You Can't Always Get What You Want

“…but if you try some time/well you just might find/that you get what you need.”

Some readers have reminded me that I did not quote The Rolling Stones for quite some time. They seem to be missed. So why did I now pick this particular classic, written in the aftermath of the 1968 Grosvenor Square demonstrations?

The good thing, maybe the best, about being an Editor-in-Chief is the chartered independence which comes with the job. One may be editing the scientific journal of a learned society owned by a prestigious publisher, but neither can theoretically interfere with how the job is done—as long as the journal functions. Of course, they can, but if they did and the Editor started to complain in public about potential infringements of his important strict neutrality, this would make extremely bad press. So in the security of this seemingly untouchable freedom thoughts can be uttered which would be felt to be absolutely out of place if associated directly with the society or the publisher. The following opinions are completely my own and do by no means represent those of the German Society for Thoracic and Cardiovascular Surgery or Thieme Publishers. Readers may hate me for them or they may like me for them—I do not care. All I care about is the right of the independent Editor to voice his observations.

Ever since a new treatment modality for aortic valve stenosis became available the cardiac world has changed continuously, and definitely not for the better. It is pretty self-evident that it is less harmful for a human being if a valve prosthesis can be shoved up the aorta compared with through whatever form of thoracotomy and using cardiopulmonary bypass. It is also pretty self-evident that new technologies bear imperfections and need constant modifications during the first period of practical experience leading to even newer devices. It is also pretty self-evident that to compare long-term durability of such a device alone you need identical time-spans, in the case of biological heart valves approximately 10 years. To finish with the self-evident facts for now (and there are many more) it is logical that catheter-based techniques will find fast and efficient dissemination in the cardiological community whereas the surgeons will in general feel more comfortable brandishing a knife. The most banal of statements is that there are exceptions to the rule.

Despite these apparently logical facts the age of evidence-based medicine unfortunately seems to require appropriate proof confirming them. This has led to a multitude of publications over the last couple of years the quality of which tends to be on the mediocre side—at least from a critical and slightly bored Editor's point of view. The majority of studies appears to be overly busy trying to prove something rather than looking for the truth hidden behind—which should be the actual aim of scientific research. It is quite obvious that the cardiological community wants to prove that transcatheter aortic valve implantation (TAVI) is the way to go for aortic valve stenosis, whereas the surgeons keep raising warning fingers that this seemingly simple procedure can turn into a full-blown disaster independent of the performing physician's experience. The importance of a heart-team approach is emphasized in theory over and over again, only to be contradicted in practice on a daily basis, black sheep grazing on both sides of the fence. Definitions keep being redefined (never a good thing), studies get queried the day they are published, and the overall vibes have turned moody. Again, the innocent bystander cannot fail to sense an atmosphere of increasing competition and claim defense where one of combined forces and unity would be necessary to achieve really optimal results.

One more thought, although the mere mentioning of associated costs is gladly deemed embarrassing by the oh-so-ethical medical profession: with around approximately 10,000 TAVI procedures per year in Germany reimbursed with around € 30,000 each we are currently talking approximately 300 million Euros per year—a sum which simply did not exist for health insurance to cover 5 years ago. This is something nobody likes to talk about in public, often hiding behind ethical arguments. One cannot help but to remain confident that this is at least being considered by the authorities behind the scenes.

In the world of aortic valve disease nobody at the providers' end seems to get what he/she wants at the moment. It will take more than one truly (!) combined try to get what the ones at the receiving end, also known as patients, really need. For the time being your Editor has at least vented his own unimportant frustration. Which is probably a good thing, because “if we don't we're gonna blow a fifty-amp fuse.” And then it would become even darker.