Is Cardiac Surgery Threatening to go the Dinosaur Way?

Eons ago, surgery was developed to tackle day-to-day health issues such as bleeding, extraneous growth, a broken limb, or “have a look into” the abdomen/the cranium. Over the next centuries, surgical specialties matured, and subspecialties sprang up. Examples include specialties such as general abdominal surgeries, orthopedic surgeries, obstetrics, gynecology, and brain and spine surgeries, which have survived and grown over centuries. They are now here and forever. General surgeons carried out thoracic surgery and rare cardiac surgeries on similar grounds. However, in a strict sense, cardiac surgery using cardiopulmonary bypass is a recent specialty. It was “born” only in 1953 and is going through its “adolescence” by professional maturity timelines.[1] Cardiothoracic and vascular surgical specialty made spectacular growth for 3–4 decades in terms of the number, type, and innovation. The spectrum of cardiac surgeries ranged from closed heart surgeries, to begin with; subsequently, open heart surgeries became standard with better access to the inside of the heart in a stopped heart situation. Over time, cardiac surgeons performed extraordinary procedures using cardiopulmonary bypass, circulatory arrest with deep hypothermia, endoscopic surgery, robotic surgery, and nowadays into, mechanical cardiac support for failing hearts. Advances in technology have fueled this astonishing growth in cardiac surgery. Improvements in artificial valves, oxygenators, grafts, sutures, epicardial stabilizers, endoscopes, and 3-D imaging propelled the first 40–50 years of growth. In the early 2000s, the innovation seemed to dry up after supporting off-pump coronary artery bypass surgery. At the same time, the percutaneous procedures by our cardiology colleagues seemed to suffocate cardiac surgery. “Cardiac surgery has been described as a dying specialty, with the astronomical growth of the field becoming overshadowed by its impending decline. The increasing use of less invasive methods is shifting the landscape from open surgery to interventional techniques already dominated by other specialties.”[2] The “less invasive, less morbid, pain-free, short stay” percutaneous coronary (cardiac) interventions performed typically under local anesthesia appeal instantly to patients. The cardiologists brought various percutaneous interventions, ably supported by the industry and proctors. Innovations that hitherto happened to cardiac surgery seemed to have shifted the arena to cardiology. The number of interventions exponentially increased, and every intervention cost cardiac surgery. Many cardiovascular procedures include closed mitral valvotomy, patent ductus arteriosus, aortoplasty (treatment option for coarctation of the aorta), pulmonary valvuloplasty, aortic aneurysm stenting, peripheral vascular angioplasty, closure of atrial septal defect tackled surgically hitherto, went under the hammer of percutaneous interventions. The cardiologists meticulously showed evidence of equality, if not superiority, of percutaneous coronary (cardiac) interventions (PCIs) to coronary artery bypass graft (CABG) surgery/valve replacement.[3] The cardiologists self-prescribed PCIs after performing the diagnostic coronary angiogram. Consent to PCI, which logistically appeared to be continuity of care, was more straightforward and acceptable to the patients. In contrast to CABG surgery, an angioplasty was more readily acceptable to patients due to the lack of surgical pain/anesthesia/organ dysfunctions (such as acute kidney disease/neurological problems likely to be caused by the use of cardiopulmonary bypass) and surgical scar. Percutaneous valve procedures were initially prescribed for patients who could not tolerate cardiopulmonary bypass. Patients considered unmanageable by PCI were referred for surgery. However, recent data shows they are suitable for even low-risk patients. Thus, cardiac surgeons now handle either patients with poor ventricular function or poor target vessels of hemodynamically unstable patients or repeat surgeries. And this told on their outcomes. This was the inflection point at which the surgical specialty could have brought innovations and shown evidence about the long-term results of bypass surgery. The cardiac surgeons did not expect slowing down/cessation of the never-ending stream of coronary artery bypass graft surgery, but it did. A young specialty led by innovation and data started losing steam. The only arena yet untouched by percutaneous interventions seems to be the extracorporeal membrane oxygenation (ECMO), right/left ventricular assist insertion, cardiac transplantation, and correction/palliation of complex congenital heart diseases in the pediatric age group or grown-up adults. Many cardiologists are already bridging heart failure with destination therapy with mechanical support. It may only be a matter of time before the miniaturized percutaneous insertion of heart support devices arrives. If it does, even that aspect of cardiac surgery will go under the percutaneous intervention category. The switch to these less-trodden areas could have been automatic but was fraught with financial/infrastructural/manpower/outcome issues. The hitherto practiced “bread and butter” surgeries got far and few. The newer areas were phenomenally expensive and logistical difficulties prevented their growth as the procedure to bank on. Therapies for heart failure remain underexplored. Procedures other than heart or lung transplant options remain logistically challenging. Assisted device-led therapy for heart transplants remains prohibitively expensive. Young surgeons are less inclined to pursue cardiac surgery as a profession. It is common knowledge that postgraduate seats in cardiac surgery go a-begging even in prestigious national-level institutes. The decrease in the takers for postgraduate training in cardiac surgery has been attributed to various factors: reduced remuneration, many years of training before one could settle down, and the diminishing presence of cardiac surgery on the radar of surgical specialties.[4] Forming a “heart team” was suggested as a bailout strategy.[5] Young cardiac surgeons have published debates about how cardiac surgery continues to be interesting.[6] It is also predicted that the borders between cardiology and cardiac surgery may disappear, and the two specialties would merge.[7] Cardiac anesthesia has followed cardiac surgery in tandem. In our country, professionals practice only or primarily cardiac anesthesia in contrast to our counterparts in the west, who also managed many specialties and cardiac anesthesia. A typical Indian cardiac anesthesiologist practiced with alacrity state-of-the-art invasive monitoring line insertions, cardiac output monitoring, use of cell saver, mechanical support (IABP), and diagnostic tools such as transesophageal echocardiography (TEE), which essentially were novel to “non-cardiac” anesthesiologists. With the trajectory of cardiac surgery plateauing, apprehension seems to be setting in among young doctors pursuing cardiac anesthesia. The cardiac anesthesiologists who realized the downtrend of the cardiac surgical numbers quickly adopted other specialties. Their ability to manage medical conditions such as heart failure/arrhythmias/low cardiac output made them preferred anesthesiologists in other specialties. This leads us to the logical question—What next? As Charles Darwin said, it is not the most intellectual or the strongest of the species that survives; but the species that survives is the one that can best adapt and adjust to the changing environment in which it finds itself. Cardiac surgeons must look at technical advancements that would make it comparable to the ease and benefits of PCIs. Percutaneous interventions are here to stay. Cardiac surgeons could alternately look at conducting surgeries on thorax/blood vessels, which most cardiac surgeons have given up. Other endoscopic procedures—bronchoscopy, thoracoscopy, pleuroscopy, and mediastinoscopy are other low-hanging fruits, which cardiac surgeons could conduct with ease. Additionally, conducting these investigations/surgeries could complement their diagnosis and treatment. The cardiac surgical training syllabus could include PCI procedures. This will entail conducting these procedures in the cardiac catheterization labs. It is said that up to 30% of ad hoc percutaneous coronary interventions are performed in patients who would have benefitted from coronary artery bypass.[8] Such instances could be prevented and the patients could get what they truly deserve. As an add-on, other PCIs, such as coronary artery stenting/aortic grafts/transcutaneous aortic valve replacement, can be performed. This practice already exists among vascular surgeons who do the percutaneous vascular interventions themselves. 83% of the respondents in a survey agreed that residents trained in cardiac surgery should be modified to add at least one extra year of catheterization laboratory procedures, including coronary, valvular, aortic, and arrhythmia, thus introducing the interventional surgeon.[9,10] Yet another surgical opportunity that is perhaps underutilized is harvesting hearts/lungs from deceased donors for teams from other hospitals/cities. Currently, surgeons from one city travel to another by whatever means and harvest organs for their use. Existing cardiac surgeons in the donor city could proxy harvest organs. This would be a win-win formula for the transplant team and the country’s program in general. Minimal invasive surgeries are conducted to make surgery less painful and more cosmetically attractive. They not only minimize the size of the incision but also enhance recovery. Robotic cardiac surgeries are contemplated citing less pain, smaller incisions, and shorter length of stay as benefits. This, however, remains controversial.[11] Cardiac anesthesiologists, on the other hand, could complement the surgical work and take up additional responsibilities involving the management of intensive care units, and initiation and maintenance of extracorporeal membrane oxygenation (ECMO). As an extension of this initiation of ECMO in peripheral cities, the transfer of ECMO patients to the higher center is yet another opportunity. A ready option for anesthesiologists is, of course, to anesthetize non-cardiac surgical cases. They could also use their echocardiography knowledge by conducting TEE clinics to assess cardiac anatomy and function. This privilege will be available to those certified by relevant bodies who assess the efficiency of professionals. The anesthesiologists could use their vascular cannulation, sonoanatomy, and resuscitation skills by leading the extracorporeal cardiopulmonary resuscitation team within and outside the healthcare facilities. Extracorporeal-supported cardiopulmonary resuscitation shows promise in improving outcomes after witnessing cardiac arrest. It is often frustrating for the organ transplant team to note that improper hemodynamic management of potential donors renders them unsuitable donors. Being in and around potential donors, cardiac anesthesiologists could also take charge of donor resuscitation. Many cardiac surgeons and anesthesiologists are diversifying their practice. It is premature and erroneous to assume that cardiac surgery and anesthesia would soon go the dinosaur way. While the growth of surgical specialties is conventionally assessed on the yardstick for several centuries, assessing cardiac surgery by its existence for fewer than seventy-five years has been doing it an injustice. Considering that the world is going through an epidemic of heart failure, technological innovation in heart failure/transplantation would certainly soon put cardiac surgery back on a pedestal.[12,13]