AW: [HSF] Percutaneous Valves

Sun Feb 4 21:14:47 EST 2007

One of the problems with this thread is there are many issues going on. Surgery is in chaos and it is hard not to see advantages in at least some situations with alternative therapies. I would pick a few points that we usually glaze over but that we really need to think more about specifically. The arguments are going on all around us in usually over simplistic and emotional sound bites.
In no particular order, but many are related:

1)There is no over supply of surgeons, but a gross maldistribution. Dr. Cox and World Heart Health calculate 90% of the world's population do not have access to cardiac surgery much less DES (stents.)

2)If you practice in an over supply area (all large cities in the US and most of the Western world, ie most of us) and wait in the OR for what is left over, you will see the most morbidity. Your patients may really benefit from your care, considering that you are the last resort, but you likely would have been more effective with an earlier intervention. Even LVADs do better with earlier interventions. We are a self defeating specialty. 

3)Imaging is now where the "money is", but that is because it is finding earlier interventions and replacing more invasive technology. There real value is in the intervention and ultimately this will be most valued. We should use imaging to help us add our value.

4)3rd party pay (government or insurance) is "paternalistic" by definition. The patient is not asked about "value" so even very good therapies (eg CAB, 16 MDCT) are undervalued if new technology (more expensive and repetitive) is potentially available. Most of the value of many new technologies and interventions is "marginal" (but not valueless).

5)Leap frog and the AHA are wrong. Smaller programs and especially specialty programs are more efficient (or can be). It is not just "cherry picking", it is better value and better distribution. We are mute on this arena.

6)Surgeons have not led the charge in much of the above issues. It is easy to criticize the world as falling short of our peculiar intrinsic standards, but our own duplicitous views do not give us the moral imperative even if we are diminishing from the current "unfair" state of affairs. If history is predictive and if we survive at all in the modern world, we will not recognize ourselves. As Hal suggests we are in a fight, but like the military of today, it is not an even fight and is unlikely to even be recognized as a fight by many.

Obviously, there are many permutations of these ideas, and they are nascent in form. I do think there is much suggestive evidence as to the general validity of them. Changing ourselves in these directions will have far reaching and largely unseen consequences, which I believe will be mostly beneficial to our patients and thus ourselves.

Tea Acuff

----- Original Message ----
From: "Hgrmd at aol.com" <Hgrmd at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, February 4, 2007 8:05:00 AM
Subject: Re: AW: [HSF] Percutaneous Valves

Ani,
  I usually agree with most of the things you write, but you  really surprise 
me with this one.  Your basic premise is that we are only  to do open 
procedures until we truly are the "blacksmiths" of medicine.   Currently, my practice 
bears little resemblance to the one in which I was  trained.  Ninety percent 
of my cases in training were CABG.  Now, the  opposite is true.  I'm also 
looking for ways to do the same procedures less  invasively.  Throwing up my hands 
in resignation and waiting for  the cardiologists to take away the rest of my 
practice isn't going to  happen as long as I'm still able and willing to 
work.  By all means, I plan  to continue to expand my catheter based skills as I 
gear up for the  future.  Laugh if you want, but I don't plan to give up 
without a  fight.

Hal
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