LECTURES

Ottawa Heart Institute Alumni Fall Lecture
October 18, 2007

"Cardiac Surgery: Past, Present and Future"
Dr. Thierry G. Mesana

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Dr. Mesana

The Alumni-organized Fall Lecture featured Dr. Mesana, Chief of Cardiac Surgery at the UOHI. Dr. Mesana is a native of France who was hand picked for the Institute by Dr. Keon who considered him to be the most amazing talent with the greatest skills to succeed him.

A full house of attendees enthusiastically listened to his expert review of the state of cardiac surgery. Dr. Mesana commenced by stating that cardiac surgery started about 50 years ago to help babies with congenital heart problems and young patients requiring valve surgery. The services very quickly expanded to embrace other types of heart disease, e.g. coronary bypass surgery, as the art of grafting was perfected.

Providing such services to seniors came quite a bit later with the improvement of technology and the confirmation that cardiac surgery could be performed successfully on the elderly. In the 1980s, coronary heart surgery shifted to interventional cardiology conducted in cath labs.

Angioplasty is one example, using a "balloon" to undo arterial blockages without opening the chest. Instead, a catheter is introduced through the artery to perform the procedure.

In the 1990s the coronary stent was invented to strengthen the arteries to prevent re-stenosis. Once again, a catheter is used for its implant. These days, there is even a drug to prevent re-stenosis in the stents.

Valve surgery has been increasing in numbers given our ageing population. Although successful, the ever-evolving procedures of cardiac surgery coupled with extensive research have resulted in the development of percutaneous (non-surgical) valve procedures.

By-pass surgery has also been advancing since its emergence in the 1970s. Now instead of veins, the surgeon may use internal mammary arteries (IMAs) are found around the sternum that are superior conduits to veins. IMAs have been found to stay open longer, and provide a better blood flow. Current experience indicates that IMAs could last 10-15 years or longer, whereas veins could last only about 10 years.

In the 1960s the first arterial grafting surgeries were performed without using the heart-lung machine. Because of the movement of the heart, it required great dexterity to make an incision in the vessel that is only 3-4 mm and subsequently to suture it to minimize bleeding. Subsequently, greater use was made of the heart-lung machine. However, the disadvantage of this equipment is that it creates an unnatural physiological blood circulation, which can cause damage to the brain, heart and lung. Presently, there are devices and supporting technology to immobilize the specific area of the heart where the bypass will take place.

Artificial valves have also undergone considerable change over time. Evolution of valves from porcelain to piglet valves mounted on a stent (used mostly for older patients) lasts 12-15 years. Interestingly, the longer it lasts, the less likely that it will wear out. There is also a trend to use piglet valves without the stent. It appears that stent deterioration is a greater problem than that of the piglet valve. Finally, a relatively limited number of transplants of human valves are performed when a donor is available.

Dr. Mesana has specific expertise in repairing the heart valve instead of replacing it. Such repairs call for a very delicate operation. Hence it is relatively rare due to the shortage in experienced surgeons. Nevertheless, the success rate is high with a skilled surgeon. There are close to 135 repairs performed a year at the UOHI and the numbers are growing dramatically.

What does the future hold? We can look forward to further development of percutaneous valves, stented aortic valves that can be introduced in the heart through the groin with the aid of a catheter. At the present time, this is a relatively new technology with the risk of death rather high at 40%. The cost of the procedure is expensive, being in excess of $25,000.

Some surgeons are wondering if cardiac surgery will disappear in 20 years due to the growing use of less intrusive methods. Dr. Mesana emphasized that surgeons will continue to be needed. He feels strongly that the new generation of surgeons will continue to be progressive with the development and application of new technologies and skills. They will be open and adaptable to new technologies.

Therefore, more cardiac surgeons should be trained, but differently than 25 years ago. Recent medical statistics show the number of open-heart surgeries is still growing and in particular the new less invasive interventions are escalating. In fact in 2006, it was already reported that there would be a shortage of heart and lung surgeons due to retirement as 73% of the current ones will be retired by 2019. The shortage, coupled with the increased demand produced by aging baby boomers, assures aspiring surgeons of a solid career. The challenge will be to attract the best minds and abilities, given that the typical health plans do not adequately compensate cardiac surgeons by comparison to several other types of surgeons. At the UOHI, 4 residents are being trained currently for cardiac surgery.

The UOHI Cardiac Surgery Division has enjoyed well-deserved prominence for its achievements and has received many awards. With great pride for the quality and accomplishments of his team, Dr. Mesana is modest as he claims that his only legacy will be in the heart of his patients. They have maintained contact with him over the years and continue to express their thanks and admiration to this Doctor with skilled hands, a warm heart, and a glowing reputation.

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