Treatment of Cardiac Disease
A Short History
The treatment of heart disease has been developing over the last 60 years, with a very exciting increase in intensity during the last 20.
Thoracic, including cardiac, surgery came into its own during and as a result of World War II. Medical, as opposed to the surgical management of heart disease in the 1940s and 50s was limited. The common heart disease of that era was related to rheumatic fever and the devastating effect that this disease had on heart valves. The treatment of a heart attack was basically morphia and bed rest!
The surgical treatment of rheumatic heart valve disease, together with the correction of simple congenital cardiac abnormalities, heralded the first phase of success. Medical cardiology and cardiac surgery developed together over the years, with investigation techniques - cardiac catheterisation and ultra sound (echo cardiography) - providing accurate diagnoses.
Open-heart surgery became possible following the invention and perfection of heart - lung bypass machines. This resulted in heart valve replacement and repair, together with correction of many congenital cardiac anomalies.
The management of ischaemic heart disease, due to narrowing of the coronary arteries, provided the next challenge to physicians and surgeons alike. Successful surgical intervention using vein grafts to bypass diseased coronary arteries (CABG) became possible from the 1960s and in the developed world has now become an enormous industry.
Cardiac pacemakers were introduced in the late 1950s. These sophisticated devices have revolutionised the treatment of patients who suffered, amongst other symptoms, fainting episodes often occurring at inconvenient times and often resulting in death. Pacemakers have developed dramatically during the last 20 years and cardiac function can now be restored to virtually normal by dual chambered, or even bi - ventricular pacing. Some modern pacemakers are electronically able to recognise rhythm abnormalities and apply corrective electric shocks to the heart.
The Implantable defibrillators shown to the left are examples from the three major manufacturers we use. The Medtronic Device has a standard defibrillator lead attached (it has metal coils on the lead through which a shock can be delivered to the heart). The Boston Scientific device is in fact a biventricular defibrillator (hence the larger clear plastic “header” on the device), to which a third lead, positioned on the left side of the heart, can be attached, not only to deal with heart rhythm problems, but also to treat heart failure in some patients. All these devices can now be implanted at this hospital.
In the United Kingdom cardiac surgery today can be divided into three main groups:
1. The correction of congenital abnormalities, even at a very early age.
Some babies are born with holes in their heart or abnormal connections of the main vessels. A child born in 1960 with congenital heart disease had a 10% chance of reaching 18 years of age. One born in 1980 had a 50% chance of achieving that age. However one born in 2000 has a greater than 90% chance of achieving 18, due to increasingly successful surgery and other interventions.
2. The treatment of heart valve and other anomalies, themselves often congenital, rheumatic heart disease being quite rare in UK at the present time.
This expanding group of patients call themselves GUCH (Grown Up Congenital Heart disease – see the patient associated web site (www.guch.org.uk). NNUH is a specialist centre for the care of GUCH patients who need lifelong follow up, since they may need new valves, pacemakers or treatment for palpitations. Management of contraception and pregnancy is an important part of care for these patients. Other inherited conditions such as a thick cardiac muscle condition (HOCM – www.cardiomyopathy.org), tall thin people whose main artery (aorta) may dilate (www.marfan.org.uk) or high blood pressure in the lungs (www.pha-uk.com) are seen. These groups all benefit from the support given by NHT.
3. Coronary artery bypass grafting (CABG) for ischaemic disease represents the greatest work load for the cardiac surgeon, 25,000 patients approximately undergoing these operations each year.
The development of non surgical improvement of the blood supply to the heart muscle has been developing during the last 20 years or so. Percutaneous coronary intervention (PCI) was originally only performed by cardiologists in hospitals also providing cardiac surgical support. It is now recognized that this surgical support is so rarely necessary that it can be performed in many district general hospitals – NNUH being a typical unit now able to provide this service. The cardiologist passes small tubes (catheters) into the coronary artery system, taking x-rays and proceeding to dilate any narrowing visualized, with a soft balloon. To keep the artery open a stent is inserted across the narrowed vessel. This procedure has been so successful, that it has replaced the surgical treatment mentioned above in the majority of patients. These days, cardiologists and cardiac surgeons discuss the results of a patient’s investigations and decide on the treatment mode most applicable to his/her condition.
Thus it can be seen that the heart is no longer the untouchable and untreatable organ it was thought to be a hundred years ago. The Norfolk Heart Trust is committed to keeping Norfolk in the forefront of developments in the specialty of cardiology.