What is the future of cardiovascular surgery?


by Dario Remigi

The long-term future for cardiovascular surgery was discussed at the meeting of the European Society of Cardio-vascular Surgery (ESCVS) held in Warsaw, Poland, from 30 April-2 May. It emerged that even if cardiovascular surgeons may think that the transcatheter techniques are the “natural development” of traditional open heart surgery, what they really do not agree on is when changes will affect the specialty.

The second day’s longest and most controversial debate was polarised by Drs Gerhard Schuler and Matthias Thielmann’s presentation “Transcatheter valve implantation in PTS with aortic stenosis”, within the “Progress in cardiology and cardiac surgery” session. Data from the pair of the Heart Centre University of Leipzig, and of the West German Heart Centre in Essen – which has not been authorised for publication – showed that an important number of patients have been successfully treated by a joint team of cardiovascular surgeons and cardiologists. Their study may suggest that if extended in the future to other age groups and/or patient profiles, transcatheter techniques will be able to successfully treat an increasing number of patients now undergoing more traditional surgery. So, “What’s the future for the traditional cardiac surgery in ten years time from now?” asked Dr. N. Doll, Heart Centre University of Leipzig, Germany, interpreting increasing discomfort from the audience. Or – as some doctors more pragmatically confessed during the course of the day – how much work will cardiologists take away from cardiovascular surgeons in the future?

“Cardiovascular surgeons need to understand what patients really want,” Dr. Marko Turina, University Hospital Zurich, Switzerland, told Cardiovascular News. “Patients want minimally invasive procedures, minimal hospitalisation, no pain. There’s no doubt that all leading institutions are experiencing a reduction in the number of traditional surgery treatments due to the obvious advantages of minimally invasive and transcatheter procedures. Cardiovascular surgeons simply must accept this change. Either they will evolve accordingly, or they will disappear”.

“We have to recognise that the cardiovascular community is extremely defensive, especially these days, because it feels threatened by cardiologists,” added Dr. Patrick Perier, Herz and Gefaβ Clinic, Bad Neustadt, Germany. “But at the same time we have to face the fact that we are living enormous changes and the work of a cardiovascular surgeon is not the same that it was in the 19th century. I really don’t know what our work will look like in ten years time, and nobody does”.

But there are also those who, within the cardiovascular community, have opposite views: “I personally don’t feel threatened by cardiologists,” said Professor Roland Hetzer, Head of the German Heart Institute in Berlin. “And I doubt traditional cardiac surgery is experiencing any decline at all. Actually, I think cardiologists should feel threatened by me stepping into their territory: they could get unemployed soon if I start doing their job, because I can do something they simply can’t,” he added with a peaceful smile.

Cardiovascular surgeons at least agree about the complexity of the matter, which implies management policies across hospital departments, and a “strong reorganisation of the training in cardiovascular surgery”. Drs Omar Di Gregorio and Antonio Capo, Hospital Cardiac Surgery Department of Cuneo, Italy, explain why: “Dr. Turina’s idea to create ‘a new professional profile, the surgical interventionist, who will be competent both in open and percutaneous procedures’, is perfect in an ideal world. Unfortunately, in practical terms this would take 50 years in Italy and probably about the same in other European countries. Perhaps a better solution could be a hybrid team including cardiologists and cardiovascular surgeons, although this solution can be also very fragile: in a centre with a solid cardiology tradition, for example, the cardiology team will tend to phagocytise the cardiovascular team; and the other way round, in the case of a strong cardiovascular department”.

Meanwhile, during a session just one floor below, teams from all over Europe were presenting their transcatheter aortic valve replacement outcomes, ranging from “excellent” to “catastrophic”.

Poland was preparing to celebrate its Constitution Day when the last delegates left the convention centre. Walking through the adjacent Pilsudskiego square, delegates may have realised that the future of cardiovascular surgery remains uncertain.