Enough with the IC vs. CTS debate, and ?dying-CTS? arguments

I have been reading your (excellent) forum for a couple of years and while not being an aggressive poster there are a couple of things that stoke and still strike me most. I see many many people, without (any?) insight in CTS ?even people from other fields of medicine- predicting the demise of our speciality with the ease of an almighty knowledgeable insider. This thread/post is an attempt to restore the truth, review the past, explain dilemmas in the present and predict the future.

To start with the education in CTS, I read a lot about reducing the amount of general surgery before CT fellowship, maybe a 3+3 program, or maybe programs entirely dedicated to CTS like in some countries. While a small reduce in GS prior to CTS wont do any harm in CTS residents, I strongly doubt that ignoring and/or minimizing GS residency will be a step forward for CTS. Of course that all depends on what someone calls CTS: If your cases are 99% CABG then probably 5 years of GS is just an obstacle in the way of becoming a CABG specialist. But its not very difficult to see that CABG surgery is stabilizing or shrinking due to the advances in Interventional Cardiology (IC), and technologies like balloon angioplasty, stents (drug eluting or not). So is it a good time to train as a sole Coronary Surgeon? I think not. Will the training of coronary surgeons lead to innovation and breakthrough? I think not. Having the privilege of being part of the first team in my country placing LVADs in heart failure patients (IDCM, IHD) not only as a bridge-to-transplant therapy but also as destination therapy and perhaps for the most promising bridge-to-recovery therapy, I found out first hand that all knowledge from GS were greatly appreciated and needed in order to read the patients sign and symptoms correct and especially fast to understand the patients status first hand and be able to deal with any GS complication and pathology effectively. The same goes with the fascinating field of aorta surgery. Knowledge and experience from GS residency is indeed needed and proves valuable. Still though, a small reduction to the GS residency time won?t do any harm IMHO.

I have been reading many arguments about IC results, underestimation of IC results by surgeons and overestimation of IC results and possibilities by cardiologists. Well, though every part has some strong points the truth is that percutanious coronary interventions are cheaper, quicker and less invasive and more or less effective. And no matter if we go Off-pump or on-pump, MIDCAB or MINICAB, nothing (perhaps with the exception of robotics) will be less invasive than a needle bite. So, what do we have to offer in this stening, minimal evasive era? I think the answer is Quality: a 90% LIMA to LAD patency in 10-15 years follow-up, something that in my humble opinion a stent won?t be able to offer anytime soon. I see with much joy that debates like ?Off-pump vs. On-pump CABG? are beginning to lessen partly because at last we, as cardiac surgeons, are starting to see more clearly now that going down this road will lead, not to Off-pump or On-Pump but to No-CABG. What the patient needs is results and receiving the best possible treatment , not technique, something IC was very capable of providing. And as in any business unless you market and provide the right stuff, someone, someday will come and pull your plug.

Innovation?? Does this really exist in CTS? I would very much like to remind when, where and how all stings started. I would like to remind of the times of cross-circulation when the mother acted like a heart-lung ?machine? while the surgeon corrected the child?s congenital heart malformation(s). Now we have state of the art heart lung machines, monitoring literally any parameter of the artificial circulation, and cutting edge technology backing us up in case a patient can?t wean from the machine. I was told of stories when a 3 vessel CABG surgery started at 8 am and skin closing begun at 7pm. I am glad to see CT surgeons calling home at 4 pm to say ?I have one more CABG to do, I?ll be home for dinner?. The list of course does not end here. Total arterial revascularization is efficient in providing high rates of long term patencies, reducing patients symptoms and need for medication. Some years ago we were talking about maybe 50% long term potencies for vein grafts, and as many as 5-10% of the vein grafts stopped functioning as conduits somewhere between skin closure(!) and first post operative week. Now we have the privilege of announcing a 90% LIMA-to-LAD patency in 10-15 years follow-up with an operative mortality of less than 2% (unadjusted isolated CABG, STS National Database Spring 2004 Adult Cardiac Executive Summary). Mitral valve repair is now considered first choice treatment and superior to replacement, something which has been literally a leap forward in cardiac surgery, providing patients with the best possible treatment up-to-date. Aortic valve repair, while being skill demanding and sometimes problematic eventually will pay off, providing our patients another possible alternative far better perhaps than valve replacement. Off pump revascularization provided us the option of eliminating the heart-lung machine and its side effects in many patients. Aorta surgery, a really fascinating field, has evolved rapidly leading to better understanding of the pathophysiology of aorta disease and neural damage and evolution of surgical techniques so as to provide better treatment to our patients.

What does the future hold for CTS? Although that is not an easy question, allow me to risk some assumptions. Some days ago I was very glad to see the announcement of a new innovation centre in www.ctsnet.org : Arrhythmia Surgery Center. Atrial fibrillation is a field cardiac surgery has and IMHO will have a lot to offer. Patients on Afib, being at a constant risk of stroke, bleeding from aggressive anticoagulation or anticoagulation variances and with symptom worsening the patient?s quality of life, will be offered a curative treatment. Whether is the classic Cox-Maze III ?cut and saw? technique operation or with the help of cryocatheters, radiofrequency or microwave energy sources, together with the development of minimal invasive approaches, will mark surgical treatment for Afib if not first choice treatment of chronic Afib certainly a valid and definite option for Afib (a disease of more than 1 million people in the US). Heart failure: We now have a better understanding of heart failure and we have acquired the experience, the technique and the technological advances so as to provide these patients a definitive treatment. Nowadays ejection fraction is not as important nor poses a barrier to patients requiring cardiac surgery. We have become more and more aggressive in treating these patients with remarkable results: Left ventricular assist devices will eventually become not only more widely applied but better, more reliable and with less complications. This technology will buy patients that are candidates for heart transplantation valuable time, will recover patients with reversible heart disease, and will keep in life and in excellent quality of life patients that today have absolutely no other option. Dor procedure, mitral valve annuloplasty also have a lot to offer in patients with heart failure.
And for those predicting the demise of your speciality, backup up their statements with mere numbers, some numbers from me too: Today there are about 493.300 cardiac surgery cases performed each year in the US, of which
400.000 are CABG,
80.000 is valve surgery,
2.000 is aortic surgery,
10.000 Congenital,
300 heart failure
1.000 atrial fibrillation.

Under the best circumstances and technological advances even the most aggressive interventionalists believe that CABG won?t be reduced more than 25%.That is about 300.000 cases. Maybe a decline in valve surgery (though the STS stats indicate otherwise) of no more than 25% under the best circumstances may appear. Aortic surgery and congenital surgery is very unlikely to change but even if it does the number is very small. Now, if cardiac surgery can offer treatment to as many as only 5% of heart failure patients ( only 5%!) based on technology and experience already present today, we are talking about 250.000 heart failure patients that will benefit from heart surgery. If cardiac surgery gains an indications for treatment to only 10% of Afib patients ( only 10%) we are talking about 300.000 patients cured from atrial fibrillations and risk of stoke and major bleeding. And both heart failure and Afib are fields that medical treatment has offered almost everything it has to offer, after all a patient with heart failure no matter if he/she gets resynced or ICD, will eventually die of heart failure, and medical treatment of Afib has mediocre results and many complications. All these sum up to 920.000 cases, about twice as much as today?s cases. And with the baby boomers retiring and the smaller every year number of residents choosing CTS (for reasons like, long hours, malpractice issues, lifestyle etc) numbers add to more than twice today?s caseload for the future CT surgeon. Until 1968 no one could understand why so many bright surgeons entered the field of CTS because it was believed that geneticist would be in a place where they could predict or maybe treat congenital malformations before birth, no one had syphilis so aneurisms would become extinct and rheumatic fever was believed to be a thing of the past. In 1969 the first large series of CABG?s was reported, and then a whole new field opened for CTS (this is actually from a speech in STS meeting 1968) (...continue...)

(...continue...) Being a European myself I can see many differences between continents separated from the Atlantic. Things like stenting, drug eluting stents and IC advances, don?t concern me that much, though I do follow them closely. What concerns me is malpractice insurance: I see doctors in the US going bankrupt because of malpractice fees, I see professionals dropping medicine altogether because no one will insure them, I see people moving their practices to other states because of state malpractice laws (California for example). And if this goes on, I believe that people wont choose CTS or neurosurgery and many other ?under heavy fire? specialities not because of the so called ?shrinking field? in CTS, the long hours of practice in neurosurgery but because they just cant afford or take a 5 year trial battle, and a 150k settlement for a misplaced Swan-Ganz catheter. And yet I see malpractice lawyers running for vice presidents. Yes, I know that all these people found guilty could have been bad doctors, but a 5 year trial battle will wear off anyone of us, even if the outcome is in our favor. What also concerns me if FDA policy/bureaucracy and public relations. I see the Abiocor being marked by many non specialists as a mediocre device because it provided only 50-60 days of support for some patients and the company share diving after that news hits the press, when the truth is that Tom Christenson ? the longest living Abiocor patient ? survived five hundred something days 10 times the duration that the FDA would consider the device trial successful. The FDA was so strict in applying this technology, that only patients with absolutely no heart transplantation option, with end organ failure and a serious probability of death in the following days could be candidates for abiocor destination therapy. But in a patient that bad, how much can you expect? And how easily you can get disappointed and mislead? What also concerns me is the narrow minded George W Bush policy about stem cell research. Stem cell research is much easier to deploy in the EU and soon research will start paying off. Stem cell is the future, all patients and medical specialities will benefit from this kind of technology and unless things get a little bit looser in the US and get onboard the stem cell research wagon, US will fall behind, something that?s really bad because of the mere excellence of researchers and institutions based in the US.

I am sorry to see people being driven away from CTS because of wrong/misleading/unrealistic reasons. Cardiac surgery is a fascinating field of medicine, as long as you get to understand and realize the whole magnificent spectrum of it. CTS has a lot to offer. It just needs attitude readjustment and rebirth.

I am glad we are starting a nice discussion here.

I will have to disagree with droliver. Cardiac surgery never had ?easy-going? patients. Although there has been a more than twenty fold reduction in mortality over the last 30-40 years, CTS was and still will be a speciality where if something goes wrong the patient won?t leave the operating table or will end up with stroke, renal or other end organ failure. I agree that 20 years ago a 55 year old-50% EF-patient was easier to cope with than today?s 80 year old-25% EF, or maybe the 62 year old-NYHA IV-16% EF (by U/S, *with* 4/4 Mitral valve regurgitation, on intermittent inotrope infusions) that was operated here a weeks ago. But I am sure more glad to see the second one (who could not lift his hands from dyspnoea) walk, in fact run, out of the hospital after a Dor procedure plus a MV annuloplasty. And there are just so many CHF patients that can and IMHO will benefit from heart surgery. Bottom line: Cardiac surgery was always a stressful job. As for the pay cut&glory issue, if you asked a kid in the 60?s-70?s, ?what would you like to do when you grow up?, among the answers you?d get was astronaut, heart surgeon, pilot, pop star etc etc. I believe that so much glory and social status gained by a medical profession and a speciality like CTS was overestimated and abnormal. We, doctors, are people trained to help and save other people, we are not superstars. We belong to the hospital and to our patients, not to the front page of Time, Forbes and Fortune. CTS are still among the best paid physicians. But if money and lifestyle counts so much for students and residents, fine by me. Doing CTS only for the money is totally not worth it.

I think someone mentioned that nowadays things in CTS are getting worse because the cardiologists are developing protocols for caths without CT surgery presence in house. Fine by me. Pardon me but I won?t , don?t and wouldn?t train 5 years GS and 2-3 years CTS so that I could practice my science/profession as a stand-by technician, waiting for the next failed PTCA so that I would have to operate at mortality rates over 30%-40%-50%. ACC guidelines now indicate that a cardiac surgery centre should be 1 hour away from a cath lab. Fine by me, in fact the further away from me the better. Failed PTCA?s are something I certainly don?t like to see, let alone operate on.

As for the economics, i have already mentioned that what 20 years ago seemed space age technology is now present in our operating rooms and widely available. Studies like MANDIT II indicate that if every patient with <30% EF get an ICD placement (cost>13.000 euros) {instead of standard per os amiodarone} a mediocre 7% mortality reduction would be observed. And there is a huge discussion going on in almost every AHA/ACC meeting weather ICD indications should be changed so as to save a mere 7%. On the contrary, heart failure has 100% mortality, the exact percentage is just a matter of time. I don?t think that in the LVAD big bang era, in the not-too-distant-future, a patient would be denied a temporary or permanent heart assist device, much like no one is denied today transplantation/pacemaker/ICD/ventilator unless there are medical reasons against that. The first pacemaker was hand made, and was wheeled in front of the patient. Now it?s coin heavy and costs about 1000 euros. The first Novacor (LVAD) controller was also wheeled in front of the patient. As we speak, it?s cell phone size.

As for the statins havoc, every couple of years we get to hear that a certain drug will cure diseases like coronary disease and cancer (I won?t delve into AIDS, we get a vaccine promise for that every 5 years for the last 15 years). Unless we see hardcore results, we should probably stand to our beliefs and facts. When VEGF (vascular endotheliar growth factor) was launched many predicted the demise of cardiology together with cardiac surgery. Results of VEGF trials were disappointing.

And lets remember that CTS stands for CardioThoracic Surgery, it does not stand for Coronary Surgery.

CardiacSurgeon said:

What also concerns me is the narrow minded George W Bush policy about stem cell research. Stem cell research is much easier to deploy in the EU and soon research will start paying off. Stem cell is the future, all patients and medical specialities will benefit from this kind of technology and unless things get a little bit looser in the US and get onboard the stem cell research wagon, US will fall behind, something that?s really bad because of the mere excellence of researchers and institutions based in the US.

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http://www.ctsnet.org/doc/9510
Federal Funding of Stem Cell Research, and the War Against Disease

By Lawrence I. Bonchek, MD

The medical community should be profoundly disappointed, but not surprised, that the recent cloning of a human cell for stem cell research was accomplished in South Korea. Disappointed, because the U.S. is intentionally taking a back seat in a therapeutically vital field of research. Not surprised, because that is the inevitable result of the lack of federal funding for this research. Britain, China, Singapore, and others are aggressively developing stem cell research centers, and some American scientists have already left for foreign shores. In response, the U.S. is vigorously advocating a U.N. resolution to impose a worldwide ban on therapeutic cloning. U.S. Deputy Ambassador James Cunningham says the administration is not "prepared to accept" a partial ban on reproductive cloning alone.

The basis of this policy is the President's (and the so-called Religious Right's) conviction that human life begins at conception. (Considering that those who hold this view generally favor capital punishment, one wag has quipped that "the Religious Right's concern for human life begins at conception and ends at birth!") In this view, cloned cells as well as excess frozen "pre-embryos" from fertility clinics are considered humans, and even those that will be discarded may not be used for life-saving research. This seems to be a consistent position, given its premise, but in one sense, it is incompatible with the duties of the President's office.

Any President, as Commander-in-Chief, must be willing to fight wars despite inevitable casualties, and the war in Iraq has proven this President's readiness to do so. But military conflicts are not the only wars. As physicians, we are acutely aware that the perpetual global war between man and disease has caused more casualties than all of history's shooting wars combined. In New York City, more people succumb to various illnesses in three weeks, than died on 9/11. In regard to the potential of stem cell research, there is thus a certain irony in using the term "pro-life" to describe a policy that would sacrifice countless people, suffering from myriad diseases, to save fertilized eggs. Even if we regard excess "pre-embryos" as humans, we should see them not only as what they are, doomed clumps of cells that will never be implanted in a uterus nor develop their potential as humans, but as the noblest they can be: foot soldiers in the global war against disease. The President's opposition to their use in that war can therefore be viewed as incompatible with his duties as Commander-in-Chief.

From the perspective of freedom of religion also, embryonic stem-cell research should be supported with federal funds. In America, we recognize that religious opinions vary. The world's great religions permit lives to be forfeited for a greater good. Even the most peaceful religion - Buddhism, often permits it; in certain cases, Judaism mandates it. As columnist Ellen Goodman has pointed out, "It's not a question of whether the pre-embryo has any moral worth, but whether it has more worth than a person." Countless Americans of every faith, including conservative Republicans such as Sen. Orrin Hatch of Utah, have no religious objections to therapeutic cloning. Rabbi Moshe Tendler, Professor of Jewish Medical Ethics at Yeshiva University, has called it "inhumane" to abandon it. Recently, even Nancy and Ron Reagan have forcefully advocated it. Any effort to impose one sectarian religious view on the general population actually threatens the separation of church and state. Those with religious objections to stem-cell research are free to refuse its therapies, but the rest of us must be free to benefit from them.

The advance of scientific knowledge cannot be forbidden. The full potential of stem-cell research is unknown, so it will be investigated, here or elsewhere. Despite federal restrictions, California and New Jersey are providing public funds for this vital research, but support from financially strapped states is necessarily limited. Several universities are using private funds to support stem cell research centers. The pivotal question is, without the support of the federal government, will the United States be able to lead research in this exciting field, as it does in most other areas of medical research, or will it cede leadership to others, who will reap the benefits of new therapies? Of the 60 existing stem cell lines that this administration initially claimed were fully adequate for research, at most only 10 to 15 are useable. Worse, none can be used to develop treatments for humans, since all were originally grown on mouse cells, and they could expose humans to an animal virus that our immune systems could not fight. We also know that adult stem cells, though readily available, are not as versatile as embryonic stem cells.

In April, 2002, Senate Majority Leader Bill Frist, M.D. (R-Tenn.), whose opinion on medical issues understandably carries extraordinary weight with his Senate colleagues, announced his support for a bill introduced by Sen. Sam Brownback (R-Kan.) that banned reproductive and therapeutic cloning. (Frist's initial announcement on stem-cell research in July 2001 was optimistically interpreted as representing enthusiasm for stem cell research, but it imposed so many conditions, all predicated on his clearcut statement: "I am pro-life," that his support for the Brownback bill should have come as no surprise. His announcement also insisted that any funding be within a "strictly controlled framework," and "this framework must ensure the highest level of respect for the moral significance of the human embryo.") Moreover, the President's Council on Bioethics is chaired by Leon Kass, M.D., who has called all forms of cloning "repugnant."

As physicians, we have not been bashful about expressing our desire for tort reform, and perhaps because of that priority, we have not spoken out against the federal government's science policies, even though 20 Nobel Laureates from various scientific disciplines have signed a letter doing so. As cardiothoracic surgeons we must always put our patients first. The limitless potential of embryonic stem cell research (new valves, new conduits for bypass, new blood vessels, new hearts?) obliges us to complain publicly about the lack of federal funding for this vital research.


Lawrence I. Bonchek, M.D.
Lancaster General Heart Center
555 N. Duke St.
Lancaster,
Pennsylvania 17603
717-544-4995

Rony said:

Great post,
...ORs right next to cath labs where the CTS comes in for the sternotomy and LIMA/LAD anastomses and the rest is left for the ICs.
You hit the nail on the head when you mentioned that although CABGs are on the decline, there is more to CTS than coronary surgery. I believe the emerging field is actually going to be thoracic oncology and lung cancer resection. As medical oncology offers better neoadjuvant therapy, we are going to see better results with lesions that were not amenable to resection in the past.

Click to expand...

yes i've been following the hybrid operation results and they appear quite promising.
I think the next step will be C-arms into OR's and CTS melding in with Interventional Cardiology.