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Mestres et al. Vessel Plus 2019;3:38 I http://dx.doi.org/10.20517/2574-1209.2019.20 Page 3 of 12
[25]
better safety, more effective and less traumatic oxygenators with superior performance , in-line filters of
[28]
all kinds [26,27] , hemoadsorbers and other complements that allowed safer conduct of cardiopulmonary
bypass for repair of cardiac disease.

[29]
[30]
The challenges in Cardiac Surgery are like the nine-headed Hydra . As highlighted by De Paulis , new
technologies, professional issues, educational differences, the changing profile of the cardiac patient, the
increased complexity, the trend towards reducing the surgical access and the booming of transcatheter
techniques and technologies over the past couple of decades, have designed a complex scenario that can
only be addressed with imagination and adaptive willingness.

Where does the Frontier lie? Although individual opinions can be challenged by many, the frontier is
related to our understanding of what we used to neglect.

IMAGING
Imaging has evolved in the years from a diagnostic tool to an alternative to direct vision; today imaging
is critical in all phases of patient handling: from diagnosis, to stratification, indication, planning,
intraprocedural guidance and follow-up. Intraprocedural imaging is the eye of the modern surgeon for
guidance of endovascular procedures.

The impact of conventional imaging
The developments in imaging over the past three decades have substantially modified our approach to
the disease and the patient. What currently are conventional plain X-rays were impactful over hundred
[31]
years ago as radiology allowed the physicians to see things that no one could imagine . Diagnosis
improved, accuracy allowed for better delivery of care. Arteriography [32,33] allowed surgeons to identify and
understand the anatomy of lesions amenable for surgical therapy. And this applied to each and every vessel
in the body.

The ultrasound - echocardiography - quality
In the field of Cardiology and Cardiac Surgery, echocardiography developed in a way that it currently
plays the same role EKG used to play for decades, namely a foundational examination to support
[34]
a clinical diagnosis. The introduction of M-mode echocardiography in 1954 by Edler and Hertz
represented a breakthrough in diagnosis in Cardiology. Later, two-dimensional echocardiography
improved the ability to make the interpretation of cardiac valvular anatomy for better characterization of
structural competence. The introduction of the Doppler effect in echocardiography, by Hatle [35,36] paved
the way for echocardiography to become the major diagnostic tool in future Cardiology and Cardiac
[37]
Surgery. Further refinements like transesophageal echocardiography in 1976 and more recently the
[38]
3D-echocardiography anatomical description have confirmed the critical role of echocardiography in the
assessment of valve disease and cardiac function. Even 3D echocardiography has eveloved in rapid steps
to full volume with best frame rate without and even with color Doppler sonography. Computer progress
made it possible that we can see double volumes from the same data set, visualizing the mitral valve
from the left atrial side and from the left ventricle side at the same time, without stich artifacts. Machine
learning is helpful for performing anatomical models from the 3D data set and do multiple measurements
by itself with a fantastic reproducibility.

Echocardiography has also played a significant role in improving the quality of Cardiac Surgery. Surgeons
and cardologists have improved their standards by incorporating echocardiography in their practices.
Unfortunately, it took long for surgeons to adopt this tool as part of the daily activities. Surgeons
understood the value of echocardiography, however, little was done for long time to include it in the
training programmes. As echocardiography is not only a preoperative diagnostic tool but also a critical