Innovation is a part of the DNA of cardiothoracic surgery, Friedhelm Beyersdorf (Heart Center Freiburg University, Freiburg, Germany) immediate past president of the European Association for Cardio-Thoracic Surgery (EACTS) tells Cardiovascular News, discussing the organisation’s commitment to place a renewed focus on innovation within the field.
“Seventy years ago the first operation with a heart-lung machine took place,” he comments, noting that subsequent years have heralded major advances in the treatment of paediatric heart disease, valvular, coronary and aortic diseases, as well as in areas such as transplantation, which have transformed outcomes for patients.
Beyersdorf placed the commitment to innovation at the heart of his 2021/2022 presidency of EACTS, a major action point of which was the establishment of the Innovation Summit, a first-of-its-kind event taking place in Paris between 20–22 April at which experts from the cardiothoracic surgery field, as well as other scientific specialties, share new science and thinking on technologies and techniques that could drive better outcomes for patients with heart and lung disease.
“With huge innovations in other fields of science, this will help us to treat our patients even better,” says Beyersdorf of the aim to learn from ideas outside of the field of cardiac surgery. “There is a saying that the biggest room in the world is the room for improvement, and that is the reason why I said that right now is the perfect time for huge innovations.” In particular, Beyersdorf points to advances in artificial intelligence, augmented reality, molecular medicine, and quantum physics as areas where there is scope for learning and new ideas.
The two-day summit was billed as an interactive working event, including 36 presentations delivered to an audience of surgeons, engineers, scientists, cardiologists and industry leaders, with a core focus on developing new ideas and concepts to bring into everyday clinical practice. “These huge innovations, disruptive science, occurs at the border of different scientific fields,” says Beyersdorf. “Very often, everybody thinks in a certain box in his own profession. If somebody else is coming from the outside, that is the advantage of diversity. Somebody else sees it completely differently, and there is not a right or wrong, there is just different.”
Four presentations from the session have been selected to feature at the Association’s annual meeting in October (4–7 October, Vienna, Austria) with an aim to disseminate new ideas to the wider cardiothoracic surgery community. These will offer updates on topics including opto-electronic implants, an arrhythmia treatment that takes place at a cellular level using small-scale implanted light-emitting diodes (LEDs); mitochondrial transplantation, which sees healthy autologous mitochondria transferred into damaged cardiac cells; myocardial regeneration; and automated reperfusion of the whole body.
The first summit had a wide brief, Beyersdorf explains, but one of the outcomes of the meeting has been to home in on a series of topics in which it is felt that there is a clear case for further innovation (see Five key innovation trends to watch in cardiac surgery).
Though the Innovation Summit is a first-of-its-kind event, the EACTS annual meeting has for a number of years featured on its programme a Techno-College component which is aimed at highlighting innovation in technologies and techniques for cardiovascular and thoracic surgery. The 2022 edition showcased new techniques for aortic valve replacement, robotic technology, and a live case showcasing an endoscopic valve replacement. Each year a panel selects one innovation to be the recipient of its innovation prize, which in 2022 was collected by the developers of a cannula for minimally-invasive central aortic perfusion—MIC-Cannula.
Presently, says Beyersdorf, among the biggest hurdles to innovation is the regulatory landscape. Nowhere is this more evident than in Europe, where the introduction of the EU’s Medical Devices Regulation (MDR) has created new challenges for innovators looking to bring forward new solutions.
Despite these challenges, Beyersdorf says he is confident that through embracing continuing innovation the role of the cardiac surgeon will be scarcely recognisable in decades to come compared to today. “When we look back from 2023 to the 1960s we see a big change. In 20 years I am sure we will look back to 2023 and see something similar.”
Five key innovation trends to watch in cardiac surgery
Extracorporeal circulation was first used in 1953, when the first operation with cardiopulmonary bypass (heart-lung-machine) was successfully performed. In the following decades miniaturised perfusion systems were developed for lung (extracorporeal membrane oxygenation, VV-ECMO) or heart/lung replacement (extracorporeal life support, [ECLS], AV-ECMO). Then, just a decade ago, long-term perfusion for healthy organs was made possible (ex-vivo perfusion) for organ preservation for transplantation. Most recently, single human organ repair (e.g., for lung transplants) and even multi-organ repair is possible for improved survival results after cardiac arrest (controlled automated reperfusion of the whole body, CARL). “The heart lung machine is a fantastic tool to operate within the heart,” says Beyersdorf. “Now from the groin you can put in some cannulas and repair the body after cardiac arrest.”
Robotics and automation
Robotic cardiac surgery utilises small incisions avoiding the need for a full sternotomy, and has most commonly been used to perform mitral valve surgery and coronary artery bypass graft (CABG) procedures. “Robotics is really exciting, but it is probably the wrong term,” comments Beyersdorf. “In surgery the robots do not do anything by themselves,” he explains, noting that current robotically-assisted procedures are guided by skilled surgeons. However, the field is advancing, and Beyersdorf points to the recent world-first laparoscopic surgery on the soft tissue of a pig, performed without human guidance. “This will have huge implications for clinical surgery.”
Heart valves for the future
“The Holy Grail is that one day you take a skin cell and grow your new heart valve, your new coronary artery, or even the whole heart out of that,” says Beyersdorf. While he acknowledges that this concept is still “light years” from a new heart being developed using cells harvested from elsewhere in the body, that goal is “coming closer and closer” in the heart valve space.
Artificial intelligence (AI) and augmented reality
In applications such as procedural planning, training and risk prediction, the use of AI and augmented reality technologies has already begun to enter the cardiac surgery field. “We have teaching tools with augmented reality to the young surgeons. We have 3D [three-dimensional] printing of the heart of the disease patients, especially in congenital cardiac surgery,” comments Beyersdorf.
Improvements in perioperative care
“Surgical techniques themselves are fantastic,” comments Beyersdorf, “and in most instances they are better than interventional techniques”. However, he notes that for many, the advantage of opting for an interventional procedure is the shorter associated recovery time. However, efforts are being made to ensure that patients undergoing surgery can also expect to benefit from a shorter hospital stay and recovery time. “We are now on the edge of improving these perioperative techniques in revolutionary ways so that even after huge procedures you might be able to leave the hospital, if not the next day, then on the third or fourth day, and you will experience significantly fewer comorbidities. This will, of course, be great for the patients.”