Should a catheterization be performed or bypass surgery? That is one of the questions that has worried cardiologists and heart surgeons in recent years. When a patient arrives at the hospital and a heart attack is suspected, he is first sent for catheterization in order to diagnose whether he has blockages in his arteries. If any are found, the doctors deliberate whether a cardiologist should deal with opening the blockages while the patient is still in the catheterization room or whether he should be referred to a cardiac surgeon for bypass surgery.
This dilemma has made the relationship between the cardiologists, who do catheterizations, and the cardiac surgeons even more fragile than in the past. Numerous studies have tried to find a solution to the dilemma but as the research has progressed it transpired that there was no easy answer to what was best for the patient. A team of researchers from the United States and Europe examined 1,800 patients who were diagnosed with problems in three blood vessels or in the aorta. Half were sent for catheterization while the other half underwent bypass surgery. The researchers reported in the New England Journal of Medicine in March 2009 that heart surgery was preferable and prevented the risk of another heart attack or stroke a year later. However, when the findings about quality of life were weighed, catheterization was seen to be more effective than surgery.
Yet when the researchers summed up the findings of a three-year follow-up to the study and presented them to a conference two months ago, they presented surgery as the preferable path. Other studies have shown that the survival rate after five years for patients who underwent catheterization and those who had cardiac surgery were similar, at 90 percent.
While doctors have yet to agree on whether catheterization or cardiac surgery is the way to go, meanwhile another front on the battle between cardiologists and cardiac surgeons has been reopened. At the annual conference of the European Society of Cardiology, which convened in Stockholm in September, new guidelines were issued for carrying out catheterizations. They call for a revolutionary change of approach and for deliberations by an interdisciplinary team of experts about every patient who is sent for a diagnostic catheterization and is not suffering from severe heart disease.
A team of experts
Until now, many heart patients sent for diagnostic catheterization by a cardiologist were asked to give their consent in advance to undergoing direct therapeutic catheterization in order to open up blocked arteries while they are on the catheterization table. The new guidelines are aimed at changing this. They state that the cardiologist doing the diagnosis must stop the treatment and hold consultations with a team that includes two other specialists - a cardiac surgeon and another cardiologist who was not involved in the diagnostic procedure. After the consultation they must explain to the patient which solution the three experts believe is preferable for treating him so that he can make up his own mind.
It is estimated that some 80 percent of the patients in Israel who are found to have a blockage of the arteries during an investigative catheterization are referred to a therapeutic catheterization while the other 20 percent are sent for bypass surgery. According to Ministry of Health statistics, 21,502 therapeutic catheterizations were performed in Israel in 2009 while there were only 3,335 bypass surgeries.
Now the cardiac surgeons, who were left outside the picture for years, will be integrated into the process of deciding on the preferable treatment for the patient. This is likely to affect the number of therapeutic catheterizations. "The guidelines will lead to an increase in the number of patients who will undergo bypass surgery instead of catheterization," says Dr. Gil Bolotin, director of the department of cardiac surgery at the Rambam Medical Center in Haifa. "For the patient, this a dramatic difference. At present, it is only in certain cases that patients are sent for bypass surgery following a diagnostic catheterization. The European society's recommendations change the approach and state that there must be a combined consultation except for cases where it is clear that a therapeutic catheterization has to be done, usually because the situation is urgent."
The new model has already been adopted in principle in some of the European countries. "In Holland it has been accepted practice for years to hold a team discussion following a diagnostic catheterization and the decisions about whether to go on to do a therapeutic catheterization or to do bypass surgery are taken cool-headedly and not in a rush while the patient is lying on the catheterization table," Bolotin says. "When I was exposed to the Dutch system, I saw it was carried out in an effective and beneficial manner and was very good for the patient. The new guidelines will present the patient with the conditions for making a rational decision."
Under the new guidelines, a therapeutic catheterization immediately following a diagnostic one will take place only in isolated cases that have been defined in advance and in which deferring the catheterization might endanger the patient. That includes patients who are in the midst of a heart attack and need immediate assistance and those with arterial disease that is not in the left anterior descending artery that supplies blood to the heart. When the patient is stable, however, and has been diagnosed during catheterization with disease of the blood vessels, as well as the aorta, consultations must be held after the diagnostic catheterization.
A hybrid operating room
So what do the cardiologists say? Prof. Chaim Lotan, director of the Heart Institute at Hadassah Medical Center in Jerusalem and the incoming president of the Israel Heart Society, says that, "Without connection to the guidelines, a patient has the right to receive the information in the most open and transparent way. he is entitled to know what the best solution is for him and to hear not merely about the possibility of catheterization but also of bypass surgery. It must be remembered that these guidelines increase the cost of treatment and also the rate of complications. If in the past a patient would be hospitalized for both a diagnostic and a therapeutic catheterization he will now need two hospitalizations."
The Israel Heart Society is a member of the European Society of Cardiology, which has distributed the guidelines and it has been asked to examine its application in this country. "We are currently examining to what extent they are applicable to the situation in Israel," says Prof. Doron Zager of Soroka Medical Center in Be'er Sheva, who is secretary general of the Israeli society.
Prof. Yonatan Hasin of the Poriya Medical Center has already warned Health Ministry officials that there will be difficulty applying the guidelines to the Israeli reality. In a number of Israeli hospitals, for example, there is no department of cardiac surgery. "In Europe, too, the guidleines have met with differences of opinion and opposition," he says. "In principle, it is always good that there are several expert opinions and that the treatment should not be given according to one person's whim. The main question is how it is possible to apply the new instruction without harming the patient."
Heads of the Israel Society of Cardiothoracic Surgery have proposed overcoming the obstacles by holding a video conference call with experts outside the hospital, especially in hospitals where there is no department of cardiac surgery. Prof. Dan Arvut who heads the cardiac surgery department at Haifa's Carmel Medical Center, says diplomatically, "A series of discussions will begin about applying the guidelines in Israel, in cooperation with the cardiologists, in accordance with the reality in Israel and the good of the patients." A recent proposal mentioned holding a joint conference of cardiologists and heart surgeons to discuss the issue.
The upshot of the new guidelines is that cardiologists and cardiac surgeons are actually beginning to work cooperatively as they embark on the process of establishing integrated operating theaters. A hybrid operating room of this kind was inaugurated at the Sheba Medical Center at Tel Hashomer in August and operations for transplanting heart valves together with catheterizations for opening up blockages in blood vessels are carried out jointly there. Dr. Ehud Ra'anani, who heads cardiac surgery at the hospital, says: "In the future, it will be possible to carry out less-invasive treatments in the operating room on patients who have undergone severe heart attacks. Instead of doing five or six bypasses in an operation in which the abdomen is opened, it will be possible to do one bypass with a small cut that will make recovery much faster, and to deal with the other blocked blood vessels by means of catheterization."
A similar operating room is being planned for the new wing being built at the Hadassah University Hospital, Ein Karem in Jerusalem; and at Rambam and at Beilinson Hospital, Rabin Medical Center in Petah Tikva there are already hybrid operating rooms that make it possible to do operations by catheterization and bypass surgery jointly.
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