i think this issue is not as relevant to other geographical areas.  boston is unique with so many world class tertiary referral centers, truly tertiary, not locally hyped community hospitals. the usual mayhem is the town/gown dilemna, local hospital which does cabg to back up interventionalists porteys itself as cardiac center and markets convenience in own back yard vs distance and inner city location of academic medical center, which is truly a referral center. this is bad enough for routine revascularization, but a bigger issue when locak hospital starts utilizing "new" technology or attpts to take on complicated cardiac cases. there are too many cardiac centers in us of a, over 1,000 for 300,000,000 americans.  there are 55 cardiac centers for 85,000,000 germans, and they are truly of cleveland clinic/mayoclinic/ etc quality. i refer you to www.heartsurgeryguide.net/ for a good discussio of how to chose a cardiac program, and i mean program, not surgeon. cardiac surgery is a team effort

Seth,

Our options are a tertiary center 100 north that does around 1600 heart surgeries per year, three centers 100 miles south with a little more or less volume and two smaller facilities that do around 250 cases per year. For more complex surgeries, we like to refer to tertiary centers but with the strong marketing of both of the smaller centers, it's difficult to appeal to logic. Making a recommendation is easier here for us but getting the patient to understand the complexities and to make the optimal choice for their particular malady is sometimes difficult.