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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?
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?
“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
ComplacencyFear of change
MyopiaLack of resources
DistractionsBad luck
Innovation: How Is It Stifled?
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
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?
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