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Doubts on stents help pump up heart surgery

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Times Staff Writer

Open heart surgery, which many patients and doctors have avoided in the last decade in favor of less-invasive heart stents, is making a comeback.

Recent studies suggest that bypass surgery could extend many patients’ lives longer than stents, the tiny devices designed to reinforce damaged arteries.

The newest generation of stents, which are coated with drugs meant to inhibit blood clots, might actually increase the risk of clots compared with older, bare-metal versions, other studies suggest.

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Last month, a study found that for patients with clogged arteries who have not had heart attacks, the widely used surgical treatment of balloon angioplasty with the insertion of a stent was no better than conventional drug treatment.

“The basic concern is that stents may not be the best medical intervention for a significant number of patients getting them today,” said Dr. Peter K. Smith, chief of cardiothoracic surgery at Duke University Medical Center in North Carolina. Smith reports that he has been performing more bypass surgeries in recent months.

Although no official statistics are available to document a rebound, doctors at several medical centers, including Cedars-Sinai in Los Angeles and Emory University in Atlanta, report bumps in heart surgeries.

For surgeons, that increase is helping them get their mojo back. Once the undisputed kings of the medical field -- to many, they were the profession’s version of quarterbacks, receiving heaps of cash and glory -- heart surgeons’ fortunes have fallen of late.

By some estimates, their average annual salary has dropped from nearly $1 million a decade ago, in today’s dollars, to half that now. According to an article in the Annals of Thoracic Surgery last year, 12% of the cardiothoracic residents surveyed received no job offer in 2004.

“The rules of the game changed dramatically a few years ago,” said Dr. Richard Shemin, the newly installed chief of cardiothoracic surgery at UCLA Medical Center, pointing out that cardiologists have been performing more heart procedures, and surgeons fewer. “Things may be changing again.”

On the advice of her doctor, Gail Miller, a 60-year-old art instructor in Sacramento who had been diagnosed with advanced heart disease, chose to have bypass surgery two days after Christmas last year.

“At first, I was terrified, and my family was even more scared,” said Miller, who was close to full recuperation. “But after I read about all the issues with stents lately, I am kind of happy I got a bypass.”

Stents, which come in varying sizes and designs, are inserted by a cardiologist -- heart specialists who diagnose and treat conditions such as congenital defects and coronary artery disease but don’t perform surgery. The stents are put through a small opening, typically in the leg. They are then snaked to the heart on a microscopic balloon that opens the artery and is removed after the stent is in place.

By contrast, bypass surgeons use the comparatively medieval procedure of opening a person’s chest and using blood vessels from throughout the body to fashion detours around lesions in the heart to keep blood flowing freely.

Stent procedures can take a few hours from start to finish, and patients increasingly go home the same day. Bypass patients may stay in the hospital for a week or more and can require months to fully heal.

Should the surgery trend accelerate, it would amount to a stunning U-turn in the treatment of cardiac patients, especially the sickest ones, as the U.S. population ages and the plague of heart disease promises to spread.

Already, it’s restoring credibility to a procedure that is credited with saving millions of lives since it was developed more than a century ago but has been considered a relic of the past in recent years.

Heart disease remains the leading cause of death in the U.S., killing more than 600,000 people a year, or about one every minute.

Duke University surgeon Smith headed a study released last year that showed patients with more advanced cardiac disease who had bypass surgery had a significant survival advantage over those who received stents.

It estimated that more than 3,600 people a year could be dying because they aren’t getting cardiac bypass surgery.

Congress recently opened an investigation into the stent industry. Analysts expect stent sales to fall 10% to 15% this year.

“The stent market is going to keep slowing for a while,” said Jeff Jonas, a portfolio manager with Gamco Medical Opportunities Fund, which owns shares of Johnson & Johnson, the parent company of stent maker Cordis Corp.

Few medical treatments have become as popular as quickly as stents. In just over a decade, more than 20 million have been used in patients, with some people receiving more than one.

Yet few can pinpoint precisely why they are so popular.

Doctors say many patients prefer stents because they are less invasive and less frightening than full-scale surgery. Manufacturers of the devices, such as Cordis and Boston Scientific Corp., also have aggressively marketed them.

Another contributing factor, some critics say, is that cardiologists who implant stents are often the same physicians making the diagnosis, raising the possibility of a conflict of interest.

A stent can be inserted at the same time and via the same catheterization that cardiologists use to diagnose patients, making it enticing -- and more lucrative -- for doctors to perform the procedure right then.

Otherwise, they would write a prescription and send patients home or pass them along to cardiac surgeons.

“There’s no checks and balances here,” said Dr. Frederick Grover, head of surgery at the University of Colorado at Denver.

Other surgeons worry that patients aren’t always told that a bypass may be a good option.

“If someone has a triple vessel blockage [or more], it’s my opinion they should get surgery,” said Dr. Vaughn Starnes, chairman of the department of cardiothoracic surgery at USC’s Keck School of Medicine. “It’s black and white.”

And experts caution that stenting and angioplasty -- the procedure used to expand arteries so that stents can be inserted -- remain the gold standard for patients who have suffered a heart attack because of coronary artery blockage.

Prominent doctors warn that the new research that has raised questions about stents’ survival advantage over bypass surgery largely has come from observational studies, not the randomized, controlled trials doctors typically prefer.

“We must make sure we don’t get overzealous and react without good data,” said Dr. Raymond Gibbons, president of the American Heart Assn.

Some cardiologists and stent makers say they doubt that the number of bypass surgeries will climb back near the levels of a decade ago.

They accuse cardiac surgeons of playing up the recent controversy around stents, hoping to help their beleaguered businesses and reputations.

“It’s pumping-up time,” said Dr. Donald Baim of Boston Scientific. “If cardiac surgeons say their business is going up, they’re probably hoping it will help it go up.”

Grover of the University of Colorado scoffed at the idea that surgeons were trying to capitalize on the controversy, although he didn’t disagree that cardiac surgeons had become more vocal recently.

“Everyone’s first concern should be doing what’s right for patients,” he said.

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daniel.costello@latimes.com


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