Meet the Heart Team: The Multidisciplinary Team Behind Heart Failure Treatment and Heart Transplantation

The Heart Team is a multidisciplinary medical team dedicated to the care of heart failure and heart transplantation patients. The team manages every stage of care, from assessment and treatment planning through surgery, rehabilitation, and long-term follow-up, ensuring continuity throughout the treatment journey.

In end-stage heart failure, the heart is unable to pump sufficient blood and oxygen to the body. Patients experience shortness of breath and extreme fatigue, eventually losing the ability to carry out daily activities such as going for a walk or spending time with their families.

Heart failure often progresses gradually, slowly taking away a person’s ability to enjoy everyday life with their family. That is why early recognition and diagnosis are crucial, so patients can receive appropriate treatment before the condition becomes critical.


 

What Is the Heart Team, and What Role Do They Play in Heart Failure Treatment?

The Heart Team is a multidisciplinary team made up of heart failure cardiologists, interventional cardiologists, cardiothoracic surgeons, anesthesiologists, perfusionists, nurses, pharmacists, physical therapists, nutritionists, and care coordinators.

This multidisciplinary approach allows the team to quickly and comprehensively determine the most appropriate treatment plan for each individual patient.
Team members combine their expertise and work together seamlessly from admission to discharge, and continue to provide lifelong follow-up care. The care pathway has three phases:
 
 

Phase 1: Assessment and Treatment Planning by the Heart Team

The process begins when a patient visits our outpatient department (OPD) and enters the heart failure treatment program. The multidisciplinary team then assesses the patient’s condition and provides close care.
During this phase, the Heart Team assesses the severity of the patient’s disease, analyzes the underlying causes of the heart failure, and plans an appropriate treatment strategy.
Specialists from various disciplines play distinct roles, and care is tailored to each patient.
 

Expert Care in the Cardiac Care Unit (CCU)

Patients in severe or critical condition, such as those who arrive with acute heart failure or are transferred from other hospitals, are cared for by a multidisciplinary team that works together closely and holds regular case discussions. The team includes:
Specialized Medical Team

• A heart failure specialist (cardiologist), who serves as the primary attending physician and oversees the overall treatment plan
• An interventional cardiologist, who performs catheter-based procedures to insert advanced heart support devices
• A cardiothoracic surgeon, who works with the interventional cardiologist to place advanced life-support systems such as ECMO (extracorporeal membrane oxygenation), which supports both the heart and lungs, or a pVAD (such as Impella), which supports the heart during critical conditions
• A perfusionist, who is specially trained to operate ECMO and pVAD systems
• A CCU nursing team trained in heart failure care that provides 24-hour monitoring and can quickly recognize changes in a patient’s condition and interpret complex clinical data
• A team of pharmacists specializing in cardiac medications

The Heart Failure and Transplantation Coordination Team provides 24-hour coordination from the moment a patient is admitted, whether through the outpatient department, the emergency department, or a transfer from another hospital. The team keeps the patient’s family and other care teams informed and works with the Thai Red Cross Organ Donation Centre to register eligible patients on the heart transplant waiting list.
 
 

Phase 2: Heart Team Collaboration During Heart Transplantation

Once the Thai Red Cross Organ Donation Centre identifies a donor with a compatible blood type and heart size, the Heart Team begins the transplant process immediately. Every step must be precisely coordinated, because a donor heart can remain viable outside the body for no more than four hours.
From the moment a donor heart is confirmed, specialists from various disciplines work in close coordination.
The transplant team includes:

• A cardiothoracic surgeon, who travels to the donor hospital to recover the donor heart and then performs the transplant surgery
• An anesthesiologist experienced in heart transplant surgery
• An interventional cardiologist
• A perfusionist, who operates the heart-lung machine that temporarily takes over heart and lung function during the transplant surgery
• An operating room (OR) nursing team that travels with the surgical team to recover the donor heart and assists during the transplant surgery
• A coordination team that manages every aspect of the process: communicating with the Thai Red Cross Organ Donation Centre, the donor hospital, and Bumrungrad’s medical team; keeping the patient’s family informed; and coordinating with the Royal Initiative Traffic Police to arrange rapid transport of the donor heart

 
 

Phase 3: Rehabilitation and Ongoing Care After a Heart Transplant

After a heart transplant, patients receive ongoing care from the Heart Team to monitor for complications, support physical recovery, adjust medications, and prepare for their return to daily life.
Following a successful transplant, the patient is closely monitored by:

• Cardiac rehabilitation specialists who help plan a holistic physical rehabilitation program
• Interventional cardiologists who provide care until the ECMO device can be removed
• CCU nurses who ensure the patient’s safe recovery
• A coordination team that provides guidance to patients and their families on post-transplant self-care, including home environment adjustments, diet, medication, and recognizing warning signs, and is available 24 hours a day for support
• A physical therapist who begins rehabilitation as soon as the patient’s vital signs are stable, helping to restore muscle strength and mobility
• A nutritionist who plans nutritional therapy tailored to the needs of heart transplant recipients
• A pharmacist who collaborates with the physician to evaluate, review, and adjust medication dosages, including anti-rejection (immunosuppressive) medications
• An OPD nurse who ensures the patient attends scheduled medical appointments

 
 

Key Takeaways

Treating end-stage heart failure requires more than a single specialist. It relies on the combined expertise of a specialized team, which at Bumrungrad is the Heart Team. The team manages every stage of care, from diagnosis and treatment planning through heart transplantation, rehabilitation, and long-term follow-up.

The Heart Institute at Bumrungrad International Hospital is fully equipped to provide 24-hour care for critically ill patients. The medical team uses advanced technology for cardiac life support during these critical episodes. Specialists design personalized treatment plans and provide comprehensive care from the acute crisis stage through to rehabilitation, with the goal of helping patients overcome the crisis and regain a good quality of life.