Wired

Strolling through the industry exhibition at the recent annual meeting of the German Society for Thoracic and Cardiovascular Surgery in Leipzig, one was bound to notice a distinct shift in the kind of products advertised. Where in the past huge booths drew the audience to admire the most recent advancement in large heart–lung machines or modifications of an artificial heart with extracorporeal consoles and the like, many items on display this year were of a distinctly more diminutive nature. Many, in fact, involved an impressive array of wires of some sort.

To be fair, one must take into account that this year's convention was held in parallel with that of the German Society for Pediatric Cardiology, also sharing the industry space. This gave the interested surgeon a perfect chance to marvel at the tiny plugs and coils and baskets and whatnots, not to speak of cutting balloons, highly sophisticated malleable stents, etc. In pediatric cardiac surgery, the so-called hybrid approaches, that is, combinations of surgical with interventional catheter techniques, have been commonplace for a long time now. So has the Heart Team, without bearing this ostentatious denomination. One has simply always been talking to and working with each other trying to delineate what could best be done for the patient and by whom. And it was, and usually still is, the cardiologist wielding the wires.

In the “adult world,” which still accounted for the majority of the floor space, this distinction is not so clear. A prime example where wires have invaded the cardiac surgical armamentarium is the (much debated) transcatheter aortic valve implantation (TAVI). Here, a new technique has become available to treat a disease in which the cardiac surgeons have been experts for decades. It is only befitting for the surgeons, therefore, to take up this new technical challenge and thus broaden the variety of methods available to them. A common misconception is that TAVI is for the cardiologist and standard aortic valve replacement (SAVR) for the surgeon. The reasonable truth is that the new technique has something to offer for both, and meanwhile, there are good examples where the surgical department is in fact the driving force behind TAVI procedures.

This often comes as a surprise to patients, but also to general practitioners and even the occasional cardiologist. Since when have surgeons been able to fondle wires? For a long time, in fact. We have been inserting intra-aortic balloon pump balloons transfemorally forever. We have been cannulating all sorts of arteries (and veins for that matter) to establish various extracorporeal circulations. We have been advancing catheters into virtually all chambers of the heart to measure hemodynamics on our intensive care units. So the basic knowledge is present in most of us. It is, however, necessary to stay on track with the recent and more invasive techniques.

The young generation growing up with these therapies must be involved right from the start on “both sides.” Cardiologists should open up their catheter laboratories just as surgeons should open their operating rooms for a true interdisciplinary education. The skeptics should talk to their pediatric colleagues. They will doubtlessly be assured that both sides can learn a tremendous lot of things from each other. It is not about protecting turfs, after all. It should be about treating patients appropriately and safely.

Maybe an Editorial such as this one appears to be just rambling along, the author longing for an ideal world of harmony and goodwill which, as he knows only too well, does not exist. However, if we stop dreaming and having distant goals, we should pack up and leave. Idealists have always had a hard time to be heard, and an even harder one to gain power of some sort. They have, however, continuously played a decisive role in influencing their surroundings. It is therefore important that they stay wired.