Creating Value

I t is with great pleasure that I may address you today as president of the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS). Presidents come and go, and this position in most societies is regarded as a purely representative job that one gets for one’s long-term service within the organization. From the outside, it often looks as if the president has been selected through some sort of an ‘‘old boys’’ buddy network, and very often, this is actually the truth. What most people do not understand, however, is the fact that this network, which undoubtedly exists, is not a result of the exclusiveness of some back-door boardroom activists but because of the very limited number of individuals that engage themselves for something more than their own business, practice, patients, and family. When ISMICS was founded, the idea was to establish an organization that would serve as a platform to promote the international scientific exchange on new ideas on minimally invasive surgery. Although established associations and societies such as the Society of Thoracic Surgeons (STS), the American Association of Thoracic Surgery (AATS), and the European Association of Cardiothoracic Surgery (EACTS) were struggling with their position toward some of the new technologies and minimally invasive access surgery, the ISMICS was designed to embrace and foster these developments. A substantial number of enthusiastic researchers were frustrated at the time that their work on endoscopic and less invasive techniques, off-pump surgery, and hybrid techniques was not accepted for presentation and publication at major meetings. For ages, the dominant and very successful philosophy in the field was characterized by two attitudes, ‘‘the pump is your friend,’’ and ‘‘a sternotomy is the best (and only acceptable) access. ’’ The cardiac surgical community was run by an established group of giants that had forgotten about their own pioneering efforts a few decades before and was by and large not ready for new adventures and the cost of change. As one former CEO of one of the medical device companies phrased it, cardiac surgeons ‘‘were the button salesmen in the age of zippers. ’’ As a consequence, in May 1997 at the Second World Congress in Paris, France, the idea of a minimally invasive cardiac surgical society was born. A small group of inventors and early adopters presented the issue to the 600 member audience, and finally, the ISMICS became an official organization in January 1998. At the same time, the large-scale use of percutaneous coronary intervention created a substantial threat that was largely ignored as long as a few coronary patients would still find their way into the surgeon’s office. The constant decline of coronary artery bypass surgery, the bread-and-butter business for most cardiac surgeons, did not trigger a major innovation of search for new strategy in most centers but was simply compensated by changing the age limit for valve operations and offering surgery to higher-risk populations. The demographic change came at the right time to secure the caseload and to support this adaptive behavior. For obvious reasons, this is not going towork again with the event of catheter-based valve interventions. By intention, the early randomized trials were designed to demonstrate noninferiority in the very high-risk population. With the proof of concept in our hands and equipoise between surgery and percutaneous treatment in the sickest and, more recently, in intermediate-risk patients, the target has nowmoved to younger and low-risk patients. A number of new interventional meetings largely covering percutaneous valve therapies have evolved in only a few years, all of them outnumbering ISMICS by far. Transcatheter Cardiovascular Therapeutics, EuroPCR, and London Valve, to name a few, cover all aspects of structural valve disease. The occasional surgical visitor will note that the only accepted definition of minimally invasive at these meetings is percutaneous. Interventional cardiologists cannot be impressed by techniques discussed at surgical meetings such as ministernotomies, small thoracotomies, no-touch aorta, or endoaortic balloon clamping. In their thinking, cardiopulmonary bypass is a thing of the past, and a sternotomy is considered a defeat. With a few exceptions, all big players in the device industry more or less share this view and have cut down their research and development expenditure for their surgical product lines and invest preferably in catheter-based technology. In line with the growth of sales of percutaneous devices and the cutback on surgical device sales, the willingness to bring new surgical devices to the market is increasingly limited. This comes at a time when venture capital flow into cardiovascular companies is already only half of what it used to be a few years ago. In 2013, device company investment represented only 7% of all venture investments, the lowest percentage since 2001. This reluctance of corporate venture to support early-stage device investment is shortsighted PRESIDENTIAL ADDRESS