Emerging Technologies in Cardiac Surgery

Dr Om Prakesh Yadava of the National Heart Institute in New Delhi, India, interviews Professor Vinayak Bapat of Columbia University in New York, USA. They discuss transcatheter approaches and sutureless valves implanted by minimally invasive approaches.

When asked to name three disruptive technologies, Prof Bapat picks transcatheter aortic valve replacement (TAVR), transcatheter mitral valve replacement (TMVR), and minimally invasive cardiac surgery using sutureless valves. Dr Yadava asks if TAVR technology is moving too fast, and Prof Bapat comments that he would “rather embrace it and refine it than stay outside on the fence and criticize it.” Taking a pragmatically conservative stance, he maintains that although transcatheter therapies are advancing for low risk patients, in terms of TAVR they are currently more applicable to 75 or 80-year-old patients, especially in redo settings after CABG with patent grafts. He suggests that one should “match the life expectancy of the patient with that of the valve” and make a balanced decision when implanting transcatheter valves.

Dr Yadava poses the question as to whether sutureless valves were developed as a felt need of surgeons or whether they were introduced as a reactive response to the onslaught of cardiologists with transcatheter valve solutions, and Prof Bapat candidly agrees that it was more of the latter than the former. Ideally, the evolution of valve therapies would have begun with surgical valve implantation, followed by sutureless valves, and, in the end, transcatheter options, but in reality, sutureless valves came into their own after the transcatheter valve therapies had evolved. Prof Bapat is a proponent of lateral thinking and innovation, and he is critical of people who call this technology “futureless valves.” He recalls that Dr George Magovern was the first to introduce sutureless valves in the 1960s, but people were not ready for them then. He contentiously predicts that minimally invasive aortic valve replacement with sutureless valves is likely to challenge TAVR in the future, as the design, the circularity, and the durability of surgical valves are likely to be better than the transcatheter options.

Prof Bapat also feels that transcatheter and sutureless technologies are likely to evolve, even with respect to mitral valves. TMVR is a need, as mitral valve surgery is technically more demanding and has a higher morbidity and mortality in most centers than surgical aortic valve replacement. Dr Yadava asks whether a developing country like India should let these innovations evolve and stabilize and wait for the cost to come down, or whether it should join the bandwagon in the initial formative stages. Prof Bapat responds that the developing world should be a part of innovation, but in a rational way and with careful patient selection.

Alluding to skill development, Prof Bapat exhorts surgeons to respect the wire skills of cardiologists and to learn from them, not to egoistically presume that since surgeons are used to doing major open heart surgeries these are trivial procedures that they can perform without any issues. He supports training in wire skills during early residency days and the amalgamation of the two specialties of interventional cardiology and cardiac surgery going forward.