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a Cardiothoracic Surgery, University of Michigan, 1500 E Medical Center Dr, 5144 Cardiovascular Center, Ann Arbor, MI 48109-5864
b Department of Surgery, Oregon Health and Science University, Mail Code L-223, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098
c Division of Cardiology, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8 Canada
d Pediatric Cardiac Surgery, Rainbow Babies and Children's Hospital, RBC 380, Mailstop: RBC 6021, 11100 Euclid Ave, Cleveland, OH 44106
e Division of Cardiac Surgery, Doernbecher Children's Hospital, Oregon Health and Science University, Mail Code DC-8S, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098
(Email: tarakara{at}med.umich.edu; diggsb{at}ohsu.edu; brian.mccrindle{at}sickkids.ca; ross.ungerleider{at}UHhospitals.org; welkek{at}ohsu.edu).
We appreciate the comments of Drs Opotowsky and Webb [1]. They indicate that our article [2] created one of its intended aims: to generate thoughtful controversy about current practice patterns.
We agree that there are patients who have likely benefited from the ease of patent foramen ovale closure by catheter-delivered devices. For appropriately selected patients, this has undoubtedly reduced the risk of stroke without the invasiveness and risk of surgery and provided enormous benefit [2]. On the other hand, the risk of device closure [3, 4] for atrial septal defects is not negligible and the same as with any intervention, in that it is most important to be offered for well-described indications. It is not possible to determine the indications for intervention in any retrospective review, even one with a large sample size. Therefore, we offered a provocative suggestion that in a "revenue for procedure" business model, device utilization may be driven, in some instances, by factors unrelated to medical indication. We believe that this is not a cardiologist versus cardiac surgeon issue; rather, as health-care professionals, we have a collective responsibility to harness utilization to indication (ie, a "best practice" in which we all must engage). What is the best way to treat atrial septal defects and specifically, which patients should be treated by device, which ones with surgery, and which ones should not be treated at all?
This also begs the question of cost conceptualized as the issue of benefit described in some quantitative form. In other words, there are nonmonetary ways to measure cost, some of which we can not yet numerically define. What is the cost to a patient of carrying around a device for several decades? What is the cost savings from preventing long-term morbidity from strokes? What is the cost of lost catheter laboratory revenue to an organization if device closure indications were more regulated than by the current system of decision by the delivering cardiologist? In 2000, surgical programs had to adapt to the loss of surgical revenue when atrial septal defect devices became a more common approach for many patients. Can the catheter laboratory of today adapt if we learn there are patients receiving devices that fall outside appropriate indications? We are not claiming that one approach is better than another; we are merely pointing out that atrial septal defect closures have increased exponentially since the advent of device closure, and we suspect this utilization far outstrips previously accepted indications. Perhaps indications need to change in the device era. There is no question that technology can lead to changing indications for treatment of various entities. Surgical treatment of peptic ulcer disease has all but disappeared in the era of histamine receptor blockers, which can now be purchased directly by consumers. Can we expect consumers to be able to make the same determinations regarding whether or not they should have an atrial septal communication closed, and if so by which technique? Cost differential between surgery and percutaneous technique becomes a staggeringly less important issue when measured against the importance of determining which patients will best benefit from all the options in our treatment armamentarium.
We are grateful to Drs Opotowsky and Webb [1] for rising to the challenge that this article creates for all of us. We are all on the same team: professionals who have made a career of treating patients with heart disease. It will not be helpful for us to debate the distracting issue of whether percutaneous closure is better than surgical closure of atrial septal defects. It is more important that we create a model in which we are all invested together in deciding how to best treat the patients who need our expertise.
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