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Eur J Cardiothorac Surg 2004;26:S32-S35
© 2004 Elsevier Science NL
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Heart Centre, University Hospital Umea, Umea S-90185, Sweden
* Tel.: +46 90 785 3676; fax: +46 90 785 3601. (Email: torkel.aberg{at}vll.se).
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Abstract |
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 Top Abstract 1. Cardio-thoracic surgery is...2. Counterattack3. What about defence?4. What about retreat?Appendix |
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Key Words: Strategy • Medical development • Demography
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1. Cardio-thoracic surgery is under attack. What are our reactions to this attack? |
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TopAbstract1. Cardio-thoracic surgery is...2. Counterattack3. What about defence?4. What about retreat?Appendix |
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Three main options are attack, defence and retreat. All three options should lead to peace, i.e. a stable situation that can be tolerated for a long time. The tactical situation is most often such, that all three options can and should be used at any one time. This is most often the case in the beginning of a campaign. Towards the end when facts, costs and reality press themselves upon combatants, there is usually only one main option left.
This is all very interesting, but how can we use this strategic knowledge in our own situation?
One of the golden rules of warfare is Know thy enemy. Who, then, is our enemy? Our enemy is not cardiology as subject, nor the individual cardiologist, but medical and social development itself. The most important of our enemies is the social development. Western societies have now developed to a point where the severe message of Health Economy is being realized: We cannot give all citizens everything in all part of their lives. The western world at the moment is not economically developing fast enough to be able to honour all the promises made by our politicians to all citizens. The demographic development speaks its silent and to many planners horrifying message that we will not be able to uphold the medical service that we can provide today. In short, there will be too many individuals expecting medical service on a level that society cannot afford.
Medical development is something per se positive as it helps us better to serve our patients. Medical development, therefore, is something that cannot and should not be fought. However, as society cannot afford or indeed does not have the means to take advantage of all medical development, it may be said that medicine at the moment is the victim of its own success. Society cannot receive and take on much more medical development unless it makes current treatment of the patients cheaper. Thus, our efforts at being able to successfully operate on very elderly people do not necessarily win acclaim among health service planners.
The degree to which this is true differs from country to country. In some countries, the salaries for health workers are still so low that expansion of medical service is still feasible, in other countries, including Sweden which has the largest proportion of elderly people in the world, this is no longer possible. On the contrary, relative diminishing resources for health care are being implemented.
Another aspect is also changing. Earlier, medicine was focused around the individual patient. At the moment, there is a strong belief among planners that medicine should focus much more on health policies towards the population, i.e. a more holistic view. What can we do to prevent problems as regards hypertension, diabetes, mental health, child health, old age, etc. so that we can obtain a healthier population that does not need advanced services? It can be understood that against such a more holistic, population based policy, the very individual activity of cardio-thoracic surgery may be seen as a problem or at least not prioritized.
Thus, our main enemy is not the development within cardiology, but rather the lack of financial development within the western society. Against such an enemy, we have to sharpen our weapons.
However, the attack on cardio-thoracic surgery is being mediated, I would say, by the medical development of PTCA. PTCA is being claimed as a superior method and therefore, cardio-thoracic surgery does not need any additional resources and may indeed be diminished.
Who are our allies? Of course, our patients are our allies. However, as cardiology has access to our patients before we do, our presumptive allies are not very effective as such. Furthermore, PTCA has as its main advantage its non-invasive nature, something that is much appreciated by the normal patient.
How have we prepared ourselves? We have known since Gruntzig published his first paper that PTCA is a method in direct competition with CABG. It may be ironic to some to realize that PTCA was created within a surgical setting, that of the department of Åke Senning. However, we as a speciality have been neither active nor really interested in the evaluation of PTCA. Thus, we have lacked in the preparations and have to suffer from the consequences of this omission.
Thus, the stage is set. Cardio-thoracic surgery is under attack. Our strategic position is weak. We are not very well prepared. Our enemies are all around us. We have to consider our options.
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2. Counterattack |
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TopAbstract1. Cardio-thoracic surgery is...2. Counterattack3. What about defence?4. What about retreat?Appendix |
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There are other operations and I am thinking primarily of arrhythmia surgery. However, also in this field we have stiff competition from less invasive procedures as well as reluctance from society to finance them.
Is counterattack a viable option? Yes, indeed it is! I think that we have to pursue scientific development, but of course mainly with the aim of better treating our patients, not primarily to defend our present territory. This has to be our main direction of action!
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3. What about defence? |
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TopAbstract1. Cardio-thoracic surgery is...2. Counterattack3. What about defence?4. What about retreat?Appendix |
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One main advantage of CABG is its known and excellent long-term results. The longer PCI is followed up, the less convincing the long-term results seem to be in comparison with CABG. Also as regards long-term results, a comprehensive study with relevant subgroups should be initiated. Again, I believe that we as a profession—with some outstanding exceptions—has lacked in the scientific evaluation of our own field.
The issue of neurological complications is a short term study that could be made within a year. However, the long-term study by definition has to last up towards 10 years. It will not be possible to maintain a good defence, waiting for such a study. Thus, again, CABG is at a disadvantage. Good registry studies, however, could be done fairly quickly.
One field for counterattack is the issue of total revascularisation. It has been the opinion of cardiac surgeons that a total revascularisation is desirable and improves long-term results. The value of the concept of culprit lesion and less than total revascularisation should be seriously questioned with good studies.
Another field in which we can well defend ourselves is costs. Cost for PCI in the modern era is much dependent on the costs of the catheters and stents. CABG on the other hand has a relatively constant cost irrespective of number of vessels involved, PCI becomes much more expensive with increasing complexity of the coronary anatomy. Here is a field where we can readily defend ourselves towards the cardiologists and hospital authorities. Indeed, this would be a main argument against PTCA taking the field of triple vessel disease.
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4. What about retreat? |
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TopAbstract1. Cardio-thoracic surgery is...2. Counterattack3. What about defence?4. What about retreat?Appendix |
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Retreat should be faced without emotions and as an intellectual exercise in order to adapt to new circumstances. Retreat is an honourable strategic undertaking, aiming at a new, stable situation.
The retreat may be looked upon from many views. We can look upon retreat with the eyes of the patient, of the department, of the hospital, of the region or country and indeed from the speciality itself. Finally, we can look upon the situation with our own eyes. What will the development do to my situation and how can I influence?
Our responsibility, apart from the patient, is the department and not least the jobs of our good collaborators who depend on us. However, as responsible citizens, we also have to take a broader view. The department is the tool, by which the hospital and society wants to achieve some goals. When these goals change, the tool may become redundant. It should not be defended in absurdum. The most responsible chief of department is the one who can take his department through the change of time in a constructive fashion, including handling the sometimes necessary decrease in size and activity.
In our case, the form of retreat can differ from situation to situation. Also in retreat, a constructive strategic thinking can assist in shaping a better final situation. For instances, what allies do we have? There are specialities that are in worse shape than we are, I am thinking primarily of vascular surgeons. Do they have needs that we can assist them in order to achieve a common goal of thoracic and cardiovascular surgery? The alternative may be that the hospital looses both cardiac and vascular services. And that makes the cardiologists, ironically, our best allies within the hospital. It is therefore important to maintain good relationships with our adversary and ally, the cardiologists.
The closing of departments may actually have a beneficial effect on the speciality. Many of us believe that major surgery should be performed within reasonably large units in order to be able to maintain a good on call schedule and ancillary services such as good computer and follow-up facilities. Thus, if two small or middle-sized departments would combine in order to create a department with adequate facilities, something good has been created. The issue of size versus results may be used to the advantage of the speciality. This is now being undertaken in Stockholm, where the departments in Huddinge and Karolinska are combining forces in one unit in anticipation that coronary surgery will decrease some 40%.
The changes that an imposed reduction in size of a department creates an unstable situation that may be used to further develop the future department! All change is an opportunity to the one with a creative mind!
Thus, in spite of our strategic position being weak and that we are influenced by sometimes overwhelming forces, our options could be summarized as follows:
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Appendix |
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TopAbstract1. Cardio-thoracic surgery is...2. Counterattack3. What about defence?4. What about retreat?Appendix |
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Mr J. Monro (Southampton, UK): Just while people are thinking of any questions to ask, could I have a little poll from everybody. Personally, and I will exclude anybody who has had prior cardiac surgery to their coronary arteries, or indeed, angioplasty, if you had a 90% isolated lesion 2 cm down your left anterior descending coronary artery, would you have surgery or a drug-eluting stent?
Dr K. Engstrom (Umea, Sweden): I think it is very important, too, if you look into the cardiology reports and papers they write, you can see that they have the same problems with drug-eluting stents as they have with the bare metal stents in terms of branch lesions, main stems, small size vessels and what else, diabetes of course, although the percentage of target lesion revascularization is a bit lower. But one of the big problems are the branches, and in Sweden, in Umea, we don't see many cases that are suitable for PCI, they go to surgery, but we don't see the simple cases anymore. So I don't think there will be a big difference in the future. And that summarizes the picture there, the questions I had for Keith (Keith Dawkins).
Dr S. Hagl (Heidelberg, Germany): Jim (James Monro), your last question on the paper given by Torkel (Torkel Aberg) brings me to a point. Torkel, what are we defending at the moment? Do we defend our specialty or do we defend our methods and techniques where we should be convinced that they are better for certain patients? I think that is a very important point in the whole discussion. When I consider that the majority of this group of outstanding surgeons pefers to have an eluting stent to treat an isolated proximal LAD stenosis despite the fact that a LIMA bypass produces excellent long-term results I am sure that we are not in the best ‘defending position’ if we don't believe in our art. This question has to be answered. That is one point.
And the second is a problem which was addressed several times this morning, that having no primary access to the patients, we have to realize that we have to improve the cooperation with our cardiology partners.
I remember about 10 or almost 15 years ago, when this battle started in oncology. There were different groups, oncology, radiology, surgery, and nuclear medicine competing. Today, as you know, all over the world there are so-called comprehensive cancer centers where all the different specialties sit at one table. For example, in our university hospital in Heidelberg, the individual patient is seen by all these members of such a group, including a basic scientist. I think this is probably the way to go into the future also in cardiovascular medicine.
So I think we have to put all our efforts in that direction, to sit really together and determine and define what is the right way for the individual patient together with the cardiologists. and I think that is the only way to improve and, for the future, maintain cardiac surgery on a scientific level.
Dr Aberg : My speech may have come out a bit gloomy, which was not my intention. My intention was to realistically point out the difficult strategic situations that we have to face and how we could handle them.
What, indeed, are we defending. We will be defending our size, not our existence. Cardiac surgery is one of the more effective treatment modalities that exists in medicine. So it is more the size that we are defending than anything else.
Dr L. von Segesser (Lausanne, Switzerland): I have a comment about the tumor board analogy that was made with regard to PCI. I think the problem is that when the time comes to discuss, the patient has already got his stent, because this is done during the diagnostic procedure. There is no time or opportunity to get involved in a discussion, and that is why I think this discussion will never happen. Sorry.
Mr S. Nashef (Cambridge, UK): Of course, the example that you asked us to vote on was a single vessel, with a straightforward, away-from-bifurcation, 90% lesion, and unfortunately, or fortunately, we do not see many of those anyway; they never come to us. Most of the patients that we treat have got triple vessel disease, impaired left ventricular function, left main stem stenosis and diabetic, and these are patients for whom there is strong evidence that coronary artery bypass grafting makes a difference to prognosis.
Now, correct me if I am wrong, but I don't think there has ever been any evidence whatsoever to show that stenting has any impact on prognosis. What Keith alluded to was the quick-fix culture, which says that patients want something done quickly so that they can be back on the golf course, but I wonder whether the patients are being told that there is a trade-off between the quick fix and the long-term benefit.
Now, of course, you need to have 17 angioplasties before the level of invasiveness reaches that of a coronary artery bypass graft, but the patient at least must have the choice of whether they want to have something more invasive but with more durable results and better long-term survival. It may be that they will not and they will still opt for angioplasty, but I think one of the problems that we have is that that information is not reaching them, and perhaps that is something we should work on.
Dr C. Mestres (Barcelona, Spain): I agree with Sam (Sam Nashef), because I think there are so many biases. It is a pity that Keith Dawkins left, because my opinion is that we talk a totally different language and we speak about totally different things than cardiologists talking about stents. It's true. So diabetes, everything, all these kinds of things, they are very serious and affect our practices.
So, number one, at least in my place, we don't see any vessel above 2.5. So they are talking about small stents, 2.5. They use a different language because they are talking about long-term results of six months, and we are trying to look out for our patients for 15, 20, 25, 40 years, for life. So this is to me basically an obscene way of managing information. I mean, would anybody in the room accept that if I am doing an operation, long-term results are going to be six months postop?
So I think it is so biased, and the information that has been distributed, as Sam said, I think is the key point. We are talking about totally different things and using totally different languages. There is not going to be any communication at all.
Dr T. Wahlers (Jena, Germany): My point of view would be from a Society perspective what action can be undertaken.
Why don't we start an active information policy of the Society addressing the public that the results in coronary surgery are good, especially long-term, that is understandable and can be read in the Internet or wherever.
Thereby, you can address everybody, make up your own mind, but there is an information site where you can read how things are. I am not saying that we are changing our future with that, however, we are defending what we are having. And since it is difficult to gather good scientific information for a simple patient, that perhaps might help, if it is easily addressable and if everybody is referring to such type of a Web site and if it is actual and all nice studies are plugged in there, and that would be a suggestion.
Dr Engstrom : It's an interesting question. When you meet a 100 cardiologists, at a recent Nordic PCI meeting in Reykjavik, you realise they belong to groups, more or less believers in drug-eluting stents. There was even a presentation by one cardiologist who doesn't believe in stents because he said there is no survival benefit putting stents in coronaries. It is equally good with a balloon. And the latest papers also show that there is no survival benefit with drug-eluting stents. There was a big hope among cardiologists that they finally would prove that PCI would save lives, but it doesn't.
Dr A. Kappetein (Rotterdam, Netherlands): I agree that we should improve our publications but we hardly have any firm data. For example we don't even have results from large trials comparing coronary surgery and medical treatment. The largest study completed enrollment 25 years ago and included 780 patients. There were no statins, there were no new ACE inhibitors, half of the patients were using beta blockers. So we didn't perform any proper trial comparing coronary surgery versus medical treatment or another treatment.
As surgeons we work with retrospective studies or we participate in a trial which only comprises 5% of the total population.
We always failed in setting up randomized trials, and that is because there is no industry who sponsors it. An industry which makes sutures is not going to sponsor surgeons comparing coronary surgery versus another treatment. So we don't have the money, so we are not able to carry out a proper trial and we will not have the results to publish, unless we work together.
Dr Aberg : The last few minutes have been about defense, defense about the value of PTCA, and I am quite certain that there are areas where we can defend ourselves quite readily, and I think the lack of putting together the comprehensive literature that is available is something that we as an Association should do.
Dr F. Mohr (Leipzig, Germany): I just have a feeling that the wording ‘defense’ is just the wrong heading, excuse me. I listened to the last presidential addresses of the major meetings in America and it was always like you go to a funeral, that we are dying.
I think Siegfred Hagl's suggestion to get more involved is absolutely necessary. If you look at this meeting today, we only had one cardiologist, and we are talking about cardiovascular medicine. If you look at the European Society of Cardiology, how few surgeons are involved in this Society. We just leave it to the cardiologists. There is, especially through Siegfried Hagl, very close cooperation between the German cardiac surgeons and the cardiologists and in some sessions that I know also in the European Association.
It doesn't help us if we complain here. We just have to take, for example, the strategy which is upcoming for the next session, the percutaneous valve session, for example, to get the experts from the cardiologists. The interventionalists will take a percutaneous ring somewhere in the coronary sinus. He does not understand mitral valve disease. However, we have to come up with a suggestion to attack this. I mean, it is not a counterattack. We have to attack it in a positive manner. I don't like ‘defense.’ We have to get the interested people in the special fields and working groups, and we, as surgeons, have to get involved in the European societies to discuss these issues. This is just my gut feeling right now.
Dr Aberg : In essence, I agree with you, Fred (Friedrich Mohr). The first thought from a surgeon is usually to attack and to do more for your patients. I am pointing out that we have to know about all three modes of handling a very difficult situation that the whole western society is facing. We should be prepared to use all three modes, if necessary. Of course, I would prefer to be on the attack because it is a more rewarding situation, but we may not be in that situation. The main thrust of my talk is that, regardless of what we would prefer, we should be well informed, well prepared and use all possible options constructively. And there is a wealth of interesting development in the future!
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Footnotes |
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Presented at the EACTS Symposium for the Future of Cardiac Surgery, Frankfurt, Germany, July 1–2, 2004.
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