Hybrid strategy—the future of cardiac therapies! A myth or galloping reality?

Cardiac diseases are a major cause of morbidity and mortality. Innovative treatment options have developed significantly over the last several years. Despite constant clinical improvements that are the result of important technical developments, cardiovascular surgery and interventional cardiology therapies (percutaneous coronary intervention, coronary artery bypass grafting, valvular and vascular surgery) have remained unchanged for years. In parallel, however, demographic conditions have changed. Patients are presenting with more challenging surgical indications. Indeed, the numbers of fragile, elderly and other high-risk patients eligible for invasive treatments have grown. In those patients, hybrid procedures would obviously be beneficial, offering the best of both approaches and a less invasive cardiovascular therapeutic procedure. Consequently, the demand for less traumatic hybrid strategies will surely increase dramatically in the near future [1, 2]. Whereas some conditions still demand an open surgical approach (endocarditis, congenital defects, valve repair in young patients, severe complications of non-invasive interventions), hybrid therapies can offer safer, more effective and durable treatment with reduced surgical trauma in selected patients. The rationale for this observation lies in the fact that the recent tremendous clinical and technological advances allow us to offer better treatment. Robotics and minimally invasive techniques are expanding, opening a new era. Hybrid cardiac surgery can offer and combine procedures, such as percutaneous transluminal ‘coronary angioplasty’ and off-pump ‘coronary’ artery bypass, transcatheter aortic valve implantation and minimally invasive direct ‘coronary’ artery bypass, minimally invasive valve repair and percutaneous coronary intervention. It offers different strategies to accomplish interventional cardiac care while remaining minimally invasive. Abdominal and thoracic aortic stenting techniques also are evolving and expanding [3]. A multidisciplinary approach with a heart team became a reality and is now used and recommended by scientific and governmental stakeholders in selecting the best therapy for each patient. Therefore, new procedures, their potential implications and educational needs should be assumed, developed and discussed. They also need to be scientifically addressed and investigated. Cardiac surgeons should see in this new direction a revival of cardiac surgery. Indeed, heart treatment is getting a new look in which coming generations of cardiac surgeons should be involved and in which they will have an important role to play. However, to grow in times of change, we need vision and anticipation. Meanwhile, as the number of patients receiving endovascular therapies increases, it is obvious that the indications for cardiovascular surgery could be subject to reduction worldwide. In addition, there are subtle potential advantages for lowering the already enviable morbidity/risk threshold for conventional surgical treatment. Assuming reliable techniques for percutaneous therapy [4, 5], treatment might be offered earlier during the course of disease progression with improved outcome and more effective palliation. But is it enough to say, ‘the pendulum has swung too far away from surgery’? We, as cardiac surgeons and interventional cardiologists, do not need to sharpen our weapons and review our battle strategies. But, in a world overblown with ambiguity, guild mentality and conservatism, how does one know where to start? What questions to ask? What tasks to perform? For coming generations of cardiac surgeons and interventional cardiologists, the solution is clear: the antidote to guild mentality is hybridization. However, the amelioration and the development of these new therapeutic tools must not be a reason to underestimate the importance of training with different techniques or to forget the importance of patient safety. Those who shape the future should have an open mind and impartial mentality. Indeed, despite the preceding statement, safety concerns over long-term risks of endovascular therapies remain [6, 7]. In addition, increasing data show that selected patients may live longer if they benefit from surgery [8, 9]. Surgeons provide practical « from the inside » knowledge, expertise and a valuable, secure perspective on the interventional environment. They can help clarify a sometimes surprising lack of fundamental anatomical and physiological knowledge about the nature of failing heart diseases. Furthermore, this knowledge appears to be essential not just to a specific disease but also to a specific lesion. One contemporary example is the development of the ‘percutaneous’ concept of the replacement of cardiac valves. The latter is progressing at a rapid pace, reflecting intense professional and commercial interest. However, the knowledge that supports this endeavour must not lag behind. From this perspective, the hybrid surgeon who has received surgical and catheter-based interventional training is ideally positioned to make an unbiased treatment decision about patients with cardiovascular disease. On the other hand, the lessons learned from the past in interventional cardiology tell us that we cannot presume that what appears formidable may prove forgiving, and unforeseen setbacks will doubtlessly occur [10]. Interventional cardiologists and expert cardiac and vascular surgeons should work together to define a ‘feuille de route’ (roadmap) for future therapeutic endeavours. Because educators from different specialties are again facing the educational demands of uncharted territory, professional organizations must form task forces or committees to examine this issue. The topics discussed by these task forces would include the present and the future of all current and validated therapies: medical therapy, balloon valvuloplasty, percutaneous transluminal coronary angioplasty, on-pump surgery, off-pump cardiac revascularization, repair of congenital defects in the adult population, minimally invasive mitral surgery, percutaneous mitral valve treatment, percutaneous aortic valve implantation and surgical repair of ascending and descending thoracic aortic aneurysms. The long-term objective would become a fusion of different disciplines where specific courses would provide an essential ‘core’ of courses for all students. Medical applications of hybrid strategies that should be assessed and subjected to institutional research include the following: Open and percutaneous electrophysiology procedures Minimally invasive valve replacement or repair Myocardial revascularization techniques involving both percutaneous transluminal coronary angioplasty and robotically or minimally invasive realized coronary artery bypass grafting A combination of stenting for thoracic aortic aneurysm repair and open surgery of the ascending aorta (debranching) Percutaneous aortic valve implantation Percutaneous mitral valve repair and replacement The variety of treatment options highlights the need for specific patient selection, and the mix of surgical and interventional therapies provides the rationale for multidisciplinary heart team decision-making to discuss all potential treatment options and obtain informed consent. More physicians should receive dual training in surgery and interventional techniques, because hybrid procedures are an emerging trend. Importantly, physicians should follow and even lead this evolution. Indeed, big multinational firms are powerful pioneers of the development of endovascular therapy, which is a large, prosperous business. They have invested heavily in expanding the use of endovascular therapeutic technologies. The multidisciplinary approach provided by hybrid physicians would establish the warranty to offer the best treatment options and minimize the marketing influence. Guild mentality should be avoided, whereas persistence to face reality and accompany progress should prevail. Tools that lead to the success of these future goals are mandatory. Towards that purpose, hybrid operating rooms designed to achieve both interventional and surgical therapies should accompany future clinical strategies. The hybrid operating room should integrate robotics, videoscopy and other technologies necessary in the cardiac and vascular operating environment, as well as the innovative imaging modalities and other critical electrophysiological and catheterization technologies. Integrating clinical and technical expertise in addition to having a realistic approach as to what is clinically achievable is key for a successful hybrid operating room project. Due to wide variations in utilization, generic recommendations are only of limited use for these highly individualized rooms and certainly cannot replace the diligent work of the project team. Although the educational challenges created by hybrid strategies are daunting, collaborative efforts between educators and professional organizations, with input from the diverse constituencies, will lead to technical solutions and open the way for a revolution in the treatment of cardiovascular disease, where hybrid surgeons will have a central role. Hybrid strategies offer a new scheme for developing innovative cardiovascular therapies and will therefore become an essential resource in cardiovascular surgery. The trend towards hybrid techniques must be considered as an evolution requiring the rapid integration of new surgical techniques. All areas of cardiac therapy, including procedures for ischaemic, structural and heart rhythm diseases, are involved. Fluoroscopy integrated with image fusion, 3-dimensional/4-dimensional imaging, soft tissue visualization, modelling and navigation allow advanced surgical applications. As a consequence, it is reasonable to assume that the hybrid approach is here to stay and that it will definitely transform surgical and interventional indications despite a dominating guild mentality. We can hope and even expect that progress will continue to carry effective hybrid therapies and allow us to achieve reliable decisions. But many questions remain. Conflict of interest: none declared.