LETTERS
ment that they would find subsequent randomization to be unethical. David H. Spodick, MD, DSc, FACC Department of Medicine University of Massachusetts Medical School Division of Cardiology St. Vincent Hospital Worcester, Massachusetts References 1. Spodkk On: Letters. (a) American Heart Jownal79:579.1970. (b) Mod Med 26 January 1970. (c)N Eng J Msd 282:340, 1970. (d) Lance1 1:724. 1970 2. Spodfck DH: Revascufarlzation of the heart-numerators in search of denominators. Am Heart J 81:149-157, 1971 3. Sraumekf E: Direct cowtary revascularization. A plea not to let the genie escape from the bottle. Hasp Practics: 9-10, May 1971 4. Chalmns TC: Randomization of ttw first patient. f&d Clin North Am 59~1035-1038, 1975
MORE ON CORONARY
BYPASS SURGERY-III
One point I would like to raise concerns the absolute acceptance of a left main coronary lesion as an indication for surgery. The only study that has explored this in a controlled manner is the Veterans Administration study. Criticism on this point has recently been published by Graham.’ An argument can be made that not all of the patients treated medically were receiving propranolol, none were receiving sulfinpyrazone (later shown to reduce the incidence of sudden death)* and all were taken care of in a clinic setting as provided by VA institutions. One could suggest that caring for patients in a private practice setting might favorably influence prognosis. In addition, subsets of patients with left main coronary artery disease have been described.3*4 Such patients should be further categorized as to whether the left main artery is narrowed by 50 to 70 percent, 70 to 90 percent or 90 percent or greater, the status of the right coronary artery and of the left ventricle, as well as other clinical and noninvasive indicators. It would appear that medical management has advanced significantly since the VA study and that further randomized trials of selected patients with left main coronary artery disease might very well be warranted. George B. Prozan, MD Burlingame, California
renal disease (creatinine clearance less than 30 ml/min) were generally excluded from surgery or experienced an increased mortality rate. All of these patient groups are now operated upon with a 1 percent, 30 day operative mortality rate.’ This practice pattern and these results in two settings (Penn State’s Milton S. Hershey Medical Center in Hershey, Pennsylvania, and the University of Texas Medical Branch in Galveston, Texas), best described as “cottage industries”compared with the Cleveland Clinic, contrast sharply with the exclusion of all but low risk candidates from the Veterans Administration Cooperative Study. To believe that in 1978, only lower risk patients are being operated upon, as the VA study group obviously does, further illustrates their separation from the main stream of cardiological and surgical experience. We also fail to see how Braunwald’s ability to find two reports of operative mortality as poor as those reported in the VA study answers Loop’s complaint that a clinical trial should be designated to study the operation, not the surgeon. It doesn’t take a prospective study to determine that any act of skill can be performed poorly. The fact that a few VA hospitals (for example, that of Hines) contributed a majority of the patients and that their results are well within the national average, is also “bypassed.” Equally important is the knowledge that many VA hospitals did coronary bypass surgery only occasionally with mortality and complication rates far above the national average. In short, the means in the VA study are less interesting than the ranges, which the apologists never mention. Finally, the sensational headlines generated by the original report and editorials in The New England Journal of Medicine2p3 and the subsequent interviews that portrayed cardiologists and cardiothoracic surgeons practically at battle over indications for bypass surgery can hardly be passed off as the “sober analysis” characterized by Braunwald.2 G. Frank 0. Tyers, MD, FRCS(C) Edward H. Williams, MD Division of Cardiovascular and Thoracic Surgery Department of Surgery The University of Texas Medical Branch Galveston, Texas References 1. Tyen GFO, Williams DR. Babb JD, et al: The changing status of e@ction fraction as a predictor of early mortality following surgery for acquired heart disease. Chest 71: 371-375.1977 2. Eraunwald E: Coronary artery surgery at the crossroads. N Engl J Med 297:661-663. 1977 3. Murphy ML, Hultgen HN, Detre K, et al: Treatment of chronic stable angina. A prsliminaw report of swvival data of the randomized Veterans Administration Cooperative Study. N Engl J Med 297:621-627. 1977
Reterences
2. The Anturane &infarction Trial Research c;roU~: Sulfinwrazone in the prevention of cardiac death after myocardial infarction. N En& J Med %269-295. 1676 3. Canfey MJ. Ek RL Kbsb J. I.M KL Met&u. JF.RoutI RA:Ttwwouwstic we&urn ._ of leftwmain St&&is. Circubtlon 57:947-952. 1478 4. CampOeU L, Corbua F, Crochet D. P~Stclerc R: Left main coronary artery stenosis. The influence of aortCUX_ bypaSS Sugery on suvival. Circulation 57: 111 l-l 115. 1978
RETROGRADE CROSSING OF AORTIC BJORK-SHILEY PROSTHESIS
.
MORE ON CORONARY BYPASS SURGERY-IV We take issue with the statement by Hultgren et al. that “improved patient selection” is an important factor in the decrease in operative mortality for coronary bypass surgery seen during the last 8 years. Before 1974, patients with a systolic ejection fraction of less than 0.30, recent myocardial infarction, unstable angina, poorly visualized vessels beyond obstructions and chronic
1082
May 1979
The American Journal of CARDlDLOOY
Karsh et al.’ report on the safety and efficacy of retrograde left ventricular catheterization in patients with aortic valve prostheses, and record their experience with 27 patients with either a Starr-Edwards or a Bjork-Shiley prosthesis. No mention is made of how many patients had each prosthesis. Their Figure 3 shows a catheter crossing a Starr-Edwards valve prosthesis, showing little disturbance of the poppet while the catheter is across the valve; however, this frame was taken during systole and would therefore not be expected to show interference with the diastolic closing mechanism of the valve. We strongly advise caution regarding the retrograde crossing of aortic Bjork-Shiley prostheses. Unlike the Starr-
Volume 43
ment that they would find subsequent randomization to be unethical. David H. Spodick, MD, DSc, FACC Department of Medicine University of Massachusetts Medical School Division of Cardiology St. Vincent Hospital Worcester, Massachusetts References 1. Spodkk On: Letters. (a) American Heart Jownal79:579.1970. (b) Mod Med 26 January 1970. (c)N Eng J Msd 282:340, 1970. (d) Lance1 1:724. 1970 2. Spodfck DH: Revascufarlzation of the heart-numerators in search of denominators. Am Heart J 81:149-157, 1971 3. Sraumekf E: Direct cowtary revascularization. A plea not to let the genie escape from the bottle. Hasp Practics: 9-10, May 1971 4. Chalmns TC: Randomization of ttw first patient. f&d Clin North Am 59~1035-1038, 1975
MORE ON CORONARY
BYPASS SURGERY-III
One point I would like to raise concerns the absolute acceptance of a left main coronary lesion as an indication for surgery. The only study that has explored this in a controlled manner is the Veterans Administration study. Criticism on this point has recently been published by Graham.’ An argument can be made that not all of the patients treated medically were receiving propranolol, none were receiving sulfinpyrazone (later shown to reduce the incidence of sudden death)* and all were taken care of in a clinic setting as provided by VA institutions. One could suggest that caring for patients in a private practice setting might favorably influence prognosis. In addition, subsets of patients with left main coronary artery disease have been described.3*4 Such patients should be further categorized as to whether the left main artery is narrowed by 50 to 70 percent, 70 to 90 percent or 90 percent or greater, the status of the right coronary artery and of the left ventricle, as well as other clinical and noninvasive indicators. It would appear that medical management has advanced significantly since the VA study and that further randomized trials of selected patients with left main coronary artery disease might very well be warranted. George B. Prozan, MD Burlingame, California
renal disease (creatinine clearance less than 30 ml/min) were generally excluded from surgery or experienced an increased mortality rate. All of these patient groups are now operated upon with a 1 percent, 30 day operative mortality rate.’ This practice pattern and these results in two settings (Penn State’s Milton S. Hershey Medical Center in Hershey, Pennsylvania, and the University of Texas Medical Branch in Galveston, Texas), best described as “cottage industries”compared with the Cleveland Clinic, contrast sharply with the exclusion of all but low risk candidates from the Veterans Administration Cooperative Study. To believe that in 1978, only lower risk patients are being operated upon, as the VA study group obviously does, further illustrates their separation from the main stream of cardiological and surgical experience. We also fail to see how Braunwald’s ability to find two reports of operative mortality as poor as those reported in the VA study answers Loop’s complaint that a clinical trial should be designated to study the operation, not the surgeon. It doesn’t take a prospective study to determine that any act of skill can be performed poorly. The fact that a few VA hospitals (for example, that of Hines) contributed a majority of the patients and that their results are well within the national average, is also “bypassed.” Equally important is the knowledge that many VA hospitals did coronary bypass surgery only occasionally with mortality and complication rates far above the national average. In short, the means in the VA study are less interesting than the ranges, which the apologists never mention. Finally, the sensational headlines generated by the original report and editorials in The New England Journal of Medicine2p3 and the subsequent interviews that portrayed cardiologists and cardiothoracic surgeons practically at battle over indications for bypass surgery can hardly be passed off as the “sober analysis” characterized by Braunwald.2 G. Frank 0. Tyers, MD, FRCS(C) Edward H. Williams, MD Division of Cardiovascular and Thoracic Surgery Department of Surgery The University of Texas Medical Branch Galveston, Texas References 1. Tyen GFO, Williams DR. Babb JD, et al: The changing status of e@ction fraction as a predictor of early mortality following surgery for acquired heart disease. Chest 71: 371-375.1977 2. Eraunwald E: Coronary artery surgery at the crossroads. N Engl J Med 297:661-663. 1977 3. Murphy ML, Hultgen HN, Detre K, et al: Treatment of chronic stable angina. A prsliminaw report of swvival data of the randomized Veterans Administration Cooperative Study. N Engl J Med 297:621-627. 1977
Reterences
2. The Anturane &infarction Trial Research c;roU~: Sulfinwrazone in the prevention of cardiac death after myocardial infarction. N En& J Med %269-295. 1676 3. Canfey MJ. Ek RL Kbsb J. I.M KL Met&u. JF.RoutI RA:Ttwwouwstic we&urn ._ of leftwmain St&&is. Circubtlon 57:947-952. 1478 4. CampOeU L, Corbua F, Crochet D. P~Stclerc R: Left main coronary artery stenosis. The influence of aortCUX_ bypaSS Sugery on suvival. Circulation 57: 111 l-l 115. 1978
RETROGRADE CROSSING OF AORTIC BJORK-SHILEY PROSTHESIS
.
MORE ON CORONARY BYPASS SURGERY-IV We take issue with the statement by Hultgren et al. that “improved patient selection” is an important factor in the decrease in operative mortality for coronary bypass surgery seen during the last 8 years. Before 1974, patients with a systolic ejection fraction of less than 0.30, recent myocardial infarction, unstable angina, poorly visualized vessels beyond obstructions and chronic
1082
May 1979
The American Journal of CARDlDLOOY
Karsh et al.’ report on the safety and efficacy of retrograde left ventricular catheterization in patients with aortic valve prostheses, and record their experience with 27 patients with either a Starr-Edwards or a Bjork-Shiley prosthesis. No mention is made of how many patients had each prosthesis. Their Figure 3 shows a catheter crossing a Starr-Edwards valve prosthesis, showing little disturbance of the poppet while the catheter is across the valve; however, this frame was taken during systole and would therefore not be expected to show interference with the diastolic closing mechanism of the valve. We strongly advise caution regarding the retrograde crossing of aortic Bjork-Shiley prostheses. Unlike the Starr-
Volume 43
