Optimal Heart Team Protocol to Improve Revascularization Decisions in Patients with Complex Coronary Artery Disease: A Sequential Mixed Method Study

Aims Current guidelines recommend a heart team in the decision-making for patients with complex coronary artery disease (CAD). However, the decision-making stability of these teams has not been evaluated and the optimum protocol is unknown. We assessed inter-team agreement for revascularization decision-making and influencing factors to inform the development of a heart team protocol. Methods and results This sequential, explanatory mixed methods study included (i) a cross-sectional quantitative study to assess inter-team agreement on treatment strategy for retrospectively enrolled complex CAD patients and (ii) a qualitative study that used semi-structured interviews with heart team members to identify factors influencing decision-making discrepancy. We randomly selected 101 complex CAD patients. Sixteen specialists were randomly assigned to four heart teams to make decisions for these patients. The primary outcome kappa of inter-team decision-making agreement was moderate (kappa 0.58). Factors influencing decision-making were generated through inductive thematic analysis and were summarized by 3 themes (specialist quality, team composition, and meeting process) and 10 subthemes. Recommendations of heart team implementation were generated based on qualitative and quantitative data at five levels: specialist selection, specialist training, team composition, team training, and meeting process. A detailed protocol on the integration of guidelines, previous experience, and recommendations was generated to establish and deploy a qualified heart team. Conclusion Agreement between heart teams for revascularization decision-making in complex CAD patients was moderate. Potential factors associated with decision discrepancies were summarized and recommendations were generated. A detailed heart team protocol was designed and should be validated in future.