Re: “Clinical Impact of Telemedicine Network System at Rural Hospitals Without On-Site Cardiac Surgery Backup” by Nagayoshi et al. ( Telemed J E Health 2017;23:260–261)

Dear Editors:

We read with great interest the article by Nagayoshi et al. ¹ that analyzed their experience in teleconference for referring critical cases needing cardiac surgery. However, we are of the opinion that the role of telemedicine in cardiac surgery should not be limited to urgent or critical cases, so as to centers in the same country.

Diagnosis and management of cardiovascular diseases are just some of the areas where telemedicine is already developing, particularly for the benefit of cardiology. In contrast, “elective” cardiac surgery seems to be excluded from the benefits of e-health, although it is precisely in this particular field of medicine that we could reap the benefits of e-health. Cardiac surgery has taken a path of great renewal over the past decade; contrary to expectations of the beginning of the century, there has been a significant increase of total procedures (about 11%) ² and an expansion of therapeutic offer, with the introduction of percutaneous valve prosthesis, sutureless valve prosthesis, minimally invasive access techniques, and implantation of permanent circulatory assistance. The correct selection of the patient who can take advantage of these procedures is a key aspect to keep in mind, because it affects the surgical indication and it requires remarkable experience in the field. This approach has become widespread in recent times under the name of “Heart Team.” ³

In this context, the collaboration between the Department of Cardiothoracic Surgery at the German Hospital Klinikum Nuremberg–Paracelsus Medical University in Nuremberg, Germany, and the Network of Diagnostic Centers Artemisia Lab S.r.l. in Rome, Italy, fits a new scientific commitment. The purpose is to offer a service of teleconsulting cardiac surgery, both for patients and for doctors, on Roman territory, on the model currently applied in the territory of Nuremberg.

The aims of such cooperation can be summarized in the following points:

• Completing the diagnosis of the patient in the same institute, with the opportunity to consult, on the spot, a heart surgeon in case of surgical question.

Logistical support of consulting takes advantage of the electronic document transmission and of the videoconference with dedicated terminal. The videoconference will use the H.323 standard, which enables the end-to-end technology to ensure the security of communications. Videoconferencing is an essential element for maintaining a direct clinical contact (“face-to-face”) between doctor and patient, despite the distance. In this way, the surgeon may easily evaluate important aspects such as physical frailties or cognitive abilities.

The World Health Organization (WHO), through the resolution “WHA 58.28” of May 2005, ⁵ had recognized the importance of e-health more than a decade ago and has urged member states to adopt measures to promote its development. ¹ In Italy, at the meeting on February 20, 2014, the State-Regions Conference adopted the “National Guidelines on Telemedicine”, ⁶ drawn up within the Superior Health Council, in February 2011, to create a single national standard. Nevertheless, the global survey on e-health, conducted by WHO in 2015, ⁷ has not yet been able to locate telemedicine projects enabling to extend beyond the territory of the province (“intermediate level”). This project, with its features so far discussed, represents the first case in Europe, both in content (international teleconsulting focused on minimally invasive heart surgery) and the means used (videoconference). The success of cooperation between big cities is the prerogative for exporting the model, even in outlying areas. Our contribution aims to add value to the debate regarding advantages of telemedicine in new unexplored fields.