Editorial

The future of cardiac surgery seems to be in dark because of improved health awareness in public and improved cardiac Cath quality stents. I am discussing in my editorial how the cardiac surgery has evolved from nowhere to everywhere. But as there are ups there are downs also. The downward phase of cardiac surgery has started and now only we has to act otherwise we again go back to nowhere.

Coronary artery disease has been termed as bread and butter of the cardiac surgeons. The disease has been managed since as early as 19th century and has seen many landmarks. Coronary artery disease is one of the important cause of death. Out of the organs whose failure can result into death ,heart holds a special position as the defect responsible can be surgically corrected .Since coronary artery disease is one of the major causes afflicting the heart, hence coronary bypass holds a significant position. Coronary bypass was started by Favalaro in 1969.Since then the surgery has seen many improvements and from being done on pump in beginning but nowadays it is being done off pump mostly. Recently MIDCABS and robotic [Da Vinci System] have entered the scene in taking care of CAD. The off pump CABG has drastically changed the whole scenario, as the morbidity and mortality associated has gone down significantly. Patients with poor LV and associated risk factors like kidney dysfunction and diabetes are managed quite easily. The overall mortality has come to less than 1 %.MIDCABS have become commoner and the operative procedure has been largely helped by the special Fehling’ s retractor which help in taking down LIMA even through a small incision. This procedure has helped to further reduce the invasiveness and added the cosmetic benefit to the surgery though in selected group of patients [as only left side vessels can be managed comfortably by this approach].

Problems

As the cardiac surgery advanced in all these years, simultaneously the Cath lab and the interventions have also improved in their respective field. Cardiologist with help of cardiac surgeon started with plane angiography and occasional PTCA to SVD [LAD] has now reached to a full blown task of managing complex TVDs and even left main and also post CABG blocks, only critical triple vessel diseases and left mains are left for surgeons to take care of. As a result the cut in the surgical work has been quite significant. This in turn has opened a whole new chapter, as the task of getting patients for surgical intervention has become a big deal. Middlemen [so called marketing professionals] have cropped up everywhere and they are making a good killing, by taking advantage of the situation. Refferal have become a routine, in many situation the referrals exceed the surgeons fees, thereby forcing the surgeon to rethink why the hell he went through all that grilling path to become a cardiac surgeon when someone who does not know even ABCD of medicine is earning more than cardiac surgeon and that to because of cardiac surgeon as without him the things would come to standstill. Hospitals have been very kind to exploit the surgeons, as a result, the cardiac surgeons are paid the least and not at all by citing various reasons like nonpayment or delayed payment or reduced payment from the panel or the patients. The cardiac surgeon has to bear with all this mutely as he is a soft target and is unable to do much in such a situation.

Future

Seems to be grim, as stents are making all the news and the noise as more safer and beneficial stents are on their way into scene. The primary PTCA and dissolvable stents are becoming routinely used. In addition health consciousness is neck deep in the society with morning exercises, the yoga and the walkathon and the half marathons causing decreased incidence of critical triple vessel CAD .The low fat diet, olive oils, toned milk and antilipidemic drugs, the government banning the tobacco, the free heart and health checkup camps all of this have become the order of the day. With all this the health of society is on its way to wellness and goodness. In such a scenario the future of cardiac surgery looks grim.

Advice

Cardiac surgeons may have to step back into the Cath lab what they had given up at one point of time and regain the lost ground .Another important thing is to turn toward rural areas where all above factors are still a dream or think of something better. Lastly improve the skill so that whatever difficult cases the cardiac surgeon gets handle them successfully.