In the midst of an unprecedented global pandemic few of us cardiac surgeons came together, virtually, to set up a group that was christened the Endoscopic Cardiac Surgeons Club (ECSC). A not for profit company was set up in November in Leeds UK and this entity is now a reality. We have no doubt that there will be many questions raised on the motives and ambitions of this club and we felt that the best way would be to answer this borrowing a “Kaizen” (constant improvement) concept of asking 5 why’s to get to the root of issues.
1: Why Endoscopic?
The first question we faced was why do we need a group with a focus solely on an endoscopic approach? Is it not too narrow? Is it not too exclusive? These are all valid questions and concerns and we debated this, on virtual platforms for hours. There is no doubt that cardiac surgical interventions for heart valve disease and coronary disease achieve some of the best cost effective outcomes in modern medicine. These treatments were, initially developed in the late 1960’s and over the past 50 years the cardiac surgery community has improved these techniques such that we can offer complex procedures with very low mortality to a wide range of age groups. The sternotomy approach to cardiac surgery was introduced after many initial series used a thoracotomy approach to access the heart and this was seen to be a lot less painful with less long term implications on patients. All of us surgeons have seen the majority of patients doing very well with a sternotomy approach. It is no secret that bone takes its time to heal and an uneventful sternotomy will take 3 months to fully heal. Today we send home patients very quickly after heart surgery but the rehabilitation is still slow and time consuming. Endoscopic techniques have helped other surgical specialities to reduce morbidity and improve both outcomes, time to full recovery and improved visualisation for junior trainees. There is increasing evidence that an endoscope can improve both experienced and novice surgeons performance with regular review of past recordings. Apart from reducing incision size the endoscope provides light, magnification and a better ergonomic sitting position for surgeons doing long and complex procedures. We as a group, believe that using an endoscope will not only improve the outcomes for the patient and reduce rehabilitation costs for the community, the endoscope will help trainees learn faster and established surgeons extend their careers.
2 Why Club?
The next common question is why we decided to call this group a club? It comes across elitist, and it has connotations of a past era of secrecy and exclusivity, and is a reasonable criticism . As you can imagine this was also discussed widely by us and the final decision was not reached lightly. Patrick Perrier suggested that we call this group a “club” in order to give homage to “le club mitrale” a very successful enterprise set up by Alain Carpentier, to achieve a wider acceptance of mitral valve repair at a time when the standard option was to replace the mitral valve. Over a few decades this lead, to a gradual and progressive acceptance of mitral valve repair being offered to appropriate patients around the world.
We all agreed that we did not need another society. There are many excellent societies in the cardiac surgery space and they are all doing a good job in what is very difficult times. Our plan was to set up a focus group with a narrow field in order for us to gradually achieve a collaboration between industry and surgeons to help the wider dissemination of endoscopic techniques. Like mitral valve repair, endoscopic cardiac surgery is a collaborative improvement on the current approaches and we do not believe a randomised control trial is required to find its space in the armamentarium of options available to cardiac surgeons. We believe that the more urgent need is to create a pathway to safe and smooth adoption of these newer techniques. The reason for setting up the club, was to bring experts together to understand how we could mentor new surgeons interested in taking this approach on safely.
The other reason we decide on a club was so we could work with established societies to help move forward this approach partnering with them in health systems that are ready for this exciting patient centred approach.
3: Why Now?
There is never a good time to start a new group and certainly planning to set this up in the middle of a global pandemic could be seen as a particularly ambitious or foolhardy idea. When we got together in the midst of the first wave of the pandemic all of us surgeons were particularly aware of the pressure that intensive care beds were going to be for the coming few months. We all agreed that an endoscopic approach had in our own experience shown a reduced need for time in intensive care after cardiac procedures. We all felt that an endoscopic approach should be a focus for our group when we all come out of the pandemic, as there would be an expected pressure on health related costs. Demand for cardiac surgery had seen a reduction during the pandemic but we were all convinced that with gradual lifting of restrictions there would be a surge in the demand for cardiac surgery. This would be on the background of tired and demoralised work force who had faced the brunt of this pandemic exposed to the daily tragedies unfolding in intensive care units across the world. Of course there was also likely to be pressure on the most cost effective options and we were all convinced that an endoscopic approach would be ideal cost effective option for many cardiac surgery procedures. The challenge would be to increase the numbers of surgeons who are able to offer this procedure safely. We understood that with reduced training time and increased scrutiny on results there would be a lack of incentive to take on a new learning curve. We decided as a group that there was a need for a focus on this type of cardiac surgery and a forum that brought like minded surgeons and industry partners together. Despite the obvious concerns we believe that this club will be a very timely endeavour.
We were quite surprised and pleased that many other surgeons shared this view and we were buoyed by positive interest from industry partners too. Despite the evolving pandemic we forged ahead with this idea and we hope you will join us to make a success of it
4: Why Not?
Another question that has come up a lot while putting together this club has been, why not include all minimally invasive approaches? Why not include robotic surgeons in the group? These are also points we discussed, as we were aware that too narrow a focus and we would be accused of being irrelevant. Too broad an area of focus and we would be treading on the good work of other established societies. We decided that the term minimally invasive cardiac surgery was too broad as it covered everything from a limited sternotomy to some newer trans-catheter approaches. All of us surgeons had started our journey away from a full sternotomy to lesser incisions of the sternum and gradually moved away from disrupting the sternum to eventually relying on an endoscope for light, magnification, recording and education. In the process we had noticed a big change to the patient pathway post cardiac surgery. We believed that the step to take surgeons towards an endoscopic approach was going to be the most rewarding for both patients and surgeons. We did not believe that there would be a need for a randomised control trial to prove its benefits but rather like the adoption of mitral valve repair where registries of like minded surgeons would provide the required evidence over the coming years. We felt our club could be a good opportunity to facilitate this between surgeons around the world with the support of industry partners.
The more difficult question is why we did not include robotic surgeons into the group. Actually we are not against robotic cardiac surgery. It is an advanced form of endoscopic cardiac surgery and so we as a group are very supportive of this technology. We feel that endoscopic cardiac surgery can achieve very good results in the hands of trained surgeons without the added expense of robotic arms. There are many health systems where robotics are unlikely to be able to show cost-effectiveness and in the post Covid era it will be our responsibility as cardiac surgeons to look to adopt the most widely applicable technology as a group of global surgeons. We hope in time with more advances there will be an overlap of interest in both endoscopic and robotic approaches and we will learn techniques from each other. Once more these approaches are not competitive but very collaborative and adoption of one or the other will likely depend on economics rather than patient factors.
5: Why us?
The final question is probably why we came together as individuals? We were all doing less operating in the midst of the viral surge in Europe. We were all aware of the work that each of us had done in both adopting endoscopic procedures but also an interest in trying to teach this approach to others. Patrick had a global reputation of both adopting new techniques like mitral valve repair and endoscopic mitral surgery but also was widely accepted as a pioneer in transferring knowledge with his busy schedule of mentoring and lecturing all over the world. Mattia had been the first surgeon to popularise the right anterior thoracotomy approach to the aortic valve and taught many visiting surgeons and teams the safe principles of minimal access heart valve surgery. He has a long experience of teaching cardiac surgery in China too. Antonios trained in the UK and established a very successful cardiac surgery program in Greece and has adopted endoscopic heart valve techniques and is a good teacher and communicator. Marco also works in Italy and is a very keen teacher of endoscopic surgery with a wide experience in heart valve surgery. Marco leads a very successful endoscopic heart valve surgery program in the beautiful coastal town of Massa Italy. Jorg is one of a new breed of surgeons who is fully trained in trancatheter and endoscopic approaches to the aortic and mitral valve and in Berlin is able to choose endoscopic heart valve surgery when indicated. He is an excellent educator and enjoys teaching. Joe has spent the past 15 years developing one of the largest experiences in endoscopic cardiac surgery in the UK under intense public scrutiny due to surgeon specific results publication, and has a passion for teaching and training other surgeons.
We feel that we have a broad group of age, experience and reputation, that we hope will attract other like minded surgeons to collaborate and exchange ideas and techniques so that we can put endoscopic cardiac surgery to the forefront as a subspecialty interest. We do hope you will get in touch with us and look forward to growing the Endoscopic Cardiac Surgeons Club (ECSC) into a diverse, inclusive and vibrant global group that puts patient benefit at the centre of our mission while improving the experience of surgeons and trainees in the years to come.
