International Circulation: The data from the SYNTAX-LE MANS study will be presented here at EuroPCR 2009. What can we learn from this study? What is your opinion about the status of CABG in patients with left main disease and/or three vessel disease?

Prof. Kappetein: LEMANS was a great opportunity for us as surgeons to finally perform an angiographic follow-up of left main grafting. In the surgical literature there was very little data on the fate of grafts after they have been placed in case of a  left main coronary artery stenosis. With the SYNTAX trial we had an opportunity to perform  an angiographic follow-up of both the PCI patients and the CABG patients. After 15 months follow-up 10% of the patients had an occlusion of a graft  and  6% had an obstruction of one of the grafts. Surprisingly， that  did not lead to  a  MACCE. . The key message is that in case  of an isolated left main lesion we normally put two grafts， if one of the two grafts gets obstructed or occluded you still have another graft that  functions and probably will give enough blood supply to the myocardium so the patient won’t have any adverse events from

International Circulation: Do you think that transcatheter valve replacement will replace surgery in the future? What are the advantages and disadvantages of the technique?

Prof. Kappetein: I think it offers a great opportunity for a lot of inoperable patients. At the moment， we are shifting to the surgical candidates. It might  be a  good indication for a patient of over  80 years old that we now normally operate on. For such a patient， even if the operation goes well， it takes about two weeks in the hospital and approximately 3~4 months for recovery. Hopefully with percutaneous valve replacement we can shorten that time and they can be discharged from the hospital earlier.

On the other hand， we still do not know the durability of the valves. I am a little bit concerned that if we move towards the younger patients like 75 year old patients that there may be a problem with the durability of the valves. Suppose they start failing after about 5~7 years， which isn’t a problem in an 80 year old patient， but in a 75 year old patient it could be a problem. The procedure itself is quite safe. These are the first and  second generation of these valves and they are already doing pretty well and they can even  improve further.

International Circulation: Implanted stem cells are one of the promising treatments for patient with structural heart disease. What have surgeons been doing in this field?

Prof. Kappetein: As surgeons we are following what the cardiologists have already been doing. They started first because the stem cell industry has been targeting cardiologists to help patients with acute infarctions. I think it is quite easy for surgeons to inject cells in a myocardium that has had an infarction. We can clearly identify during surgery where the infracted area  is located and inject cells.. We try to work together with cardiologists to apply this therapy in the operating room.

International Circulation: What is your opinion of the hybrid revascularization approach， especially the one-stop hybrid procedures?

Prof. Kappetein: I think that every cardiologist is convinced that a mammary artery is the best thing that you can offer a patient with a  stenosis in the LAD. If we can offer a minimally invasive therapy to patients and we can， for example， put a LIMA on the LAD and the cardiologist  puts a stent in  the circumflex and  the right coronary artery that would be offer  good option for the patient.

At the moment，  minimally invasive surgery  takes a long time to perform and carries a long  learning curve We haven’t found the solution for that yet. Presently a hybrid approach to coronary artery disease is not a viable approach on a large scale

International Circulation: How can we optimize the collaboration between surgeons， interventionalists， and others to have a true team approach?

Prof. Kappetein: This is an important message that you will hear often at this conference that the indications and the choice of therapy for the patient is crucial . In the Thoraxcenter of the Erasmus MC  the cardiologist and surgeon meet every morning and discuss t what the best therapy for the patient is. Is it PCI， coronary surgery， should the patient have a surgical valve implantation or a percutaneous valve implantation? If you sit down together and discuss it you can choose the best treatment option for the patient.