Heart surgery: yesterday, today and tomorrow

Abstract

For a long time the heart was considered outside the limit of Surgery. In 1881 Theodore Billroth, one of the leading surgeon in the world had remarked that: "any surgeon who dared to operate on the heart would lose the respect of his fellow surgeons".

In 1896, the usually perceptive British historian Stephen Paget wrote: "Surgery of the heart has probably reached the limits set by nature to all surgery; no new method, and no new discovery can overcome the natural difficulties that attend a wound of the heart".

However, things started changing in the late 19th Century. Through the work of brave surgeons and other health workers who risked their careers and reputation and their patients who risked their health and lives, heart surgery developed at a fast pace and has advanced to a stage where even the complex procedures do not make news any more.

Development of products and processes in related fields aided the rapid progress in heart surgery. These include development of intubation anesthesia and modern anaesthetic drugs that made positive pressure ventilation possible. The development and introduction of synthetic, monofilament, non-absorbable sutures such as prolene in the 1960s made vascular anastomoses on both small vessels such as coronary arteries and large vessels including the aorta possible.

The discovery of the immuno-suppressive drug Cyclosporin dramatically improved survival after heart transplantation.

All these have facilitated significant advances in cardiac surgery as we know today.

Heart surgery has become very routine. There has been advances in equipment, such as the use of robotics and development of assist devices for the failing heart as well as improvement in techniques such as minimally or non-invasive management of valve replacement, aortic aneurysms, coronary artery disease and congenital heart repair.

In spite of all these developments, there will continue to be coronary bypass and valve surgery, arrhythmia ablation, heart failure procedures, and endovascular treatment of aneurysms as well as repair of congenital heart disease.

What will be debatable is who do perform the different procedures. The lines of division amongst cardiac surgeons, interventional cardiologists and interventional radiologist are blurring.

The important question in medium to short term will be about the timing of service-line integration and who will do what procedures to which patients. This calls for a close look at the concept of the heart team that calls for complete and close collaboration among clinical cardiologist, interventional cardiologists, cardiac anesthesiologists and cardiac surgeons, the nursing team to achieve the best results patients.

In the area of transplantation the question will be whether devices can be developed and miniaturized that will replace the function of the heart on long term basis or whether gene editing and gene manipulation and introduction of human genetic material into suitable animals, such as pigs, will allow those animals’ to produce transgenic hearts that can be transplanted into human with any rejection reaction.