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Eur J Cardiothorac Surg 2004;26:S74-S75
© 2004 Elsevier Science NL
Working Group Report |
Klinik fur Herzchirurgie, Herzzentrum Universitaet Leipzig, Strumpellstrasse 39, Leipzig 04289, Germany
* Tel.: +49 341 865 1421; fax: +49 341 865 1452. (Email: mohrf{at}medizin.uni-leipzig.de).
The open discussion following the ‘Integration of catheter-based techniques in cardiac surgery’ workshop went on as follows.
Appendix
Conference discussion
Dr T. Aberg (Umea, Sweden): Are all in agreement with these points or is there anybody who disagrees?
Dr L. Bockeria (Moscow, Russia): Could I ask to say a few words in more detail about congenital points of interest?
Dr Mohr : I don't recall the name of the presenters, I think they came from Turkey, but they presented at a past EACTS meeting a transventricular approach to close VSDs in the OR echo-guided through a sternotomy. So like deep muscular defects, they just took a catheter, punctured the ventricle, this is catheter-based, and they just put a kind of umbrella in. You should know more about it. I just happened to listen to it.
Mr J. Monro (Southampton, UK): If I could just elaborate on that, I think people have done exactly what you described, but I am sure the cardiologists will close more VSDs, both muscular and perimembranous, but the particular ones that might be useful in the operating room are the apical ones. There are other things that can be done with cardiologists in the operating room, particularly putting stents in more peripheral pulmonary arteries. If you are doing an operation but you don't really want to go right down into the hilum of the lung, stenting can be very useful. In a few situations where you have big collateral arteries, for instance with pulmonary atresia and VSD, you don't really want to occlude the collaterals before correction as the child may become very cyanosed. If you don't, the collaterals will cause flooding during the operation. So to occlude the collaterals at the same time as surgical correction would be optimal.
Dr R. Benetis (Kaunas, Lithuania): Regarding PCI, PTCA, echo and MRI techniques, did you foresee that as a residency program part or post graduate training?
Dr Mohr : We thought that should be part of the residency program, that the residents should have spent some time in the echo lab and it should be part of the EACTS board exam in the future, that you can ask for echo evaluation, MRI evaluation, and they should also be capable to perform echo themselves. So this is something that we think should be part of the residency program. And especially if we want to address heart failure, we thought that a better understanding of MRI techniques is very, very helpful, also part of the resident's program.
The fellowship is something which is more or less a post graduate training for one person, and I think we need to discuss the working hours in these aspects. We have to have people who truly just work in this field and get the training in this specialized field in some areas where they really can get the training, and maybe we have to take them out of the night shift and something like that. Otherwise it is not possible.
Dr A. Haverich (Hannover, Germany): I made a few notes now how to disseminate that information, because I think this will be of utmost importance for the future of cardiac surgery. If we want to expand into this field, and I think we have to move. We heard about residency, we heard about the Bergamo teaching, post graduate training, and fellowships. But I think the most important thing is that we have to convince the chiefs of the departments that this is the way we have to go for the future, and the modalities that have been discussed now would not reach there. They are not attending the post graduate course, probably, and just writing that in the newsletter or in the Journal may also not be enough. But I think we have to change the mind of the older surgeons that are running and are responsible for the departments in order to convince them to direct their programs in this direction.
Dr Mohr : May I make just a remark to that? I felt we had a terrible experience at the last German meeting, and I remember some meetings from the AATS also, where the presidential address was negative and only the old proven techniques were really something to go for. I am open for any criticism, but I would really take the chance to address you, Jim (James Monro), and Bruce (Bruce Keogh) and all of us to take the next EACTS meeting and to address all young surgeons. We will not convince the 80–90% who will never change, but we have to address at the presidential address and everywhere that this is the way we really want to direct cardiac surgery, and we need young surgeons who are interested to follow these pathways we foresee now, and it is our duty to really help them to get this specialization.
Dr M. Turina (Zurich, Switzerland): I must say that I totally disagree. All of which was said is correct, but these ideas are pipe dreams. The people are 25, 26 years old by the time they graduate. With the European Work Directive, training in cardiac surgery will be hardly finished in eight years. Adding up a year in the lab in cardiology, a year in one of the specialized training, and then having somebody going into pediatric surgery, which needs again three or four years, these people will be well above 40 by the time they start practicing. That is not realistic. The only way to achieve the goal is to have young people being sent in a certain professional direction very early, and to be heavily subsidized in the beginning. You cannot have everything in cardiac surgical training; I am afraid that the field is going to split more and more into different professional areas.
Dr D. Birnbaum (Regensburg, Germany): I would like to give a comment; maybe you have already discussed the way what happens with new inventions. We obtain some experience with these intentions, they were not always positive. In this case with a restrictive critical attitude of a surgeon his opinion is simply categorized as you say conventional, conservative, old fashioned and then finally negative. This attitude however is the result of experience. I wonder whether the Society should not take the burden to care for some regulations how new methods are introduced into our field of work.
Everybody starts with something that industry advertises in brilliant colors saying you can do this easily, it is fine and it is a wonderful technique. Then the application explodes and everybody does it and there is no control about it. If this then finally declares the invention as a catastrophe, the whole invention finally comes out as negative and gives a negative reputation to all our profession. I wonder whether the Society, the Council, should not reflect about this, whether there are by some way directives, guidelines or something regulative for new techniques.
Dr C. Mestres (Barcelona, Spain): Just a couple of things. Talking about endocardiopulmonary bypass, I think you should change the terminology, because this is addressing cardiopulmonary bypass in any way, by miniaturizing, whatever, because endocardiopulmonary bypass, as you know, is a commercial term coined after port-access surgery, which is basically ECMO, meaning extracorporeal circulation through extrathoracic cannulation. This is running for 30 years. So everything is endo, like Swan-Ganz is endo, like everything. So I think we should focus more on the entire field of cardiopulmonary bypass.
And the second thing is, do you think that by promoting too highly specialized teaching with a solid foundation we may face meeting functionally illiterate surgeons in the future?
Dr Mohr : As to your first point, this is in another working group; it has been addressed. So we can change that.
As to your second point, I truly believe whatever you take, if you specialize, you improve your quality, and in the long run you will have, number one, better results, and secondly, you will have a better referral base. And the best is if you have in your own center several specialists who will have expertise for mitral repair, for aneurysms, for congenitals, you have two guys who do video-assisted mitral valves, don't allow more to do them, et cetera, I think this is something which we have to think about, and if everybody would be allowed to do that, you will not get that quality.
Dr L. von Segesser (Lausanne, Switzerland): I would like to say something about what Dietrich Birnbaum has just said, that we need regulations about introduction of new technologies and devices, and I am totally opposed to that, like too many other things that were said here today.
But the problem is we have already the FDA, we have the CE marking, we have the ISO approval, we have I don't know how many bodies who interfere and who limit the possibilities to go for new ideas and to test new things, and if we go further in this direction, I mean, the inventions, they will not stop. They will just be applied in India, in Brazil, and we are totally out of business.
Dr Aberg : The issue here is not whether we should take away our possibilities but rather how do we evaluate new things in a convincing way so that it can be effectively spread.
In our hospital now, we have a new procedure that any new method that comes in has to go through the hospital board in order to check the evidence. It is done in a constructive way in order to finance the new costs of that technique. I think that we should be as good at creating and collecting evidence. Otherwise we will not get the funding to do the things.
Dr von Segesser : If it is new, there is no evidence. That is the definition of new.
Dr Aberg : Yes, and that is why we have to create the evidence in order to get it implemented. There are good methods to create that evidence which we are not applying.
Dr Mohr : So what do you suggest, should we always go ahead and do the animals first, which we usually do, is that your precondition, not relying on anybody else's?
Dr Aberg : Well, one of the hallmarks of evidence-based medicine is the randomized study. As surgeons, we are way behind pharmacology and oncology and other specialties in arranging good randomized studies.
Dr A. Haverich : Evidence-based medicine will kill medical progress. I wrote that in an article in Germany, because none of the surgical procedures that we do these days, has been evaluated by a prospectiverandomized trial, including PTCA, of course. So I much oppose these things if we talk about progress in the future. It is probably good to evaluate longstanding procedures, but what I would suggest something, which would be good for the Society in order to more control of what we are doing with the new technologies we need to have registries, as many as possible, to gather data on what has been done within the European Association. To also get some food for publication and also some food for discussion with industry. So registries are very important, and I think that has been neglected in the past. But we should not go for prospective randomized studies in the new technology field.
Footnotes
Presented at the EACTS Symposium for the Future of Cardiac Surgery, Frankfurt, Germany, July 1–2, 2004.
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