An Exciting Time in CT Surgery?

All of us look back with fondness upon the golden years of cardiothoracic surgery, when surgical pioneers attempted and succeeded in performing daring operations and pushing the realm of the possible.  The birth of our specialty was one of the most exciting times in the history of medicine. 

The rapid advances and unbelievable nature of the operations captivated the medical community and the attention of the world.  Since then, however, we have gone from being seen as a specialty of miracle workers, heroes even, gracing the cover of Life magazine and performing the impossible, to a specialty that cannot fill its training positions, find jobs for its graduates, has an ever shrinking scope of practice, and is enduring dwindling reimbursement.  In the face of this reality, today it is often said that it is an exciting time in cardiothoracic surgery.  But how does today compare to the golden years?  What makes this an exciting time for cardiothoracic surgery?  In my opinion, this is an exciting time because of the potential for revolutionary changes in the therapy our specialty offers. 

There has been little fundamental change in the surgical approaches to coronary artery surgery, valve replacement, pulmonary resection, and esophagectomy in the last 20 years.  We can quibble about on- or off-pump grafting, tissue or mechanical valves, stapled versus hand sewn anastomoses, and other nuances, but the fundamental operations are unchanged.  Over time we have perfected these procedures and now offer some of the safest and most effective treatments for cardiovascular and thoracic disease. However, much of this progress has been achieved through improvements in perioperative and critical care. During this time of relative stagnation in cardiothoracic surgery other fields of medicine and technology have rapidly advanced.  Previously, patients with many cardiovascular and thoracic diseases had no therapeutic choice other than operation.  However, new technology and research have enabled tremendous advances in the treatment of cardiovascular and thoracic diseases.  The capacity to treat is greater than ever, and nearly all of the increases in therapeutic options have come forward in the form of treatments that do not require a scalpel.

Previously, patients with no choice other than operation or death were thrilled just to have survived an operation intact.  However, as treatment choices have increased, patient expectations have also changed.  Operations which were once considered daring and nearly impossible are now accomplished routinely, with operative survival and excellent long-term outcomes expected. 

Mortality is no longer the measure of a successful operation, but rather post-procedure quality of life, time to return to work, and other secondary outcomes.  This change in patient expectations has made our traditional therapy seem less desirable to patients and their referring physicians.  We are now faced with a patient population that does not want what we offer despite several decades of proven safety and efficacy. 

How do we as a profession reconcile what the patient wants with what we believe is best for the patient?  First, patients and their referring physicians must have accurate and unbiased data regarding the safety and efficacy of all the therapeutic options.  I was fortunate to have heard Dr. David Taggart’s lecture on the data supporting CABG versus coronary artery stenting at the Society of Thoracic Surgeons Annual Meeting in January 2006 (seewww.sts.org for a webcast of the lecture).  Dr. Taggart laid out an elegant, data driven argument for the superiority of CABG over stenting for most real world patients.  While he received a well deserved standing ovation, I doubt there was anyone in the audience who didn’t already think that CABG was better than stenting.  Having a surgeon tell other surgeons that surgery is superior to other therapies is reaffirming, but it is preaching to the choir.  This data must be taken to patients, referring physicians, and even payers.  As surgeons we know the data, but the patients and physicians making treatment decisions may not.  At a minimum, patients must be well informed and given accurate information about their disease and all appropriate treatment options. 

However, what patients do with even the very best information - how patients choose between highly effective but highly invasive treatments and other options that are clearly less invasive, but possibly less effective - is where we as a specialty need a healthy dose of new perspective.  Even in well informed patients, it is too often human nature to choose the easy road today, and think about tomorrow later.  This natural bias will always lead patients away from our present day operations.  As patients have more input than ever into their treatment choices, it is understandable that many patients, as the ones who must endure the ordeal, are choosing less invasive procedures even if that means receiving less effective treatments, or, in some cases, no treatment at all. In today’s world, treatments are selected based not only on their efficacy, but also on their invasiveness.

As surgeons we can argue forever that this is the wrong approach, that efficacy and results alone should dictate treatment decisions, but it is highly unlikely that these arguments will work, and they only serve to distract further our energies and focus.  Instead of fighting against the current, we must be smarter and make our operative treatments more in line (similar in invasiveness) with the other therapeutic choices.  If two choices are similar with respect to the patient’s ordeal, then efficacy and outcome data become more persuasive.  As our field continues to develop less invasive operative approaches we will narrow the perception gap and begin to level the playing field.  On a level playing field, if history is any guide, our approaches will win out.

This progress won’t happen overnight, and it will be stepwise. A patient with coronary artery disease may choose robotic assisted mammary to left anterior descending coronary artery bypass combined with stenting of other coronary artery lesions to obtain the proven survival benefit conferred by mammary bypass and still avoid sternotomy.  While this treatment regimen may not be as effective as multivessel CABG, it is clearly superior to multivessel stenting, medical therapy, or no therapy.  The ability to routinely perform totally endoscopic multi-vessel bypass will blur this choice even further.   When laparoscopic cholecystectomy became available, the number of operations increased five-fold.  This occurred not because patients were suddenly convinced that surgery was the best treatment, but rather because the best treatment became more acceptable to patients.  

The challenge is to draw from our extensive knowledge of operative therapy for cardiovascular and thoracic disease and transform our therapy into procedures that are less invasive and more acceptable to patients, while preserving our proven safety and efficacy.  The most fundamental change in this process will be the use of imaging technologies rather than direct vision.  Given the advances in technology, imaging, and supporting medical services, there has never been a better time to transform our practices.  By offering safe, effective, and less invasive procedures that patients can embrace we will enable decision making to be driven by outcomes rather than by the approach taken to achieve them.

Breaking new ground is never easy.  History shows that there will always be more detractors than supporters.  This was true in the golden era of cardiothoracic surgery as well - Lillehei was taunted for performing the only operations with a potential for 200% mortality.  New treatments, when first applied, are rarely as effective as the established alternatives.  However, as the techniques are perfected, technology improves, and experience grows, the new treatments become more effective and easier to apply.  Innovations must be supported by accurate and timely reporting of results. However, we must be patient in their development, and we cannot overly criticize or analyze early forays into new and disruptive technologies.  This principle applies to our field as we pursue minimally invasive options, and it also applies to our colleagues in other fields who are developing and evolving their own treatments.  The safety and efficacy of coronary, pulmonary, and other interventions have steadily increased, and we must not forget that this trend will continue.  History has shown us that procedures that were once considered experimental or even dangerous – such as left main stenting or radiofrequency ablation of lung cancer - will only improve with time.  Some of these treatments will eventually be proven safe and effective and will achieve wide use as standard practice.  If new innovations and techniques are developed within our specialty our scope of practice and our specialty will flourish.  If we turn away from efforts to innovate others will continue to pursue them, and when successful, they will further erode our scope of practice, stature, and influence.

Our shrinking scope of practice is partly explained by our reluctance to innovate and evolve along with other specialties.  However, the major factor driving the shrinking scope of cardiothoracic surgery is our position as end of the line referral-based specialists.  Waiting for patients to be referred to us at a time when the referring physicians are increasingly able to deliver definitive treatment themselves is a recipe for extinction.  Instead, we must become more involved in the management and treatment decisions of patients with cardiovascular and thoracic disease, some of whom may require interventional treatment, and some of whom may not.  The most common example of disease-based management by cardiothoracic surgeons occurs with thoracic aortic disease.  Many patients with thoracic aortic disease are followed by cardiothoracic surgeons without ever undergoing an operation.  By partnering with our non-surgical colleagues to assist in providing complete management across the full spectrum of disease, patients will ultimately receive better care.  This model is already employed in multidisciplinary thoracic oncology settings and is increasing rapidly in team approaches to endovascular treatments and among electrophysiologists and surgeons engaged in arrhythmia surgery.  It is reasonable to hope that similar partnerships will evolve as percutaneous valve therapies become more widely available.  The trend towards transdisciplinary management will continue, and we should embrace this, become involved, and help direct this process.  The continued development of non-catheter based coronary imaging has the potential to radically alter the current cardiologist-cardiac surgeon relationship and makes our involvement in the patient care team essential.

Steady advances in technologic capacity and in fields supporting and related to cardiothoracic surgery have created a tremendous potential for innovation and advances within cardiothoracic surgery.  As we participate actively in the development of less invasive treatments and become more involved in the pre-operative care and decision making process of our patients, I believe that our field will again flourish.  I look back with fascination, amazement, and appreciation on the golden years of cardiothoracic surgery, and I marvel at what was undertaken and achieved.  I think that our field is poised for another such revolution, with an impact equal to or even greater than that of our predecessors.  However, we must possess their same courage and resolve in order for the future to be what we can make of it.