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Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery:
doi: 10.1097/IMI.0b013e3181f84ca7
Presidential Address

Our Origin, Our Passion, and Our Responsibility

Diegeler, Anno MD, PhD

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From the Herz-und Gefäßklink Bad Neustadt, Bad Neustadt, Germany.

Accepted for publication July 22, 2010.

Presented at the Annual Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 16–19, 2010, Berlin, Germany.

Address correspondence and reprint requests to Anno Diegeler, MD, PhD, Klinik für Kardiochirurgie, Herz- und Gefäß-Klinik GmbH, Salzburger Leite 1, Bad Neustadt 97616, Germany. E-mail: a.diegeler@herzchirurgie.de.

It is a good tradition to give, as a president of this Society, a statement about what we stand for and where we should go. This address is about “Our origin, our passion, and our responsibility.” Standing here today, I look with awe and humility to our ancestors, in particular to those who have shaped cardiothoracic surgery for the modern time. On these shoulders we stand today, with our own ideas with which we are evolving the surgery of tomorrow. I do not need to call the pioneers of heart surgery by name. Too young is the subject. It is just a bit more than a hundred years ago since Ludwig Rehn had broken the spell and performed the first operation on the untouchable organ. Like hardly any other surgical discipline, cardiac and thoracic surgery was always very closely connected with the development of medical technology. You can say it was even dependent on it.

The pioneers of cardiothoracic surgery accomplished great things. We think of names like Starr and Edwards, Lillehei, DeBakey, Cooley, Yacoub, Carpentier, and many others. These people went with their time. It was a heroic time driven by dreams, which finally became reality. The airline industry picked up boundaries. People could reach any destination in the world within hours. The first man put his foot on the moon. At the same time, surgeons dared the most challenging operations. How great was the courage of a surgeon as Walter Lillehei to take over responsibility for cross-circulation, for nothing more than to close a hole in the septum of the heart. No less courageous were the first operations with the new heart-lung machine, which was almost as big as a room. And how bold was it to believe, and even to try, to transfer human organs from body to body? We all, even my generation, are shaped by the spirit of this time. It might have inspired some of us to become a heart surgeon. I well remember the atmosphere that prevailed in the cardiac clinics, the spirit of optimism, the enthusiasm, and the drive to go a step further the next day. Indeed, our teachers were kings of the heart, and we should be proud to continue their work. What kind of spirit do we carry on?

Surgeons always aim to understand the disease to solve the problem. We want to solve it by ourselves in time and sustainably. We take risks. We know that any error can in minutes influence the fate of the patient negatively, even resulting in death. We enjoy a personal satisfaction when we succeed in curing the patient. Almost all patients thank us in a special way, and that is perhaps the best reward for our work. Therein lays our success—the success of cardiothoracic surgery over the past 50 years. We all carry a particular spirit, and this is our ancestor's heritage. It may also be a burden, but we have to accept it and carry on, when cardiothoracic surgeons will remain members of an autonomous society, which acts on its own initiative.

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OUR PASSION

Today, we find ourselves in a new situation. Our environment has changed substantially, the mainstream changed, the patient's expectations changed, our abilities changed, surgery changed, cardiac surgery changed, and we have to change.

We have to leave dear rituals of surgery. We can no longer draw satisfaction from the size, extent, or danger of our surgery. We have to adapt all the technology, which is evolving quickly and substantially. Think about information technology, the new imaging options, the development of automatic devices, catheter-based techniques, and telemanipulator machines, which take our hands away from the direct approach to the organ heart. We might even learn to work in a virtual environment and become a kind of “Cyber Surgeon.”

We increasingly approach interventional cardiology. This is important and good because we do not expect innovations by a deepening of surgery alone. Together we have to look for new solutions. Frankly, there is competition in the field. However, competing in regard to find and offer the best treatment is a strong drive for any evolution. There are some concerns and fears. Do we face a battle, who owns the heart? Many of us believe that the autonomy of cardiac surgery is at stake. Furthermore, some cardiologists would be glad to incorporate us. And even clinical managers would be too happy to question our freedom of design. Do we move away from our roots? We ourselves must give the answer. We can defend our surgical mind and our surgical skills. But, we have to transfer them into a new era of cardiothoracic surgery.

Friends, the new era of cardiothoracic surgery is different. It is more fragmented and more specialized. We have to accept that knowledge is increasing dramatically. The future is no longer driven by just a few great personalities.

Our new environment is interdisciplinary; thus, we have to cooperate even more closely with our partners, and these are not only cardiologists. However, we should not give up our leadership in decision making. Transcatheter aortic valve replacement is a good example of our new role. Does anyone feel that patients with aortic valve disease are treated better by a cardiologist than by a surgeon? Our answer to that question is clear. But, we have to understand that we will never do this treatment alone anymore. We will perform it in a team approach with cardiologists and others, or they will do it alone. So, we have to share our surgical knowledge, and at the same time, we must quickly incorporate other skills. Those we have to exercise. We have to invest in ourselves and in the next generation.

It is not enough just to request the lead in this new field.

Friends, it makes no sense to stare in awe at the past, to hold up its achievements, and to pause in retrospective. Especially, the people here today do not stand for this. If we do not lead our surgical society into the future, the next generation will create its future anyway. The question is whether this generation will name themselves cardiothoracic surgeons and will have their training at our side. The era that most of us look back to with reverence and pride of our profession will never return. It is no longer a reality. Our view has to go forward. In this we believe, for this we stand, that is the reason we are meeting here in Berlin, and this is the motor of the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS).

ISMICS is in its 13th year now. We are young, but our contribution to modern cardiothoracic surgery is substantial. It all began with the search of reducing invasiveness by smaller incisions and avoiding cardiopulmonary bypass. The Utrecht group including Cornelius Borst, Eric Janssen, and Paul Gründemann brought people together in early meetings from 1994 onward. People like Federico Benetti, Antonio Calafiore, Manny Subramanian, Hani Shennib, and Michael Mack shared their early vision about off-pump and minimally invasive direct coronary artery bypass surgery. At the same time, Friedrich Mohr and Hermann Reichenspurner met the group at Stanford around John Stevens and shared their innovation of an endoaortic balloon occlusion as the new basis for minimally invasive mitral valve surgery.

Telemanipulator systems from Computer Motion and Intuitive Surgical entered the field. I had the privilege to give an early talk on this topic at the “World Congress of Endoscopic Surgery” in Rome in May 1998, just 2 weeks after the worldwide first intuitive-guided coronary artery bypass grafting was performed in Leipzig. Volkmar Falk was one of the early leaders in this field, and Ranny Chitwood took this topic to the United States. Off-pump surgery became a routine technique for coronary bypass surgery. In the United States, it was scientifically represented by John Puskas and his coworkers. Minimally invasive lobectomy became a standard procedure in thoracic surgery; Rex Stanbridge was a forerunner in the United Kingdom.

At ISMICS, we implemented a thoracic branch in 2004 and consequently modified our name. Kemp Kernstine became the first director of the Board as a deputy of the new thoracic section. Minimally invasive surgical treatment of atrial fibrillation was the next innovative topic. Randall Wolf and Ralph Damiano were involved in this topic from the beginning.

Automatic devices for coronary anastomoses came into focus. The Utrecht group performed early research in their animal laboratory. Michael Mack, John Puskas, Jan Gummert, Gerhard Wimmer-Greinecker, and many others worked scientifically on this subject. Recently, transcatheter aortic valve placement with Michael Mack and Thomas Walther in a leading position came to the center of our interest.

All the mentioned topics are genuine ISMICS topics. Furthermore, all people I named and many others I could not mention here are great innovators and scientists, and they are all members of our society, the ISMICS. Most of them served ISMICS as a member of the Board of Directors or even as a leader and President of our Society. Less invasive surgery is our common mission. This mission follows the same enthusiasm with which our predecessors began surgery on the heart. The audacity to perform coronary bypass surgery on the beating heart, to repair the valve through a 5-cm chest incision, the placement of a new valve by catheter techniques, or to work with a telemanipulator inside the heart characterizes our work and our goals. New technologies should make our work not more extensive but less invasive, painless, and even invisible if possible.

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OUR RESPONSIBILITY

Responsibility is a particular attribute of physicians. Ethically you expect more of a physician than of a salesman. You will find the humanistic values related to medicine in every culture around the world. However, we can reach limits of what we can achieve and what we are responsible for. Today, for example, there is no longer merely the question of feasibility. There is also the issue of affordability. The potential of knowledge and research are no longer the only limits. Much faster, we also reach the limits of cost. What medical resources can a society provide? Are the resources equally available for everyone? Is a society willing to pay for innovation? Are all resources equally available even in advanced age? Who has to decide this? My aim is not to raise a political or intellectual discourse, and I am aware that different solutions for each country and culture are needed. But, we cannot cower away. Innovative surgery occurs precisely between feasibility and affordability. We here, altogether, are the self-appointed forerunners of innovation. Do we have the legitimacy for this? Yes, we have.

It is a task of medicine to look always for new ways. And furthermore, it is minimally invasive medicine that comes from a humanistic understanding that follows the principle to maintain human integrity and to avoid any pain and harm if possible. Thus, minimally invasive surgery is a commitment of our generation.

Its development, its costs, and its risks are as essential as any evolution in medicine. Above all, the evolution of minimally cardiac surgery depends on our competence.

This sounds appealing, but we must realize that we are not alone on the playground. Innovative surgery is expensive, and its reimbursement is not appropriate in most countries. It is a fact that you never will have progress in innovation without investing money, starting a business, and creating a market. The problem is that the so called “third party”—our politicians and insurance companies—do not trust innovation at first sight. They doubt whether the new is better than the established, and, simply, they do not want to spend more money. So, what is our role as innovative surgeons in that situation? We have to convince people about the value of minimally invasive surgery. We ourselves have the mandate, and it is our duty to do it. We should encourage ourselves to use our expertise and our strong position so that we are appreciated highly by our patients. We have to keep in mind that we are the patients' direct representatives. “Doctor, I follow your advice. I put my faith in your hands.” Such words, we often hear the day before surgery. We are the only ones who make the contract with the patient face-to-face. No politician, accountant, or administration director is in the patient's room the day before surgery, just we are. We have to defend our vision against skeptics on the one hand, but we have also the duty to convince our patients and society by proving that patients benefit from less-invasive surgery.

I guess most of you will agree with me. But, as always, behind easily stated words, there is waiting challenge and hard work, honesty and discipline. What must we do in this sense and what is the role of ISMICS?

First, we have to master the craft. Cardiothoracic surgery is a craft that must be learned and exercised. We all, even the most experienced of us, must continue to invest in new skills. And we have to ensure that the next generation can exercise and learn the skills needed for tomorrow. If endoscopic or interventional techniques are important, our fellows must have access to this training. This generation has to learn to work with the fluoroscope and with guide wires and catheters. When imaging techniques are part of tomorrow's minimally invasive surgery, our fellows need to understand and learn how to use it. If we do not provide these new technologies to the next generation, our young physicians will move to other disciplines. We have to build an environment to work with this new technology, and we have to readjust our work flow and the decision-making process. Above all, excellent training and providing the exciting atmosphere for new technology and innovation is a commitment of those who are in leading positions in our specialty.

Second, we are responsible for innovation, not industry. Industry makes innovation possible. We need to work closely alongside our industry partners. We must be honest advisers. But, we must also understand and respect the rules of business. We have to maintain the demanded distance. But, this does not change the fact that we are responsible to keep innovation running. Innovations have to be free from the suspicion that they only serve particular interests and not our patients' welfare. We are the patients' advocates, not part of a business, or marketing plan. We have to understand that the great confidence of our patients is an outstanding credit.

Third, we need to ensure the safety of any innovative surgery. It belongs to our duties to introduce innovations into clinical routine without any additional risk that could be avoided. We no longer work in an environment where we are the only people who save the patient from death and misery. Often, our innovations are aimed to replace therapies that are proven and lead to success with predictable risk and safety. To exchange an established procedure with a therapy that looks great, but has not been proven yet and carries an unpredictable risk, is unethical and not accepted by the society. Visible “learning curves” are no longer reasonable in the 21st century. We need a protocol that follows a staged and transparent plan to ensure safety before we go from the bench to the bedside. We do not have universal rules for this. And who is reviewing our protocols, standards, and results at an early stage? Who, if not we ourselves, should take the responsibility to define these standards and prove our results? But friends, we must do this.

Fourth, we need scientific evidence and transparency. We ourselves have to do the scientific work, and we must ensure that we do not compare apples with oranges. The currently published results about graft patency after endoscopic vein harvesting or the value of off-pump coronary surgery are important studies. We may not agree with the results of these trials for good reason, but only these critical publications spark discussion about the potential risks and benefits of innovative surgery. We complain about the design of the Randomized On/Off Bypass trial. But in the end, we have to accept that the results reflect our daily work. We need studies, indeed we need good studies. And if we are not confident about a given study design or protocol, we must perform a better one. I would like to mention our German Off Pump Coronary Artery Bypass in Elderly Study trial, which mandates that the best surgeon of each technique is doing the procedure. We will see whether that will provide a different result than the Randomized On/Off Bypass trial. Again, because it is so important in my opinion, it is our responsibility to prove the efficacy of a new technology compared with the established techniques. We must encourage our colleagues to participate in multicenter trials, and we should not kid ourselves and set up true guidelines for scientific study design to prove a benefit.

Dear friends, we have to accept that all of this is work. It is a bulk of work that demands diligence and discipline. This work is costly. We need money to perform good clinical trials, and this money has to be independent. It is our responsibility to do this job.

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RESOURCES

Finally let us talk about resources. Resources are not infinitely available. We have to ask ourselves, whether medical innovations help people in every phase of their life. We know that we are not able to cure every disease or keep every patient alive. But, it is our duty to relieve suffering and give people the chance to go the last mile of life with dignity. For this, we should claim for any technical improvement or costly innovation, but our view should not be limited to the walls of our institution.

I must say it again: we should not leave our responsibility to others in this issue.

We want to be innovative. But, our surgical approaches should not be reserved only for just a few wealthy people of a limited community. Thus, we need to search not only for the most sophisticated but also for the so-called simple things. Off-pump surgery is a good example for this. It is a rather effective and cheap treatment. Such an innovation is important for many countries. Think about India.

Consider that in 10 years from now, 60% of the people worldwide who are suffering from coronary artery disease will live in India. Naresh Trehan, one of our past presidents, introduced us to his new facility called Medanta–The Medicity in New Delhi during our Winter Meeting last December. High class and innovative medicine is offered there to people with a limited income. This is a challenge, but the way innovations can be used successfully in this particular environment is phenomenal.

We should be aware that in 2050, only 10% of the worldwide population will live in Europe or North America. We should expect that innovation will come from elsewhere and must play its important role there and not predominantly in the so-called “Western World.”

Ladies and gentlemen, what has all this to do with ISMICS? ISMICS plays an important role. ISMICS aims to represent our work as innovators in cardiothoracic surgery. ISMICS is not the only, or the largest, or the most important medical or cardiac society. But, ISMICS has its own unique responsibility in this field. We are ISMICS; we are here together, with our passion for innovative surgery and our particular responsibility as innovators. We do not run just along. We want to make a difference; we want to move things. We have influence. Let us use it together.

We share ideas. Let us discuss better ways. We report our complications and try to find solutions. We create scientific transparency. We test new surgical procedures on the basis of evidence. We check out literature and dare to publish ISMICS's consensus statements. You have just listened to our last one about minimally invasive mitral valve surgery. We have struggled in reviewing the data, and we endorsed a statement, which was not in line with our expectations. But, this statement is based on the published data and facts. Thus, it demonstrates the seriousness of our work and the scientific value of our society. We, as ISMICS, provide the platform for representing this kind of review and discussion. We provide this not only at our annual meetings but also in our Journal “Innovations.” It is the credit of Ralph Damiano and Carol Blasberg to have shaped “Innovations” into a high-quality journal, which is in its best shape ever, and I am sure that we will be approved for the index listing soon. At this point, I emphasize the importance of our journal for our society. And I kindly ask you to support the journal “Innovations” with manuscripts.

ISMICS is an important partner of the industry. We share our ideas, support trials, and bring people together. ISMICS connects cardiothoracic surgeons from all over the world, and we go out in the global world. Our next Winter Meeting will be in Buenos Aires together with the Argentine Cardiothoracic Society. You see, ISMICS is still young but a very active community. But, members and friends keep this in mind: ISMICS is nothing more than the sum of you, your interests, and your work. Please stay with us, stay with ISMICS. Dear friends, our profession as a cardiac or thoracic surgeon is very valuable and fulfilling. We are innovators in a humanistic sense, and we might follow humanistic ideas as “science, organization, verity, distinctness, value, and dignity.” We add a good dash of inspiration, such as passion, faith, devotion, vision, and audacity to our work. That is our mission. The inscription of a Greek temple in Delphi is as follows: “Be aware of your wonderful abilities, your great faith, your dignity, and your duties, but never forget, you are not God.” Our work has to be in balance not in conflict between the devotee Caritas on the one hand and the smart businessman on the other hand. That all lies in our hands.

Dear members and friends, it is an honor being your president.

Thank you all.

© 2010 Lippincott Williams & Wilkins, Inc.

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