The responsibility of the cardiologist in recommending cardiac surgery

Abstract

T HERE are fashions in medicine as well as in other human activities. I mention this because recent technical advances in cardiac surgery have led many patients, and even some physicians, to believe that surgical operations will “cure” certain cardiac lesions in much the same way an appendectomy “cures” appendicitis. This is where the cardiologist plays an important role, because he must be able to answer the following questions before he can recommend cardiac surgery: (1) Is a cardiac lesion present? (2) If so, can it be corrected surgically? (3) What is the natural history of this group of patients? (4) What are the risks of surgery? (5) Will the patient benefit from the operation? Is a Cardiac Lesion Present? Many patients are first brought to a cardiologist’s office because of a loud murmur. However, we all are aware that significant and serious cardiac disease can be present without a murmur, and that a very loud murmur may be present with insignificant heart disease. Physical examination, x-ray examination of the heart and lungs, and an electrocardiogram will usually enable the examiner to determine if heart disease is present. In many cases these simple office procedures can rule out further diagnostic examinations. However, when indicated, phonocardiography, cardiac catheterization or angiocardiography can also be done. Can the Cardiac Lesion Be Corrected Surgically? From this point of view surgical operations can be divided into two groups: (1) Palliative oberations. These include the operations for rheumatic heart disease (with either the closed or open technic, with or without valve replacement) . Regardless of the skill of the surgeon, the patient returns from the operating room with an abnormal heart. Similarly, the Blalock operation for tetralogy of Fallot, pulmonary artery banding operations, even some cases of total repair of the tetralogy of Fallot are palliative. (2) Curative operations. These include ligation of an uncomplicated patent ductus, resection of an uncomplicated coarctation of the aorta and correction of some atria1 or ventricular septal defects. What is the Natural History of Patients with a Particular Lesion? Most if not all cardiologists will agree that the mere presence of anatomic mitral stenosis or pulmonary stenosis, for example, is not necessarily an indication for cardiac surgery. The functional impairment of the patient, signs of cardiac enlargement or of ventricular hypertrophy, pulmonary hypertension, or inadequate growth rate are some of the important considerations that will help determine the need for an operation. A middle-aged woman with anatomic mitral stenosis, but with no signs of right ventricular hypertrophy in the electrocardiogram, with minimal enlargement of the cardiac silhouette, and no obvious signs of pulmonary h>-pertension nor congestive heart failure, does not require an operation because the natural course of such a patient is excellent. Similarly, an adolescent patient with a mild pulmonar~~ stenosis, no obvious chamber enlargement, a normal electrocardiogram and no significant findings on cardiac catheterization also does not require an operation. The question of operation, however, does arise in a patient with mitral stenosis who is beginning to show signs of cardiac decompensation, or in a child with an atria1 septal defect, because we know that the life expectancy of such patients is less than normal. What iire the Risks of Cardiac Surgery? Mark Twain said, “There are three kinds of lies--plain lies, damn lies, and statistics.” Actually,