Integrating Cardiac Surgery and Interventional Cardiology for Optimal Patient Care

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• Hybrid Heart Team Approach
• Evolution of Cardiac Procedures
• TAVI Impact on Surgical Standards
• Cross-Training Future Specialists
• Technology Driving Safety
• Full Transcript

Hybrid Heart Team Approach

Dr. Francesco Maisano, MD, highlights a paradigm shift in cardiovascular medicine, moving the focus from the specific procedure to the ultimate objective of saving lives and improving quality of life. He points out that no single solution is perfect for every patient, making a full spectrum of treatment options crucial for safety. This philosophy is embodied in the hybrid heart team model, where collaboration between cardiac surgeons and interventional cardiologists ensures the best decision is made for the individual, not just the most familiar technique.

Evolution of Cardiac Procedures and Evidence

Dr. Maisano provides critical context on the history of cardiac surgery, established in the 1950s, which accumulated vast long-term experience without the highly scientific data collection seen today. He explains that for decades, surgical procedures were the standard of care with no alternatives, negating the need for comparative studies. The advent of new transcatheter technologies has fundamentally changed this landscape, forcing a rigorous re-evaluation of all treatment options with core lab-adjudicated outcomes that were previously uncommon.

The Impact of TAVI on Surgical Standards

The introduction of transcatheter aortic valve implantation (TAVI) serves as a prime example of how new technology challenges and improves established practices. Dr. Francesco Maisano, MD, notes that surgical aortic valve replacement was never subjected to the intense scrutiny it now faces from TAVI trials. This competition brings new light and opportunities, ultimately improving the entire field of cardiac care. Dr. Maisano shares his unique perspective as a fully trained cardiac surgeon who later learned endovascular procedures, finding that skills from each discipline profoundly benefit the other.

Cross-Training the Next Generation of Specialists

A major challenge identified by Dr. Maisano is modernizing medical education to create the cardiovascular specialists of the future. The rapid pace of technological change means a doctor cannot practice their entire career based solely on what they learned in school. Academic institutions must develop flexible educational pathways that provide a new, combined skill set. The very job description for a cardiovascular doctor is evolving, requiring a confluence of surgical and interventional fields to cross-fertilize and create a common understanding for optimal patient care.

How Technology and Competition Drive Patient Safety

The flexibility offered by multiple treatment options directly translates to improved patient outcomes. Dr. Francesco Maisano, MD, cites data showing that mortality risks for procedures like mitral valve interventions have decreased yearly. This improvement is not limited to patients receiving new endovascular procedures; it also benefits those undergoing traditional open surgery. The competition to be less invasive, safer, and more effective raises the standard for everyone. This allows physicians to tailor treatment, offering less invasive options to fragile patients and more durable, time-tested procedures to those who can afford them.

Full Transcript

Dr. Anton Titov, MD: This is very interesting that you mentioned the combination of skills of a cardiac surgeon and interventional cardiologist. I had a very interesting conversation in Boston at Brigham and Women's Hospital with Professor Tsuyoshi Kaneko about the Dr. Michael Davidson Fellowship. It was established in the memory of Dr. Michael Davidson, who focused on both interventional cardiology and cardiac surgery. So a physician understands the best approach for that particular patient rather than going from a particular surgical or interventionalist technique. It's something that you mentioned before: "It's not how we do things. It's how we make the right decision." I think that is something you highlight in your own professional career.

Dr. Francesco Maisano, MD: You point to a very important aspect of our profession. I think we often focus on what we do rather than the objective of what we are doing. The objective is to save lives and improve quality of life. This is a very simple background of any intervention. There are many ways to obtain this objective. Probably there is no single solution which is perfect for every patient. There is always a compromise.

Having the full spectrum of treatment options creates an environment that is safer for the patient. If it is well-adopted and well-organized, this approach to treatment can probably provide better outcomes. I still believe we need to learn a lot. We are still in a transition phase where we have different treatment options. There are still a lot of controversies.

Don't forget cardiac surgery was established in the 1950s. We have very long-term experience. Maybe the collection of data has not been so highly scientific. Initially, there were no alternatives. So there was no reason to make comparison studies between cardiac surgery and alternative options of treatment. After many years, cardiac surgical procedures became such a standard practice that there was no need to test it again against anything.

As new technologies become available, now we start to have this discussion. Let us make an example of transcatheter aortic valve replacement. It is called TAVI in Europe or TAVR in the United States. TAVI is an alternative to surgical aortic valve replacement. There was no such study on surgical aortic valve replacement as of today before TAVI became available. So we didn't study TAVI with core lab-adjudicated outcomes before the challenge of new technology.

In general, I really believe the new technology is bringing new light and new opportunities, improving even cardiac surgery. Personally, in my experience, I have a very special viewpoint because I started cardiac endovascular procedures after I was fully trained as a cardiac surgeon. I found that, on the one hand, it was pretty simple for me to learn the endovascular procedures. At the same time, I applied a lot of knowledge from the endovascular cardiology field. It is very useful in the open surgical field and in minimally invasive cardiac surgery.

So, in general, from my viewpoint, I see the advantage of the confluence of the two fields into one field. Cardiac surgery and interventional cardiology need to cross-fertilize. Every year it happens more and more. We need to ensure that what we learn in the two areas becomes a common understanding. We must find the right solutions for our patients.

We also must find the right way to train the surgeons and interventional cardiologists of the future because this is now becoming the question. Who is going to do this? What is going to be the educational pathway to provide the new generations of doctors with the best educational package? What is the job description for a properly trained cardiovascular doctor? This is already a question today.

Dr. Anton Titov, MD: All that's very important because clearly breaking silos in medicine is a very important task. I think your career clearly illustrates the importance of that for the benefit of the patient, which is the ultimate goal.

Dr. Francesco Maisano, MD: Absolutely. This is one of the biggest challenges for academic institutions—to provide modern educational pathways. We all need to change the way we teach our profession. We all need to understand that the pace of changes in the job descriptions is so fast that we need to be flexible enough to be able to change direction even in the next two or three years.

Things are changing so fast that you cannot anymore do your profession the way you learned at school. My father went to school, became a surgeon, and he was able to do almost the same operations for all his life. Only at the very end of his career, I remember, he was telling me that he needed to learn how to do endoscopic, laparoscopic gallbladder resection. This was a little challenge for him.

Imagine today. Today we have one procedure which I learned in cardiac surgery: closing the ASD, atrial septal defect. Today it is something that I cannot use for my fellows, surgeons-in-training. So we need to really be flexible there. But the good news is that all this flexibility at the end improves patient outcomes. It is creating new opportunities.

Overall, if you look at the data, the mortality risk of mitral valve interventions, for instance, in the United States, has been shown over time to decrease every year. The introduction of less invasive cardiac procedures has been decreasing mortality for my patients. It is true not only in those patients who undergo endovascular procedures but also in open surgical treatment.

Because overall, it's a kind of competition to do better and better, to be less and less invasive, to become safer and safer. When you have different treatment options, you may also offer less invasive options for those patients who are more fragile. You can do procedures that are more tested by time for those patients who can afford a more invasive and more durable procedure.