Innovation in Cardiac Surgery

Craig R. Smith , MD

Chairman, Department of SurgeryProfessor of Surgery, College of Physicians & Surgeons

Division of Cardiac Thoracic and Vascular Surgery

Innovation in Cardiac Surgery

Craig R. Smith , MD

Disclosures: As Surgical PI of the PARTNER Trial, I receive reimbursement from the Sponsor, Edwards LifeSciences, for travel and customary expenses

associated with Trial management.

Always the wild card

Always occurring, only the pace varies

Incremental: Training the ox

Disruptive: Goring someone’s ox

Innovation

“Never let the future disturb you. You will meet it, if you have to, with the same weapons of reason which today arm you against the present.”

Marcus Aurelius

Innovation: Too Daunting?

“You can't connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future.”

Steve Jobs

Innovation: Too Daunting?

100 Years of Innovation in Naval Artillery

Specific:No incisionNo anesthesiaNo heart-lung machineNo recurrencePerformable from earth on mars

(Sounds a lot like medical treatment, or interventional cardiology!)

General:Instantaneous, painless elimination of disease

Surgery is something no one wantsTreatment success = eliminating surgery

What Would Be the Ultimate Innovations in Cardiac Surgery?

Specific:Projectiles capable of destroying any targetAbsolute accuracy over infinite distanceComplete safety for the firing platform

(Sounds a lot like nuclear submarines!)

General:Overwhelming superiority of force such that opposition is pointless

Artillery is something no one wantsUltimate success = eliminating artillery

What Would Be the Ultimate Innovations in Naval Artillery?

“Ultimate success” may be the wrong goalConfuses an idea with an outcomeToo unconstrained and abstract

Most often reactive--starts with solutions to problemsConstraints impose discipline on thinkingSmall, conceivable stepsLinks innovator’s capabilities to the scale of solutions

Innovation: How Does It Start?

100 Years of Innovation in Naval Artillery

PROBLEMS

Projectile weightPlatform stabilityComplex, dangerous executionWeight/strengthWindWeatherHumiditySaltBarrel and projective corrosionMoving target

SOLUTIONS

Strong decksLow gun decksWatertight doorsManeuverabilityFrequency of firingSteamSteelRifled barrelsTurretsGear drives

100 Years of Innovation in Naval Artillery

PROBLEMS

Projectile weightPlatform stabilityComplex, dangerous executionWeight/strengthWindWeatherHumiditySaltBarrel and projective corrosionMoving target

SOLUTIONS

Strong decksLow gun decksWatertight doorsManeuverabilityFrequency of firingSteamSteelRifled barrelsTurretsGear drives

What happened in 1898?

100 Years of Innovation in Naval Artillery

“Ultimate success” may be the wrong goalConfuses an idea with an outcomeToo unconstrained and abstract

Most often reactive--starts with solutions to problemsConstraints impose discipline on thinkingSmall, conceivable stepsLinks innovator’s capabilities to the scale of solutions

Stealth innovation End-user drivenIncremental, training the oxRecognized as innovation in retrospectAccounts for most of the action

Innovation: How Does It Start?

30 Years of Innovation in Cardiac Surgery

Heart-lung transplantationCirculatory arrest for arch, dissectionNeonatal repairsTAH/VADTEEMitral valve repairAICDRetrograde cardioplegiaSkeletal myoplastyTMRGrowth factors/stem cells for LVSeptal-superior approachRetrograde cerebral perfusionEndoscopic conduit harvestBattistaRossAortic valve repairOff-pump coronary bypass

Minimal access operationsRoboticsMaze variations for atrial fibrillationArtificial chordsAntegrade cerebral perfusionAlternatives to hand-tyingValve-sparing root operationsHybrid aortic reconstructionsHybrid valve/PCI, CABG/PCITAVRTMVROpen/TAVR/TMVR hybridsdel NidoTissue engineering3D modelingSpinal protectionHLH operationsFontan variations

30 Years of Innovation in Cardiac Surgery

PROBLEMS:

Myocardial protectionCerebral protectionSpinal protectionFragility of dissected tissueIntraop assessment of resultsMorbidity of conduit harvestVein graft durabilityValve prosthesis shortcomingsPump-associated complicationsMorbidity of sternotomyLimitations of poor ventricular function

SOLUTIONS:

Transplantation/VADCirculatory arrestTEEMitral valve repairAICDRetrograde cardioplegiadel NidoVentricular regenerative therapiesAntegrade cerebral perfusionEndoscopic conduit harvestRossMultiple arterial conduitsAortic valve repairOff-pump coronary bypassMinimal access operations

30 Years of Innovation in Cardiac Surgery

PROBLEMS:

Myocardial protectionCerebral protectionSpinal protectionFragility of dissected tissueIntraop assessment of resultsMorbidity of conduit harvestVein graft durabilityValve prosthesis shortcomingsPump-associated complicationsMorbidity of sternotomyLimitations of poor ventricular function

SOLUTIONS:

Transplantation/VADCirculatory arrestTEEMitral valve repairAICDRetrograde cardioplegiadel NidoVentricular regenerative therapiesAntegrade cerebral perfusionEndoscopic conduit harvestRossMultiple arterial conduitsAortic valve repairOff-pump coronary bypassMinimal access operations

Back to 1898….

Scott to Sims to Roosevelt

Innovation: How Is It Stifled?

ComplacencyFear of change

MyopiaLack of resources

DistractionsBad luck

Innovation: How Is It Stifled?

“The past is always tense, the future perfect.”

Zadie Smith

Rare

Big, hairy, audacious ideas

Tenacity, determination, luck

Low success rate

Major application of resources

Quantum-leap Innovations

What have they been?Heart-lung machineTAVR

What will they be? (Ingber, Wyss Institute)Coated surfacesDialysis-like magnetic rx of sepsisShear-stress activated TPA balls Organs on a chip

Personalized medicine?

Quantum-leap Innovations

Always the wild card

Always occurring, only the pace variesIncremental: Training the oxDisruptive: Goring someone’s ox

Will we lead it, or someone else?

Early adoption can beat inventionBecause best beats first

Innovation

“He not busy being born is busy dying”

Bob Dylan

Give yourself creditCut the problem down to sizeThrow stuff at the wallThrow more stuff at the wallTired of throwing stuff at the wall?

Change hands!

Innovation: How Does It Start?

Sometimes it’s the people no one can imagine anything of, who do things no one can imagine.

Imitation Game