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Eur J Cardiothorac Surg 2004;26:1063-1072
© 2004 Elsevier Science NL
EACTS Presidential address |
Wessex Cardiothoracic Centre—Mailpoint 46, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
* Tel.: +44 2380 796241; fax: +44 2380 796614. (E-mail: monro1711{at}aol.com).
It has been a very great honour and climax to my career to serve as President of this Association and I would like to thank you for trusting me with this responsibility. It is always nice to be associated with success, and the birth and formative years of this Association have been an undoubted success, as can be seen from the increasing attendance at the Annual Meeting (Fig. 1).
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Foreseeing the future is an art. One can get quite a good idea from past trends, but we have to adapt and do the best we can, and this is our next challenge. Undoubtedly one of the major changes that has already occurred and will affect us more in the future is the reduction in coronary artery surgery. The increasing use of stenting by the cardiologists, and particularly with drug eluting stents, has resulted in fewer patients with coronary artery disease being treated primarily by surgery (Fig. 2). I say primarily because as coronary artery disease is a progressive disease, these patients will develop further stenoses and many will eventually come to surgery.
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In addition to this assault on our previous territory of coronary arteries, it looks as though the cardiologists are entering the valve business too. Percutaneous mitral valve repair is already possible, using a stitch in the Alfieri fashion to create a double orifice valve [2]. Although still in its beginnings, it is quite possible that within the next 5 years, a large proportion of mitral valve repairs will be performed like this. Also percutaneous aortic valve replacement with tissue valves mounted in stents seems a distinct possibility and this technique has also been used successfully in the pulmonary region [3]. Although the aortic valves we currently replace are mostly heavily calcified and one would have thought unsuitable for this percutaneous procedure, there are methods of removing the calcium percutaneously being developed and it is therefore quite possible that cardiologists will be replacing a significant proportion of aortic valves within 10 years.
The cardiologists have also made inroads into the practice of congenital cardiac surgery, with devices to close atrial septal defects, ventricular septal defects and ducts. They are also doing balloon dilatation of valves, coarctations and pulmonary arteries with or without stenting. However, because of the increase in adult congenital heart surgery, the total work of the congenital heart surgeon is likely to remain about the same.
It may not only be cardiac surgeons who are affected, because if a cure or major change in management comes for cancer, the thoracic surgeons' practice may change.
The cardiologists are the gatekeepers, and the patients get to them first. So most patients will be treated by the cardiologist if possible and only passed on to the surgeon if not. Furthermore it is very unlikely that the cardiologists will let us into their catheter laboratory to do angiography, let alone stenting. The cardiologists offer a ‘quick fix’ and may accept a less than complete and perfect result, whereas the surgeon probably performs a more long-lasting procedure. However, during our symposium, I asked if the surgeons present would have a stent rather than surgery in the right circumstances and 90% said yes. So we must do the best for our patients, and if a more minor stent procedure will produce a good result then we should not recommend surgery just because we want something to do. If a patient can get a satisfactory result without his chest being split open, and be back at work a few days later, then this is in his interests.
So history may be repeating itself, when tuberculosis was waning because of the advent of streptomycin, thoracic surgeons found something else to do, namely cardiac surgery. So we in turn should find something else to do.
There are large numbers of people with atrial fibrillation, many of them with coincidental cardiac disease. It would seem sensible for anyone coming to operation with coincidental atrial fibrillation to have a ‘Maze’ type of procedure at the same time [4]. For the patients with isolated atrial fibrillation, the surgical option has excellent results, particularly as the various methodologies and instruments are improving all the time.
The other main area where there can be very considerable expansion is in the treatment of heart failure. Already some surgeons are very involved with this, and remodelling of the left ventricle along the lines advocated by Vincent Dor with or without coronary artery grafting can improve ventricular performance [5].
Unless there are major changes in the law so that we can get more human donors, it is unlikely that there will be much change in the transplant field. Furthermore it makes sense to centralise transplant units, rather than having one in every University Department, some doing less than 10 per year. The progress with left heart assist devices has been disappointing, but if only we can develop a really successful, small, lasting, non-thrombogenic device that can be completely buried in the body without external wires, we would be putting them in by the thousand. If industry had put the same amount of money into this field that they have into stents and pacemakers, I think that we would have a good implantable device now.
Another field in which the cardiac surgeon can be involved, is the insertion of intra-luminal stents for aortic aneurysms, dissections and transections. It is necessary to have the right imaging to do this and although it can be done by the surgeon with ultrasound in the operating room, it is probably better to have a team approach with radiological input.
It is essential that we talk to industry. They can help us to improve the equipment we use. For instance, more user friendly endo stent applicators and the ability to stent branches as can be done with coronary stents, would improve this rapidly advancing field. Industry is not so interested in smaller ‘niche’ markets, but when there is something like atrial fibrillation surgery and implantable left ventricular assist devices where millions of patients may be helped, they are very interested, and it is up to us to help ourselves by getting them alongside.
It is difficult to look into the future and see what we will be doing in 10 or 20 years time. However, the work currently going on with stem cells and tissue engineering is likely to have a major effect. Stem cells that can become myocytes and be injected into failing myocardium may transform the management of heart failure. Already tissue engineered valves are being inserted experimentally and also clinically in small numbers. Whether this will make surgeons even less busy remains to be seen.
Training
Apparently fewer young doctors want to be cardiothoracic surgeons. In the USA 30% less graduates are currently applying for cardiothoracic training. This is probably due to the fall off in coronary artery surgery, but may also partly be due to the bad press that we have had, particularly in the UK, following events at Bristol.
The problem of reduced working hours required by the European Working Time Directive is already having a major effect on training, and indeed the care of patients. A recent editorial in the British Medical Journal [6] pointed out that 10 years ago in the UK, the average surgical trainee spent 30,000h from the start of their surgical career until they become a consultant. As a result of changes in training arrangements and the European Working Time Directive, the duration of training is now 8000h and the intention is to reduce this further to 6000h. I quote ‘To become a competent surgeon in one-fifth of the time once needed either requires genius, intensive practice or lower standards’.
Again we will inevitably compromise and must do our best to guard patient safety. However, may be we do need and could have a completely different way of training. To date a very large amount of the trainees' time is spent on service commitments which could very well be done by someone else—for instance, nurse practitioners. Personally I have always felt that learning to be a surgeon is an apprenticeship. If you want to be a plumber, carpenter or blacksmith, you start out as an apprentice. You watch, assist, do it yourself with help and advice and then on your own. In the case of cardiothoracic surgery which is technically demanding, this has usually taken quite a long time. I think we all owe it to our trainees to help them with this apprenticeship. It of course depends on the experience of the trainee, but we should encourage them and assist them to what ever level is appropriate. Early in my career I found it difficult to delegate and allow my trainees to do much. This is perhaps even more so today when individual surgeons' results are being published. However, for many years I have enjoyed helping young surgeons to increase their technical ability and experience. I enjoy learning from them too and reckon I still learn something every day. Even when the young surgeons have finished training and start in their new consultant careers, patient safety is paramount, and helping or mentoring is important to avoid a learning curve.
Obviously the trainee must learn the academic side of surgery as well as the technical. However, gone are the days when one had to slog through out of date books in the library. Computers have revolutionised learning and the CTS net has made this so much easier for cardiothoracic surgeons. There is so much information put out that it is very difficult to keep up. The journals I received last year contained some 13,000 pages. However, all this information can be accessed easily on CTS net. E-learning and the Multi Media Manual that Marko Turina is developing will make it even easier for our trainees. There are many meetings and excellent postgraduate courses including those at our own School at the Villa Elios in Bergamo (Fig. 4). Continuing medical education is important for all of us throughout our professional lives.
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Adequacy of training is traditionally assessed by examinations which vary greatly from country to country and even in the same country from time to time. In the UK there have been frequent changes in the postgraduate examination arrangements over the last few years. These have in fact produced improvements in what was already a good system. However, it is frustrating for those caught up in the changes. As Mark Twain said ‘I am all for progress, it's change I can't cope with’.
The introduction of the European Boards Examination a few years ago has given us a standard exit examination for all trainees in cardiothoracic surgery. It does not mean that just because a surgeon has passed the exam he is competent to do every operation, but it is a minimum requirement that all European would-be cardiothoracic surgeons should pass, and we should encourage our trainees to do the exam.
Research
This leads on to the thoughts of research. Most of us have done some research at some stage in our lives. Sadly I think most young surgeons only do it because they see it as a means to an end. It is difficult, certainly in the UK for a young surgeon to get on to a good training programme unless he has done the research leading to a higher degree. This takes at least a year and probably more. Because this research is done at such an early stage, it is usually fairly basic and the trainee may well end up doing something entirely unrelated to his research.
Clinical research of course continues throughout ones career. Trainees often come to me asking if I have any ideas for something they could ‘write up’. I usually have a little list of ideas and suggest something they may have been involved with. I then suggest that they should read the literature before going any further. Of course this is much easier these days and after a quick search in Medline, they have a thick pile of abstracts to look through. They then return with a long face saying that the Mayo Clinic had already reported the same thing only the number was 10 times greater!
Most things one can think of have usually been done before. The first description of the circulation of the blood is attributed to William Harvey, who was an Englishman studying in Padua in the late 16th and early 17th century. Harvey's great work was published in Latin in Frankfurt in 1628 [7] and we are familiar with his simple experiment showing the valves and direction of venous blood flow (Fig. 5). However, some 300 years before an Arab physician called Ibn al-Nafis described the circulation in some detail, and even described the purpose of the coronary arteries. His work was translated into Latin in the mid 16th century, and it is possible that Harvey may have had access to it.
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Although the first coronary artery bypass grafting using saphenous vein is generally attributed to Rene Favoloro at the Cleveland Clinic in May 1967 [10], in fact Edward Garrett working with Michael Debakey in Houston performed an aorta to left anterior descending coronary artery bypass using saphenous vein on 23 November 1964 [11]. Coronary angiography 7 years later showed the graft to be patent.
Donald Effler reported the Cleveland experience at the American Association of Thoracic Surgeons in 1971 [12], by when they had performed 1965 vein bypass grafts with a mortality of 3.4%. He went on to say that ‘as the years go by I have become less eager...about claiming priorities of any kind. Every time we had done something original, we found that Gordon Murray had done it years before’!
This is even more true today and particularly if one looks into the non-English literature.
Although clinical research is very important, times have changed, and just reporting retrospective series of, for instance, valve replacements adds little to our knowledge. Furthermore on the subject of valves, reports of so called ‘long term’ follow-up are all too often far short of ‘long term’. I suppose different people define long term differently but 5 or 7 years does not qualify in my book. Fig. 6 shows the 30-year follow-up of a cohort of 200 consecutive patients who underwent aortic valve replacement with antibiotic sterilised aortic homografts performed in Southampton between 1973 and 1983. The Kaplan–Meir curves show 52% patient survival and 35% freedom from reoperation at 25 years after operation. Seven patients still have the original homograft in position and the longest valve survival is 29 years. However, it may not be very relevant as because of the difficulty in obtaining homografts, I have not used one for aortic valve replacement for many years, reserving them for congenital heart disease. Furthermore the valves available today are cryopreserved and I think very different in lasting qualities from the original valves we used stored at 4°C.
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However, back to serious research and this is in some danger largely because the amount of money available is less. The world stock market slump of recent years has been partly responsible for this and industry may have its eyes in a different direction to us. Certainly the enormous amount of money poured into stent design and improvement dwarfs that coming the way of surgeons. We must have well motivated, dedicated people who want to undertake research if we are not to lose our opportunities in this direction. We should support and encourage them.
There are still so many problems that confront us daily, and well supported research in these areas could bring enormous benefits. For instance, most units still have at least a 20% incidence of post-operative atrial fibrillation. We should surely be able to overcome this and also post-operative renal failure.
Data collection
Data collection is so important, yet we are still a long way off knowing what we do in Europe. We do not know how many units there are or how many surgeons are doing what sort of cardiothoracic surgery. We certainly do not know how many operations a year they do, let alone the results. Some years ago I collected data from 20 European countries regarding the number of paediatric cardiac operations performed [15]. Few countries had a national register and I eventually mostly relied on information gathered by one surgeon in each country. In the end a reasonably accurate figure of the total numbers was produced but to have included early mortality would have been impossible. Some countries were even rather reluctant to release the totals.
In that every surgeon must presumably keep a log of all operations performed, why is it so difficult to collect this data? Is it apathy or a fear that it may eventually be used against them? If their results are bad, might they be stopped from operating? Well certainly patients have a right to know what their surgeon's results are and in a form that they can understand. If a surgeon's results are worse than those of his colleagues, or a whole unit's results are significantly worse than the national figures, then they should be looked at. Firstly the accuracy needs to be checked and reasons why the results are worse should be looked into. The surgeon's performance may not be any worse than expected, but other factors such as case selection, anaesthesia and post-operative care may be responsible. These factors need to be optimised without the surgeon being victimised. It must be in everybody's interests to improve outcomes for the patient and honesty when submitting results and the avoidance of ‘gaming’ is vital. The wish to have ones published early mortality as low as possible inevitably results in some surgeons turning down high risk patients. These difficult patients may then be operated on by better surgeons elsewhere who will end up with a higher mortality. However, if a surgeon is performing poorly, it is important to help him, perhaps with some redirection. Once he is stopped from operating, it is extremely difficult to retrain and return to operating. We should all be aware of this and try to help our colleagues. It is always possible that with a run of bad luck, we could find ourselves in that situation.
Risk stratification is very important when comparing results of different units and although even with the Parsonnet and Euroscore systems it is still difficult in adults, it is much more difficult in children where there are so many more diagnoses. The recent progress made by Francois Lacour–Gayet and colleagues [16] with the Aristotle scoring system is very encouraging, but there is still some way to go before this is universally adopted.
In the United Kingdom, a national register was started by Sir Terence English in 1977. This was voluntary and anonymous and each unit submitted their total number of cardiac operations and early mortality every year. A thoracic register was also subsequently undertaken. So every year the national total figures were produced with the early mortality for each condition. Each unit could compare their own results with the national figure and see how they were performing. One example of how this did not work is Bristol, where although the surgeons must have known that their results, particularly for certain conditions, were much worse than the national figure, continued to operate on those babies with the sad results of which we are all now well aware.
As a result of the Bristol events it became apparent that a more accurate and complete method of data collection was necessary, and the British Government set up the Central Cardiac Audit Database (CCAD) to ensure the complete, accurate, and validated collection of data from all the UK units. It is collected in an encrypted manner to ensure confidentiality and after initial trials and some tribulations, is now computerised, collected from every unit and funded centrally. The other great advantage we have in the UK, is that every patient has a unique number, and with the help of the Office of National Statistics, each patient can be tracked. So that this is an enormous help with validation. Each unit is visited annually by a validation team including a doctor, which assesses the accuracy of the data and goes through the operating room log books and any other source available to ensure that every operation is entered.
The UK results for 2000–2001 were recently reported in the British Medical Journal [17], and it was alarming to find that despite each unit trying hard to enter all their data, 22% of early deaths were missed initially. Of these 45% were patients who had left hospital but died within 30 days and the death was picked up by the Office of National Statistics. However, this really does show how important good validation is, and puts doubt about the accuracy of all unvalidated data. An example of how useful the tracking of patients by the Office of National Statistics can be is seen in Fig. 8, which shows that for instance although survival at 30 days following procedures on bypass in infants was 95%, it had dropped to 90% at one year.
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In the adult field, our Secretary General, Bruce Keogh set up an ‘Adult Cardiac Database’ in the UK, which now has all the hospitals in the country submitting data [18]. An excellent report has been produced for the last few years and many interesting trends and differences between units have been shown. A similar database for Europe has been started, but needs the cooperation of all units to submit their data including mortality and morbidity. Already interesting data has been produced, as shown in Fig. 9, which demonstrates the considerable difference in the proportion of patients undergoing coronary artery surgery in different countries.
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In the UK following events in Bristol, the Government set up a Paediatric and Congenital Cardiac Services Review [20], of which I was Co-Chairman. The terms of reference were basically to find out what was going on in the UK, set standards and make recommendations as to how the Paediatric Cardiac Services could be improved. After lengthy discussions, we produced a set of standards that would be expected in every unit, including, for instance, the important role to be played by the liaison nurses. This would help communication with parents and children so that they understand what their treatment involved and with follow-up. Among our recommendations was that there should be a reduction in the number of paediatric surgical units. Currently most have only two surgeons, and particularly with the European Working Time Directive coming into force, this is not sustainable in the modern era. However, the Government after sitting on the report for more than a year, decided (presumably for political reasons) that no surgical units should close. Furthermore the increased financial support needed to comply with the standards set has not been forthcoming. So no surprises, nothing changes.
Bureaucracy
There seems to be ever more bureaucracy in our lives. The 10 countries who recently joined the European Union will probably already be appreciating this. The never-ending rules and regulations coming from Brussels produce mounds of paperwork and decreased efficiency.
In England there has been a spate of bureaucratic measures in recent years. We have new contracts and job plans supposedly to reward us more appropriately for what we do, but in effect probably tying us down to a less flexible and less efficient work pattern. Annual reappraisal and accreditation are supposed to ensure that we are doing a good job. Of course we must do a good job, but if someone is not, why wait for a year, and for the vast majority who are doing a good job, what a waste of everyone's time.
No doubt many other European countries are developing the same policies. I think we must all be aware of becoming too bound by regulations which stifle us and particularly the European Union Working Time Directive, whilst having reasonable aims, will make our lives and particularly training difficult and probably reduce standards of care for patients.
In the UK our government is obsessed with targets and reducing waiting lists. To be fair they have put a lot more money in and waiting lists are reducing, but sometimes at the expense of a more urgent patient being given less priority than a completely non-urgent patient who is about to wait longer than the target, maximum waiting time. If less money was spent on bureaucracy, more would be available for front line patient care.
Closing remarks
Not only must we keep our patients well informed, but we must be considerate to them and their families at all times. However, the patients in turn must be reasonable, and the tendency to sue us for the least reason is why litigation has already become such a concern in Europe. It is worse in the USA where there are 125,000 cases pending litigation. Physicians are usually cleared in about 80%. Fig. 10 shows the increase in my own annual indemnity insurance. This year it is nearly £14,000 or 21,000 Euros. However, this is still much less than in the USA.
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We are all busy surgeons, but we must keep a sense of proportion. It is also important to have enough time to see our families and relax. Sports and hobbies are also important and remember we need something to do when we retire from surgical practice.
As my title says, we must adapt to change and do the best primarily for our patients, but also for our profession. I would like to finish by quoting Francis Fontan in his first Presidential Address. "If we who have the talent and knowledge don't look after the problems ourselves, then others who are less talented and more ignorant of those problems will certainly do it for us" [21].
References
This article has been cited by other articles:
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  O. O. Al-Radi, F. E. Harrell Jr, C. A. Caldarone, B. W. McCrindle, J. P. Jacobs, M. G. Williams, G. S. Van Arsdell, and W. G. Williams Case complexity scores in congenital heart surgery: A comparative study of the Aristotle Basic Complexity score and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) system J. Thorac. Cardiovasc. Surg., April 1, 2007; 133(4): 865 - 875. [Abstract] [Full Text] [PDF]
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 L. K. von Segesser Changes in font design--should surgeons align? Eur. J. Cardiothorac. Surg., January 1, 2005; 27(1): 1 - 2. [Full Text] [PDF]
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