What started as a kerfuffle, a kind of whispering mutter, in the back rows of conferences has now grown into a loud chorus. Wire-skills for cardiac surgeons has in fact become a war cry. I know this editorial will stir an hornet’s nest, but then isn’t this what the editorials are meant to do — stimulate the lazy and laid-back intelligentsia to cogitate and join cognitive exercises on burning and contemporary issues confronting our profession. I indeed will be delighted if some colleagues were to riposte, or even remonstrate, because that is precisely my intent. Hope it does not remain an unfulfilled wish.

This, rather ill-orchestrated chorus for wire-skills is akin to a church choir, where an ensemble plays out music sans any deep knowledge of the notes and scales. What may be picayune to the choir, is however, a matter of serious and fundamental existential import to the cardiothoracic surgical community. Notwithstanding its significance and relevance, no wide consultative exercise or deep cognition has gone into the demand for introducing wire-skills into the cardiothoracic surgical curriculum. It is therefore opportune to look at the flip side of the coin also and to spare a thought for the unintended collateral repercussions and ramifications of such a disruptive action.

To begin with, let us understand the genesis behind this mad rush. Cardiac surgery certainly is at a critical inflection point. It has been challenged by interventional cardiology. More and more surgical ailments and pathologies are being brought under the ambit of percutaneous technologies, and let me grant, with salutary results too. This seems to have given a kind of doomsday scenario message to the cardiac surgical community at large, that the speciality of cardiac surgery may be a dying supernova. Alas, how far removed from truth are these lapping tongues.

Another reason for the recent allure towards wire-skills of cardiac surgeons may be financial. The recompense per unit time in terms of money is much higher with percutaneous interventions than for surgical endeavours. No wonder then, youngsters would be more inclined towards percutaneous technologies, to compensate for their late entry into the cadre of big time earners, due to the long cardiac surgery training schedules.

Let all our detractors and denigrators be suitably enlightened — Cardiac surgery is not ‘dying’; it is ‘evolving’. The better long-term results of surgery compared to percutaneous interventions, e.g. coronary artery bypass surgery over percutaneous coronary intervention [1] and of surgical mitral valve repairs as against percutaneous repairs [2] etc., have been well documented. Even guidelines have incorporated these new messages so that percutaneous coronary interventions are on the decline [3] and surgical bypass surgery is steady. Moreover, pathologies, especially in the realm of congenital and end-stage heart diseases, are still, virtually entirely, or at least in a large measure, in the surgical domain. Therefore, I do not see any valid reason for a sense of despondency and dejection on the grounds of probable extinction of the cardiac surgeon or of the speciality. All we need to do is to conduct surgeon-led randomised controlled trials (RCTs), with extended follow-ups, and generate long-term data bringing the message home that surgery is more durable and effective.

We also need to invest in what we are good at — develop minimally invasive techniques, standardize them, and make them reproducible and simple enough so that they can be disseminated to the cardiac surgical community at large. Life is a constant evolution and so is the journey of any speciality. Today’s cardiac surgery is unrecognisably different from when it started, and the same shall hold true for the fore also. Some techniques and procedures may become obsolete, but then contemporaneously new avenues will open up. Let us be suitably counselled by the Doris Day’s famous song of the 1960s:

Que Sera, Sera

What ever will be, will be,

The future is not ours to see,

Que Sera, Sera.

“TAVI will be outdated as well on (a) day, because it will be possible to teleport prosthetic valves right into the body without the need of any incision or puncture: “Beam it in Scotty!” [4] — a phrase, oft-misquoted to the television series ‘Star Trek’. Therefore, instead of bemoaning and fretting over a slipping turf, we need to invest in development of the speciality and at its evolution.

Teaching wire-skills may create cardiac surgeons, who are jack of all trades, but trust me friends, they will be master of none. When the attention is divided between two streams, high calibre skilful surgical output will be curtailed. Our trainees will be seeped in mediocrity for their life time. By investing in this kind of training, using Indian Medical Association’s lexicon, we would be investing in ‘Mixopathy’ — something, which we have been so vehemently resisting. The mind-set of a scalpel astute surgeon is very different from the mind-set of a needle- or wire-wielding physician. Moreover, we all know from K Anders Ericsson’s pioneering work [5] that for optimum results, a critical mass of procedures is required, which has been fixed at roughly 10,000 cases, so as to achieve reasonable proficiency [6]. If a cardiac surgeon were to invest his/her time in both surgery and wire-skills, it may be nigh impossible for this to be achieved. The risk of creating a breed of physicians, who are neither skilled cardiac surgeons nor competent interventional cardiologists, would be a gory reality.

In the absence of an adequately and appropriately skilled and dedicated cardiac surgical workforce, the moot question arises, what happens to those maladies, where there are no percutaneous options, e.g. end-stage heart disease, especially when needing mechanical circulatory support and organ transplantation; complex congenital heart diseases; advanced coronary artery disease with high Synergy between percutaneous coronary intervention with Taxus and Coronary Artery Bypass Surgery (SYNTAX) scores; pericardial disorders; infective pathologies etc. In any case, there is no data available supporting the premise that if the catheter-based procedures are performed by surgeons, the results would be better than when they are performed by interventional cardiologists. Therefore, to claim that the surgeons have better understanding of the anatomy, tissue planes, and local geometry does not hold ground.

A caveat is in order here — one must not take a parochial view of the matters. Wire-skills just don’t involve physical techniques of handling the wire and getting a catheter across. It also involves having a deep knowledge of imaging, like transthoracic 2D and 3D echocardiography, trans-esophageal echocardiography (TEE), computerised tomography (CT), and magnetic resonance imaging (MRI). These are all very important even for follow-up of the patients and are in fact stand-alone specialities in their own right. Moreover, one becomes master, not by just performing an index procedure, but only after one has handled all possible complications attendant to that procedure. This deep knowledge cannot come with a wide palette and dichotomous spread of skill-sets, but only through a focussed and repetitive effort to acquire the skills necessary to become either a hard core interventionalist, or a deft cardiac surgeon. It is either, or none! No wonder then that operator volume has a direct impact on outcomes for most interventions [7, 8].

Another important issue concerns logistics. From where would cardiac surgeons get their patients? Are they expected to run regular cardiology out patient service? Would treating hypertension, diabetes, and heart failure, besides a heavy load of neuro-psychotic chest pains, excite them? If not, the gatekeepers will still be cardiologists. They will never offer a patient to a cardiac surgeon to do a percutaneous procedure, which they themselves can handle. Therefore, even if we teach wire-skills to the surgeons and they become adept at handling these procedures, they would also have to run parallel clinics and learn clinical cardiology, at a level stipulated under the qualifying courses for cardiology. Obviously, the human mind has its limits and would it not be too much of an ask to expect an average cardiac surgeon to be proficient in clinical cardiology, cardiac surgery, imaging, and wire-skills; and also be able to find time to work-up the patients, operate, do catheter-based procedures, and to follow them in perpetuity.

It has been suggested that with the surgeon doing a percutaneous procedure, handling an unintended emergency or a complication can be expeditious. Nothing can be further from truth than this averment. Whenever a complication occurs, the sense of failing hurts the ego of the operator and prevents him from giving up. It’s only after multiple and unduly prolonged attempts have failed to retrieve the situation, that one’s ego allows the individual to abnegate and offer the patient for surgery. In that state of upset mind, following a failure, one can not be expected to don a surgical hat and retrieve a situation, when the surgical skills required would be of a much higher calibre than for a routine elective surgery. In such situations, it is better for the percutaneous team to take a step back, introspect, and do a root cause analysis of its misfeasance, and let a de novo surgical team take over, which handles the situation with clarity of mind and with no remorse of a decision or action having gone awry.

Cardiothoracic surgery is a speciality which is driven by passion, something which drives one to higher echelons of glory, and the seeds of which are sown in the formative years of life. Surely we cannot legislate skills into any doctor through an orchestrated programme either at the post-doctoral level or at the junior consultancy level. They have to have that inner passion and drive, and inherent aptitude and skill-sets for either ‘wire’ or the ‘scalpel’. It will have to be an odd maverick who may possess both. Thus, wire-skills with a cardiac surgeon may prove to be efficacious in the hands of truly the gifted ones, but the vast majority of us are the bourgeoise class, the garden variety, for whom, skills have to be effective, and not just efficacious, so that they can be learnt and disseminated at the grassroots level. Innumerable wire-skill courses have been run over the last five years. Even our association, Indian Association of Cardiovascular and Thoracic Surgeons (IACTS), ran multiple courses, wherein even a lot of senior surgeons enrolled for them. At the risk of ruffling a few feathers, I dare say, not many of them have taken to catheter-based interventions in right earnest, despite attending these courses. Proof of the pudding, after all, is in eating! Wire-skills for cardiac surgeons may be efficacious, but are unlikely to be effective.

The way forwards

Lest you get me wrong, I am by no means suggesting that surgeons cannot learn wire-skills. They most assuredly can. Surgeons are a talented lot, and skilful at that, so that they can easily become dextrous in handling the catheter, albeit in which situation they cease to be cardiac surgeons, and should be labelled interventionists. Therefore, my only objection is to multi-tasking and for the hybridisation of the speciality of cardiac surgery. A better alternative would be to have a common track for all trainees for 2 years in a total course duration of 5–6 years after graduation. Core curriculum thereof should include, besides epidemiology, pathophysiology, and therapeutics, streams dealing with prevention, intensive care, and, most pithy, imaging — echocardiography, CT, and MRI [9]. Thereafter, the trainees should choose from one of the 3 streams:

  1. i.

    Clinical Cardiology,

  2. ii.

    Cardiac Surgery, or

  3. iii.

    Interventional Cardiac Sciences

The latter can be taught basic surgical principles and skills required for exposure of major blood vessels and haemostasis, and wire-skills in details, and taken on a path, wherein they will provide high-end percutaneous catheter-based options. Cardiac surgeons should develop their speciality parallelly and harmoniously, getting adept at dealing with complex cases, which are not suitable for percutaneous interventions; or handling adroitly complications and issues arising out of these procedures, for which a high skill-set would be required.

I know fully well that I am overwhelmingly out-numbered on this issue of wire-skills for surgeons. If it were a shouting match, I would easily be over-decibled; however, fortunately, it is not. It is an issue of vital and paramount significance with attendant consequences for the proverbial ‘bread-n-butter’ for each one of us. It is therefore imperative that we have a wider discourse on the subject. It is high time that we take the call — whether we want to preserve the purity and the nobility of the profession that we all grew up in; or do we want to move towards hybridisation, and pollute, not only its sanctity, but also its authenticity by indulging in an endeavour ‘far from their (our) vocation, belief, and passion’ [4].

May be a bit harsh, but that’s me …. heart always rules the head, and pen spills the ink, no matter how much I resist or ratiocinate.

May good sense prevail on us all!