Medtech Insight - Custom Research for the Medical Device Marketplace

Medtech Insight went to the 39^th Annual Meeting of the Society of Thoracic Surgeons to find
out the answers to these and other provocative questions. This Pr³ Physician Survey shows clear
trends in cardiac surgery and provides the need-to-know answers to various questions on cardiac
surgeons’ practice trends, revascularization procedures, surgical treatment of atrial fibrillation, use
of anastomotic devices and valve surgery.

Over 110 cardiac surgeons participated in the survey, which was a self-administered, written
survey conducted at the 39^th Annual Meeting of the Society of Thoracic Surgeons in
February 2003. Physicians attending the conference were asked almost 150 questions
(listed below).

SURVEY QUESTIONS
(N=sample size)

Demographics

1. In which region of the country do you practice? N=111

2. How many years have you been practicing cardiac surgery? N=113

General Practice Trends

3. How many total cardiac surgeries were performed at your institution in 1999 N=89 1999
and 2002 and how many do you project for your institution in 2005? N=92 2002

N=85 2005

4. What percent of your institution’s case mix was CABG in 1999 and 2002 N=101 1999
and what percent of your institution’s case mix will be CABG in 2005? N=106 2002

N=101 2005

5. What percent of your institution’s case mix was valves in 1999 and 2002 N=102 1999
and what percent of your institution’s case mix will be valves in 2005? N=109 2002

N=104 2005

6.                  What percent of your institution’s case mix was congenital in 1999                  N=98 1999
and 2002 and what percent of your institution's case mix will be                    N=104 2002
congenital in 2005?                                                                               N=102 2005

7.                  What percent of your institution’s case mix was other procedures in 1999         N=97 1999
and 2002 and what percent of your institution's case mix will be other              N=99 2002
procedures in 2005?                                                                                N=99 2005

8. What percent of your institution’s CABGs were performed on beating N= 111 2002
heart in 2002 and what percent will be performed on beating heart in 2005? N=106 2005

9. What do you account for the changes in CABG volume at your N=84 mentions
institution? (Decreasing volumes only; Open-ended question)

10. What do you account for the changes in CABG volume at your N=18 mentions
institution? (Increasing or no change in volumes; Open-ended question)

11. What percent of your institution’s valve surgeries were performed N= 104 2002
using minimally-invasive techniques in 2002 and what percent will N=98 2005

be performed this way in 2005?

12. Profile of cardiac surgeons who practice at respondent’s institution:

How many cardiac surgeons are on staff at your hospital? N=115

How many cardiac surgeons on staff at your hospital perform

beating heart surgery? N=113

How many cardiac surgeons on staff at your hospital perform

Minimally-invasive valve surgery? N=111

How many cardiac surgeons on staff at your hospital use robotics? N=112

13. How many total cardiac surgeries did you perform in 2002 and how N= 79 2002
many will you perform in 2005? N=72 2005

14. What percent of your total surgeries were congenital in 2002 N= 110 2002
and what percent will be congenital in 2005? N=104 2005

15. What percent of your total surgeries were other procedures in 2002 N= 110 2002
and what percent will be other procedures in 2005? N=104 2005

16. Did you use transmyocardial revascularization (TMR) in 2002 N= 111 2002
and do you plan to use TMR in 2005? N=109 2005

17. Did you use any new treatments for heart failure in 2002 N= 111 2002
and do you plan to use any new treatments for heart failure in 2005? N=107 2005

18. What do you think will be the biggest growth areas in cardiac surgery N=215 mentions
in the next 3 to 5 years? (Open-ended question)

Revascularization

19. What percent of your total surgeries were CABG in 2002 N= 114 2002
and what percent will be CABG in 2005? N=105 2005

20. What percent of your CABG procedures were performed on beating N= 113 2002
heart in 2002 and what percent will be performed on beating heart N=105 2005

in 2005?

21. What percent of your CABG procedures were minimal access incision N= 105 2002
in 2002 and what percent will be minimal access incision in 2005? N=99 2005

22. What percent of your CABG procedures were endoscopic non-robotic N= 104 2002
in 2002 and what percent will be endoscopic non-robotic in 2005? N=89 2005

23. What percent of your CABG procedures were endoscopic robotic N= 105 2002
in 2002 and what percent will be endoscopic robotic in 2005? N=95 2005

24. Did you use robotic techniques in 2002 and do you plan to use N= 112 2002
robotic techniques in 2005? N=111 2005

25. Did you use percutaneous or interventional techniques in 2002 N= 112 2002
and do you plan to use percutaneous or interventional techniques in 2005? N=110 2005

26. Based on your current practice volume, what percent of your CABG N=105
patients will you likely lose once drug-eluting stents become available
(assuming restenosis rates remain <10%)?

Please rate the importance of the following factors as obstacles to the growth of
beating heart surgery:

27. Lack of surgeon motivation N=112

28. Lack of cardiologist demand N=114

29. Lack of clinical data showing significant advantages N=114

30. Technical difficulty N=114

31. Lack of anesthesiologists trained in beating heart N=114

32. Procedure cost N=109

33. Lack of surgeon training N=114

34. Reimbursement issues N=110

35. Obstacles to the growth of beating heart surgery by mean ratings of
importance. (Compares mean ratings of surgeon motivation, cardiologist demand,
clinical data, technical difficulty, anesthesiologist training, procedure cost,
surgeon training and reimbursement issues.)

36. What is the single MOST important obstacle to the growth of beating N=88
heart surgery?

Given the current technologies, education programs and clinical data, how
important are the following in driving beating heart surgery in the future?

37. Cardiologist demand N=112

38. Patient demand N=115

39. Surgical society procedure recommendations N=115

40. More anesthesiologist training N=113

41. Innovators moving to small incision beating heart N=110

42. More surgeon education programs N=114

43. Better stabilizers, positioners N=115

44. Availability of distal anastomotic devices N=115

45. Advances in proximal anastomotic devices N=115

46. Advances in robotic surgery N=113

47. More ways to avoid clamping the aorta N=112

48. Better methods for exposure N=112

49. Issues driving the growth of beating heart surgery by mean ratings of importance.
(Compares mean ratings of cardiologist demand, patient demand, surgical society
procedure recommendations, anesthesiologist training, innovators moving to small
incision beating heart, surgeon education programs, stabilizers/positioners, distal
anastomotic devices, proximal anastomotic devices, robotic surgery, ways to avoid
clamping the aorta and better methods for exposure.)

50. What is the single MOST important issue driving the growth of beating N=105
heart surgery?

51. Compared to the total cost of routine on-pump surgery, is the total cost N=105
(consumables and length of surgery) of a typical off-pump CABG in your
institution considered significantly higher? Slightly higher? Same as on-pump?
Slightly less? Significantly less?

52. What is the likelihood that you will be performing “hybrid procedures” N=112
(combined CABG + stents) in multi-vessel disease by 2003?

53. What is the likelihood that you will be performing “hybrid procedures” N=110
(combined CABG + stents) in multi-vessel disease by 2008?

54. Likelihood that cardiac surgeons will be performing “hybrid procedures” N=112
(combined CABG + stents) in multi-vessel disease in 2003 and 2008?

Surgical Treatment of Afib

55. Do you currently perform or plan to perform surgical afib procedures? N=112

56. Did you surgically treat afib with an energy source in 2002 N= 111 2002
and do you plan to surgically treat afib with an energy source in 2005? N=110 2005

57. If you currently perform surgical afib procedures, do you perform it with N=78
concomitant valves?

58. If you currently perform surgical afib procedures, do you perform it as a N=78
stand alone procedure?

59. If you currently perform surgical afib procedures, do you perform it in N=78
conjunction with CABG?

What percent of your surgical afib procedures are performed via the following
methods/technologies:

60. Cut and sew technique N=61

61. Dry unipolar RF N=61

62. Dry bipolar RF N=60

63. Irrigated RF N=61

64. Microwave N=61

65. Cryo N=61

66. Laser N=61

67. Summary of methods/technologies used for surgical afib procedures by mean
percentages. (Compares mean ratings of cut and sew, dry unipolar RF, dry bipolar
RF, irrigated RF, microwave, cryo and laser.)

68. Which methods/technologies used for surgical afib procedures do you think will N=80
grow the MOST in the next five years?

What is your impression of the following ablation energy sources regarding their promise
to treat afib in the future?

69. Cryoenergy N=86

70. Radiofrequency N=92

71. Microwave N=86

72. Laser N=77

73. Ultrasound N=77

74. Summary of ablation energy sources regarding their promise to treat afib in the
future by mean ratings. (Compares mean ratings of cryoenergy, radiofrequency,
microwave, laser and ultrasound.)

How important are the following items in increasing surgeon adoption of the surgical
ablation procedure?

75. Surgeon education N=104

76. Cardiology/electrophysiology referral N=105

77. Product ease of use N=104

78. Transmurality feedback N=102

79. Published outcomes N=104

80. Reimbursement N=103

81. Factors important in increasing surgeon adoption of the surgical ablation
procedures by mean ratings. (Compares mean ratings of surgeon education,
cardiologist/electrophysiologist referral, product ease of use, transmurality
feedback, published outcomes and reimbursement.)

82. What percent of clinical efficacy (i.e., % of patients cured from afib) would be N=109
required for you to adopt a new surgical afib technique?

Please rank these variables in order of importance (1 being most important) in affecting
your hospital’s purchasing decision for a surgical ablation device:

83. Availability of clinical data N=108

84. Purchase price N=109

85. Prepurchase trial and training program N=108

86. Energy source N=107

87. Device design and features N=108

88. Factors affecting hospitals’ purchasing decision for a surgical ablation device by
mean ratings of importance: (Compares mean ratings of availability of clinical
data, purchase price, prepurchase trial/training, device design/features and
energy source.)

89. For your afib patients, which of the following procedures do you MOST frequently N=110
perform?

90. Given the following afib treatment approaches, what would be your preferred N=98
lesion set?

91. Given the following afib treatment approaches, what would be your preferred N=98
technology?

92. Given the following afib treatment approaches, what would be your preferred N=94
incision?

Anastomotic Devices

93. Do you currently use an anastomotic device? N=112

94. What percent of your CABG procedures were performed using an N= 106 2002
anastomotic connector in 2002 and what percent will be performed N=95 2005

this way in 2005?

95. If you don’t currently use an anastomotic device, do you plan to use one in N=42
the future?

96. Will six month angiographic follow up be sufficient to demonstrate patency N=107
performance?

Please rank the following according to their importance (1 being most important) in
your decision to use PROXIMAL anastomotic devices:

97. Speed” (equal to or better than current standard) N=106

98. Convenience (equal to or better than current standard) N=102

99. Consistency (equal to or better than current standard) N=104

100. Quality (equal to or better than current standard) N=106

101. Cost (equal to or better than current standard) N=102

102. Clinical impact (equal to or better than current standard) N=105

103. Summary of factors important in deciding to use PROXIMAL anastomotic devices
by mean ratings: (Compares mean ratings of speed, convenience, consistency,
quality, cost and clinical impact.)

Which of the following, if any, would cause you to consider using PROXIMAL anastomotic
devices for ON-PUMP CABG (Check all that apply):

104. Elimination of partial-occluding clamp on double-clamp technique N=111

105. Reduction of cross-clamp time N=110

106. Speed (equal to or better than current standard) N=111

107. Convenience (equal to or better than current standard) N=110

108. Consistency (equal to or better than current standard) N=110

109. Quality (equal to or better than current standard) N=109

110. None of the above N=13

Please rank the following according to their importance (1 being most important) in your
decision to use DISTAL anastomotic devices:

111. Speed (equal to or better than current standard) N=97

112. Convenience (equal to or better than current standard) N=97

113. Consistency (equal to or better than current standard) N=99

114. Quality (equal to or better than current standard) N=104

115. Cost (equal to or better than current standard) N=98

116. Summary of factors important in deciding to use DISTAL anastomotic devices by
mean ratings: (Compares mean ratings of speed, convenience, consistency,
quality and cost.)

117. What percent of anastomoses do you believe will be performed with a distal N=104
anastomotic device in 5 years?

Rate each of the following variables according to their importance to anastomotic
patency:

118. Suture technique—interrupted or continuous N=110

119. Compliance N=107

120. Flow characteristics N=110

121. Target vessel size N=110

122. Conduit type (arterial or venous) N=109

123. Factors important to anastomotic patency by mean ratings of importance:
(Compares mean ratings of suture technique, compliance, flow characteristics,
target vessel size and conduit type.)

124. If a successful DISTAL anastomotic device was available, how likely are you to N=108
increase the number of beating heart procedures that you perform?

Valve surgery

125. What percent of your total surgeries were valve procedures in 2002 N= 114 2002
and what percent will be valve procedures in 2005? N=105 2005

126. What percent of your total heart valve procedures were tissue vs. N= 111 to 112
mechanical in 2002 and what do you project for 2005?

127. What percent of the aortic and mitral valve repair/replacement N= 102 to 105
procedures will be performed by minimal access in 2002 and 2005?

128. If technology was available for percutaneous mitral valve repair, what
clinicians do you think will perform these procedures?

Cardiac surgeons? N=105

Interventional cardiologists? N=104

Interventional radiologists? N=103

Other physicians? N=94

129. If technology were available for percutaneous aortic valve replacement, what
clinicians do you think will perform these procedures?

Cardiac surgeons? N=104

Interventional cardiologists? N=104

Interventional radiologists? N=104

Other physicians? N=94

130. Will percutaneous valve REPAIR require the same outcome data as traditional N=113
surgical repair?

131. Will percutaneous valve REPLACEMENT require the same outcome data as N=113
traditional surgical repair?

Please rank in order of importance (1 being most important) the following percutaneous
technology procedures:

132. Tricuspid valve repair N=101

133. Tricuspid valve replacement N=99

134. Mitral valve repair &