The Multidisciplinary Heart Team in Cardiovascular Medicine: Current Role and Future Challenges.

Cardiovascular multidisciplinary heart teams (MDHTs) have evolved significantly over the past decade. These teams play a central role in the treatment of a wide array of cardiovascular diseases affecting interventional cardiology, cardiac surgery, interventional imaging, advanced heart failure, adult congenital heart disease, cardio-oncology, and cardio-obstetrics. To meet the specific needs of both patients and heart programs, the composition and function of cardiovascular MDHTs have had to adapt and evolve. Although lessons have been learned from multidisciplinary cancer care, best practices for the operation of cardiovascular MDHTs have yet to be defined, and the evidence base supporting their effectiveness is limited. This expert panel review discusses the history and evolution of cardiovascular MDHTs, their composition and role in treating patients across a broad spectrum of disciplines, basic tenets for successful operation, and the future challenges facing them.

Best Practice Recommendations for Optimizing Care in Structural Heart Programs: Planning Efficient and Resource Leveraging Systems (PEARLS).

The COVID19 pandemic brought unprecedented disruption to healthcare. Staggering morbidity, mortality, and economic losses prompted the review and refinement of care for structural heart disease (SHD). To mitigate negative impacts in the face of crisis or capacity constraints, this paper offers best practice recommendations for Planning Efficient and Resource Leveraging Systems (PEARLS) in structural heart programs. A systematic assessment is recommended for hospital capacity, Heart Team roles and functions, and patient and procedural risks associated with increased resource utilization. Strategies, tactics, and pathways are provided for the delivery of patient-centered, efficient and resource-leveraging care from referral to follow-up. Through the optimal use of capacity and resources, paired with dynamic triage, forecasting, and surveillance, Heart Teams may aspire to plan and implement an optimized system of care for SHD. Abbreviations: AS: aortic stenosis; ASD: atrioseptal defect; COVID19: Coronavirus disease 19; LAAO: left atrial appendage occlusion; MI: myocardial infarction; MR: mitral regurgitation; PFO: patent foramen ovale; PVL: paravalvular leak; SHD: structural heart disease; SAVR: surgical aortic valve replacement; SDM: shared decision-making; TAVR: transcatheter aortic valve replacement; TMVr: transcatheter mitral valve repair; TMVR: transcatheter mitral valve replacement; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography.

Anatomy and Function of the Normal and Diseased Mitral Apparatus: Implications for Transcatheter Therapy.

Transcatheter mitral valve therapy requires an in-depth understanding of the mitral valve apparatus (annulus, leaflets, chordae tendinae, and papillary muscles) and the impact of various disease states. Adjacent structures (left atrium, left ventricular outflow tract, aortic valve, coronary sinus, and circumflex artery) must also be respected. This article reviews the anatomy and function of the normal and diseased mitral valve apparatus and the implications for catheter-based intervention.

Not for adults only: MitraClip use in a paediatric patient.

We present the primary report of a paediatric patient who had placement of the MitraClip device for severe functional mitral regurgitation. The patient was a 14-year-old boy with symptomatic end-stage non-compaction type cardiomyopathy secondary to a mitochondrial cytopathy. He had severe mitral regurgitation, tricuspid valve regurgitation, a severely dilated LV with apical non-compaction, severe LV dysfunction and severe pulmonary hypertension. Despite optimal medical therapy he developed progressive symptoms of congestive heart failure and he was not a candidate for an assist device or cardiac transplantation. Multimodality imaging with fluoroscopy, two-dimensional and three-dimensional transoesophageal echocardiography was used to guide the procedure. Two MitraClips were placed resulting in an adequate decrease in MR severity to no more than mild-moderate. Five months post MitraClip implantation, he has improved exercise tolerance. Transthoracic echocardiography showed mild to moderate mitral regurgitation and a decrease in left ventricular size. To our knowledge, this is the first reported paediatric patient to be offered this innovative procedure. Percutaneous edge-to-edge MV repair may prove to be a novel and effective palliation to consider in a subgroup of paediatric, adolescent and young adult patients. This case report describes some of the considerations specific to the paediatric patient.

Transcatheter aortic valve replacement program development: recommendations for best practice.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an increasingly available therapy for the management of aortic stenosis in higher risk populations. Beyond addressing the procedural challenges, centers must attend to the unique requirements of developing TAVR programs from referral to follow-up. AIM: The aim of this article is to outline the recommendations for best practice for program development from centers with early and extensive experience. RECOMMENDATIONS: The guideline-recommended Heart Team approach requires interdisciplinary agreements, delineation of roles and responsibilities, and the development of the role of the TAVR Coordinator. To support appropriate case selection, the screening and evaluation must be organized in a comprehensive clinic visit. In addition to the multimodality imaging tests, the assessment of functional status and frailty is pivotal to the eligibility decision. Throughout the TAVR trajectory, careful attention must be afforded to the integration of geriatric best practices. Pre-procedure care requires patient and family education to manage expectations and facilitate early discharge planning. Peri-procedural care planning, including equipment requirements, monitoring protocols, and emergency intervention agreements, contributes to procedural success. The aims of post-procedure care are to monitor the recovery, facilitate the rapid return to baseline status, and optimize length of stay. TAVR programs require data management strategies to facilitate and monitor program growth, support program evaluation, and meet the requirements for submission to national registries. CONCLUSION: TAVR represents a paradigm shift in the management of structural heart disease. Programmatic success and patient outcomes depend on the development of a comprehensive and collaborative program tailored to TAVR.

International immersion programs in baccalaureate nursing education: professor and student perspectives.

This article presents the dual perspectives of professor and student in relation to the explicit need for nurses to become acutely conscious of cultural competence through self-awareness and how this influences nursing care. Mary Anne Levine, Professor of Nursing, discusses the development, planning, implementation, and evolution of the International Immersion Program (IIP) at Humboldt State University. The student experience, integration, and evaluation of IIP and its impact on one's professional and personal life are described by Elizabeth Perpetua, currently a practicing RN, who participated in the program in Nakhodka, Russia.