Innovation in Cardiothoracic Surgery: From Incremental Progress to Transformative Change

Technological innovation has continuously transformed medicine, often through incremental refinement of established techniques. In contrast, disruptive innovation does not simply improve existing practice; it changes the logic of care delivery by introducing new technologies or workflows that initially may appear inferior by conventional standards, but ultimately reshape who is treated, how treatment is delivered, and which professionals or systems guide decision-making. Cardiothoracic surgery itself emerged through a series of disruptive innovations. Early cardiac operations in the 1950s relied on hypothermia, inflow occlusion, or cross-circulation.1 The clinical introduction of the heart–lung machine by Gibbon2 fundamentally transformed cardiac care, enabling direct intracardiac surgery and redefining the boundaries of treatable disease. Subsequent advances, including coronary artery bypass grafting (CABG), valve repair, or heart and lung transplantation, were similarly disruptive and initially met with professional scepticism. Importantly, many of these innovations were driven by surgeons themselves, highlighting that the specialty has historically been a primary source of disruptive, transformative change rather than merely a recipient of external sustaining innovation. More recent examples of disruptive innovation include, for example, percutaneous coronary interventions (PCIs) or transcatheter valve therapies: initially developed for patients considered inoperable or at prohibitive surgical risk, they subsequently expanded into broader patient populations and altered referral pathways, treatment boundaries, and the relationship between surgical and interventional care. While much of medical progress has historically been driven by clinician-led, iterative improvement, advances in artificial intelligence (AI), data-driven systems, and automation3 are now introducing changes that extend beyond technical improvement and increasingly affect how clinical decisions are made, how care is organized, and how responsibility is distributed. These developments are not isolated innovations but part of converging socio-technical systems that integrate data, algorithms, digital platforms, and increasingly automated workflows. Cardiothoracic surgery is particularly exposed to these dynamics. The specialty relies on high-cost interventions, operates in data-rich environments, and is subject to increasing pressure to improve outcomes while optimizing limited resources. Over the past decades, progress has been driven primarily by sustaining innovations—refinements in surgical technique, perioperative management, and technology—resulting in a higher standard of care. The current wave of innovation, however, increasingly challenges not only how surgeons operate, but when, for whom, and by whom surgical care is delivered. Importantly, innovation in cardiothoracic surgery does not occur solely through disruption. It reflects a continuum ranging from incremental refinements to system-level transformations, often coexisting and interacting within clinical practice. Understanding the nature of disruptive innovation is therefore no longer a theoretical exercise. It has become a strategic necessity for cardiothoracic surgery as a specialty and for the institutions and scientific societies that represent it. This editorial aims to: Illustrate the distinction between sustaining and disruptive innovation in the context of medicine; Explain why cardiothoracic surgery is particularly susceptible to disruption; Describe typical professional and institutional responses to disruptive change; Explore why established leaders often struggle to adapt; Outline the responsibility of scientific societies, including European Association of Cardio-Thoracic Surgery (EACTS). The distinction between sustaining and disruptive innovation was articulated by Christensen,4 who described how market-leading organizations are often displaced not by inferior performance, but by innovations that initially appear unattractive or irrelevant to established players. Although developed in an industrial context, this framework provides a useful lens through which to examine developments in medicine. Sustaining innovations improve existing practices along dimensions already valued by established users and institutions (Figure 1), such as safety, durability, precision, and procedural success. In cardiothoracic surgery, these include refinements in myocardial protection and valve repair techniques, advances in prosthetic valve function and durability, improved cardiopulmonary bypass technology, enhanced imaging for operative planning, and the evolution of less invasive techniques. These innovations strengthen the existing therapeutic model while preserving the central role of the surgeon while enhancing safety and outcomes. Sustaining vs Disruptive Innovation. Conceptual illustration of performance trajectories over time, showing incremental improvement in sustaining technologies across low, medium, and high-quality use as well as most demanding use levels and the eventual performance crossover of a disruptive technology. The figure was generated with the assistance of OpenAI’s DALL·E (via ChatGPT) based on author-defined input and subsequently refined by the authors. By contrast, disruptive innovations introduce a different value proposition. Rather than competing primarily on conventional performance metrics, they often initially underperform according to traditional standards. For example, from a purely technical perspective, interventional valve therapies may not achieve the same anatomical precision and long-term durability as surgical repair or replacement.5 However, they may offer other advantages, including reduced invasiveness, broader accessibility, shorter recovery, lower system burden, and new modes of decision-making (Figure 1). These short-term benefits have contributed to broader acceptance by patients and referring physicians, thereby accelerating their diffusion and reinforcing their disruptive potential. In cardiovascular medicine, such innovations frequently enter practice by addressing patients previously considered unsuitable for surgery and/or by offering different risk-benefit trade-offs. Percutaneous coronary interventions (PCIs) or transcatheter aortic valve implantation (TAVI) exemplifies this trajectory: initially reserved for inoperable or high-risk patients, it has progressively expanded into lower-risk populations, reshaping referral patterns and professional boundaries. However, unlike in industrial settings, healthcare innovation is shaped by biological constraints, ethical considerations, and regulatory frameworks, which often moderate or reshape disruptive trajectories. Thus, incremental innovation typically improves the existing model, whereas disruptive innovation may alter the model itself. Although the general principles of disruptive innovation apply across disciplines, cardiothoracic surgery exhibits characteristics that warrant particular attention. Surgical decision-making involves irreversible interventions, high immediate risk, and clear attribution of responsibility. Training pathways are long, credentialing is rigorous, and evidence generation is slow compared with the pace of software-driven innovation. These characteristics, while essential for patient safety, may slow adoption but do not preclude innovation. Rather, they shape the form innovation takes within the specialty. These features justify a cautious approach to adoption, but they also increase susceptibility to disruption originating outside traditional surgical structures. AI-supported patient selection and referral triage systems6 are already influencing which patients reach surgical evaluation. Machine-learning-based risk prediction models increasingly rival conventional scoring systems such as EuroSCORE II or STS scores.7,8 Automated imaging analysis enables detailed characterization of valve pathology, ventricular function, and aortic anatomy with minimal human input.9 As a result, critical decisions in the patient journey increasingly occur upstream of surgical consultation. In this sense, disruption begins well before the operating room, subtly redistributing clinical authority across digital systems, workflows, and institutions. At the same time, many of these technologies function as decision-support tools rather than replacements, reinforcing the importance of clinical interpretation and multidisciplinary integration. Scepticism towards disruptive innovation is understandable and often justified but carries considerable risk. Across disciplines, professional responses to disruptive change are remarkably consistent. Common reactions include concerns that algorithms cannot capture clinical nuance, fears of eroding professional autonomy, and demands for long-term outcome data before engagement. Another common response is the assertion that clinical teams are fully occupied with routine work—which, for obvious reasons, must take priority—leaving no capacity to engage with seemingly abstract or “immature” disruptive ideas (Figure 2). These responses reflect legitimate concerns related to patient safety, accountability, and evidentiary standards. The Challenge and Reward of Process Improvement. Initial resistance to process improvement—often justified by perceived lack of time—can delay simple changes that ultimately lead to substantial gains in efficiency. The figure was generated with the assistance of OpenAI’s DALL·E (via ChatGPT) based on author-defined input and subsequently refined by the authors. Statements such as “this technology cannot replace surgical judgement” (Table 1) reflect legitimate concerns, but they may sometimes obscure a critical point: disruption rarely aims at direct replacement. Instead, it redistributes decision-making authority across systems, workflows, and time points. Another frequent response is the delegation of innovation to industry or future generations, resulting in externally driven development rather than proactive professional stewardship. Typical Reactions of Surgeons and Institutions “Artificial intelligence cannot replace surgical judgement” “This will never replace clinical judgement” “My patients are different” Overreliance on historical excellence Resistance to automated planning tools Expectation of long-term outcome data before engagement Over-demand for RCT-level evidence before adoption Delegation of innovation to “industry” or “the next generation” Abbreviation: RCT = randomized, controlled trial. While understandable, this reactive posture risks relegating surgeons to downstream users of systems that increasingly shape clinical practice. Christensen’s observation that established leaders often struggle with disruptive innovation4 applies particularly well to cardiothoracic surgery. Centres of excellence are optimized for complex open procedures, supported by infrastructure, training programmes, and performance metrics that reward technical mastery and procedural volume. When disruptive alternatives emerge, misalignment often develops between patient preferences, payer incentives, and institutional priorities. It is important to recognize that these challenges do not reflect a lack of innovation capacity, but rather a structural misalignment between established systems and emerging models of care. Resource allocation typically favours established workflows, while emerging technologies may lack clear reimbursement pathways or institutional ownership. Declining volumes in certain open procedures10,11 further intensify this tension. Past excellence, while foundational, can become structural inertia when value systems emphasize complexity over scalability and system-level efficiency. Consequently, the capabilities that once defined leadership in cardiothoracic surgery may inadvertently constrain adaptation. The term disruptive innovation is frequently applied to AI-based technologies in cardiothoracic surgery. However, not all AI-enabled developments represent disruptive innovation, and disruption does not automatically imply clinical benefit. Conceptual clarity is therefore required to distinguish different forms and degrees of innovation. Importantly, not all technologies labelled as “disruptive” result in sustained clinical impact, and many ultimately integrate into existing frameworks rather than replacing them. Three levels can be distinguished: Incremental innovation refers to technologies that improve existing tasks within the current clinical workflow, without fundamentally changing decision-making structures.12 Examples include automated large image segmentation, preoperative planning support,13 risk stratification,12 and assistance with clinical documentation. Workflow-level disruption refers to technologies that reorganize, compress, or partially automate parts of care delivery. Examples include AI-supported referral triage, automated image interpretation prior to specialist review, or digital platforms that shorten the interval between diagnostic assessment and treatment planning. In such cases, the institutional structure may remain largely intact, the operational logic of care changes. Role-level disruption involves a redistribution of professional responsibilities and authority. Emerging examples of role-level disruption include AI systems influencing which patients are referred for surgical evaluation, platform-based outcome monitoring linked to reimbursement or quality oversight, and partial automation of procedural planning or execution. Additional applications may extend to help in guideline development,14 grant evaluation, and peer review of scientific publications and automated assessment of clinical documentation. Such developments do not necessarily replace surgeons, but they may alter where authority resides and how clinical decisions are being made. Distinguishing between these levels is important because each raises different questions of validation, ethics, governance, and regulation. In practice, the evolution of cardiothoracic care is increasingly characterized by hybrid models rather than binary replacement. Surgical, interventional, and digital approaches are progressively integrated into patient-specific pathways. This convergence suggests that the future of the specialty will be defined less by competition between modalities and more by their coordinated application within multidisciplinary systems. Scientific societies such as the EACTS occupy a pivotal position in navigating innovation. Their role is neither to promote indiscriminate adoption nor to resist change reflexively, but to provide structured leadership in evaluation, implementation, and governance. European Association of Cardio-Thoracic Surgery (EACTS) should foster innovation across its full spectrum, from incremental advances to transformative change, and support researchers in translating promising ideas into clinical use. This role includes several concrete functions. First, EACTS can expand and intensify the to help define standards for evaluation by curating evidence, identifying clinically meaningful end-points, and promoting validation frameworks for emerging technologies such as AI-based decision support, robotic platforms, and digital monitoring tools within the Clinical Practice Guidelines Committee (CPG). Second, EACTS can use and expand current platforms that accelerate exchange and responsible adoption, including scientific sessions during the Annual Meeting, innovation summits, focused webinars, training opportunities, and collaborative research initiatives through the EACTS Innovation Committee and Hub. Such formats help expose surgeons early to developing technologies while preserving critical appraisal. Third, EACTS can contribute to professional guidance through guidelines, expert consensus statements and position documents in areas such as robotics, AI, digital surgery, and data governance. In rapidly evolving fields, such guidance may be essential before high-level trial evidence becomes available. Fourth, EACTS can shape future training and accreditation pathways by defining competencies required for the use of new technologies, integrating innovation into surgical education, and supporting the development of reference centres or centres of excellence. Fifth, EACTS can represent the specialty in regulatory and policy discussions. Initial progress in this direction has already been achieved in contributions to discussions surrounding revisions of the medical device regulation (MDR) concerning the use of robotics in cardiac surgery, in collaboration with other professional organizations such as the European Society of Cardiology (ESC).15,16 In this way, scientific societies can help ensure that innovation develops within standards defined by clinical expertise, patient safety, and ethical responsibility, validation of AI tools, and integration of digital technologies into training and certification pathways. Disruptive innovation in cardiothoracic surgery is neither a distant future scenario nor an external force imposed solely by technology developers. It is an ongoing process shaped by decisions made—or deferred—by surgeons, institutions, and scientific societies. While caution is appropriate, disengagement risks relinquishing influence over how surgical care is organized and governed. The central challenge is therefore not whether disruption will occur, but whether cardiothoracic surgeons will actively lead its integration into clinical practice. As algorithms increasingly influence patient selection and clinical pathways, the principal threat to surgical autonomy may lie not in technological advancement but in the absence of strong surgical leadership to guide its integration in clinical practice. Cardiothoracic surgeons, institutions, and scientific societies must therefore move from awareness to active engagement, ensuring that innovation is aligned with patient outcomes, professional standards, and societal trust. Shaping the Future Rather Than Reacting to It. All authors declare that they have no conflict of interest regarding this Editorial. None declared.