The work of Dr. Christiaan Barnard was one of the most influential factors inspiring me to pursue medicine with the goal of becoming a heart surgeon. Pioneering heart surgeon Dr. Denton A Cooley shared his opinion about the impact that the first heart transplantation had on the field of cardiac surgery, »But none were, or ever will be, in my opinion, as spectacular as the first human heart transplantation reported from Capetown, South Africa, in December 1967. This event made Dr. Christiaan Barnard one of the best known figures in the world.(1)
Truly the 50s and the 60s were pioneering for cardiothoracic surgery, with novel utilization of cardiopulmonary bypass, valve replacement, and coronary artery bypass graft surgeries (CABGs). Reading about cardiothoracic surgery in its infancy takes over my imagination. That being said, it is important as a medical student to remain ambitious, always inventing the future of ones prospective field. In what manner then, can I give importance to the past while forging forward?
Looking at the field of cardiothoracic surgery today, it is evident that much has changed. In my eyes, the excitement of the field is no longer as apparent, as this branch of surgery has become relatively routine. Further, the fast progress of percutaneous therapeutic methods is lessening the need for cardiothoracic surgery. Balloon angioplasty emerged in the late 1970s and percutaneous coronary intervention (PCI) is already the procedure of choice in treating coronary artery disease (2). PCI is the main cause for the declining number of CABGs, which represents the major source of income for heart surgeons (3). Without it, a career in heart surgery can be unstable. The number of CABG operations decreased by 28% between 1997 and 2004, while the number of cardiac stent placements increased by 121% in the USA (2).
At the EACTS (European Association of Cardiothoracic Surgery) symposium for the Future of Cardiac Surgery a small survey of 50 invited CT surgeons was taken; 90% agreed to placing a stent rather than CABG for their own hypothetical care. This shows that even surgeons admit the importance of the PCI in treatment of coronary disease (4).
Alongside, and perhaps as a result of this progress, there have been a declining number of applicants for cardiovascular surgical fellowships. There were only 100 applicants for 132 fellowship positions in 2007 in the USA (2). Three years later, only 88 positions were filled out of 113 positions (3). In addition, the number of practicing cardiothoracic surgeons fell in 2003 for the first time in 20 years (2).
An article published in Circulation claimed that a shortage of cardiothoracic surgeons is likely by 2020, while a demand for these specialists could increase by 46% (2). Are we facing the dusk of the field or are there still many opportunities in cardiac surgery?
Minimally invasive cardiothoracic surgery is already a well established practice and an alternative to traditional surgery (5). Robotic aids were introduced into the field at the beginning of the new millennium and currently the following procedures can be performed by minimally invasive surgery: mitral valve repair and replacement, aortic valve repair, atrial septal defects repair, coronary artery bypass, removal of cardiac tumors, and ablation of atrial fibrillation (5,6).
The benefits of this type of surgery are numerous. Improved cosmetic result is the most obvious advantage. In addition, because median sternotomy is avoided keeping the breastbone intact, trauma and postoperative pain are greatly reduced thereby improving quality of life and reducing hospital stay. On the other hand, patients are still exposed to the usual surgical risks such as bleeding, infection (5).
Apart from these ‘classical heart surgery operative targets’ there are at least two important fields where heart surgery will play an important role. First is in the treatment of advanced heart failure. Around 5 million Americans are affected with this syndrome (3). The chronic shortage of organs for organ transplantation has led to a search for mechanical circulatory support. Currently, some research focuses on designing new ventricular assistance devices that may serve not only as bridge for transplantation, but also, a permanent treatment for patients with failing hearts.
Second, atrial fibrillation (AF) is the most common cardiac arrhythmia (7). Surgical ablation may provide an efficient therapeutic approach in patients with medically refractory AF and in patients undergoing cardiac surgery for other pathology who have concomitant AF (7).
We can further expand the list. Some congenital heart defects such as hypoplastic left heart and complete transposition of the great arteries are large operative challenges and will remain in the surgical domain. However, pediatric heart surgery will probably be centralized in a few small centers.
On the other hand, cardiology has become more invasive. Coronary artery disease, valvular, and aortic disease can often be treated with a transcatether approach. Aortic valve replacement used to be completely within the surgical domain; however, since 2003, when first transcutaneous aortic valve implantation (TAVI) was performed, things have changed (8). For now, this method is reserved for high risk patients, but with improvement in technology, we can expect indications to expand further.
Cardiac surgeons responded to TAVI by developing sutureless valves. With this technique, operating time and cardiopulmonary bypass time is shortened, which importantly lessens the invasiveness of surgical treatment. In addition, aortic valves can be replaced through mini sternotomy or thoracotomy.
Endovascular procedures are taking over the care of some aortic pathologies as well (9,10). Over the past few years there have been significant developments in stent-graft technology. Endovascular treatment is an alternative approach to open surgery repair for aortic dissection type B, thoracoabdominal aortic aneurysm and abdominal aortic aneurysm (9,10).
From this, we can conclude that conventional open heart surgery is changing dramatically. In my eyes, the future lies in the formation of one specialty combining cardiology and cardiac surgery. Heart-teams are already being established today. More and more hybrid operating rooms are built-up in hospitals worldwide. The need for the formation of the heart team concept arose from the development of many new devices and approaches for the treatment of cardiovascular disease. To provide the most optimal care the following hybrid procedures can already be performed for the following realms: coronary artery disease, atrial fibrillation, complex aortic pathology, combined carotid and coronary artery disease, valve surgery with PCI, and even congenital heart disease (8). The possibilities are numerous.
Sources:
1. Denton AC: Reflections and observations : essays of Denton A. Cooley ; collected by Marianne Kneipp. Austin, Tex. : Eakin Press, 1984
2. Grover A, Gorman K, Dall TM et al.: Shortage of Cardiothoracic Surgeons is likely by 2020. Circulation 2009 120:488-494
3. Weisse AB: Cardiac Surgery: A Century of Progress. Texas Heart Institute Journal 2011 38 (5): 486 – 90
4. Monro JL: Closing remarks: EACTS Symposium for the Future of Cardiac Surgery . European Journal of Cardio-thoracic Surgery 26 2004: S86-S87
5. Iribarne A, Easterwood R, Chan EYH et al.: The golden age of minimally invasive cardiothoracic surgery: current and future perspectives. Future Cardiol 2011 7(3):333-346
6. Chitwood WR: Robotic Cardiac Surgery by 2031: Texas Heart Institute Journal 2011 38 (6): 691-93
7. Robertson JO, Lawrance CP, Maniar HS et al.: Surgical Techniques Used for the Treatment of Atrial Fibrillation. Circulation Journal 2013 77: 1941 – 51
8. Leacche M, Umakanthan R, Zhao DX et al.: Hybrid Procedures, Do They Have a Role ? Circ Cardiovasc Inter 2010; 3:511 – 18
9. England A, McWilliams: Endovascular Aortic Aneurysm Repair (EVAR). Ulster Med J 2013;82(1):3 – 10
10. Hughes GC: Endovascular Repair Will Be the Best Option for Thoracoabdominal Aortic Aneurysm in 2020. Texas Heart Institute Journal 2012 39 (6): 834 – 35
Featured image: Provided by Aleksander Garvic