See Article page 1010. Commentary: There is strength in heart teams, whether or not the numbers add up Moritz C. Wyler von Ballmoos, MD, and Michael J. Reardon, MD “None of us is as smart as all of us” —Ken Blanchard The concept of a multidisciplinary team approach to cardio- thoracic disease treatment has long been used in areas such as thoracic oncology and transplantation. More recently, this approach has extended to coronary disease and aortic stenosis based on studies such as Synergy Between Percuta- neous Coronary Intervention with TAXUS and Cardiac Surgery 1 and randomized trials for the evaluation of trans- catheter aortic valve replacement (TAVR). 2,3 The US 4 and European 5 valve guidelines now both suggest heart team evaluation as a class I recommendation for the treatment of severe aortic stenosis—but with a level of evidence C. Robust comparative studies for what intuitively makes sense; that is, approaching patient scenarios not as an individual specialty but rather as a multidisciplinary team, are lacking. As a field, we should attempt to base our recom- mendations on the best data available and not just expert opinion, even if that expert opinion is widely held to be true. Porterie and colleagues from Laval University in Qu ebec 6 suggest evaluating the question of whether or not a heart team approach to octogenarians undergoing surgical aortic valve replacement (SAVR) improves outcomes. Spe- cifically, they retrospectively compare surgical treatment and outcomes in patients from 2 distinct clinical pathways: patients referred to a multidisciplinary heart team for TAVR, and patients referred for SAVR directly to surgeons at the same institution. The authors studied 528 patients aged 80 years or older referred to their institution for TAVR and seen by their heart team between 2007 and 2016. Of these, 101 after heart team discussion were redir- ected to SAVR by 3 different surgeons who are part of the heart team. They then compared these with a select group from 506 patients during the same time period referred directly for SAVR performed by 10 different surgeons (including the 3 heart team surgeons) but without having a heart team evaluation. As such, the exposure of interest for this study should be considered evaluation by a heart team and the actual procedure (ie, SAVR) and related variables (eg, crossclamp time) are intermediate variables on the causal pathway. A priori, patients referred for TAVR (and therefore seen by a heart team) and those sent directly to a surgeon for SAVR tend to be 2 different cohorts from the larger popula- tion of patients with aortic stenosis. This is notably evi- denced by the much higher prevalence of concomitant coronary artery bypass graft procedures, and hence longer procedure times, in the group that was not evaluated by a heart team. Appropriately, these higher-risk patients with coronary artery disease who had indications for revascular- ization are preferentially referred to surgeons directly, rather than to a heart team for TAVR evaluation. On the flip- side are patients excluded from TAVR for anatomic reasons, concomitant pathology, and low surgical risk. All this makes a comparison of the groups tricky. The concern for these selection biases persists, despite propensity score matching; an analysis restricted to all isolated SAVR or low-risk patients might have provided a clearer picture. The authors make a valiant effort to find exchangeability, and the validity of the proposed comparison ultimately is From the Department of Cardiovascular Surgery, Houston Methodist Hospital, Hous- ton, Tex. Disclosures: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Received for publication March 8, 2021; revisions received March 8, 2021; accepted for publication March 9, 2021; available ahead of print March 12, 2021. Address for reprints: Michael J. Reardon, MD, Department of Cardiovascular Sur- gery, Houston Methodist Hospital, 6550 Fannin St, Suite 1401, Houston, TX 77030 (E-mail: mreardon@houstonmethodist.org). J Thorac Cardiovasc Surg 2023;165:1020-1 0022-5223/$36.00 Copyright Ó 2021 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2021.03.029 Moritz C. Wyler von Ballmoos, MD, and Michael J. Reardon, MD CENTRAL MESSAGE The value of heart teams in car- diac surgery may be difficult to measure, but the value is real and gains importance as case and patient complexity increase. 1020 The Journal of Thoracic and Cardiovascular Surgery c March 2023 Commentary Wyler von Ballmoos and Reardon ADULT