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J Thorac Cardiovasc Surg 2008;136:816-819
© 2008 The American Association for Thoracic Surgery

Expert Commentary

Fool me once, shame on you; fool me twice, shame on me! A perspective on the emerging world of percutaneous heart valve therapy

Baylor Healthcare System, Cardiopulmonary Research Science Technology Institute, Dallas, Tex

Received for publication May 24, 2008; accepted for publication June 2, 2008.

^_* Address for reprints: Michael Mack, MD, Baylor Healthcare System, Cardiopulmonary Research Science Technology Institute, Dallas, TX 75230. (Email: mmack@csant.com).

The first 300 words of the full text of this article appear below.

In the late 1970s, catheter-based therapy for the percutaneous management of patients with coronary artery disease (CAD) was introduced. At that time, coronary artery bypass surgery (CABG) was the sole interventional treatment available for patients with CAD and offered superior outcomes to medical therapy in many patients.¹ This new interventional but less invasive treatment, percutaneous coronary intervention (PCI), was met with skepticism, disdain, and dismissive arrogance from within the surgical community. Attitudes manifested by statements such as "we have a superior procedure," "angioplasty will never work," or "outcomes are being compromised" only served to foster complacency and stifle surgical innovation. This comfort in complacency within the surgical community was further reinforced by the annual increase in CABG procedural volume that continued for 20 years after the introduction of catheter-based therapy² (Figure 1 ). However, the field of PCI progressed rapidly, catalyzed by incremental improvements in technique and technology including steerable catheters, stents, drug-eluting stents, and adjuvant pharmacology. These advancements both decreased procedural morbidity and improved outcomes so that within 10 years after the first interventional coronary procedure was reported, procedural volume of PCI eclipsed that of CABG. So much has the treatment paradigm continued to shift that currently in clinical practice, both interventionalists and their patients often view CABG as the procedure of last resort; the default treatment decision is frequently "if it can't technically be stented, then we'll have to do surgery."

View larger version (8K):   Figure 1. Procedural volumes of coronary revascularization. PCI, Percutaneous coronary intervention; CABG, coronary artery bypass grafting. (Reproduced with permission from The Advisory Board Company, Future of Cardiac Surgery—2004, © The Advisory Board Company, 2004.)