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Eur J Cardiothorac Surg 2004;26:S25-S26
© 2004 Elsevier Science NL

Review

View from the cardiologist

Wessex Cardiothoracic Surgery Centre, Southampton University Hospital, Southampton SO16 6YD, UK

	Abstract

Top Abstract Introduction Appendix

 
Dr Keith Dawkins, a consultant cardiologist at Southampton General Hospital in the UK and President of the British Cardiovascular Intervention Society outlined the explosive growth in cardiological treatments for coronary heart disease, including drugs and percutaneous interventions. He challenged surgeons to accept the inevitable reduction in requirement for surgical revascularisation and to explore alternative areas for development. He indicated that emerging technologies would also impact on valve surgery. He warned that complancency and failure to recognise the need to change was the greatest threat facing the speciality.

Key Words: Percutaneous interventions • Cardiological treatment • Valve surgery

	Introduction

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	Appendix

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Conference discussion

Dr J.L. Pomar (Barcelona, Spain): Keith (Keith Dawkins), I was trying to tell you before, during the intermission, what you were now saying. Fred (Friedrich Mohr), Pieter (Pieter Kappetein) and I, as you well know, we are surgeons of the steering committee for the Syntax Trial. You state that this is an important trial but, is it really going to be important for our daily practice or it is just an academic issue, because, as you said, it is payed by the industry and tries to get or to enrol just a little bit of the cardiac surgery population. Also, we know this is a trial showing long term results through a registry. You mentioned that patients don't care about long term; they only care about short term. I don't think it is true... this is what some cardiologists believe. Those cardiologists, who are the ones dealing with the patients, give a misleading message: stenting is going to be quick and durable.

I had to have a hip replacement when I was skiing in Austria, and the first thing they told me was that I could get my fracture fixed quickly but, there were high chances that, in two years I could have a necrosis of the head of the femur and a reoperation. Conversely, a total hip replacement could last 20 to 25 years. What do you prefer, to have a hip replacement or a screw fixation? And I certainly preferred to have something for 25 years as, I am convinced, any single patient would be happier with a long-term great result achieved by a heart operation.

So, again, do you think it is worth really to do these trials when we know nobody is going to follow them?

Dr Dawkins : I think the unique thing about this trial, and it answers the question that Axel (Axel Haverich) posed to me earlier and one of the reasons I am sure you as surgeons are on board over this trial, is that it takes 100 consecutive patients in your center with three-vessel or left main stem disease, and instead of your cardiologists saying, I can treat all these patients, you will sit down with him, or the surgical or the PCI team will sit down, and go through each patient and say, these patients can only be treated by surgery, I don't want to do these, and I certainly don't want to randomize them in the trial because I may be exposed, these few patients cannot be treated by surgery because they have got a co-morbidity that makes them unsuitable, and these patients in the middle could really be treated with either technique.

So this consecutive cohort study looking at the registries in parallel to the randomized trial I think is very important, and I think it will cut out a lot of the interventional bullshit of we can deal with everything, because it will actually show what the cardiologists can deal with, and that is why it has an attraction to surgeons. And of course, that is the bit that, if you like, was sold to surgeons: it is not the reason Boston Scientific is investing in the trial, but it has a real appeal to you.

Dr F. Beyersdorf (Freiburg, Germany): I enjoyed your talk very much, and the reason why I enjoyed it is that it expresses exactly what many other cardiologists think and what is also perceived by the general population. I think that we have to face the truth, what is in the minds of many people.

On the other hand, it also will be the starting point for us to go into a different new direction. And a new direction means that we, first of all, have to state more clearly the long-term results of our treatment. Secondary we have to encourage people who open new fields that they gain a broader role in our Society. And your example with Bilroth is very well taken.However general surgery has also not vanished from the scene. They have switched to other directions. And I am always making the same comparison to physiology, anatomy and biochemistry. For example, anatomy has changed from description of bones and muscles to a speciality doing research on cell recepters, etc., so that differences between anatomy, physiology and biochemistry are smaller than in the years before. I mean, we just have to change our field. To what extent we have to change it, nobody knows.

Therefore, I really enjoyed your talk very much because it clearly showed that all these dots which are there cannot be fought against by fighting against these dots. We just have to sit somewhere else and let the dots be on the right side; we are on the left side. Who cares about these dots? But this really explained everything and you fulfilled all our desires.

Dr R. Dion (Leiden, Netherlands): I too enjoyed your talk, but for a different reason. It was fine to hear from you about our common future, and it is remarkable that it was coming from a cardiologist. You didn't so much underline the necessity of innovative technology. You just underlined in your last slide that we have to redirect our focus. And I believe, and I would like to have your opinion on that, I believe that we face a future which is going to be bidirectional. There will be units concentrating on complex pathology, complex patients, patients with more than two or three procedures, with difficult postoperative care, and they we will need DBCs to reimburse them in a different (higher) way. And these centers, they are not really under the threat of the new technology because they are occupying a niche of patients which will not disappear but will even probably enlarge even more so with the probable reduction of the number of these centers.

And then the surgeons who are really under threat are those who are not pushing to repair the (difficult) valves, or to perform complex and/or combined procedures in heavily diseased patients: they will have to change and embark in the so-called innovative (percutaneous, minimal invasive) technology.

So do you agree with that, that you will have centers doing all sorts of complex things and then more classical surgical centers who will have to embark soon on ‘new’ technologies, because what they do now is under threat?

Dr Dawkins : I certainly agree with that, and I think also, and we haven't really discussed this today, you need far fewer surgical centers. There are some countries where you have this expertise, this multidisciplinary team working in a big center doing the complex patients that you said. Why should you have a little center doing very small numbers of relatively simple patients, particularly in the setting of the European Working Time Directive where you can't even provide an on-call service? You need to rationalize the provision of the service to big centers. So I agree with you entirely.

But in centers that are doing small numbers and operators therefore within those centers that are doing unacceptably small numbers, they have to close, they have to be amalgamated in the big centers, and that is a whole other issue I think, which we haven't really touched on today.

Dr M. Turina (Zurich, Switzerland): At the risk of appearing antiscientific, I must tell you that I have the gravest doubts about your trial. A number of years ago I analyzed all these trials, BARI, RITA, GABI, EAST trial. Out of 93,000 patients screened, 3.4% entered into various trials. Out of the ARTS trial, which is now presented every year in the European Society of Cardiology, in Zurich only 0.4% of the patients entered the trial. So the only true way to analyze the situation would be to take all-comers, randomize all patients with three-vessel disease into PTCA/stenting or surgery, and then we might have the true results relecting the clinical routine. But this will never happen.

Dr Dawkins : The problem with ARTS and all those is that they didn't have formal registries where the patients were followed. So this has looked at consecutive patients. And you will never get surgeons or PCI doctors to agree to randomize all patients. The same is true of the surgeons; possibly less patients with the surgical group.

We haven't got time to go into it, but there are virtually no exclusions to this trial; poor ventricles, recent stroke, recent infarct, you can do anything you like. Now, the surgeons wouldn't take all those patients randomized one-to-one, neither would the interventional cardiologists. So we are trying. It's not perfect, but we are trying.

	Footnotes

 
Presented at the EACTS Symposium for the Future of Cardiac Surgery, Frankfurt, Germany, July 1–2, 2004.

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