Editorial - The “Interventional cardiac surgeon”: the (new) member of the interventional Heart Team

The cardiac surgeon as an innovator

The father of endovascular interventions was a surgeon in training. In 1929, a 25-year-old intern named Werner Forssman was dissatisfied with the available methods of evaluating cardiac function at his hospital in Berlin. His appeals to his supervising physicians for permission to test a cardiac catheterization technique he had envisioned were flatly denied. Secretly, Forssman enlisted the help of a nurse and conducted the experiment on himself. Threading a rubber catheter through a vein in his left arm to the level of his heart and injecting dye, Forssman completed the first successful cardiac catheterization. Upon discovery of his experiment, he was promptly fired from his job and ostracized by the medical community. It was not until 27 years later, in 1956, that Forssman was awarded the Nobel Prize in physiology and medicine for his achievement… This was two years after the first open heart procedures…

Many additional contributions come from innovative surgeons (Figure 1): Lillehei developed electrostimulation, Fogarty developed balloon interventions, Inoue initiated endovascular mitral interventions, Alfieri developed the therapy for catheter based mitral interventions, Mohr and Mack contributed to aortic interventions, and the list may continue... Because cardiac surgeons are also often innovators.

Once upon a time, cardiac surgery was a promising innovative profession within medical practice. Cardiac surgery developed in a time of great technological endeavors for the world. The development of the heart-lung machine made the unthinkable feasible: to intervene inside the heart and to fix a multitude of cardiovascular conditions. In the 50’s mortality for acute myocardial infarction was almost 50% at 1 month, and the only available treatments were palliative, offering care more than cure. Then the revolution happened. The growth of cardiac surgery not only introduced the treatment of many cardiac conditions, but also fostered the understanding of the heart. Cardiology evolved dramatically, pushed by the need of more deep understanding of the anatomical, functional and physiological potential targets of therapy.

It was a time of great discoveries, made by great pioneers, who overcame great challenges, talents with a scientific mindset, innate technical skills and a powerful and resilient body. The pioneers of cardiac surgery are often depicted as semi heroes, mythological figures gifted by extraordinary talents, public figures who frequented the jet set. In the 80’s and 90’s every cardiac surgeon was the King of the Jungle.

The search for less invasive treatments

Then Gruentzig came… In the continuous search for less invasive treatments, inspired by surgical ones, but supported by new technological advancements, better understanding of anatomo-pathology and by sophisticated imaging. Then came the stents, the plugs, and finally the valves… And today cardiac surgery is no longer the unique invasive method to treat patients with cardiovascular disease. Endovascular procedures are safe, effective and less invasive, therefore more accepted by the patients. The drawback for surgeons is that they lost their monopoly. The advantage for the patients is that today there are more options. The potential for a tailored approach is today more evident, and as we know more about the disease, we need to deliver the best to our patients.

Delivering best practice and unbiased treatment via the Heart Team

For this reason, in the late 2000’s the concept of the Heart Team became of high priority, to deliver best practice and unbiased treatment to patients with cardiovascular disease (reference to the ESC Guidelines in 2015 bringing Heart Team discussion for proper decision making to the I C level of recommendation).

The initial structural heart teams were established from the physicians’ need to discuss the more complex coronary cases together. With the emergence of TAVI, it was then applied to some aortic stenosis cases given the acute necessity of overcoming the lack of knowledge and skills to perform such interventions. In the pioneering phases (2003-2009) such multidisciplinary teams were very solid, based on mutual respect of the complementary roles and competences. After the ESC guidelines stated that the Heart Team discussion was a mandatory step to perform transcatheter procedures, the initially efficient and solid teams evolved in some cases in more political, and sometimes wasteful, oversized structures. Under such circumstances, there has been the risk of lack of efficiency, mainly due to redundancy of processes. In the worst case scenario, team members have been complaining of waste of time spent on sterile discussions, often based on personal interest and conscious or even unconscious bias. After some years of turbulence, we realize that there is a need to take advantage of the good and bad experiences and to develop (or reestablish) the Heart Team 2.0: a Heart Team based on confluence of goals and respect of competences.

The Interventional Team at the core of the Heart Team

The core element of the Heart Team remains the “Interventional team”: it is the team of physicians who are actively involved in the performance of the procedures, aiming at the highest possible safety and efficacy. The interventional team is based on three elements: the interventional cardiologist, the interventional imager and the “interventional” surgeon. Many other participants are attending the Heart Team meetings, but the final responsibility, the periprocedural management and the performance of the procedures remain mainly in the hands of these three stakeholders. They are similar, they act similar, they think similar: they believe that an intervention, when well conducted, can produce a benefit, even when facing possible risks. Their job description is to evaluate the risk benefit, to manage the risks to the minimal possible level, and to obtain the best from any procedure. In this effort, they differentiate from those colleagues who are not involved in interventions. The mindset of an interventional cardiologist and of a surgeon are similar. The same applies for the interventional imager. The close vicinity to the operational aspects of our profession creates a strong substrata to improve the skills and the attitude to cope with challenges and to protect and rescue patients from complications. The involvement of the three elements in the procedures eliminates the barriers and creates an environment of trust, where good and bad outcomes are shared: the success is a reason to go forwards, the failure a lesson to improve safety for the patients to come. It is a continuous flow of learning and improvement, relying on mutual support, critical mindset and scrupulous attention to details and to achieve best practices and standard operating procedures.

The Interventional Cardiovascular Surgeon: a new definition for a new role

This activity relies on a close collaboration that induces the potential for a cross-fertilization of knowledge. In some cases, the team members develop new skills, in some cases they become hybrid operators. Potentially, this could embody a new generation of interventionalists, incorporating the skills set of the multidisciplinary team in a single individual. This development should not be surprising. Interventional cardiology has evolved to become a profession that it is very difficult to differentiate from surgery, if not in the skills at least in the mindset and the competences. As the two fields are merging, there is need to restructure our organigrams and, more importantly, our educational pathways. In general, there is a need to generate a new identity. The new generation of surgeons should be able to be an integral part of the interventional team, having the ability to interact, understand, support and team-up with the other colleagues as their most important asset. A modern cardiac surgeon should know and sometimes master catheter skills. Today most minimally invasive surgeries require peripheral cannulation with large bore cannulas, and the use of closure devices as well as sutureless valves and other devices which require skills derived from interventional cardiology. But besides the operational aspects, a modern surgeon should be up to date with the most recent endovascular therapeutical alternatives in order to offer a seamless spectrum of options to the patients.

This is why it is time to call these surgeons by their real name: “interventional cardiovascular surgeons”. It is more than just a new name, it is a cultural brand, it is a way to generate a new identity, the identity of the Interventional team.

PCR is the ideal landing zone for all those professionals who are ready to overcome the limits of our out-of-date definitions. PCR is welcoming all specialists involved in research and care of patients with cardiovascular disease. PCR enables mutual exchange of expertise and competence among professionals, eliminates cultural barriers, and accepts diversity within the interventional community.

Access the Interventional Cardiovascular Surgery section