EDITOR’S COMMENTARY

Reflections on the Evolution of Cardiology and Cardiac Surgery

Over the Past 50 YearsJoseph S. Alpert, MD

AddressDepartment of Medicine, University of Arizona Health Sciences Center, 1501 N. Campbell Avenue, PO Box 245035, Tucson, AZ 85724-5035, USA. E-mail: jalpert@u.arizona.eduCurrent Cardiology Reports 2003, 5:91Current Science Inc. ISSN 1523-3782Copyright © 2003 by Current Science Inc.

Last week, I saw a 32-year-old man who was born with avery severe form of congenital heart disease (CHD) knownas pulmonary atresia. This condition would have been uni-formly fatal 50 years ago, because it prevents blood frommoving smoothly through the lungs to the left side of theheart. All but a handful of children afflicted with this disor-der died in the past. And yet, here was my 32-year-oldpatient, happily married, employed in a local credit union,and living a totally normal lifestyle. Indeed, he participatedactively in martial arts and other aerobic forms of exercise.Fortunately for him, he had undergone three separateoperations to correct the pulmonary atresia during hischildhood years. An ultrasound examination of his heartdisclosed that the left and right ventricles were functioningnormally, and his prosthetic pulmonic valve was function-ing normally, despite the fact that it had been placed in hisheart 15 years earlier.

Seeing patients achieve such remarkably good results isalways a joy for a cardiologist, particularly one whoremembers the days when attempted repair for compli-cated CHDs such as pulmonary atresia was fraught withdanger. Now, such operations are routinely performed witha very low risk for surgical death, and with excellent long-term results. Most patients with repaired CHD can nowlook forward to a normal or near normal life expectancywithout shortness of breath or fatigue. The technicaladvances in cardiac surgery and cardiology have made theoutlook for patients with CHD truly excellent. Manypatients with repaired CHD are now entering their fifthand even sixth decade of life following childhood cardiacsurgical repair. Most of these individuals are doing very

well indeed. The complications and management ofpatients with the various forms of repaired CHD are nowwell documented, and were the subject of a recentBethesda conference [Care of the adult with congenitalheart disease. Presented at the 32nd Bethesda Conference,Bethesda, MD; October 2–3, 2000. J Am Coll Cardiol 2001,37:1161–1198.]. I highly recommend this document to car-diologists, cardiac surgeons, and internists/pediatriciansinvolved in the care of these patients.

Later the same day, I was talking with Dr. Gordon Ewy,co-director of our University Heart Center (Tucson, AZ),about my fortunate patient. He also remembered the dayswhen surgery on such patients was a dramatic undertak-ing. We discussed how many other advances in the field ofcardiovascular disease had led to marked improvement inthe lives of our patients: thrombolytic therapy for acutemyocardial infarction, angioplasty and bypass surgery forindividuals with coronary and valvular heart disease, anda whole raft of new medications aimed at a variety of heartdiseases. All of these advances have contributed to themarked decline in the death rate from heart disease thatwe have all witnessed in the United States during the sec-ond half of the 20th century. We wondered what the stateof therapy for heart disease would be after another 25years of research and development. It will almost certainlybe even better than what we have today, given the pace ofcurrent cardiovascular research. We asked each other if wewill ever see heart disease disappear entirely? I said that Idoubt that it will ever disappear completely; however, I dolook forward to an era when premature death from cardio-vascular disease will be distinctly uncommon. Of course,we will all die some day; the important questions are howsoon and how unpleasant will that death be? Our goal inmedicine should be to get as many people as possible to avery functional old age, for example, more than 85 years.After this point in time, a relatively painless death shouldbe an additional goal. Only the future will tell how suc-cessful we will be, but the future certainly looks brightfrom my vantage point.