This brief history of cardiac surgery and anaesthesia shows how difficult the first steps of any new technique can be. Pioneers need a great deal of tenacity and independence of mind to persevere in developing therapies that are considered daring, even reckless, until they are accepted by the medical establishment. The later is not above passing judgement on events whose significance it does not appreciate. When something new comes along, it's almost impossible to know whether it has a future or is a dead end. The fact that the first attempts are failures proves nothing. The future is therefore too dangerous to predict to risk it here.
We can also see how curious the human mind is. Just as rats in unfamiliar territory are driven to explore their surroundings, so humans are in a constant state of dissatisfaction, constantly trying and discovering new things. While there is always an element of chance in the discoveries, there is also an immense amount of energy and incredible persistence put into creating the conditions in which success becomes likely. It is not uncommon, for example, for discoveries to be made simultaneously in two independent centres because a climate of emulation has been created that encourages serendipity. The tragedy is that, despite the huge upfront investment in experimental research, in medicine it is often patients who pay the price for innovation. If the first heart surgeons seem very brave, what can we say about their patients who risked their lives!
History also tells us that anything new goes through three stages as it becomes established in clinical practice [2]. Whether it's a drug or a technique, it begins with a phase of enthusiasm; publications list the benefits and the indications expand indiscriminately. This can lead to the trap of unnecessary indications: if there is no benefit, patients only experience the side effects. Then comes a critical phase: numerous studies show a lack of impact on patient outcomes, or even a dangerous increase in morbidity and mortality. It usually takes several years to reach the third phase, a period of equilibrium when sufficient knowledge is available to define the indications correctly. From the Swan-Ganz catheter to beta-blockers, there are countless examples of this evolution over the last thirty years. So we need to keep a critical eye and our wits before we pass judgement on the scope of a product, and try to distinguish which phase it is in before we praise or pillory it.
Cardiac anaesthesia is an ideal area for teamwork. As RC. Brock said in 1949: "It is a kind of surgery that is not for the lone operator. Teamwork is, of course, essential in the operating theatre, where the anaesthetist plays a fundamental role that deserves special recognition" [1]. The sharing of knowledge and skills within the team leads to performances that are superior to the sum of individual possibilities, such as the emergent properties of complex physical systems. From this point of view, TEE is the quintessential multidisciplinary tool. Moreover, the cardiovascular anaesthetist occupies a privileged position: he is not only part of the operating theatre team, but also at the centre of the equation between the operating theatre, cardiology and intensive care [3]. Thanks to his knowledge of echocardiography, cardiac resuscitation and intensive care medicine, he gradually moves from being a simple sleep provider to becoming a consultant internist in the operating theatre. He also has a good command of perioperative follow-up, from pre-operative medical preparation to the management of post-operative events, which are conditioned by the circumstances encountered in the operating theatre. He thus becomes a practitioner of perioperative medicine [4].
Finally, history shows us that no idea is ever definitively established; every opinion can be challenged by a new theory, every certainty can be disproved by new facts. This brings us to some thoughts on the evolution of knowledge.
© PG Chassot April 2007, last update September 2019
References
- BROCK RC. The surgery of pulmonic stenosis: The Alexander-Simpson-Smith Lecture. BMJ 1949; 2:399
- GIDWANI UK, GOEL S. The pulmonary artery catheter in 2015: the Swan and the Phoenix. Cardiol Rev 2016; 24:1-13
- MORDECAI MM, MURRAY MJ. The value of teamwork. J Cardiothorac Vasc Anesth 2006; 20:1-2
- SHEAR TD, GREENBERG S. Pro: cardiac anesthesiologists should provide critical care consultation in the operating room. J Cardiothorac Vasc Anesth 2014; 28:1154-8
- BROCK RC. The surgery of pulmonic stenosis: The Alexander-Simpson-Smith Lecture. BMJ 1949; 2:399
- GIDWANI UK, GOEL S. The pulmonary artery catheter in 2015: the Swan and the Phoenix. Cardiol Rev 2016; 24:1-13
- MORDECAI MM, MURRAY MJ. The value of teamwork. J Cardiothorac Vasc Anesth 2006; 20:1-2
- SHEAR TD, GREENBERG S. Pro: cardiac anesthesiologists should provide critical care consultation in the operating room. J Cardiothorac Vasc Anesth 2014; 28:1154-8