President's Column: Shattering the Paradigm with Innovation

Joseph E. Bavaria, MD, President

STS News, Winter 2017 -- Advances in cardiothoracic surgery have been nothing short of remarkable over the past few decades.

We’ve progressed from crude surgical techniques that kept patients in the hospital for weeks to minimally invasive operations that allow patients to be released from the hospital in only a few days. These innovations are good for patients and their families; in many cases, patients experience better outcomes and easier recoveries, which also lead to lower health care costs.

Adoption of new technology can be a very slow process, especially in cardiothoracic surgery. We have a mandate for quality, which is critically important, but sometimes great quality can be at odds with innovation, especially for “early adoption.”

We can’t stay stuck in old paradigms, however. Quality and innovation need to travel on the same path—in the same direction—so that our patients can lead longer and better lives.

Technology at our Doorstep

Some of the most recent technological advancements in our specialty relate to treating heart valve disease.

Transcatheter aortic valve replacement has evolved rapidly with good outcomes. In late 2011, TAVR received regulatory approval; a few months later, CMS issued a National Coverage Determination for the technology. In the months leading up to the regulatory approval, I personally worked closely with several organizations to establish criteria for the safe introduction of TAVR into clinical practice for high-risk patients. These criteria included participation in the STS/ACC TVT Registry to track short- and long-term outcomes.

Now, more than 5 years later, TAVR use has expanded to patients at moderate operative risk and even some with low operative risk.

A recent STS survey of surgeon participants in the STS Adult Cardiac Surgery Database found that, among those surgeons with TAVR programs at their hospitals, 91% played an active role in the TAVR process, including participating in multidisciplinary meetings, performing TAVR procedures, and conducting follow-up patient care.

I’ll provide more results from this important and revealing survey on Tuesday morning during the upcoming STS Annual Meetingin Houston, which also will feature dozens of presentations on use of new technology, including results from early feasibility trials for transcatheter mitral valve replacement.

Other innovations that will be highlighted, discussed, and debated at the Annual Meeting include novel ways to treat the thoracic aorta and the lungs.

All of these innovations have been made possible by new technologies and treatments, such as sutureless valves, TEVAR devices, state-of-the-art cardiopulmonary bypass platforms, third or fourth generation LVADs, and advanced VATS techniques.

If you’re like me, you get really excited about new technology and dream about ways it can help your patients. But then you realize that the traditional rollout paradigm makes it difficult to adopt these technologies as quickly as we would like. That’s where STS can play a crucial role.

Quality and innovation need to travel on the same path—in the same direction—so that our patients can lead longer and better lives.

Steering Innovation and Quality in the Same Direction

The Annual Meeting and upcoming STS standalone educational programs, including an ECMO course, a robotics course, and a structural heart course, will help you see and experience the present and future of cardiothoracic surgery. It is through educational activities such as these that we learn from the experts, experience hands-on training, and review and analyze outcomes data—all vital in the process to adopt new technologies.

Clinical outcomes databases, such as the STS National Database and the STS/ACC TVT Registry, also play a role in the process. Our databases are valuable assets in medicine because they provide opportunities for quality improvement and patient safety.

It is through participation in the STS National Database that you also can take part in STS Public Reporting. The initiative, one of the most sophisticated and highly regarded overall measures of quality in health care, offers risk-adjusted outcomes for common cardiothoracic surgical procedures. STS Public Reporting was launched in 2010 and has expanded over time (see related story).

Because continuous improvements in quality and rapid adoption of innovation can be inherently at odds with one another, I will use my Presidential Address on Monday at the Annual Meeting to examine these colliding imperatives.

Complementary to my address will be the C. Walton Lillehei Lecture on Tuesday by Dr. Samer Nashef, who co-developed the EuroSCORE risk-assessment system. Dr. Nashef, author of The Naked Surgeon: The Power and Peril of Transparency in Medicine, will provide his overview of quality initiatives and their unintended consequences.

Clarion Call

Although medicine adopts technology very slowly, we can shatter that paradigm by working together to drive innovation and quality along the same path. We need to see the big picture; we need to connect the dots.

Please join me in Houston at the STS Annual Meeting so that we can begin an accelerated journey into a new era of medicine where patients benefit more quickly and today’s innovations truly become tomorrow’s standard of care.