Advances in Heart Surgery and Cardiac Care

The defining advance in heart surgery is that many operations no longer need a long cut down the middle of the chest. Dr. Ajay Kaul, Chairman Cardiac Science, Fortis Hospital, Noida, India, said that a big midline incision is no longer the default; it remains standard for heart transplantation, most multi-vessel bypass and complex aortic surgery. Valves, bypass grafts and aneurysms can be treated through one or two inch cuts or a puncture in the leg, and most patients go home within days.

That shift is the thread running through his Jivo Masterclass for international doctors, held on 1 December 2024. This guide sets out what has changed in cardiac care, what it means for recovery, which patients benefit, how congenital heart disease fits in, and the habits and check-ups that keep people from needing a cardiac surgeon at all. Two companion articles go deeper: one on heart surgery without opening the chest, covering valves, bypass and aneurysms, and one on the choice between an artificial heart and a heart transplant when the heart fails.

Advances in heart surgery and cardiac care: three fronts at once

The progress is not confined to the operating theatre. Dr. Kaul described advances on three fronts that now reinforce one another.

• Medical management. A generation of new medicines has changed the way patients are managed.
• Cardiology procedures. Angioplasty (opening a narrowed artery from the inside with a balloon, usually followed by a stent) and other catheter-based treatments, performed by interventional cardiologists, are done in new ways.
• Surgery. For many operations no long incision is required, because they are now carried out through small openings, much as laparoscopic surgery works in the abdomen.

Taken together, he said, these advances allow major surgical procedures to be avoided. He named three aims behind them: procedures that are less invasive, procedures that are safe, and procedures that deliver good long-term results. The order matters. A smaller incision is only an advance if safety and durability are not traded away for it, and the techniques he showed are judged on all three counts.

The four conditions where the change is most visible

Dr. Kaul organised the surgical part of his lecture around four conditions:

1. Valve disease. Single and double valve replacements are now performed through small incisions, including endoscopic approaches.
2. Coronary artery disease. Coronary artery bypass grafting (CABG), the operation that reroutes blood around blocked heart arteries, can be done through a small incision, and the leg vein used as a graft can be removed endoscopically.
3. The failing heart. When the heart is too weak for any corrective operation, the options narrow to a heart transplant or an artificial heart.
4. Aneurysms. A dangerously ballooned artery, once treated with very large open operations, can now be sealed from the inside with a tube placed through the leg.

The first, second and fourth are covered in depth in the article on minimally invasive valve, bypass and aneurysm treatment. The third is the subject of the article on advanced heart failure, LVADs and transplantation.

Recovery time after minimally invasive heart surgery

For patients and their families, the most tangible change is the speed of recovery. Dr. Kaul listed the advantages of minimal access surgery as follows:

• The breathing tube is removed within 6 hours of surgery. This step, called extubation, marks the point at which the patient is breathing unaided after the general anaesthetic.
• Pain is lower than after conventional surgery.
• The patient spends one day in intensive care.
• Discharge from hospital follows on the fourth day.

He described recovery as quick, with patients able to be discharged in two to three days. The contrast with a conventional operation lies in the breastbone. A full median sternotomy divides the sternum from top to bottom, and the bone typically takes about six to eight weeks to heal, during which lifting and driving are restricted. Avoiding that division is what allows the faster return to normal activity.

For an international patient and the family travelling with them, a shorter hospital stay also means less time away from home.

Heart surgery for high-risk patients: lower morbidity and mortality

Dr. Kaul's closing message was that cardiac surgery has evolved significantly over the last century, and that surgeons are now treating more and more high-risk patients. Morbidity means complications and illness after an operation; mortality means death. Advances in three kinds of approach, he said, have reduced morbidity and mortality to a great extent:

• Minimal access surgery: open-heart operations performed through small incisions rather than a full sternotomy.
• Transcatheter procedures: treatments delivered through a catheter threaded along a blood vessel, without opening the chest at all.
• Hybrid surgery: a combination of a surgical step and a catheter-based step, planned together for one patient.

The practical consequence is that patients who were once turned down as too old or too frail for a large operation can now be offered treatment. A smaller physiological insult, with less blood loss, less pain and earlier mobilisation, is what makes that possible.

Heart disease or other chest disease: telling them apart

A question at the session asked how to tell chest abnormalities from cardiac disease, since the two are often confused. Dr. Kaul's answer clarified the scope of the session. The chest contains the lungs, the oesophagus, the heart and the blood vessels, as well as muscle, bone, the spine and the breast. His session dealt only with two of these: the heart and the blood vessels. Diseases of the lungs, muscles, bones, spine and breast sit with other specialists, even though they present in the same part of the body.

For a referring doctor, the distinction is a useful reminder that chest pain or an abnormal chest X-ray has several possible sources, and that the referral pathway depends on which organ is at fault.

Congenital heart disease: tetralogy of Fallot and Eisenmenger syndrome

Two questions from the Live Discussion concerned heart defects present from birth, and Dr. Kaul's answers point in opposite directions.

Tetralogy of Fallot treatment: a normal life ahead

Tetralogy of Fallot is a congenital heart defect with four components: a hole between the two pumping chambers (ventricular septal defect), narrowing of the outflow to the lungs (pulmonary stenosis), an aorta that sits over both ventricles, and thickening of the right ventricle. Together they send too little blood to the lungs, which is why affected babies can appear blue.

Dr. Kaul was emphatic that tetralogy of Fallot is very well treatable. Children who are operated on go on to lead a normal life, and he has patients who are now 25 to 30 years old and doing very well. The results are very good, he said, with the exact outcome depending on the type of tetralogy. Complete surgical repair is usually performed in infancy. The cost of tetralogy of Fallot repair is set out separately.

Eisenmenger syndrome: what happens when a heart defect is left untreated

Eisenmenger syndrome is what happens when a correctable defect is left untreated. Dr. Kaul explained the sequence: the heart has an operable disease, the patient does not get it treated, and over time the heart disease damages the lungs. The lung blood vessels become so stiff that no corrective treatment of the heart is possible any longer. In established medical terms, years of excess blood flow through a hole in the heart cause irreversible disease of the lung arteries, the pressure on the right side of the heart rises, and the flow through the defect reverses, leaving the patient cyanosed.

Treatment still exists, Dr. Kaul said, but it is a heart and lung transplant: a very difficult operation, with a success rate he put at around 40 to 50%. The lesson for referring doctors is the earlier one. A child with an operable defect who reaches a surgeon in time has an excellent outlook; the same child, referred too late, is beyond corrective surgery, with a combined transplant as the definitive option and roughly even odds. Under current guidelines, medicines that lower pressure in the lung arteries, such as endothelin receptor antagonists, are used to relieve symptoms, and transplantation is reserved for patients who deteriorate despite them. The question of when to operate on a child's heart defect is examined in Dr. Aseem R. Srivastava's article on the correct timing for congenital heart surgery.

How to prevent heart disease: a cardiac surgeon's rules

Asked what a healthy person should do every day to protect the heart, Dr. Kaul sorted risk into three groups: what cannot be changed, what can be partly avoided, and what is entirely preventable.

Risk factors that cannot be changed

Three factors are fixed. The first is genetics: if a parent or sibling has coronary artery disease, hypertension or diabetes, that risk is inherited, and, as he put it, nobody can choose their parents. The second is age, since heart problems become more likely as people grow older. The third is sex, because some heart diseases are more common in men and others in women.

Risk factors that can be partly avoided

Some exposures can be reduced, if not removed. Living in a heavily polluted city is one; Dr. Kaul gave Delhi as an example and said that someone who can change job and move away should do so. Air pollution is now recognised as an independent risk factor for cardiovascular disease. Chronic stress, whether at home or at work, is another. He warned that stress of that kind can itself bring on a heart attack, and that it is better avoided.

Risk factors that are entirely preventable

• Tobacco. Smoking, in his words, is the only thing in the world with no advantage. Chewing and smoking tobacco are equally harmful: smoked tobacco destroys the heart and lungs, and chewed tobacco damages the heart and causes cancer of the mouth.
• Alcohol. His advice was to drink no more than two to three pegs, two or three times a week, because beyond that the liver cannot cope and cirrhosis follows. The World Health Organization's position is that no level of alcohol consumption is free of health risk.
• Inactivity. Dr. Kaul favours exercise built into the day: get off the metro one station early and walk to the office, and take the stairs down even if the lift is used going up. He encourages wearable step counters and a target of at least 10,000 steps a day.
• Diet. Avoid junk food as far as possible.

His single best form of exercise is walking 3 kilometres in 30 minutes, twice a day if possible, and he said no gym does better. That pace is brisk walking, and at that rate the routine comfortably exceeds the World Health Organization's recommendation of 150 to 300 minutes of moderate-intensity activity a week.

At what age to get a heart check-up

Dr. Kaul set two ages for a first proper health check-up from a doctor. People with a family history of heart disease, diabetes or related problems should have one at 20. People with no family history should have one by 40. The advantage, he explained, is that precautions taken early can delay or prevent the disease altogether: someone from a diabetic family who manages their health early may not develop symptoms of diabetes until late in life. Major prevention guidelines, including those of the American Heart Association, recommend assessing traditional cardiovascular risk factors from the age of 20.

He added a third rule that he considers very important: anyone about to take up strenuous exercise, such as joining a gym, should first be checked by a cardiologist. Collapses in gyms and during runs are reported every day, he said, because the heart has so much reserve that even serious disease can go unnoticed. A diseased heart, in his analogy, is like a weak horse that keeps running as long as it is whipped, until one day it simply drops dead.

He also challenged the pride some people take in never having seen a doctor. A new car is taken to the garage for servicing every six months; the body, he argued, deserves at least the same attention. A health check-up package is the practical starting point.

Related articles on heart surgery and heart failure

• For the surgical techniques, read heart surgery without opening the chest: valves, bypass and aneurysms.
• For the failing heart, read artificial heart vs heart transplant.
• The questions doctors put to Dr. Kaul, with his answers, are on the Live Discussion page.
• His training and areas of practice are on Dr. Ajay Kaul's profile, and related masterclasses are grouped under cardiac surgery.