Cardiac Surgery Falling Back or Springing Forward

Cardiac Surgery Falling Back or Springing Forward

Cardiac Surgery Falling Back or Springing Forward

It has been my recent pleasure to attend two very interesting but separate meetings in cardiothoracic surgery. During my time at the meetings I was fortunate enough to speak to many other surgeons and was surprised how many of my concerns spanned international borders. It lead me to think that there may be some purpose in putting together thoughts that materialised out of some of those discussions. This is not in anyway meant to hurt any individuals and if it does, I hope I can start by apologising for it.

As a surgeon born after the first heart transplant was carried out there was no way of growing up unaware of the giants that seemed to propel this amazing speciality forward. To some extent this awe of the speciality partly made me steer clear of a posting in it as a medical student. Strange circumstances lead me into this speciality and having fallen in love with it since the first day I was allowed to cradle a beating heart in my hands, I still believe that this is probably one of the most rewarding jobs available today. If that is the case why are we struggling to attract youngsters to our speciality? I am aware that the speciality and many of the senior surgeons in it are jaded and confused as to what the future turn of events will have in store. Are we a speciality in terminal decline or are we just a group in the wilderness needing redirection to a better future?

Percutaneous Coronary intervention (PCI) is considered by many in the speciality to be the single intervention that started this steady decline in fortunes and stature of Cardiac surgery. I completely disagree. I think this will be looked back at some later time as the moment our speciality was forced to move from complacency to innovation. As much as I agree with Professor Taggart and his evidence collation against the widespread use of PCI, the real drivers of this “disruptional technology” are often patients rather than cardiologists. We have to understand one basic tenant of public psychology. As Steven Lewitt describes it in his bestseller Freaknomics; Percieved Risk = Hazard X Outrage.
The hazard of PCI and Surgery is often the same in most randomised studies. The stroke, heart attack and death rates are very similar in the short term. As the author suggests we have the option of changing things by either highlighting the hazard risk of PCI in the short to medium term, or inflating the outrage that goes with complications that occur. This was what happened with drug eluting stents last year. Despite this, patients will perceive surgery to be more risky because of the outrage that the idea of surgery creates in the mind. To understand what specific aspect influences the outrage most, I have spoken at length to patients in different countries. The common three issues come up most often, sternotomy or “splitting of ones chest”, the saphenectomy or “the big cut up the leg” and general anaesthesia for its “loss of control”. If we are to win the battle of risk perception, we as a group have to approach each of these systematically and increase the percentage of our patients who can avoid one or all of these violations.

I am amazed that 13 years after the original papers regarding Off pump surgery we are still debating this issue at international meetings. This must mean only one thing. Off pump surgery is not the disruptive change we had all hoped for. I remember attending a breakout session some years ago that was titled “OPCAB or Pension”. I attended it to find out if they were talking about the impact of OPCAB on the surgeon or the patient. I left unsure. There is no doubt that for a group of patients, OPCAB is excellent. Most of the benefits seem to be related to the lack of aortic manipulation. Some benefits are gained in avoiding cardioplegia. But I do not think that bypass itself is as detrimental as it was initially considered. I must confess that I shared the initial enthusiasm for this procedure but it has not shown the wide-ranging benefits we all hoped for. Certainly I do not think patients the next morning after surgery can tell you if they had their operation on or off pump. They certainly can if you do or don’t do a sternotomy. I applaud the many surgeons who are able to do closed chest OPCAB. These are probably surgeons akin to Dr Kolesov and Dr Lillehei. They did procedures that will not be applicable to the wide majority of patients across the world. It was cardiopulmonary bypass that made this speciality what it is today. Trying to avoid it was a great idea but we need to now regroup and pick the lessons learned from this experience and try and apply it to closed chest procedures. We need to use the stabilisers, the use of bilateral mammaries to avoid manipulating the aorta, use shunts to protect from regional ischaemia and think of many other ways to improve the patient experience. We need to continue to use better and smaller bypass circuits to avoid the dreaded but rare, unpredictable pulmonary complications that sometimes follows, even the shortest of pump runs. Most importantly we need to partner with industry in making the technology available to do this safely in the hands of many surgeons.

The next challenge we face as a speciality, is the lack of multicentre trials to answer important questions that would benefit patients. We need to collaborate more and learn from each other rather than give the impression of creating competing techniques with minor differences. We need to understand that competing procedures need to exist alongside rather than have to replace each other. We need to learn the lessons learnt by religion and recently by food experts that one size does not fit all. As a group we need to get better at picking the right case for the right patient and stop preaching blanket therapies. Medicine has got too complex for simple answers.
The case of Atrial fibrillation management is case and point. Instead of using techniques with 60-70 % results (however minimally invasive) we must support cardiologists in their efforts but offer a complete left and right-sided procedure on bypass through a right mini thoracotomy as the fall back. We must not peddle half cures for the sake of numbers. Our house was made on the back of excellent results and that reputation must be protected even at the expense of a possible reduction of volumes. We must learn from cardiologists how to standardise procedures so that trials can be carried out to answer important questions quickly. If a procedure is too complicated to be reproducible we need to put our best minds to make it simple. I am reminded of a basic science researcher who once commented that if a trial result could not be replicated in basic science the original author would be full of shame but in surgery, the first author, would be filled with pride. Sure some surgeons are amazing and I have had the good fortune to work with a few of them. Sadly if we are to get the next generation interested in our speciality we will have to embrace technology to make most cardiac surgery safely reproducible in hands of surgeons interested in a healthy work life balance. The challenge we face as a speciality is not to dumb down training but to rise to different ways of training and working together.

Finally I would like to say that we presently are starved of visible role models in our speciality. Growing up we were always aware of Cardiac surgeons in the popular media. Their struggles for success, against all hardship was covered by the popular media and that lead to an interest from young bright kids who wondered if they would grow up into astronauts or cardiac surgeons. With improving technology making robotics, destination ventricular assist devices, and minimally invasive valve surgery a reality, we have another opportunity to interest the public in our efforts to improve our already excellent results. It is indeed hard to learn new procedures without a learning curve. But it is being done all around us. As a speciality we need to capture the imagination of our future trainees. We need to continue to attract the most talented to secure the future of this speciality. I have been exposed to some fine role models in this speciality, as a group we need to increase our profile in medical schools and junior doctor training programmes. I was recently asked to speak to a bunch of medical students about the future of cardiac surgery. I was surprised as to the knowledge and interest many of them showed to the speciality. The interest is out there. It is upto us in the speciality to reinvigorate it and share with the future generation the huge potential that this amazing speciality has and let others realise the many gifts it gives each one of us.

Mr Joseph Zacharias is a Consultant Cardio-Thoracic Surgeon who over the past 18 years has introduced many patient centred procedures and reviewed, presented and published his excellent results. He is passionate about teaching and training and continues to help disseminate his learning and skills to doctors at all levels of training. Mr Zacharias has one of the largest experiences in endoscopic heart surgery in the UK and continues to maintain a busy practice in both complex heart and lung surgery.

Contact

Consultant Cardiothoracic Surgeon | Joseph Zacharias

Alexandra Hospital Mill Lane, Cheadle, Manchester

0161 5273832

info@josephzacharias.com

www.josephzacharias.com