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Commentary
March 16, 2009

Hybrid Cardiac Surgery: A Resident's Perspective

Arch Surg. 2009;144(3):207-208. doi:10.1001/archsurg.2008.576

If you want to go fast, go alone; if you want to go far, go together.—Old African proverb

Approaching the end of my cardiothoracic surgery residency, I felt the need to share with colleagues, young residents, and the cardiothoracic community in general some thoughts that have been ringing in my mind as I face the theater of the surgical world.

Five years ago at the beginning of my training, I had the chance to learn both the more traditional aspects of cardiac surgery and the actual routine of it, first observing the older surgeons performing coronary artery bypass graft procedures on pump and with vein graft, then learning from the younger surgeons using challenging, new beating-heart techniques with arterial grafts and minimally invasive procedures. My last 2 years of residency have been in the United States, where I have spent most of my time trying to find new approaches for cardiac surgery, in few words, trying to think “out of the box.” During these 2 years, I have had the opportunity to learn a new way to excel at my job, collaborating with colleagues with different and specific skills. Working with cardiologists, engineers, and surgeons was very stimulating and helped me in the process to find new and different answers for our challenging future. Yet there is a gap between the possibilities that I discovered during the last 2 years and the reality of most cardiac surgery practices.

Over the last few years, I have read and heard about new approaches for cardiac surgery: the hybrid cardiac procedures. In an era where traditional cardiac surgery is losing “popularity” in favor of interventional cardiology, which seems to gain wider applicability each day, it seems that this new hybrid concept could be a junction point for cardiac surgery and interventional cardiology and result in more complete and reliable techniques to fix the heart. In medical terms, a hybrid therapy or procedure is a mixture of therapies from different subspecialties. In the specific case of the heart, it can be defined as a combination of surgical and catheter-based procedures to repair a diseased heart.1,2 In the daily practice of both interventional cardiologists and cardiac surgeons, the hybrid procedure can be a solution for deficiencies characteristic of both disciplines.

Specifically, cardiologists and cardiac surgeons both have to deal with the following facts:

  • Patients ask for minimally invasive procedures and current surgical procedures are highly invasive.

  • Devices introduced through catheters are, by necessity, small with limited functionality and limited control of the force that they can apply.

  • Current imaging technologies, including fluoroscopy, 2-dimensional transesophageal echocardiography, magnetic resonance imaging, and computed tomographic scan, provide suboptimal visualization.

Hybrid cardiac surgery approaches offer solutions to these limitations. To grow, our specialty must change and to change, we have to adapt our skills to closed-heart surgery methods. In particular, we must be prepared to

  • Create a new and strong partnership with interventional cardiologists.

  • Change and improve the clinical and surgical training for the future generations of heart physicians.

  • Conceive new hybrid procedures that will use a new generation of surgical tools and new 3-dimensional imaging systems to be used for real-time guidance and will be at least as reliable as open surgeries for most cardiac pathologies.

None of this work can happen until we get the field's scientific attention focused on these problems. Most importantly, not a single one of these things can happen without partnerships with interventional cardiologists. We cannot improve the discipline of cardiac surgery by ourselves.

The first part of the proverb that I cited earlier—“If you want to go fast, go alone”—is a polite way of saying that partnerships can be really difficult. They are hard to maintain and we all know that if you have to make a fast decision, your first reaction probably is not to consult half a dozen colleagues or form a steering committee. Partnerships also cause friction. Informed, opinionated people will not always agree on the best way to solve a problem. At the same time, I truly think that friction has great benefits. It forces us to test our beliefs about our work and the results we are getting.

The partnership that I envision would ideally be a relationship where no single person has to solve every problem or do all the work, where the relationship is untainted by past dissents and competition, and where each partner contributes his or her own particular expertise.

A good relation between both practitioners is the basis of success in patient outcome and satisfaction. In 2001, Richard G. Sanderson, MD, speaking about the relationship between cardiologists and surgeons, said,

The concepts of patient care and patient advocacy must remain foremost as guiding principles in these relationships. . . Optimal resolution of these issues between cardiac surgeons and cardiologists is best made by forthright and reasoned discussions between the two subspecialties that result in guidelines and policies based on ethical principles agreed to by both groups.3(p5)

In my opinion, the only logical step in the evolution of cardiac surgery and interventional cardiology is to create, in a short period, a strong and durable partnership that leads in the long-term to the creation of a new specialist with both surgeons' and interventional cardiologists' skills: the surgical cardiologist.

All of this may sound theoretical. It is not. A handful of colleagues currently are trying to ride the waves of innovations. Their numbers must be expanded. In the end, the patients will have the most to gain. This will be the power of this strengthened partnership.

To carry out this transformation of our discipline, the training of cardiac surgeons must be changed, or at least renewed. Rotations in interventional cardiology must be inserted into cardiothoracic surgery residency programs and cardiology residents must have a cardiothoracic surgery rotation too. Like most of my peers, I have not had the chance to obtain training in percutaneous techniques during my residency in Europe and in the United States. Surgical training and education in both percutaneous and surgical skills during residency will prepare future generations of young surgeons to face the future challenges of a deeply transformed cardiac surgery. Worldwide, surgeons are already dealing with this but few of them are offering training in endovascular and transapical approaches.4 Additionally, some large institutions around the world are already creating hybrid cardiac programs (eg, Cleveland Clinic, Cleveland, Ohio; Leipzig, Germany).5,6 The prevalence of these programs should be expanded and each and every cardiac surgery resident should consider the potential advantage of this cross-training to his or her career.

Before the development of cardiopulmonary bypass by Gibbon in the 1950s, cardiac surgeons were ingenious in developing instruments for closed-heart surgery. We must strive to regain our former spirit of innovation toward devices to be used on the beating heart. We must to be ready because in the near future, new 3-dimensional visualization systems will enhance the ability of surgeons, relying on visual feedback, to manipulate inside a beating heart. These technologies will allow us to accomplish operations more safely and increase the types of hybrid cardiac surgeries that will be possible.7,8

Although current publications and clinical trials express the intent that new technologies will be limited to compassionate use, in reality most new devices expect a wider use and the patient population for most technologies will become larger within a short period.9 A report of the Cardiovascular Roundtable predicts 13 000 yearly percutaneous aortic valve implantations in the United States within 7 years.10 That is for just one class of defect! Soon novel, minimally invasive approaches will be clinically available for other heart pathologies and we must be ready to receive them. Emerging technologies are growing rapidly and the only way to keep up with them is for interventional cardiologists and cardiac surgeons to work together and merge our experiences and skills to be the best for our patients.

I may be an optimist and a dreamer, but I’m not naive and not the only one. I know this transformation to a hybrid specialty will not be easy. On the contrary, it will be gradual and maybe, one day, not too far in the future, interventional cardiologists and cardiac surgeons will work together facing the treatment of cardiac diseases.

Remember, if you want to go fast, go alone, but we all must and want to go far. Let's accept the challenge. Let's go together to provide the best care for our patients.

Correspondence: Dr Bajona, Division of Cardiac Surgery–HLESI, University of Pittsburgh, 200 Lothrop St, Ste C-700, Pittsburgh, PA 15213 (pietro.bajona@gmail.com).

Financial Disclosure: None reported.

Additional Contributions: I thank my mentor, Giovanni Speziali, MD, for his training, constant guidance, and significant input on the points in this commentary and Shannon Wyszomierski, PhD, for editorial assistance.

References
1.
Reicher  BPoston  RSMehra  MR  et al.  Simultaneous “hybrid” percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes [published online March 5, 2008].  Am Heart J 2008;155 (4) 661- 667PubMedGoogle ScholarCrossref
2.
Hughes  GCNienaber  JJBush  ELDaneshmand  MA McCann  RL Use of custom Dacron branch grafts for “hybrid” aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms [published online ahead of print May 7, 2008].  J Thorac Cardiovasc Surg 2008;136 (1) 21- 28PubMedGoogle ScholarCrossref
3.
Sanderson  RG Ethical and legal concerns in relationships with cardiologists.  Ann Thorac Surg 2001;72 (1) 3- 5PubMedGoogle ScholarCrossref
4.
Svensson  LGKouchoukos  NTMiller  DC  et al. Society of Thoracic Surgeons Endovascular Surgery Task Force, Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts.  Ann Thorac Surg 2008;85 (1) ((suppl)) S1- S41PubMedGoogle ScholarCrossref
5.
Vahanian  AAlfieri  ORAl-Attar  N  et al.  Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI) [published online May 27, 2008].  Eur J Cardiothorac Surg 2008;34 (1) 1- 8PubMedGoogle ScholarCrossref
6.
Svensson  LGDewey  TKapadia  S  et al.  United States feasibility study of transcatheter insertion of a stented aortic valve by the left ventricular apex.  Ann Thorac Surg 2008;86 (1) 46- 54, discussion 54-55PubMedGoogle ScholarCrossref
7.
Carroll  JD The future of image guidance of cardiac interventions.  Catheter Cardiovasc Interv 2007;70 (6) 783PubMedGoogle ScholarCrossref
8.
Vasilyev  NVNovotny  PMMartinez  JF  et al.  Stereoscopic vision display technology in real-time three-dimensional echocardiography-guided intracardiac beating-heart surgery [published online May 2, 2008].  J Thorac Cardiovasc Surg 2008;135 (6) 1334- 1341PubMedGoogle ScholarCrossref
9.
Robicsek  F Will the use of percutaneous aortic valves remain compassionate? [published online May 1, 2008].  Eur J Cardiothorac Surg 2008;34 (1) 9- 10PubMedGoogle ScholarCrossref
10.
Cardiovascular Roundtable, 2007 National Membership Meeting.  Washington, DC The Advisory Board Co2007;
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