At EACTS 2024, surgeons and cardiologists weather the EXCEL firestorm

LISBON, Portugal—Five years ago, the surgical committee chair of the EXCEL trial took the stage at the 2019 European Association of Cardiothoracic Surgery (EACTS) meeting and accused the management of the trial of manipulating the data—turn on a fire storm between surgeons and interventional cardiologists.

But this month at EACTS 2024, in that same auditorium, representatives from both sides seemed ready to put the past behind them.

In a joint EACTS and European Society of Cardiology (ESC) session, Alaide Chieffo, MD (Vita Salute San Raffaele University, Milan, Italy) and Patrick Myers, MD (Lausanne University Hospitals, Switzerland), were scheduled to debate about the best coronary. revascularization strategies for patients with multivessel CAD, left main disease, and/or heart failure. Instead, more harmoniously, the two discussed the many permutations of suitability for PCI and CABG, often referring to ESC. latest iteration of guidelines for the treatment of chronic coronary syndromes (CCS) using a patient-centered approach.

The CCS guidelines themselves represent a kind of olive branch between cardiologists and surgeons, who came together to write and sponsor them after EACTS. formally withdrew its support of the main document of the left of 2018 in the wake of the EXCEL controversy.

Chieffo, who serves as president of the The European Association of Percutaneous Cardiovascular Interventions (EAPCI) and was part of the drafting committee of the new guidelines, told TCTMD that it is happy with the current distension. “As always, it takes a while,” he said. “Being part of the European Society of Cardiology’s CCS guideline task force was work – we did a lot of work.”

It took time to find harmony, Chieffo continued, “but at the end of the day, I think it’s the evidence and the people that make the difference.”

We have come full circle. Patrick Myers

“We’ve come full circle,” Myers, who serves as EACTS’ general secretary, told TCTMD. The latest guidelines have a “left main chapter that EACTS endorses, because we all believe that this best represents the evidence,” he said. “It’s very positive to see that we’ve gone from surgeons looking at the data one-sidedly and saying, ‘Wait a minute, that’s not reasonable.’ We don’t agree with that,’ by saying, ‘Okay, let’s work on this together,’ and getting there to be joint guidelines that we endorse.”

Session co-moderator Volkmar Falk, MD (German Heart Center Berlin, Germany), the current president of EACTS, acknowledged past controversy but encouraged future cooperation. “The fact that we have just endorsed the latest ESC guidelines as an organization shows that we are very close to our friends in cardiology,” he told those attending the session. “Although we consider this a debate, I think we will reach an agreement, and that is the whole point. We do it for our patients and for ourselves.”

Return to data

For his talk, Chieffo emphasized the need for heart team discussion in cases where the CCS guidelines give the same class of recommendation to surgery and PCI. He also emphasized the new focus on a “patient-centered” approach.

“We need to take care of the unique, individual patient, taking into account not only the anatomy of their coronary arteries, but also the patients’ comorbidities, as well as hospital practice and protocol,” Chieffo said. “Because obviously we are talking about guidelines that extend to many countries where the capacity of each individual center is not the same.”

The left-wing main section of the CCS guidelines was “debated very heavily” during the drafting committee meetings, he said. In the end, however, there was mutual agreement that CABG received a Class I, Level of Evidence A recommendation for patients at low surgical risk because it is “superior to medical therapy; it is also higher than PCI,” Chieffo noted.

At the end of the day, I think it’s the evidence and the people that make the difference. Alaide Chieffo

In his presentation, Myers explained that over time he has come to understand that everyone’s understanding of the data is biased by personal experience, and that this bias played a role for both surgeons and cardiologists. in the main controversy of left revascularization.

“But if we look at the data, there are no RCTs that show survival (for) PCI over medical therapy,” he said. “Many of the trials are designed to show non-inferiority to CABG, and this is a somewhat biased comparison.”

Still, he noted that much of the surgical data is observational and not randomized, leading to unresolved questions. “We are far behind. In interventional cardiology, you are more advanced. It’s definitely something we have to do,” he said.

Patient-centered vs. patient preference

The concept of “patient-centered” appeared to cause some confusion during the discussion, with Chieffo having to redefine it at least twice, clarifying that the CCS guidelines do not specify that every patient should be reviewed by the cardiac team.

“There are specific patients where you should have a cardiac team, otherwise it would be too complicated,” he said.

Defining exactly how the heart team works remains a “big problem,” Myers said. “This is something we hope to work on in the future. . . . In a way, we should make the heart team’s decision reproducible because if we give the same file to a (different) group of people, they should get to the same conclusion, which is not always the case”.

Nor do the guidelines place undue weight on patient preference, he clarified, a concern often heard from surgeons who can empathize with the desire to undergo a less invasive procedure while also wanting to provide their patients with the best care.

“We want the patient to be at the center of the decision-making process, right?” Falk said. “But at the same time, how can we ensure that we give the best information to the patient and that we do it in an unbiased way? And also convincing patients that yes, (surgery) can be more invasive, but can it be the best for them in the long run?

Chieffo clarified that a patient-centered approach does not mean being guided only by the patient’s preferences.

“Patient-centeredness is something that involves more functions being considered,” he said. “It is not the same for all patients. It’s not patient preference, but patient-centered: moving from the pathology itself to a deep, deep emphasis on that specific patient.”

The fact that we have just endorsed the latest ESC guidelines as an organization shows that we are very close to our friends in cardiology. Volkmar Falk

After the presentations, audience member Christoph Nienaber, MD, PhD (Royal Brompton Hospital, London, England), noted that patient inclusion in the decision-making process is “increasingly important.” If a patient has multiple treatment options and ultimately refuses CABG, “what can you do?” he said “At the end of the day, we’re a service provider, and we give you another option, whether it’s medical management or multivessel PCI. The options are always there.”

Another audience member, Mustafa Cikirikcioglu, MD, PhD (University Hospitals of Geneva, Switzerland), called the heart team “the most important revolution” he has seen in his surgical career, but also expressed concern that decision-making centered on the patient in some cases can be “abused”. ”

“If there is no real heart team discussion for a patient, there is a potential risk that the patient may (prefer) percutaneous revascularization, even though surgical revascularization (is) more appropriate,” Cikirikcioglu argued , and added that in his experience. , has also seen too much weight placed on patient preference over best evidence.

building bridges

Looking ahead, Myers noted, “the future is bright, and just having cardiologists here at the meeting is a testament to that. As at our home institutions, we can work together very well.”

For TCTMD, he said the EACTS has been actively working to build bridges with other associations that represent the spectrum of the choir team, organizing joint sessions, attending meetings of other societies and encouraging open-mindedness. . “Once we get past the discussion about guidelines and turf wars and things like that, we realize that actually the mindset of an interventional cardiologist is much closer to the mindset of a surgeon,” he said.

Falk also emphasized the importance of attending a wide variety of conferences. “It’s important to go to cardiology meetings as well,” he said. “Go to ESC, go to EuroPCR, be present at these meetings and participate in the discussion there. It’s one thing to talk about it here at EACTS, where we are all heart surgeons. it’s easy We also need to get together with our friends in cardiology and go to their meetings, and maybe yes, but I think this is a task that we all have”.

“The only way forward is collaboration,” Chieffo said. “I don’t think our field of cardiology and cardiovascular disease can be without collaboration, and collaboration is in the best interest of the patient.”