Ann Thorac Surg 2004;78:476
© 2004 The Society of Thoracic Surgeons
Invited commentary
Thomas Orszulak, MD
Department of Thoracic and Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
e-mail: orszulak.thomas{at}mayo.edu
The article by Locker and colleagues outlines further refinement of our knowledge and treatment of coronary artery disease. There are limitations of the study in that it is not randomized. It is a consecutive series that adds some strength to the results; however, a selection bias cannot be excluded. This selection bias is most evident in the number of vessels treated in each group and the risk profile of the groups. There were more vessels revascularized with a higher risk profile in the coronary artery bypass cohort versus the percutaneous intervention (PCI) cohort. Although the general approach to an article such as this is to attack the better group to improve the standing of the other in the "standard" competitive fashion, I would like to take the information in this article and use it as an argument to eliminate the competitive aspect of coronary artery disease of the providers and to propose imagining that each patient had but one revascularization option available per decade and it is our responsibility to choose an option—medical therapy (it still works for some), PCI, or surgical revascularization.
Medical resources are becoming more and more limited, and we as physicians need to determine the best option for each patient to maximize its benefit and efficiently use the resources available. It is not possible to provide healthcare free of charge, but with capitation and dwindling resources, we physicians need to determine our sustaining ability by distributing these resources in the most careful, healthful fashion. The above article provides some of the framework to accomplish this. Patients with one- or two-vessel disease should initially be considered for medical intervention or PCI. Patients with three-vessel and or left main disease in need of revascularization should come to operation. It is obviously not that distinct for most patients, but with honest surgical and medical collaboration, and the patient as the central focus, we will provide a balanced, responsible, and satisfying result.
