The life and hard times of a coronary surgeon.

Coronary artery bypass is arguably the most extensively studied operation in surgical history. The technical advances and beneficial effects on symptoms and prognosis have been well documented over four decades. Percutaneous coronary interventions (PCIs) have also evolved through numerous modifications, and symptom relief has been substantiated; both modalities have been challenged by many randomized controlled trials. The rapid growth of PCIs has decreased coronary artery bypass volumes, and resulted in concerns about training, teaching, research, jobs and income. The most important concern, however, is the increasing 'off-label' application of PCIs with drug-eluting stents to a variety of untested coronary lesions. The randomized controlled trials studied a small fraction of those registered and excluded patients who are known to benefit from surgery and, thus, these studies were inherently biased. The results were then extrapolated to 'real-world' patients, who had been misinformed and misled about the performance and prognosis of coronary stents, as was later revealed in various registries. Hospitals should develop a collaborative revascularization strategy to provide patients and families with realistic alternatives.