Percutaneous treatment of coronary bifurcations To the Director

498
LETTERS TO THE
REVISTA ARGENTINA DE CARDIOLOGÍA / VOL 76 Nº 6 / NOVEMBER-DECEMBER 2008
EDITOR
Percutaneous treatment of coronary bifurcations
To the Director
We have read with great interest the work published
by Dr. Mariano Albertal M.D. et al., “Outcomes of the
Percutaneous Treatment of Coronary Bifurcations”, in
which clinical outcomes in patients with bifurcations
treated with conventional stents or drug eluting stents
(DES) are assessed.
These are complex lesions that require experience
and techinque to achieve good hospitalization and late
outcomes. Recently, we have presented a series of 86
patients treated according to the operator’s criterium,
and we have observed different strategies. The main
branch and branches in 65% of the cases were treated.
Among these patients, the rotational atherectomy was
used in 14 of them, and 19 received a “Twin Rail”
bifurcation stent (Invastent). The rest was treated
with stent in both branches or balloon dilation and
provisional stent. In Albertal et al.’s work, nearly 20%
of the patients were implanted a stent in both treated
branches, whereas this percentage was only 8% in our
series. The use of DES significantly reduces the need
for reinterventions, but this benefit could be hampered
in the case of bifurcation lesions, mainly because of
their deformation when the lateral branch is treated.
This phenomenon has been observed in all types of
stents with a higher incidence of restenosis and increase of acute thrombosis. Maybe this is the reason
why, in our series, the DES was used mainly on patients who had only received treatment of the main
branch.
A different treatment modality in our centers was
the use of a stent designed to treat bifurcations. This
device allows the use of the kissing balloon technique
without modifying the anatomy of the prosthesis. In
this subgroup, we got positive outcomes in angiography, hospital evolution, and follow-up a year later.
However, its implant requires training, since it is often necessary to recross the lesions, and in two initial
cases we observed the distal dissection of the main
vessel, which required the use of a second stent. We
then modified the strategy by applying the 3.0 mm
system for 3.5 mm lesions, which resulted in avoiding
new events. We agree on Dr. Albertal et al.’s conclusions in that it is possible to get better results with a
simple technique. The use of a drug eluting stent for
bifurcations could result in the right strategy.
Dr. Rubén Kevorkian, M.D.
Dr. Laura De Candido, M.D.
Dr. Oscar Carlevaro, M.D.
BIBLIOGRAPHY
- Albertal M, Cura F, Padilla LT, Pérez Baliño P, Candiello A, Belardi
J. Resultado del tratamiento percutáneo de las bifurcaciones
coronarias (Outcome of the percutaneous treatment of coronary bifurcations). Rev Argent Cardiol 2008; 76:341-6.
- Carlevaro O, Centeno S, De Candido L, Maffeo H, Etcheverry M,
Kevorkian R et al. Angioplastia en lesiones bifurcadas de arterias
coronarias (Angioplasty in coronary artery bifurcation lesions). Rev
Argent Cardiol 2007; 75:40. Abstract N° 273.
- Centeno S, Carlevaro O, De Candido L, Brandeburgo S, Ruiz N,
Kevorkian R et al. Tratamiento de lesiones coronarias complejas: Stent
bifurcado Twin Rail (Treatment of complex coronary lesions: Twin
Rail bifurcation stent). Rev Argent Cardiol 2007; 75:180. Abstract
N° 61.
- Colombo A, Moses JW, Morice MC, Ludwig J, Holmes DR Jr,
Spanos V, et al. Randomized study to evaluate sirolimus-eluting
stents implanted at coronary bifurcation lesions. Circulation 2004;
109:1244-9.
- Lefèvre T. Bifurcation lesions: the simpler, the better. Rev Esp Cardiol
2005; 58: 1261-5.
- Pan M, Suárez de Lezo J, Medina A, Romero M, Segura J, Ramírez
A, et al. A stepwise strategy for the stent treatment of bifurcated coronary lesions. Catheter Cardiovasc Interv 2002;55:50-7.
Evidence-based empathy
To the Director
Motivated by your letter “Beyond the feeling of empathy. The need for professional behavior”, (1) and encouraged by a vague curiosity, I opened the Diccionario
de Filosofía (Dictionary of Philosophy), by J. Ferrater
Mora (2), and looked up the term “empathy”. I found
out it referred to two terms: endopathy and sympathy. With respect to the first term, the author describes
it as equivalent, and he defines it as “affective and
usually emotional participation of a human being in a
reality other than his or her own”. I liked the prefix
“endo”, which obviously denotes “incorporation”.
According to Theodor Lipps –who developed the
endopathic concept in the field of esthetics–, the
endopathy has two components: the projection (for
which the individual expands his own being to his
environment), and the imitation (for which the individual takes possession of certain elements from the
surrounding reality). In a way, it relates to what
Damasio expressed and was cited in your letter: the
emotion related to the projection and the feeling to
the imitation. Now, implementing feelings deliberately
with the aim of getting closer to the patients we interact with and providing them with satisfaction (for
instance, professional behavior), has an undeniable
499
LETTERS TO THE EDITOR
Hippocratic root. One of Hippocrates’ writings, On
the Physician, provides guidelines regarding how to
speak and behave, trying to look serious and friendly,
concerned but with no bitterness, avoiding being rude;
it expressly recommends the physician that he be “fair
in any treatment, since justice will be of great help to
him. The relationship between the physician and his
patients is not a minor issue. Since they (the patients)
are in the hands of physicians… they have to control
themselves, first and foremost”. (3) In spite of these
illustrious antecedents, many of us have the feeling
that the professional conduct is getting lost. How can
these concepts be used to build an adequate professional behavior? If evidence is to be found in PubMed,
there are 10,396 quotations for the term “empathy”
and 2,973 for “empathy AND education”. The fact that
one third of the registered articles refer to education
illustrates the magnitude of the problem. An interesting example is a systematic revision of qualitative
studies that assessed educational interventions on
empathy on medicine students, which reveals that it
is possible to get improvements in this field. (4) While
the way to measure empathy is food for debate, the
article suggests that education can be effective. How
to implement this in the degree plan is another
conflictive issue. We are aware that studying Bioethics
and Deontology in a nineteenth century style has not
achieved great results in the current groups of students. The teachers will have to take up the glove
and adapt that content to the new learning styles.
Dr. Mariano Giorgi, M.D.
BIBLIOGRAPHY
1. Doval HC. Beyond the feeling of empathy. The need for professional
behavior. Rev Argent Cardiol 2008; 76:330-4.
2. Ferrater Mora J. Endopatía. In: J. Ferrater Mora. Diccionario de
Filosofía. 1st edition Barcelona: Ed Ariel Filosofía; 2004. Tomo II, p.
1008-12.
3. Hippocrates. Sobre el médico (On the Physician). In: Juramento
hipocrático (Hippocratic Oath) Tratados Médicos. Buenos Aires: Ed
Planeta-DeAgostini; 1995. p. 73-80.
4. Stepien KA, Baerstein A. Educating for empathy. J Gen Intern
Med 2006; 21:524-30.