Veteran surgeon unpacks major changes in the world of cardiac surgery
Cardiac surgery is going through major changes as a result of technological advances, evolving patient demographics and intensified collaborations with interventional cardiology. These factors are pushing surgeons to adapt to the times or risk being left behind.
Mario Gaudino, MD, PhD, director of translational and clinical research and the Stephen and Suzanne Weiss Professor of Cardiothoracic Surgery at Weill Cornell Medicine and NewYork-Presbyterian, is at the forefront of this evolving landscape. He spoke with Cardiovascular Business and outlined several key trends shaping the future of cardiac surgery.
Considering the value of minimally invasive surgery
Minimally invasive surgery, both robotic and non-robotic, has long been a tantalizing goal in cardiac care. The appeal is clear: smaller incisions, potentially faster recoveries and less trauma. But Gaudino warns that the rush to adopt these methods often outpaces the evidence supporting them.
“These are techniques that are generally more challenging to perform technically and they're also more expensive very often, so we need to show that there is a benefit for the patient,” he said.
He notes that many of the existing studies are non-randomized, which introduces significant bias due to the fact that healthier patients tend to be selected for these procedures. Also, he added, the surgeries in these studies are often performed by the most experienced surgeons. This can create skewed results that do not necessarily reflect real-world outcomes.
Despite the excitement surrounding minimally invasive surgery, Gaudino insists on the need for rigorous, randomized data to determine whether these techniques genuinely improve patient outcomes.
There is pressure on surgery departments to try and innovate to find ways to make procedures minimally invasive, which is partly driven by the fact that transcatheter procedures continue to gain momentum.
A new culture of evidence-based surgery
One of the most promising shifts Gaudino sees is a cultural one; he believes there is a renewed commitment among surgeons to deliver evidence-based medicine.
"In the past, the surgeons didn't really devote a lot of their time and energy to clinical trials. But now I think surgeons, especially the new generation of surgeon leaders, grew up with evidence-based medicine. And that's good, because now they realize we need more evidence," Gaudino explained. "I think the next few years will be very exciting with a lot of very important surgical trials coming out."
This transformation has been partly due the past decade of collaboration with interventional cardiologists on clinical trials and heart teams in the structural heart space. Interventional cardiology is all about evidence-based medicine strongly driven by clinical trials and this subspecialty has outpaced surgery in clinical trial participation. This was due to interventional cardiology needing to show its minimally involve procedures were comparable with the old gold-standard of surgery.
But now the tables have turned where surgery is finding the need to perform its own trials to improve outcomes. High-profile trials focused on transcatheter aortic valve replacement (TAVR) as well as mitral and tricuspid edge-to-edge repair have resulted in many detailed comparisons with surgery. That competition, in some cases, has shown surgery may fall short.
"Competition is always good and leads to improvement that ultimately is better for patients. There is no doubt this is what has happened and I think it's important that surgeons acknowledge and accept what's happening and are willing to be part of this evolution," Gaudino explained.
The challenge of training
Perhaps the most pressing challenge, however, is the future of surgical training. As less-invasive procedures grow in popularity, the volume of traditional surgical cases is declining. This poses a serious problem for training the next generation of heart surgeons, Gaudino said.
In addition, the cases that do exist are becoming more complex and often involve older patients with multiple comorbidities.
"I would say cases are becoming more challenging and at the same time a trainee has less exposure to surgery. So this is a conundrum that to requires a dedicated strategy and also commitment by surgical leaders to train the new generation," Gaudino said.
Unfortunately, surgical training is still very manual and difficult. Gaudino said it is actually much easier to train physicians in transcatheter interventions than open surgery. However, he stressed that there is still a need for people who are trained in open surgery.
"I don't think it's a crisis, but it's definitely something that requires a lot of attention," he said.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]