Eur J Cardiothorac Surg 1999;16:S117-S118
© 1999 Elsevier Science NL
Interventional cardiology versus minimally invasive cardiac surgery
Jai-Wun Park*
Cardiovascular Institute, University Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany
* Tel.: +49-351-450-1200; fax: +49-351-450-1202
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Abstract
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Comparing interventional cardiology with minimally invasive cardiac surgery 1998 goes back to the early 80s when cardiologists treated coronary artery disease patients with balloon angioplasty under a permanent observation of cardiac surgeons who could offer to the patient the well established Conventional CABG, which already had proven to be safe, effective, durable, reproducible, and complete. At that time some critics predicted PTCA would remain the hobby of some cardiologists. During the last two decades, however, an explosive proliferation in the number of PTCA procedures has occurred, which soon exceed the number of CABG procedures. As technology has advanced and operator experience has increased, the application of PTCA has expanded from dilatation of simple, concentric single-vessel stenotic lesions to progressively more complex lesions in multivessel disease. Within the last 5 years the minimally invasive cardiac surgery has progressed, which allows the performance of even complex cardiac surgery through small incisions with (port-access technique) or without (MIDCAB technique) cardiopulmonary bypass. The rationale of enthusiastic users of these new techniques leads to improved cosmetic results, less surgical trauma, decreased length of hospital stay, reduced cost, and comparable long-term results with respect to conventional CABG. Similar to the prediction about PTCA two decades ago, some critics say that minimally invasive cardiac surgery would remain the hobby of some cardiac surgeons.
Key Words: Interventional cardiology • Minimally invasive cardiac surgery
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1. Introduction
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In comparing interventional cardiology with minimally invasive cardiac surgery several outcomes could be assessed: clinical outcome, cost, cosmetic outcome, and others. Clinical outcome, the most important one, could be measured in terms of mortality, myocardial infarction, LV-function, angina pectoris, exercise tolerance, quality of life, and others. Data, comparing PTCA with CABG, PTCA+STENT with CABG, PTCA+STENT with MIDCAB, which correctly mirror clinical practice, are often lacking or rare. The basic rationale giving legitimization to perform any kind of revascularization (by knife or balloon) still consists of three major bypass studies – the European Coronary Surgery Study [1], the Veteran's Administration Coronary Artery Bypass Surgery Cooperative Study [2] and the Coronary Artery Surgery Study [3]. In general, these studies demonstrated that the absolute benefit of CABG is proportional to the long-term risk of medical therapy. Various anatomical markers, such as number of vessels diseased, involvement of the proximal LAD, and lower ejection fraction, have been identified as major determinants of long-term risk.
Five trials have been published comparing PTCA with CABG in multivessel disease, GABI [4] (Germany), RITA [5] (UK), CABRI [6] (Europe), EAST [7] (US), and BARI [8] (US). In all five studies significantly less than 10% of totally evaluated patients were finally randomized for the study (2.4–8.3%). Therefore, these selected patients do not automatically represent average multivessel disease patients in clinical practice. However, these studies revealed comparable outcomes in terms of mortality, myocardial infarction rate, improvement of angina pectoris. It was not unexpected that the hospital stay be extended after surgery. A fundamental difference between PTCA and surgery was the need for a second procedure during the first year. All five studies showed that about 20% of all dilated patients need surgery and additional 20–25% need a second PTCA. On the contrary, only 5% of patients receiving bypass surgery need a second procedure (in general PTCA) during the first year. The basic costs for multivessel PTCA are about the half of the costs required for surgery [9]. However, in long-term this saving becomes smaller and smaller, and so is a quarter after the first year.
Both, minimally invasive cardiac surgery as well as interventional cardiology, are still an evolutionary process. Temporal changes in each mode of therapy continue to occur and may significantly alter relative efficacy. In the last years, as a consequence of improved anti-coagulation management (ticlopidine, glycoproteine IIb/IIIa receptor blocker) and stent technology, the therapeutic strategy in interventional cardiology has changed significantly. Now, in vast majority of all interventional procedures PTCA is combined with stent implantation resulting in improved management of acute procedure related complications and reduction of restenosis rate [10,11]. This again had a significant impact on the indication of multivessel PTCA. The influence of all these new developments in cardiology as well as the influence of developments in surgery (more arterial revascularization, minimally invasive techniques) are now under investigation within two international, randomized trials, the ARTS- and SOS-Trial.
Patients' characteristics are changing, older and sicker patients with severe co-morbidity are now accepted, who were in former years believed to be contra-indicated. In clinical practice, both modes of therapy are not utilized in a mutually exclusive fashion. Often, they are complementary. The question is not which mode of treatment is better, but in which sequence and in what combination are therapies optimally appropriate for a specific patient, at a specific time point in the disease process. Furthermore, the need for ‘hybrid' procedures has been raised. Recently, Cohen et al. reported that the integrated coronary revascularization (MIDCAB to the LAD combined with PTCA of the other diseased vessels in patients with multivessel disease) to be a safe and effective treatment. Even patients at high risk, with left main disease, low ejection fraction, advanced age, and significant comorbidities, were successfully treated with no mortality and minimal morbidity. The elimination of cardiopulmonary bypass in these patients with particularly high risk, may avoid the significant incidence of neurological sequelae reported with routine CABG [12]. In future it is no longer a question of minimally invasive cardiac surgery versus interventional cardiology, but the question of revascularization versus medical treatment, because of the explosive advances in development of new drugs which can influence the pathogenesis and the natural history of coronary artery disease.
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Footnotes
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Presented at the International Symposium ‘Present State of Minimally Invasive Cardiac Surgery – Meet The Experts', Dresden, Germany, December 3–5, 1998.
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References
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- European Coronary Surgery Study Group: long-term results of prospective randomised study of coronary artery bypass surgery in stable angina pectoris. Lancet 1982;ii:1173..
- The VA Coronary Artery Bypass Surgery Cooperative Study Group: 18 year follow up in the Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery for stable angina. Circulation 1992;86:121..
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Abstract
1. Introduction
