Surgery claims few certainties, but here’s one you can count on: The key concepts and skills you learned in training will not be the key concepts and skills you use at the end of your career.
“When you look at surgical practice on a day-to-day basis, not much changes,” said Michael J. Mack, MD, FACC, medical director, cardiothoracic surgery, and chair, cardiovascular service line, Baylor Scott & White Health, Dallas, TX. “But when you look back on a career, it is amazing how much things have changed in a relatively short time. Innovation makes a tremendous difference in what we can do in surgery and how we do it.”
Dr. Mack will explore the role of innovation in surgery Monday morning during the annual John H. Gibbon, Jr. Lecture, Innovation: A Surgical Imperative. Cardiac surgery is a prime example of the profound impact innovation can have, he said.
“If you had told me 30 years ago that we would be replacing aortic valves with a catheter and without an incision and without general anesthesia, I would have said you were crazy,” Dr. Mack said. “I wasn’t open-minded enough to see the possibilities. But the reality is that when we have two therapies and one is less invasive, the less invasive procedure always wins, assuming that outcomes are not inferior. And when it comes to TAVR, transcatheter aortic valve replacement, not only is the catheter procedure less invasive than open surgery, outcomes are better in one of the most recent trials.”
The rate of innovation varies in different specialties and subspecialties, but there are three basic requirements for innovation to be widely adopted, regardless of the type of procedure, Dr. Mack said.
One, the innovation must provide strong evidence of a clear benefit. Without a clear benefit, there’s no reason to change procedures that already work.
Two, the new procedure must be user friendly. Surgeons are unlikely to adopt a new procedure that offers more technical challenges than the one they are already performing.
Three, the innovation must be teachable.
“One of the reasons for the success of catheter-based techniques in cardiology, for example, is that procedures have become standardized and scalable to a large number of operators in the population at large,” Dr. Mack explained. “If you have to be a master surgeon to be able to do a new procedure, it isn’t contributing significantly to the field and doesn’t make it accessible to most patients. The idea is to innovate with procedures that can be accomplished by the majority of surgeons practicing in the real world.”
Vascular surgery also has changed dramatically, Dr. Mack noted. Over the last 15 years, it has gone from a subspecialty focused primarily on open procedures to a subspecialty where 85 to 90 percent of procedures are now performed using an endovascular approach.
“Cardiac surgery will see the same paradigm shift—just 10 to 15 years later,” Dr. Mack predicted. “We have seen it with aortic valve replacement, we’ll see it next with mitral valve disease, then tricuspid valve disease, and coronary revascularization. Ultimately, we will see less bypass surgery being done.”
The future of cardiac surgery is to adopt less invasive, catheter-based techniques, just as vascular surgeons have done. “If not, then we have to accept that the specialty will become smaller and stay focused on open surgery,” Dr. Mack said.
“Vascular surgery has been introspective regarding what it is going to look like. If cardiac surgery is going to adapt and adopt these changes in the not too distant future, there has to be a fundamental shift in the way that we train, so that cardiac and thoracic surgeons are equipped with the necessary skill sets to embrace the future.”
The John H. Gibbon, Jr., Lecture was established in 1971 to honor Dr. Gibbon, a pioneer in open-heart surgery, and is sponsored by the Advisory Council on Cardiothoracic Surgery.
John H. Gibbon, Jr., Lecture
Innovation: A Surgical Imperative
Michael J. Mack, MD, FACC
9:45–10:45 am, Monday
Moscone Center South, 303–304