Update In Cardiac Surgery

Harry J. D'Agostino, Jr., M.D.,

Assistant Professor of Surgery, Division of Cardiothoracic Surgery, University of Florida / Jacksonville

"A surgeon who tries to suture heart wounds deserves to lose the esteem of his colleagues."

Theodore Billroth, 1880

"Surgery of the heart has probably reached the limit 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."

Paget's Surgery of the Chest, 1897

How things have changed! In little more than a century, surgery of the heart has progressed from the early stab wound repairs of Ludwig Rehn and Luther Hill (the latter operating by oil lamp with the patient sprawled on a farmhouse kitchen table) to the modern day operations of coronary artery bypass, valve procedures, and congenital repairs. Once considered a potential death sentence, cardiac surgery is now routine and carries minimal morbidity and mortality. For example, the mortality for coronary bypass is less than 3% nationwide and the average hospital stay is less than five days.

The birthday of modern cardiac surgery is often considered to be May 6, 1953, when John Gibbon repaired an atrial septal defect in an eighteen year old girl using a cardiopulmonary bypass machine that he himself had developed over the preceding twenty years. Valve replacement surgery became possible by 1961 with the introduction of a "caged ball" prosthesis. At approximately the same time, a number of surgeons made the first serious attempts at coronary artery bypass. Cardiac transplantation, performed worldwide by 1970, was quickly abandoned because of difficulties with rejection, only to be resurrected in 1980 by the introduction of cyclosporine. This decade also saw the first long-term mechanical replacement for the human heart. In the 1990's cardiac surgeons began applying minimally invasive approaches to many types of cardiac disease. Surgeons also developed "off-pump" coronary artery bypass, performing this procedure without the benefit of their longtime companion, the heart-lung machine.

This issue of Jacksonville Medicine is devoted to some of the recent advances in cardiac surgery. The list of contents is far from complete, but represents some of the major areas of clinical expertise. Dr. Peter Seirafi discusses the most recent advances in coronary artery surgery, including arterial conduits, "off-pump" revascularization, and transmyocardial laser. I describe the vast array of options available for patients with valvular heart disease. Dr. Eric Ceithaml discusses one of the most difficult and challenging areas of cardiac surgery, congenital heart disease. Dr. Fred Edwards, who is one of the committee members of the National Database of the Society of Thoracic Surgeons, discusses the development of the Database and some of the methods of cardiac surgical risk assessment that are possible by analyzing its million-member patient population.

The progress of cardiac surgery has been accompanied by increasing technology, increasing patient demand, and, not surprisingly, increasing cost. This has occurred in an environment of increasing governmental and private scrutiny, with shrinking clinical reimbursement and research funding. Despite these hindrances, cardiac surgery continues to evolve. Indeed, the near future will bring us a "Star Wars" environment in which cardiac surgery will be performed by a surgeon seated at an operating console, linked to the patient by a complex array of computers, monitors, and robotic arms. Hardly science fiction, these systems are already in clinical use in a few centers and should become commonplace in the next few years.

October, 2001/ Jacksonville Medicine

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