Interventional cardiology and cardiac surgery are complementary in treating patients with advanced cardiovascular conditions- A Team Approach. 

There used to be much debate regarding the superior treatment strategy for advanced cardiovascular conditions, such as severe coronary artery disease (CAD) or severe valvular abnormalities. However, recent rigorous randomized trials have shown the comparability of both cardiac surgery and interventional cardiology options for patients with these conditions. As a result, a multidisciplinary “Heart Team” approach (1) has been proposed as the ideal group effort, where both cardiac surgeons and interventional cardiologists discuss the optimal treatments for our patients and come to a consensus regarding the treatment algorithm. In addition, the preferences of the patients and their family members are sought and valued, given the equivalent benefits from either surgery or percutaneous treatment. Finally, it is unfortunately true that we do not cure any of these conditions. We are merely trying to alleviate symptoms and if possible, alter the natural history and prolong survival. Thus, when the initial treatment option fails, the other therapy could offer an alternative approach. Our role as caretakers should be to inform patients regarding different treatment options, including pros and cons, answer their questions, solicit their preference, and offer consensus treatment among the different specialists and patients.

Optimal treatment of left main CAD:

The most severe form of advanced CAD involves the left main artery. Based on coronary artery bypass surgery (CABG) versus medical therapy from decades ago (2) when coronary artery stenting had not been invented, many patients used to undergo CABG as the only treatment option for decades. However, with the development of the drug-eluting stents and the improved long-term outcome of such therapy (3), randomized trials among patients with left main (and/or severe three-vessel CAD) were performed, with results suggesting comparable outcomes as well as treatment-specific complications (4,5). On the other hand, a registry study suggested possibly lower mortality and major ischemic complications in those undergoing CABG (6). Furthermore, these studies suggest that stroke risk could be higher in CABG patients whereas the need for repeat revascularization, even with drug-eluting stents, can be higher in PCI patients. Therefore, it is important for the multidisciplinary heart team to recommend different revascularization options for different patient populations.

Optimal treatment of severe aortic stenosis:

Severe aortic stenosis (AS) has been shown to be associated with high mortality once symptoms develop (7). Until a few decades ago, surgical aortic valve replacement (SAVR) was the only effective treatment. However, there were many patients deemed too high risk for surgery and not offered this therapy, resulting in high mortality (4-year mortality rate of 45%) on “medical therapy” or untreated (8). A new form of therapy called transcatheter aortic valve replacement (TAVR) was developed initially for those at high-risk for SAVR, but since then, has been studied in randomized trials against SAVR for even “low risk” patients, suggesting either equivalent results or possibly superior to SAVR in selected patients (9). However, randomized trials enroll a selected population and thus, the two forms of proven therapy, TAVR and SAVR, need to be discussed with patients for the optimal treatment.

Treatment of other valvular conditions:

Other severe valvular conditions, such as severe mitral or tricuspid regurgitation, have also been studied with new forms of percutaneous therapy involving “clipping” of the valve leaflets (10, 11). Even though these therapies offer improved outcomes, they are not as effective as the surgical valve repair or replacement. However, continuing refinements may eventually offer an equivalent form of therapy, similar to the TAVR vs SAVR.

Optimal treatment of atrial fibrillation:

With an aging population, atrial fibrillation is becoming a more prevalent cardiac condition (“global epidemic”) that can not only cause symptoms but also increase the risk of embolic stroke (12). Catheter ablation has been shown to be an effective treatment for this condition, but there are patients, who have recurrence even after successful initial ablation. For such patients, a hybrid procedure involving catheter-based and surgical ablation could be a more effective treatment (13).

Conclusion

A Heart Team approach, a collaboration between cardiac surgery and interventional cardiology, can offer the most appropriate treatment option for patients with all forms of advanced cardiovascular conditions.