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J Thorac Cardiovasc Surg 2009;138:1105-1106
© 2009 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr Gabrial Aldea (Seattle, Wash). Decreased CABG mortality despite increased patient acuity and complexity over the past decades is indisputable and laudable. These findings were previously published by the authors. Parallel national trends presented at this meeting reviewing the national inpatient sample, the Society of Thoracic Surgeons database, our own state of Washington Clinical Outcomes Assessment Program database with more than 160,000 patients treated in the past decade, which incidentally does combine all CABG and PCI procedures in a single database, and those of other multiple states. Also indisputable is the increase in the number of PCI procedures and the increasing ratio of PCI to CABG over the same decade. I have no issues with the data, but I do have some issues with the interpretation of the data or the suggestion that this narrow gap will somehow influence treatment assignment. I have several comments and 2 questions.

Despite the marked change in treatment that continues unabated after the introduction of bare metal stents and certainly preceding drug-eluting stents, PCI and CABG still treat very different populations. In the State of Washington for CABG, more than 95% of the patients treated with coronary bypass surgery have 3-vessel disease of the left main and the average number of grafts is 3.4 grafts per patient. This is compared with only 15% of patients treated with PCI presenting with 3-vessel disease of the left main, and the average number of vessels is 1.2. Assignment to PCI and CABG surgery is also changing over this time period. Acute MI therapy has evolved dramatically in the last several years, preferentially treating acute MIs with immediate (so-called primary) PCI rather than lytic therapy or CABG, specifically targeting 1 and rarely 2 culprit lesions with a specific more limited or focused treatment strategy to minimize the . . . [Full Text of this Article]