Do you think cardiac surgery patient volume is rapidly deminishing as interventional cardiologist are doing most of the cases?
Cardiac surgery patient volume has certainly come down during the last two decades. Mitral stenosis, ASD and PDA are almost entirely done by interventional cardiologists. TAVI is emerging as a very good option for aortic stenosis even in patients with only moderately high risk for surgical AVR. Expanding indications even include cases of AR. Complex coronary cases including main stem, bifurcations, chronic total occlusions and calcified lesions are now routinely performed by interventional cardiologists. Only the very complex cases are referred to surgeons for CABG. At the same time, the quality of cases done by cardiac surgeons have changed. Now more complex and complicated cases are being undertaken with excellent outcome.
In the USA there are a few places that do amazing interventional work and can fix blocked arteries from 1974 who have failed 2 bypasses since - they work with such ease for recovery. Sadly due to insurance control of the healthcare system in the US some people die while they are waiting for the AVR to be completed as an outpatient, when 10 years ago they would have had the surgery during the same hospital stay - but pressures on the hospital owned doctors (and also from insurance company owned hospitals) takes away the accuracy of going to the OR for open AVR, waiting for outpatient TAVR - some people do not make it.
Dr koshy has nicely explained. Add to the list of diseases managed by Interventional cardiologist by percutaneus intervention are..
VSD closure
RSOV closure
Management of paravalvular leak
Closure of coronary and pulmonary AV fistula
Mitaclip
Percutaneus mitral valve replacement
Percutaneus tricuspid valve and pulmonary valve replacement
Alcohol sepal ablation in HCM
Etc... Thanks
Cardiac surgeon will soon restrict themselve into transplant and LVAD cases.
Though lot of structural heart diseases are effectively managed by interventional cardiologists, several complex cases do require the help of cardiac surgeons. Complex pediatric cardiac procedures continue to be the domain of cardiac surgeons. If a proper "heart team" approach is followed, many multi vessel CAD patients especially with diabetes qualify for CABG rather than PCI.
I think cardiac surgeons have to to be more involved in the cath lab especially with the coming new procedures i.e TAVI otherwise they will face dificult future full of high risk procedures with substantial risk and marginal benefit
I think a change in cardiac surgery training programs has to be made to involve residents in the cath lab new interventions , PCI,TAVI and others
Cardiac surgery is evolving and changing, not diminishing. Cardiac surgeons now manage the more complex cases (of which there is a high volume of cases to undertake given the large global burden of severe cardiovascular disease) and achieve very good outcomes. And indeed the efficacy of many open cardiac surgical procedures far surpasses percutaneous methods in multiple patient groups in the current literature. However, with the likely improvement in efficacy of percutaneous interventions over time, the indication for PCI/TAVI etc. will inevitably expand and start to encroach on the current caseload of cardiac surgeons. So there is a need in my opinion for catheter-based skills to be included in cardiac surgical training programmes so that the next generation of wannabe cardiac surgeons (like myself) can safely undertake any cardiac intervention (open, minimally-invasive or percutaneous) for all patients (young, old, low-risk and higher-risk) and so continue to maintain and even expand our caseload. The great specialty of cardiac surgery is here to stay, but may need to adapt somewhat.
I do agree with above comments. Interventional Cardiologist are doing more simple and complex procedures. Previously cardiac surgeons used to do these all cases when we did not have PCI facility.
this problem is perhaps real in countries with high volume of cardiac surgery, but that is not the case for low and medium income countries which are far from responding to all the needs even in cardiology and in cardiac surgery.
Khaled Alebrahim Yes to a certain extent in adults especially in patients with coronary artery disease. However, the total number of coronary surgeries has not declined but remains constant in the recent years. We are now seeing cases of in-stent thrombosis presenting for CABG after repeated angioplasties. The numbers of these cases will rise in the coming years.
As mentioned in other replies, the CABGs are now complex cases with low EF and comorbidities. The outcomes have improved. Things may change towards surgery if future report will show the benefits of internal mammary grafts when compared to stents.
In congenital cardiac surgery, we almost do not get to do secundum ASDs now. Our cardiologists have started doing simple VSDs as well. However, the complex congenitals are still there and will remain with the surgical team.
In valvular cases, the interventions have added a lot of value but the mainstay of treatment is still surgery. Ascending aorta and aortic arch surgeries also add a big volume to the surgical team.
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