: surgeons, cardiologists, vascular radiologists, anaesthesiologists, cardiovascular nurses, educational and scientific groups and
advocacy under one administrative umbrella. Recent examples
of how this collaboration might be initiated include integrating
professional societies at the level of volunteer leadership; for
example, in Germany, a cardiac surgeon (F.M.) recently served as
the president of the annual German cardiology meeting and a
cardiologist (C.H.) as the president of the German cardiac
surgery annual meeting. Such exploratory initiatives could be
used to foster closer relationships at an administrative level. The
goal would be to have the administrative umbrella of a single professional society that coordinate the educational and scientific
initiatives, the disease management registries and outcomes
analyses, the advocacy approach towards reimbursement and the
training, education and credentialing of physicians and allied
health professionals.
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