Saturday, November 10, 2007

What is surgical CAD in the light of PCI improvements

It is common knowledge in our circles that cardiac surgeons caseloads have been severely affected by improvements in PCI (Percutaneous Coronary Intervention). In the adult population, PCI has really impacted the need for bypass surgery. In paediatrics, congenital heart disease, percutaneous cardiac interventions (occluders) have also impacted on the work of congenital heart surgeons. Adult cardiac interventionist are also looking to do percutaneous valve replacements. If this trend continues, in the next ten years, probably less specialist will be going for cardio-surgical training.

Contrasted against this, is the fact that with the "hooha" about late stent thrombosis last year, we have noticed a reduction in the use of DES (drug-eluting stents), an increase in the use of bare metal stents, and also an increase in the rates of bypass surgery.

This blog is partly prompted by a paper published online in the 15th Oct 2007 edition of the Annals of Internal Medicine. This paper by Dr Bravata of Stanford University, did a meta-analysis of 23 large clinical trials (including 5,091 patients) comparing PCI and CABG, especially their 10 years survival, and the Stanford team found that after ten years, the survival differences was less then 1 percent. PCI and CABG both have the same longterm survival. Well, this is nice to know. If one looks at the subsets, over 5 years, there seems to be more perioperative strokes and more angina relief with CABG and more revascularisation with PCI. So what is new. We know this from before. It looks like all the so call poorer survival advantage of PCI in the longterm, is not true. What then is the place of CABG in the management of CAD. It looks like in a center with an aggressive PCI team, the cardiac surgeon's territory will be restricted to LMS disease and severe triple vessel disease with poor LV. Add to this the fact that most patients are adverse to surgery, if they know that PCI patients live as long as post-CABG patients. I am certain that soon, it will be rare for a cardiac surgeon to find a patient with normal LV. Of course, in centers where the cardiac surgeon has a good reputation and the PCI team is young and new, then only single vessel CAD may end up with PCI and all else with cardiac surgery. As for myself, the patients who are refered to cardiac surgeons are those who prefer CABG, those with poor LV function with at least two CTOs ( chronic total occlusion ), and those with two stents or more at the same arterial location ( no more room for stents ). We have done quite a few LMS CAD( left main stem CAD ), with good results. Yes, we had to re-do some of them, but many of the patients still prefer PCI. I am certain that not all of you out there will agree with me, and I would like to hear your comments.

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