CD&D Executive Editor

FORT LAUDERDALE, Florida — The field of cardiothoracic surgery is clearly in transition — not a new development but one heightened by a variety of pressures, professional, technological, political and economic. This assertion was highlighted in a variety of ways at the organization’s annual meeting here in late January.

A key professional issue is an apparent decrease in interest in the field; the technological issue is an obvious increase in the field’s expansion of complex therapies; and the political issue is multi-faceted —relating to the ups and downs of regulation, ethics and economics.

A combination of these factors appears to be depressing the general enthusiasm for the field of cardiothoracic surgery, according to one report delivered at the meeting.

The report, a survey of cardiothoracic programs and surgeons working in the specialty, said that the number of cardiothoracic surgery programs has decreased by 18% from 1992 to 2008 (from 92 to 75) and of 78 such programs existing in 2007, about one-third of them (27) were not filled. In contrast, enrollment in general surgery is increasing, with only one other specialty, neurosurgery, showing a decline.

The report offered a variety of reasons for this.

The field is not attracting as many women, compared to the number of women enrolling in medical school, and more students are moving into more enticing technological fields offering brighter financial rewards. And the upcoming generation is preferring improved lifestyle over altruism.

Too much discouragement

Perhaps most discouraging of all, medical students aren’t being encouraged to enter the field. About a quarter of those surveyed, currently practicing in the field, said they would not choose cardiothoracic surgery as a specialty if given the chance to choose again.

This lack of interest is magnified as an issue by a trend paralleling that of the global population: aging. An estimated 73% of cardiothoracic surgeons currently practicing are set for retirement by 2019, a mere 15 years up the road.

Given a generation of students very aware of the pressures on doctors to perform and a perceived lack of remuneration, surgeons in all fields are being asked to do more, learn more, and be familiar with a wider range of technologies.

And this too was highlighted at the STS meeting in the apparent but unstated tension between open surgery and endovascular techniques.

Ultra-polite

STS meetings may be among the most polite gatherings among the dozens of medical association meetings held every year. Speaker presentations are marked by multiple thanks (we counted more than a dozen in the address by the society’s president), obviously pre-scripted questions (and answers), and then additional thanks for those "very intelligent" and "thoughtful" responses, for those both pre-scripted and from-the-floor-unscripted, offering only the mildest of qualifications and challenges.

This intense politeness may be the result of the society’s continued domination by the traditional open-surgery community — perhaps producing an in-group, small-village aura with no great willingness to ruffle feathers.

But there was a quiet and equally intense undertone of debate here concerning the new technologies and, especially, the evolution of percutaneous therapies targeting the heart.

One indication of the underlying competitive flavor of the meeting is that it is preceded by STS/AATS Tech-Con, a gathering held on the preceding Saturday and Sunday, highlighting the most advanced computer and robotically-assisted technologies as a separate, but linked, event.

Tech-Con provides presentations offering overviews of the newest techniques that cardiothoracic surgeons are moving (or being pushed?) into, a "Simulator Village" allowing surgeons to get a hand (and handle) on these new techniques (though, somewhat nervously with other surgeons peering with great interest over their shoulders at how they’re doing with unfamiliar instrumentation), and a concluding debate on the value of randomized controlled trials to evaluate these new technologies.

Obviously useful, how can you doubt? some said; but alternate views suggest that these new technologies come with so many more variables that such RCTs are more difficult to do and have not yet been highly powered, so may not tell us very much.

The debate between standard surgical approaches and percutaneous was then highlighted early on in the opening Monday session of the regular STS meeting by one of three "memorial" papers (honoring J. Maxwell Chamberlain), focusing on the recent and steep upward spike in percutaneous closure of septal defects and patent foramen ovales, both openings in the heart thought to be risks for later cardiovascular problems and possibly, but still highly theoretically, migraine headache.

Over-utilization?

Tara Karamlou, MD, of Oregon Health and Science University (Portland), presented a paper titled "The Rush to Atrial Septal Defect Closure: Is the Introduction of Percutaneous Closure Driving Utilization?” — the title itself clearly indicating an unease with a percutaneous approach to the problem. (If there’s a "rush," things must be moving much too fast?)

Karamlou and four other researchers looked at the closure of secundum atrial septal defects over a 15-year period (1988-2003) and noted the increased popularity of the percutaneous approaches to closing these defects.

Popular indeed: 92 such procedures in 1998, 4,055 in 2003, from the database the group used, an increase of 4,293%.

Karamlou associated that rocket-propelled jump in procedures with the approval of the Amplatzer device, made by AGA Medical (Golden Valley, Minnesota) and receiving first approval in September 2001.

The primary shift, she reported, came in that year, with surgical closure decreasing by 20% and percutaneous closure increasing by 1,084%.

The concern proposed by Karamlou’s team was that this increase in percutaneous approaches had been driven by a variety of forces other than "medical need": the greater availability of the devices for providing percutaneous therapy, enhanced reimbursement for the procedure, and patient demand for minimally invasive kinds of intervention, even among asymptomatic patients — the last lowering the "threshold," that is, a reduced number of the patient’s risks.

The research reported that whether the surgical closure approach or the percutaneous approach was used, rates of mortality were the same, under 1%, and Karamlou indicated no significant differences in thromboembolism, though providing no figures for that endpoint.

While those clinical observations would appear to indicate strong support for the percutaneous approach, the researchers concluded by saying that the decreased morbidity of percutaneous closure was only "perceived," indicating a certain amount of distrust in the percutaneous approach.

The study’s overall conclusion: "In the absence of meaningful benchmarks, prospective studies comparing outcomes, criteria and cost for SC [surgical closure] versus PC [percutaneous closure] are needed to determine whether increased ASD [atrial septal defect] closure rates are justified."

Device tech needed as assistance

Despite the surgical-percutaneous competition, device technology clearly is aiding older, standard, methods in this sector.

Ralph Damiano, MD, of Washington University School of Medicine (St. Louis), discussed the traditional Cox-Maze produced used adjunctive to open surgery for treating atrial fibrillation (AF), a "cut-and-sew" procedure that is workable and effective but requiring cardiopulmonary bypass and arresting the heart.Damiano and his group have developed what they term the Cox-Maze IV procedure which substitutes the use of bipolar radio frequency energy for the cut-and-sew method. He reported superior results in 170 procedures, using Cox-Maze IV.

Despite these successes, Damiano said large improvement is needed and that a minimally invasive procedure would ultimately be developed that would be broadly applicable to all patients.

He rather optimistically predicted that advances in pre-operative imaging and diagnostics "will soon allow us to better define the mechanisms of atrial fibrillation in each individual patient" to produce "startling improvement" in AF treatment.

But Damiano’s prediction that this will happen "soon" — and an optimistic report in the STS convention newspaper, headlined "Future Bright for Atrial Fib Surgery" — contradicts a general skepticism, rather thoroughly commented on in this issue (See lead story, pp. 1-6.)

Do more, do it better

As if the need to do more isn’t large enough already, two leading speakers at the meeting challenged the attendee physicians to do more things very differently.

John Mayer Jr, MD, outgoing president of the society, emphasized the need to participate in the organization’s registry to report results and, on the wider level, to become more active in the political arena, given the frequency of policy-making at governmental levels that impacts reimbursement and regulation.

Elisabeth Tiesberg, author, with Michaeld Porter, of the book “Redefining Health Care,” encouraged a broad new paradigm for this specialty and all the others: dropping the competitive approach and developing a more cooperative strategy, also relying largely on the interchange of information through registries.

Sharing of clinical information is, she argued, the primary foundation to real healthcare improvement in the U.S. Her overall approach to the subject is that current efforts at reform are simply cost-shifting measures, and that the basis for improving value is improvement in quality through information-sharing and registry development.