Expanding the definition of a ‘heart team’

When weighing potential risks and benefits of a heart operation, the surgeon bases his/her expectations on established tools. Variables including age, sex, co-morbidities and operative characteristics comprise a patient-specific EuroSCORE, which predicts the risk of mortality, complications and length of hospital stay [1]. These variables are easily derived from patient records, unambiguous and simple to explain to the patient. Patient expectations, however, may be based on quite different values and often considerably differ from surgeon expectations. In patients undergoing orthopaedic surgery, 50–60% of patients had higher and 10–20% lower expectations for surgery than their surgeons [2, 3]. The difference in expectations is not negligible: negative expectations before cardiac surgery are shown to correlate with the longer length of stay and worse recovery experience [4]. Patients commonly report these negative feelings, fear and anxiety, before cardiac surgery [5]. Recognizing the importance of this psychological aspect and taking the initiative to affect it perioperatively, Sadlonova et al. [6] designed the randomized controlled I-COPE trial. To optimize patient expectations before coronary bypass surgery, a psychological intervention protocol was implemented, starting 2 days before surgery. The same protocol had already been used and proven successful in the PSY-HEART trial [7]. Importantly, the I-COPE trial team was trained by the developers of the PSY-HEART protocol, thus ensuring intervention feasibility and standardization. The study cohort was randomized into 3 groups: (i) standard medical care (SMC); (ii) SMC and psychological intervention; (iii) SMC, psychological intervention and miscellaneous additional treatments (light therapy, noise reduction, music, virtual reality). The effects of this psychological pre- and postconditioning were evident. In the 2 groups receiving psychological interventions, the patients felt stronger control over their own healing process. This translated to a significantly reduced total length of hospital stay: for the SMC group, the mean was 12.48 days in comparison to 9.83 days for the psychological intervention group and 9.31 days for the group with psychological intervention and additional treatments. Length of hospital stay is an indirect indicator of quality and efficiency of care [8]. Discharge culture, however, varies markedly between hospitals and countries: in the United States, >50% of patients stay in the hospital for a maximum of 5 days [8, 9] whereas Sadlonova et al. reported the mean length for even the group with the shortest hospital stay to be >9 days. In the latter case, longer stay is partly attributable to the routine hospital protocol: patients arrive at the hospital 2 days before surgery whereas in many countries patients arrive no earlier than on the day of surgery. Nevertheless, previous reports have indicated that the length of hospital stay is mainly determined by medical factors and hospital culture, with psychological factors playing a minor role in the variance [8, 10]. The study by Sadlonova et al. challenges this paradigm. The study was not blinded, and knowing the interventions could have affected the surgeon’s decision of earlier home discharge. But given the detected higher self-efficacy scores in the intervention groups, it seems reasonable to assume that earlier discharge was indeed driven by patients themselves: they simply felt more confident about their healing process. As this was only a pilot study, I look forward to seeing if the benefits of the psychological intervention are mirrored also in outcomes of a longer follow-up. For providing the best care to our patients, the importance of a multidisciplinary heart team is well established. Cardiac surgeons, cardiologists, perfusionists, intensivists, nurses and physiotherapists contribute to a safe, efficient and effective postoperative stay and excel in ensuring physical healing. However, their efforts are under constant administrative scrutiny to shorten hospital stays and thus reduce costs but should the approach be changed? Perhaps the heart of the matter is in psychological support and we should instead consider expanding the heart team.