Trusted Leader - September 2007
By Denton Cooley, MD
When I graduated from medical school in 1944, surgical treatment of cardiac and major vascular disease was limited to sporadic operations undertaken mainly in cases of trauma. Many surgeons still considered the heart to be the seat of life and, therefore, a sacrosanct organ off limits to the scalpel.
In my opinion, the historic first "blue-baby" operation performed at Johns Hopkins Hospital on Nov. 29, 1944, marked the dawn of heart surgery. As an intern at Johns Hopkins, I was fortunate to be able to participate in that operation.
Designed by Dr. Helen Taussig and performed by Dr. Alfred Blalock, it relieved tetralogy of Fallot by joining the subclavian artery to the pulmonary artery. This procedure stimulated widespread interest in the repair of congenital and acquired cardiac lesions. It also inspired cardiologists to develop precise diagnostic techniques that would make surgical treatment more direct and effective. Other advances in heart surgery were made possible by battlefield experience gained during World War II.
Until the advent of a usable heart-lung machine in the 1950s, surgery on the heart and major vessels was performed while the heart continued to beat. To attempt intracardiac repairs or replacement of diseased aortic segments, surgeons needed to be able to stop the heart. Suitable pumps for circulating the blood were already available, but the challenge was to develop an efficient oxygenator.
A major breakthrough occurred in 1954, when open heart surgery for congenital anomalies was first accomplished with temporary cross-circulation, using one of the patient's parents as a living oxygenator. Gradually, mechanical oxygenators were developed, and open heart surgery using temporary cardiopulmonary bypass became routine.
During the 1950s and 1960s, every part of the heart became amenable to repair. Prostheses were developed to replace cardiac components when repair alone was not sufficient. These substitutes included fabric grafts for replacing cardiac septa and major vessels, as well as prosthetic valves and implantable pacemakers.
During this period of growth and expansion, cardiovascular surgery acquired a glamorous aura; many young physicians were attracted to this field and eventually became its leaders. With time, total replacement of the failing heart with a transplanted heart or a mechanical pump became possible. This development caused the medical and legal professions and the public at large to redefine basic notions of what constitutes life and death. More recently, use of mechanical assist devices as bridges to cardiac transplantation or to recovery has become common.
In the late 1970s, the introduction of percutaneous balloon angioplasty and other interventional catheter techniques gave cardiologists a prominent role in the treatment of heart disease. Later, laparoscopic surgery, performed with special video instruments, ushered in a new era of minimally invasive procedures, done through so-called keyhole incisions. This approach avoided the relatively large incisions necessary for traditional surgical access. As a result, attention was drawn away from conventional techniques using direct vision toward endovascular procedures done by nonsurgical personnel.
Because these procedures are performed on the beating heart without the use of cardiopulmonary bypass, cardiac surgery appears to have come full circle. The current emphasis is on accomplishing the best result through the smallest portal of entry. This approach is attractive to patients because it speeds recovery and reduces scarring.
The trend toward minimally invasive techniques has had a major impact on the practice of cardiovascular surgery. Many procedures such as coronary artery revascularization, valve repair, and aortic aneurysm repair - which used to account for a large volume of surgical practice - are being done by cardiologists, who have now become interventionalists. They provide not only diagnosis but also direct treatment with catheters, balloons, and stents. A turf war has arisen between surgeons and cardiologists and radiologists, and it promises to increase. Time alone will prove the relative effectiveness of the newer techniques.
To a great extent, today's cardiovascular procedures require the participation of many specialists and an unprecedented degree of interdisciplinary cooperation. For instance, selected patients are treated in special hybrid suites that combine the advantages of a catheterization laboratory and a fully equipped operating room. Because of the increased need for a team approach, individual physicians are less likely now to achieve superstar status than they were several decades ago.
More Surgeons Needed
Those of us who have spent our careers as educators have recently noticed a serious decrease in applicants to many cardiothoracic training programs. Currently, there are fewer than 4,000 cardiothoracic surgeons in the United States. Because of the recent changes in this field, current applicants to training programs may be confused about the requirements. In particular, the number of additional years of training - specifically in off-pump coronary revascularization, valve surgery, and management of high-risk patients - that will be necessary to meet future needs is a matter of debate. To help trainees assess their future opportunities, the curriculum for this specialty must be modified and updated. Today's cardiovascular surgeons must encourage coming generations to enter our specialty, to prepare for the new requirements, and to devote themselves to patient care.
During the 20th century, the average life expectancy in Western nations was increased by almost 30 years because of advances in medicine, surgery, and public health. Now that acute diseases are generally well controlled, the greatest challenges are chronic, lifestyle-related conditions such as heart failure, stroke, cancer, and obstructive pulmonary disease. The goal of 21st-century physicians is to increase both the length and the quality of life, especially in the elderly. As the average age of America's population continues to increase, surgeons who are well trained in cardiovascular techniques will remain essential to health care.
As Robert Louis Stevenson stated a century ago, medicine is man's most noble profession, and it can be expected to maintain this exalted status. Whatever the future may bring, we can be sure that cardiovascular surgeons will continue to play a major lifesaving role. Future breakthroughs may be less sensational than in the early days of our specialty, but they will be equally important and meritorious. Much territory still lies ahead for cardiac pioneers to explore, and many exciting discoveries remain in store.
Dr. Cooley is president and founder of the Texas Heart Institute in Houston.
Editor's Note: This is the first in a series of essays by physicians who are members of the Texas Medical Association Fifty Year Club. The club has asked its members to share their reflections on medicine and how it has changed over the years.