Letter from the Editor

News from the Pit Lane

“We had a very good car, but we had an even stronger team.” Sebastian Vettel in Suzuka, Japan, Oct 9th, 2011, after having won the Formula I championship for the second time with four races still to go [1].

This sums it up neatly. For cardiac surgery a similar achievement has come a very long way. Surgeons always had terrific heart valves, some even sharing the carbon properties with a racing car. Cardiologists, on the other hand, became true wire wizards who seem to be able to reach and manipulate any part of a diseased heart. Until recently it had been relatively clear who could provide the maximum benefit to an individual patient, but these well-defined borderlines continue to break up and a new orientation is urgently needed. With the stent technology developing faster than a mechanic can change a front spoiler, percutaneous approaches have reached the left coronary main stem. Patients love these interventions: in and out within 48 hours almost like a pit lane stop, a tiny prick in the groin, and who cares about the cost or side effects of the little tablets that have been added to the staple diet of antihypertensive and lipid-lowering medication, let alone the state of affairs three years down the road? As a result, the number of coronary revascularization operations, affectionately called “cabbages” (from: CABGs), is steadily declining [2].

Luckily, the bulky, solid heart valves so far seemed to be a safe bet for surgery. But, lo and behold, this is no longer true. Biological grafts mounted on ingeniously designed metal stents can nowadays be shrunk like a candy wrapper and stuffed into catheters. Under X-ray control they are then released within formerly dilated aortic valves to act as their substitute. Astounding wire skills – with the surgeons staring dumbfoundedly at the monitors watching these flower-like constructions elegantly unfold before their very eyes. “What about the coronary orifices?” they scream. “What about the conduction system our fathers so meticulously taught us to avoid? Will these things really hold in place? And I could have put in one size bigger at least!” With these reservations in mind several surgical leaders thought it worthwhile to best gather experience with this new technology themselves. And judicious cardiologists quickly realized that wire skills alone would not help them to bail out of serious anatomical problems.

Thus, after Hollywood gave us the A-Team and the Dream Team, Germany created the Heart Team. Together the two German scientific societies involved (Thoracic & Cardiovascular Surgery and Cardiology) formulated a position paper defining the indications for application of these new techniques and who should be allowed to perform them [3]. An indispensable prerequisite was felt to be the said Heart Team. Only patients with a high risk for conventional open aortic valve replacement should be considered eligible. Each individual case is to be discussed by a panel of experts from both specialities with the aim to come up with a unanimous recommendation which way to go. Centres offering both methods are encouraged to share clinical training between trainees. During an interventional valve implantation both a cardiologist and a surgeon should be part of the performing team with each learning from the other one the skills best suited to the individual steps of the procedure. It should therefore be unthinkable that a cardiologist pushes devices up a thoroughly diseased aorta in the solitude of his cath lab, nor should it be possible that a surgeon inflicts a radiation-induced burn injury on a patient, endeavoring to advance a bent wire after having spent an hour trying to boot the X-ray machine.

To drive home the team idea even more, all centres performing aortic valve interventions both surgical and/or catheter guided, are obliged to report them to the German Aortic Valve Registry (www.aortenklappenregister.de). This was established as a comprehensive database in order to collect comparable data for outcome measurement. The original intention to make enrolment compulsory failed due to the intricacies of German legislature, but towards the end of 2011 one can state that registration is nearing completeness. Some are always late or too busy, but they will have to eat humble pie eventually.

In this issue we are able to present a prime example of how an established Heart Team can come up with a good solution in a difficult setting and then put it successfully into effect [4]. In the acknowledgement the individual part played by each of the (numerous) co-authors is explained. This is what both an editor and a critical reader like to see in order to make the background comprehensible. It also emphasizes the crucial role played by a team, not by a solitary luminous figure, conventionally represented by the first or last author. It remains to be hoped that this exemplary cooperation model of the Heart Team will become sufficiently engrained in the conscience of the current generation of doctors to render it normal that the best treatment results are frequently achieved after a thorough discussion with colleagues, taking their respective angle and experience into account. In order to support this, for medicine almost revolutionary concept of thought, the 2012 annual meeting of the German Society for Thoracic and Cardiovascular Surgery will be held under the motto “One Heart – One Team”, with the cardiologist Christian Hamm as the president, flanked by surgical expertise.

To put the trend of time in a nutshell once again, one may quote a verse by Roger Waters: “It's a helluva start! It could be made into a monster – if we all pull together as a team!” [5].

References

• 1 Wittershagen M. Vettels Team – Bremsen für den Titel.  FAZ. 2011;  235 22
• 2 Gummert J F, Funkat A K, Beckmann A et al. Cardiac surgery in Germany during 2010: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery.  Thorac Cardiovasc Surg. 2011;  59 259-267
• 3 Figulla H R, Cremer J, Walther T et al. Positionspapier zur kathetergeführten Aortenklappenintervention.  Kardiologe. 2009;  3 199-206
• 4 Seiffert M, Baldus S, Conradi L et al. Simultaneous transcatheter aortic and mitral valve-in-valve implantation in a patient with degenerated bioprostheses and high surgical risk.  Thorac Cardiovasc Surg. 2011;  59 490-492
• 5 Waters R. Have a Cigar. In: Pink Floyd Wish You Were Here (Songbook). London: Pink Floyd Music Publishers Ltd.; 1975