Advanced Angioplasty 2008
Angioplasty: a surgical perspective
Bruce E. KeoghNHS Medical Director
Professor of Cardiac SurgeryUniversity College London
Advanced Angioplasty 2008
Evolution & innovation in the Interventional Treatment of Ischaemic Heart Disease
1950 1960 1970 1980 1990
CPB
VA Study
European Study
CASS
LIMABypass Grafts
VenousBypass graftsVineberg
2000
PTCA
Endarterectomy
RITA-1
BARI
EAST
ARTS
STENTS
CABRI
Surgical / Medical RCT’s
Surgical / PCI RCT’s
2005
DES
Advanced Angioplasty 2008
The facts
• Surgery offers better symptomatic and prognostic benefit for:– LMS– 3VD
• Surgery is invasive
• Surgery costs more initially
• Variation in philosophy, technology & results
Advanced Angioplasty 2008
Growth of percutaneous & surgical interventions for ischaemic heart disease
Ratio 2.5 – 6 PCIs for
1 CABG
Advanced Angioplasty 2008
Number of CABG procedures declining in United States
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
200000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
0
100
200
300
400
500
600
700
800
900
1000
No of CABGNo of centers
National Center forHealth Statistics&Northern New England Registry
•Peak 1999•Decline from 2000
Society of Thoracic Surgeons decline in number of CABG despite increasing number of contributing centers
Advanced Angioplasty 2008
1. Cardiologist is the ‘gatekeeper’2. Extrapolation of RCT findings
• Conducted in 5 % of atypical, highly select patients (1 or 2 VD and normal LV function)
• Results inappropriately generalized to the whole population (true multivessel disease and poor LV)
3 EBM challenged by a multi billion dollar industry
So why is PCI replacing CABG?
Advanced Angioplasty 2008
How do new technologies gain a grip?
Why do well-managed companies that have their competitiveness, listen astutely to their customers, invest aggressively in new technologies, and yet still lose market dominance?
Advanced Angioplasty 2008
Pe
rfo
rma
nc
e
Time
Performance that customers
can utilize or absorb
Performance trajectory
Rangeof performancethatcustomers can utilise
The rate at which the performance of a product has improved or is expected to improve, over timee.g. improvements in car engines, constrained by speed limits
Advanced Angioplasty 2008
Per
form
ance
Time
Performance that customers
can utilize or absorb
Pace of
Technological
Progress
Sustaining innovations
Incumbents nearly always win
Sustaining technologies
Range
Tend to maintain a rate of improvement; that is, they give customers something more or better in the attributes they already valuee.g. improvements in Intel chips now overshot capacity for mainstream use
Advanced Angioplasty 2008
Disruptive technologies
• New
• Very different package of attributes from the one mainstream customers historically value
• Often perform far worse along one or two dimensions that are particularly important to some customers
• Products based on disruptive technologies are typically cheaper, simpler, smaller, and more convenient to use.
Advanced Angioplasty 2008
Performance Oversupply
• Once the performance level demanded of a particular attribute has been achieved, customers are less willing to pay a premium price for continued improvement in that attribute
• This triggers a shift in the basis of competition, and the criteria used to choose one product over another changes to attributes for which market demands are not yet satisfied.
Advanced Angioplasty 2008
Per
form
ance
Time
Performance that customers
can utilize or absorb
Pace of
Technological
Progress
Sustaining innovations
Disruptive technologies
Incumbents nearly always win
Entrants nearly always win
Disruptive technologies
Disruptive products•worse performance•simpler and cheaper; •lower margins, not greater profits•typically are first commercialized in emerging or insignificant markets
Advanced Angioplasty 2008
Disruptive strategies – non medical
• Amazon – low end disrupt to bookstores• Bloomberg – financial info, E stock clearing• Dell – direct to customer computers• E-mail – postal services• Intel microprocessors & then Celeron – mainframes• Kodak cameras (Brownie and Funsaver)• Photographic film – digital media• Low cost airlines – Easyjet, Ryanair –established
airlines• Palm pilot, Blackberry - notebooks• Steel minimills – integrated mills collapsed• Toyota / Lexus – initially cheap low end now high end• Xerox copiers – relative to offset printing
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Disruptive strategies in healthcare
• Drugs for TB and peptic ulcer• Endoscopic surgery• Portable blood glucose meters• Portable INR monitors• Novopen• Ultrasound relative to X-ray• Sonosite portable ultrasound machines• Physicians Assistants ?• Critical care technologists?• Stent Angioplasty
Advanced Angioplasty 2008
Disruption enables less-skilled peopleto do more sophisticated things
Disruptive innovations enable a larger population of less-skilled, less-wealthy people to do things in a more convenient, lower-cost setting, which historically could only be done by specialists in less convenient settings. Disruption has been one of the fundamental causal mechanisms through which our lives have improved.
• Computers
• Photocopying
• Angioplasty
Almost always, disruptive innovations such as these have been ignored or opposed by the leading institutions in their industries for perfectly rational reasons.
Advanced Angioplasty 2008
Percutaneous coronary interventions
• Prior to 1980’s – Bypass surgery• 1980s – Angioplasty introduced
– Often ineffective, restenosis rate high (50% per year), couldn’t solve difficult blockages so surgeons not worried
– But, it was inexpensive and simple to use by cardiologists who didn’t have to refer to a surgeon and kept the fees
– Led to massive growth in the market because it enabled less seriously ill patients get treatment that was better than the alternative (nothing)
– Cardiac Bypass continued to grow for difficult and restensoed arteries
• 1995 Stents – Rapid increase in number of Angioplasty procedures– Bypass operations started to drop
• Cardiac surgeons slow to react • Stent Angioplasty done in non surgical centres
– Which are another disruption in relation to full scale hospitals
Advanced Angioplasty 2008
Per
form
ance
Time
Sustaining innovations
Disruptive technologies
Coronary Artery Bypass
Angioplasty as a disruptive technology
Stent
Initially a lot ofNon-consumption
POBA
Advanced Angioplasty 2008
Conclusion
• Innovation is inevitable• PCI Innovation is driven by industry & patients
– Answerable to shareholders– Little innovation in coronary surgery
• Margins of utility are often blurred in innovation• Surgery and PCI are moving in to different territories• The balance will shift to a debate between medical
therapy and angioplasty
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