How interventional cardiologists can boost cardiac surgery volumes
Competition was once fierce between interventional cardiologists and cardiac surgeons, but that has changed over the years thanks to the evolution of the collaborative heart team approach. With evidence-based care decisions being a key determinant in heart team decisions, interventional cardiologists are increasingly viewed as essential partners in bolstering the field of cardiac surgery — particularly when it comes to coronary artery bypass grafting (CABG).
"It is absolutely a partnership. I'm a huge fan of interventional cardiologists. The ones I work with have been fantastic people doing wonderful work with extraordinary skill. My own father's life was saved by an acute intervention caused by an ST-elevation myocardial infarction (STEMI). I know what PCI can do; I'm a fan. But that doesn't mean it should be done for every patient. It does mean that cardiologists and cardiac surgeons should partner to advance both areas forward," John D. Puskas, MD, MSc, PhD, professor of surgery and chief of cardiothoracic surgery at Emory University Hospital Midtown, told Cardiovascular Business.
Cardiovascular surgical volumes have decreased in the past several years because of less invasive interventional structural heart procedures. However, it is interventional cardiologists who are uniquely positioned to help elevate CABG volumes. Interventionalists review a lot of patient cases and look at proper patient selection based on current guidelines. He said many times younger, more complex patients are better candidates for CABG. In addition, new data released in 2024 show that multi-vessel CABG offers improved outcomes over 10 years compared to single grafts, which could potentially increase referrals.
"I would like to see cardiologists also help to push forward coronary surgery. There are mountains of data evidence demonstrating that more than one arterial graft makes patients live longer. It took a while for us to get the whole profession to believe and be able to perform just a single internal mammary graft to the left anterior descending artery, but we now have a tremendous body of data. This includes a 1 million-patient analysis from the Society of Thoracic Surgeon database showing that multiple arterial grafting (MAG) beats single arterial grafting (SAG) over 10 years. This is an extraordinarily strong piece of evidence."
Yet despite the data, he said only about 12% of first-time CABG patients in the U.S. currently receive more than one arterial graft.
“The patients are first seen and followed by cardiologists—they know them best and take the leap of faith to refer them for surgery,” Puskas said. “They should have a say in the operation and ask: Why did my patient only get one arterial graft? Why not two or three? Why not all arteries?”
In his view, the current underutilization of advanced bypass techniques stems from outdated logistical and technical barriers, not from a lack of evidence or clinical need. He likens the reluctance to adopt multiple arterial grafting to the early resistance toward internal mammary grafts decades ago, an approach that eventually became a surgical quality benchmark.
"A lot of it has to do with the technical difficulty of the operation, but we all said the same thing about internal mammary grafting 30, 40 years ago. 'It's too hard, it can't be done, you can't teach it.' But it became a quality metric. Everyone learned to do it. Those who couldn't learn to do it stop doing coronary surgery," Puskas said.
He also called for coronary surgery to be treated with the same focused specialization as mitral or aortic surgery, with a subset of surgeons dedicating themselves to mastering advanced bypass techniques.
During a recent cardiology session, Puskas observed several technically complex revascularization cases successfully handled via PCI. But he cautioned that interventional skill alone and a less invasive option for patients should not override long-term clinical outcomes in determining treatment decisions.
“Just because you can, doesn’t mean you should,” he said, pointing to the recently presented Eclipse Trial at TCT 2024. That study showed that atherectomy—once a heavily promoted tool for calcified coronary lesions—actually led to higher mortality compared to simple balloon PCI. In many cases, the result looks great on the table, but the real question is, how does the patient do in five or 10 years?”
Ultimately, Puskas believes the collaborative dynamic between interventional cardiology and surgery is not only improving stroke rates and procedural safety, but also shaping a more effective and durable cardiovascular care system.
He said competition is good, but collaboration is better. Ultimately, patients will benefit most when interventionalists help push forward the best possible surgical care for select patients and not just the most technically dazzling intervention.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]