Fool me once, shame on you; fool me twice, shame on me! A perspective on the emerging world of percutaneous heart valve therapy

摘要

In the late 1970s, catheter-based therapy for the percutaneous management of patients with coronary artery disease (CAD) was introduced. At that time, coronary artery bypass surgery (CABG) was the sole interventional treatment available for patients with CAD and offered superior outcomes to medical therapy in many patients. This new interventional but less invasive treatment, percutaneous coronary intervention (PCI), was met with skepticism, disdain, and dismissive arrogance from within the surgical community. Attitudes manifested by statements such as "we have a superior procedure," "angioplasty will never work," or "outcomes are being compromised" only served to foster complacency and stifle surgical innovation. This comfort in complacency within the surgical community was further reinforced by the annual increase in CABG procedural volume that continued for 20 years after the introduction of catheter-based therapy. However, the field of PCI progressed rapidly, catalyzed by incremental improvements in technique and technology including steerable catheters, stents, drug-eluting stents, and adjuvant pharmacology. These advancements both decreased procedural morbidity and improved outcomes so that within 10 years after the first interventional coronary procedure was reported, procedural volume of PCI eclipsed that of CABG. So much has the treatment paradigm continued to shift that currently in clinical practice, both interventionalists and their patients often view CABG as the procedure of last resort; the default treatment decision is frequently "if it can't technically be stented, then we'll have to do surgery." We are now just over 5 years into the brave new world of transcatheter therapy of valvular heart disease, and there are certain similarities to the changing practice paradigm that we witnessed in the early years of PCI in the management of patients with CAD. Since the first report of successful percutaneous aortic valve implantation, all four cardiac valves have now been successfully treated by catheter techniques. There is now regulatory approval for the commercial sale of two devices for the treatment of aortic stenosis, and one device for the management of mitral insufficiency is in a US pivotal trial. Is this the history of coronary intervention being repeated, that is, deja vu all over again? There is enough evidence already that this is indeed the case and that, as surgeons, we should learn the lessons of the past.