Commentary: Evaluating the pieces of the puzzle in building a high-quality transcatheter aortic valve replacement team.

Fitting the pieces of the puzzle to build a collaborative culture for Team TAVR.

Integration of perspectives and attitudes of all team members to cultivate a collaborative culture is the first step in building a high-performing team providing high quality of care.

See Article page 74.

Although complications from transcatheter aortic valve replacement (TAVR) have decreased tremendously since its introduction, the need for a surgical bailout still exists. Clearly a discussion by the surgeon, cardiac interventionalist, and the patient is needed, but the ultimate decision to pursue or not pursue surgical bailout may have psychological consequences to the patient as well as all clinical providers involved in the care of the patient.

In this issue of the Journal, Robbins and colleagues report their exploratory analysis of semistructured interviews of the TAVR team (cardiothoracic surgeons, cardiac interventionalists, and cardiac anesthesiologists) in attempt to understand physician perspectives and attitudes toward TAVR and to better understand how to best involve the patient in this decision. Although this study is limited by the number of participants interviewed (n = 13) and did not include other members of the clinical team, such as technicians and nurses, the authors' analysis revealed 4 themes: (1) clinical judgment and expertise in determining viability of surgical bailout option; (2), TAVR team dynamics; (3), emotional impact on the TAVR team; and (4) importance of patient autonomy. These are all themes that need to be explored and will clearly benefit the patient as well as the clinical providers.

Robbins and colleagues highlighted the importance of shared decision-making, an evidence-based approach to decision-making where there is communication with the patient and surrogate decision makers and the clinicians. Rather than communicate in a manner that is paternalistic or neutral (providing no expert opinion), this shared decision-making model, where genuine communication between the clinician and the patient is made, has been shown to improve patient outcomes, decisional conflicts, and satisfaction.

In this study, Robbins and colleagues also sought to understand the perspectives and attitudes of the TAVR team (cardiac surgeons, cardiac interventionalists, and cardiac anesthesiologists). This is commendable because they embraced the key concept that cultivating collaborative cultures within a team leads to psychological safety of teams, especially when teams are diverse, as they often are in interdisciplinary teams. They are also beginning to address how this diversity and possible conflict can equip the team with better skills to deal with their own and their team's conflict. However, due to the limited number of participants, they were unable to answer whether the emotional toll is different for various members of the team (surgeons, cardiologists, anesthesiologists, nurses, technicians), as the interventional cardiologist and surgeon are generally the ones discussing whether a surgical bailout is indicated.

Clearly shared clinical decision-making needs to be implemented for all important decisions that a patient encounters. However, the emotional toll of the decision on all clinical providers involved could be devastating and could ultimately affect the dynamics of the team. Therefore, studying the perspectives and attitudes of all team members to cultivate a collaborative culture is the first step to quality care of the patient.