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Eur J Cardiothorac Surg 2004;26:S86-S87
© 2004 Elsevier Science NL
Closing remarks |
Wessex Cardiothoracic Centre, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
* Tel.: +44 2380 796241; fax: +44 2380 796614 (Email: monro1711{at}aol.com).
I think we have had a very good meeting and I'm grateful to you all for coming, and particularly to the organizers. I would like to thank Ken Kozlowski for taking everything down, and Ian Beecroft, Friedhelm Beyersdorf and Bruce Keogh, who are going to put it all together as a supplement in the Journal.
We invited 50 people to keep this small so that we could have good discussions, but if you have a party, inevitably, someone gets upset they haven't been invited. So I hope we haven't upset too many people.
We have had some very good ideas and we have bounced them around. We don't know the exact cost of this meeting, but I am sure it is going to be money well spent. We still have to decide some definite actions to take away from here. Bruce Keogh is going to do all that so that we go away from here not just saying, well, we had a good time, that was interesting, but we have action plans, and I think Bruce has got those in his head if not on paper yet.
We have discussed so much that it has been really very difficult to try and put it all together in a logical manner, but I will just try and summarize briefly.
I think one of the most important things to remember is that we must do the best for our patients. What we do for ourselves is secondary. Yesterday we had that little poll and 90% of you agreed that you would have a stent. So you must not deny your patients the right to have a stent if you think that is better than surgery for them. We must accept the change that has come about with this enormous explosion in stenting, but it is just like history. When TB was cured, thoracic surgeons found something else to do. So we must find other things to do. There is an enormous number of patients with atrial fibrillation and heart failure. So for a start, we can work on them.
I feel that maybe it's going to take another 10 years, and although Daniel Loisance yesterday was a bit pessimistic about LVADs, I think little LVADs like the Jarvik 2000, will be going in like pacemakers, and you can't put those in percutaneously. So the surgeons are still going to be in business doing that.
Endostenting, although a bit more of a niche market and therefore perhaps not going to get quite the same support from industry that the AF surgery and heart failure surgery will, is still something we can do, and Ludwig von Segesser gave us very good demonstrations of that yesterday. However, we have lost the battle. The cardiologists are the gatekeepers and they are not going to let us into their catheter laboratories. They are already replacing our work with the stenting, but they are going to take over the mitral valve repairs, as Ottavio Alfieri told us yesterday, and probably before too long, aortic valve replacement as well. They are not going to take over all of them but a large proportion.
Now, we must talk to industry. It has been very nice having you here, Bob Guezuraga, and you gave a wonderful talk yesterday, putting things across. They are here to help us, and we must talk to them. They want to be involved in research, they want to help us to teach our juniors, and we must teach our juniors. They are the future. We must also talk to our administrators, as we have just heard, and we must be more efficient. We heard from Randy Bolton how you can get appropriate patients out the next day. I am not sure we all want to or even all feel that is the right thing to do, but I am sure we can reduce the postoperative stay and therefore the costs. I think that we need better bypass, smaller, cheaper machines to make it easier and safer.
Whatever we do, it is going to be a compromise. The orderly retreat that Torkel Aberg mentioned, will need fewer larger units. I was talking to Toby Cosgrove yesterday, and in the USA where they are springing up units doing stenting, they are starting up little surgical units just to be there for backup, doing maybe 50 cases a year. This is awful, and we must not get into that situation in Europe. I think there are too many units now, but particularly with the European working time directive, where we are going to need more surgeons in a hospital to do the on-calls and so on, we need to go towards this.
I think less people want to do cardiothoracic surgery these days, and as Sam Nashef said earlier, maybe we could find other things to do as well. We can follow our patients better, we can do more research, perhaps spend a bit more time seeing our families or in recreation and not working 60–70 h a week. So I think that will become the norm, and our juniors, who have not worked the long hours that we do, when they come through, they're not going to want to work like that. So I think we just have to rationalize and downsize.
So what is it going to be like in 20 years? Well, I don't know, but stem cells, tissue engineering, and maybe some completely new disease we haven't even thought of will come along, and as someone said yesterday, maybe one injection will sort you out and you won't have coronary artery disease, and everything will change.
So I would like to thank you all again, it has been a most fruitful meeting, and wish you a good journey and a happy summer holiday.
Thank you very much.
Footnotes
Presented at the EACTS Symposium for the Future of Cardiac Surgery, Frankfurt, Germany, July 1–2, 2004.
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