Ann Thorac Surg 2000;70:1013-1016
© 2000 The Society of Thoracic Surgeons
Supplement: cardiothoracic techniques & technologies
Emergence of a new direction in our specialty: catheter-assisted cardiac surgery
Hani Shennib, MDa
a Center for Innovative Cardiovascular Therapy, Heart Institute at St. Luke’s Roosevelt and Beth Israel Hospitals, New York, New York, USA
Address reprint requests to Dr Shennib, The Heart Institute, First Avenue at 16th St, New York, NY 10003
e-mail: hsshennib{at}bethisraelny.org
Presented at the Sixth Annual Cardiothoracic Techniques and Technologies Meeting 2000, Ft Lauderdale, FL, Jan 27–29, 2000.
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Introduction
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Around the meeting of the American Association of Thoracic Surgeons in 1995, a very small group of surgeons held a side discussion to explore some new ideas on lesser invasive approaches for heart operations. Questions asked and discussions, which followed, were as simple as: Could they be carried out and are they worth pursuing? The instigation for this forum was a widening acceptance of less invasive general thoracoscopic surgical techniques and some recent laboratory data, which suggested that key hole cardiac operations would be possible in the future. What really attracted much attention at that meeting, however, were reports coming out of several South American heart centers elucidating successful clinical experience with beating heart coronary artery bypass grafting (CABG).
The subsequent 2 years proved totally endoscopic coronary artery revascularization to be cumbersome and not feasible given existing visualization and anastomotic technology. Meanwhile the enthusiasm for beating heart single-vessel CABG through small target incisions was growing and minimally invasive direct coronary artery bypass (MIDCAB) manifested as the first milestone toward truly minimally invasive CABG.
In the last 5 years we saw beating heart operation expand to be applied to a sizable portion of patients with primary and redo multivessel CABG. Visionary surgeons and engineers who saw its potential championed improvement in technology and techniques of beating heart CABG [1–7]. Indeed, the most important development, which had an immediate profound impact, was mechanical stabilizers. This development led to facility and comfort in performing beating heart surgical techniques. The stabilizers also improved the quality of coronary artery anastomosis rendering its successful practice and predictable results. Naturally, the adoption of off-pump CABG grew beyond expectations. This was only the beginning. The first milestone was achieved with thousands of patients worldwide benefiting from beating heart CABG. The results are either equivalent to or better than conventional CABG. It is equivalent in most regards except for reduction in operative, intensive care unit, and hospital stay time and in blood loss and requirement for blood transfusions. There may also be an additional advantage of better neurologic protection by avoiding cardiopulmonary bypass.
The awakening of cardiac surgeons to the threatening growth of interventional cardiology practice should be an added motive for cardiac surgeons to seek other innovations in our field. The obligation is more crucial for those surgeons who intend to be in active practice 10 years from now. There is clear agony in shifting from the comfort of perfected conventional cardiac surgical techniques to the technical demands of developing and adopting innovative less invasive procedures. However as in many advances, including beating heart CABG, ultimately new technology does improve and techniques become demystified.
The medical industry rallied around the ideas of minimally invasive cardiac surgery (MICS) and generated enormous venture capital in pursuit of some great or not so great inventions. Some companies survived and did well, some did not. Regardless of this, cardiac surgeons have the responsibility to further stimulate affiliated industry to develop and pursue intellectual property in our field. This is the only way we could possibly have a serious impact on the future of our specialty.
Despite the enthusiasm for new interventional cardiology devices we are threatened by the potential decline in interest of the medical industry in the shrinking market of cardiac surgery. As the surgical market gets smaller our ability to influence corporate decision also shrivels. Notwithstanding our noble cause and dedication to offering our patients what we believe is best, the truth is that patients ultimately choose their treatment modality and that leaders of medical industry listen attentively. In essence in some way, our future practice and our ability to develop and adopt new technology is very much influenced by decisions made at company boards!
Clearly, despite the wide use of the term MICS, we still do not convincingly have a truly minimally invasive cardiac surgical procedure. At least nothing as close as laparoscopic general surgical and gynecologic procedures, which lend themselves to same-day discharge. However it may be to the detriment of cardiac surgeons to aspire to achieving the "laparoscopic model." Most of our practice involves bypass of coronary arteries. The complexity of the task of precise endoscopic multivessel visualization, access, and bypass instrumentation may postpone totally endoscopic CABG to the next milestone. However, the "endovascular model," adapted by interventional radiologists and vascular surgeons for vascular therapy, may indeed be a more reasonable and attainable immediate milestone for cardiac surgeons to consider. An exponential growth in imaging and endovascular catheter-based technology and an acceptable early clinical experience in treatment of carotid, femoral, popliteal, and aortic disease should encourage cardiac surgeons to explore and adopt innovative catheter technology to the treatment of cardiovascular disease.
In essence, it makes some sense to identify "catheter-assisted cardiac operations" as the logical and feasible future milestone toward minimally invasive cardiovascular surgery. Endoscopic cardiac procedures may then function as an adjunct to advanced endovascular-based interventions.
This year’s Cardiothoracic Techniques and Technology (CTT) Meeting introduced the concept of "catheter-assisted cardiac surgery" to cardiac surgeons. The program was loaded with interventional cardiology material aimed at expanding the basic understanding of cardiac surgeons of what is currently practiced and what the future holds in the catheter-based coronary intervention arena. New sections on "endoluminal therapy" for thoracic, abdominal aortic, and arch branch arterial diseases were introduced. Operative cases were transmitted live and for the first time ever, a webcast of numerous simultaneous cardiac surgical cases and discussions from different sites were accessible live on the Internet. Not only is CTT committed to introducing innovations in techniques and technology, but also to the new process of global education of cardiovascular surgeons.
Sections on new enabling technology covered the most recent experience with robotic computer-assisted endoscopic CABG and valve operation. Experience with anastomotic devices as alternatives to conventional suturing were presented. Such avant-garde and "out of the box" thinking is needed for cardiac surgery to move on. It is no small irony that modern sophisticated robots are instructed today to perform nothing but conventional sewing.
Presentations about clinical experience in beating heart surgery were numerous and reflected its expanding adoption worldwide. The challenges of its utility in patients with marginal ventricular function or hypertrophied left ventricles and for deep posterior coronary artery grafting were thoroughly discussed and the yearly updates from centers with larger beating heart CABG experience were shared.
Naturally for a meeting on new cardiothoracic techniques and technologies, symposia covering the topics of the expanding role of new surgical procedures, ventricular assist devices, and other new technology for the treatment of heart failure were welcome additions to this year’s program. With a growing population of patients suffering from end-stage heart failure the rationale for expanding alternative surgical therapy such as restraining ventricular devices, artificial support, and salvage valve surgical techniques, and ventricular remodeling and its utility in nontransplant centers were discussed.
Furthermore, CTT continues to expand presentations on the role of angiogenesis using drugs, transmyocardial laser, and gene therapy for nonbypassable coronary artery disease. Updates of clinical trials and breakthrough data from prominent research laboratories in this area were presented.
Minimally invasive valve operation sessions allowed participants to share the latest and largest experiences on a variety of surgical approaches from ministernotomy, to minithoracotomy with and without the use of video assistance and robotic enabling technology.
One of the highlights of CTT has always been the interactive audience participation through the audience response system conducted around the 3 days of the meeting. This year and on the demand of many who attended the meeting we will be sharing with you the results of the responses to questions (Figs 1–10). We hope that the readers will use this information wisely and keep in mind as they read through the questions and answers that even though we have polled a random, unselected group of surgeons who attended this year’s meeting, their responses are still that of a selected group who have an interest in MICS.
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Fig 1. The location of your surgical practice is:
1. North America
2. Europe
3. Asia
4. South America
5. Middle east
6. Other
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Fig 2. In what percentage of CABG procedures do you currently use the minimally invasive techniques, ie, smaller incision or off-pump CABG?
1. 0%–10%
2. 11%–25%
3. 26%–50%
4. 51%–75%
5. 76%–100%
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Fig 3. What percentage of coronary bypass operations do you expect to perform using a minimally invasive approach this year?
1. 5%
2. 6%–20%
3. 21%–50%
4. 51%–75%
5. >75%
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Fig 4. If smaller incisions or no cardiopulmonary bypass are criteria for minimally invasive surgery, what percentage of coronary artery operations do you predict will be carried out by current or future minimally invasive techniques in the next 5 years?
1. 0%–10%
2. 11%–25%
3. 26%–50%
4. >75%
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Fig 5. By the year 2005, most coronary artery bypass will employ:
1. Telepresence or robotic techniques
2. Modified smaller thoracic incisions with cardiopulmonary bypass
3. Modified smaller thoracic incisions without cardiopulmonary bypass
4. Conventional median sternotomy with cardiopulmonary bypass
5. Conventional median sternotomy without cardiopulmonary bypass
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Fig 6. Have you perceived any advances in technique or technology in the last 2 years that make you more comfortable with MIDCAB and MICS valve procedures?
1. Yes
2. No
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Fig 7. If you needed an elective operation for combined LAD (not amendable to catheter-based intervention) and RCA disease, would you want:
1. An OPCAB (off-pump coronary artery bypass)
2. A port-access (eg, Heartport) operation
3. A small left anterior thoracotomy with direct cardiopulmonary bypass (MIDCAB, non-Heartport) alone
4. Hybrid MIDCAB (LAD and right stent)
5. Conventional median sternotomy with cardiopulmonary bypass
6. None of the above
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Fig 9. Training on new cardiac techniques and technologies is best accomplished by:
1. Lectures with slide presentations
2. Wet labs
3. Live case teleconferences
4. Direct observation and mentoring in the operating room
5. Few comprehensive education training centers offering all of the above
6. Concentrating resources on resident training in academic centers
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Fig 10. Postresidency credentialing of cardiac surgeons on new techniques and technologies should be the responsibility of:
1. Major traditional cardiothoracic societies (STS/AATS/EACS)
2. New superspecialized societies (endoscopic/ISMICS)
3. Cardiothoracic centers with expertise offering comprehensive training courses
4. Specialty certification boards (eg, ABTS/FRCS/EBTS)
5. Credentialing should not be required
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For those who have participated in the evolution of minimally invasive techniques, what has been achieved in the last 5 years is rewarding. Today we live the phase in which a new technique will be used not only by the few who championed it or those early adopters, but by the larger body of more conservative cardiac surgeons, who like to be convinced that it works just as good or better. CTT is proud to be the forum for exploration and dissemination of new ideas and directions in cardiothoracic techniques and technologies. It is particularly proud of its introduction of the concept of "catheter-assisted cardiac operation." I have no doubt that this is the future of our specialty. [8]
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References
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Shennib H. Evolving techniques and technology in cardiac surgery. Ann Thorac Surg 1999;68:1473-1474.[Free Full Text]
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Shennib H., Bastawisy A., McLoughlin J., Moll F. Robotic computer-assisted telemanipulation enhances coronary artery bypass. J Thorac Cardiovasc Surg 1999;117:310-313.[Abstract/Free Full Text]
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Mack M.J., Osborne J.A., Shennib H. Arterial graft patency in coronary artery bypass grafting. Ann Thorac Surg 1998;66:1055-1059.[Abstract/Free Full Text]
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Shennib H., Bastawisy A., Mack M.J., Moll F.H. Computer-assisted telemanipulation. Ann Thorac Surg 1998;66:1060-1063.[Abstract/Free Full Text]
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Shennib H. Evolving strategies in minimally invasive coronary artery surgery. Int J Cardiol 1997;62(Suppl 1):S81-S88.
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Soulez G., Gagner M., Therasse E., et al. Catheter-assisted totally thoracoscopic coronary artery bypass grafting. Ann Thorac Surg 1997;64:1036-1040.[Abstract/Free Full Text]
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Shennib H., Mack M.J., Lee A.G. A survey on minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1997;64:110-114.[Abstract/Free Full Text]
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Shennib H., Lee A.G., Akin J. Safe and effective method of stabilization for coronary artery bypass grafting on the beating heart. Ann Thorac Surg 1997;63:988-992.[Abstract/Free Full Text]
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Introduction
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