Jul 14, 2023

Bypassed: are heart surgeons dying out?

By Simon Akam

On a Tuesday morning in October 2021, Kulvinder Lall, a heart surgeon at St Bartholomew's Hospital in London, began work in a brightly lit operating theatre. Lall, a slim 55-year-old, wore latex gloves that fitted snugly over the cuffs of his gown and, propped above his surgical mask, a pair of magnifying spectacles known as loupes. (When he wasn't wearing them, he wrapped them in a cloth bearing a print of his face and the slogan "Lenswear for Visionaries", a reminder of the time that Nikon, a Japanese firm, recruited him to market their optics.)

Unconscious on the table in front of Lall lay a man in his 60s with coronary heart disease – he had developed blockages in the arteries that supply the heart with oxygenated blood. The atmosphere in the theatre was business-like, but Lall's work also had a performative element – not for nothing are the rooms where operations take place still called theatres. Lall clearly enjoyed being observed, both by his two trainees and the visiting journalist. Sometimes, he begins pre-surgery briefings by quipping to his team that he's already told the patient's family how well the operation went.

Lall was performing a coronary artery bypass graft, known in the trade as a "cabbage" after its acronym, CABG. It's a mainstay of cardiothoracic work – a term that refers to all surgery performed on the chest. A vein or artery is taken from elsewhere in the body, and sewn into the arteries that supply the heart, above and below the blockages, allowing blood to "bypass" them. The surgery is no small matter, but relatively common: some 14,000 CABGs are carried out in Britain each year, and around 200,000 in America.

The heart sustains everything else; break it and the patient dies

As the operation began, Lall's juniors sliced into the chest, first with a scalpel, then with a diathermy wand, an instrument that uses an electric current to cut and cauterise tissue. Urszula Simoniuk, one of Lall's assistants, took the lead here because, for all its drama, "opening the chest" is one of the basics of heart surgery. Cutting through the breastbone, she pushed the pinkish-grey lungs to one side, and continued through the pericardium, the membrane that surrounds the heart. Eventually she revealed the organ itself, concertina-ing in and out as it pumped blood. A specially trained nurse burrowed into the patient's leg using a tube with a camera attached and snipped off a length of vein, which would be used as a graft.

Now Lall took over. He made a small hole in the aorta, the artery that emerges from the top of the heart, and inserted a transparent pipe. Bright red blood rose up through the plastic. Lall then pierced the right atrium – the chamber that forms the other end of the circulatory system – with another tube, and connected it to a heart-lung machine, which oxygenates blood and pumps it around the body. This allowed Lall to keep the patient alive while he stopped the heart from beating, which he accomplished with a shot of potassium citrate to the aorta. With the patient's heart stilled, Lall began to suture the grafts in place.

As he sewed, Richard Galloway, one of the surgical trainees, asked him a question. The tone was polite, but the question was momentous, seeing as it addressed the future of Lall's profession. "Mr Lall," he asked – in Britain surgeons are never addressed as "Dr" – "would you still recommend cardiothoracics?"

The heart, which makes up less than half a percent of the body's weight, is small but mighty. Two of its chambers take oxygen-rich blood from the lungs and pump it around the body; the other two receive deoxygenated blood from the body and pump it into the lungs. Valves ensure that blood flows in the right direction. Electrical circuits control the expansion and relaxation that we know as the heartbeat.

Almost every part of this intricate system can fail. The heart valves can narrow or leak, and blood can flow the wrong way, causing breathlessness, blackouts or even heart failure. The electrical system can malfunction, distorting the rhythm of the beat, leading to dizziness, or the sensation of a racing or fluttering heart. Worse, as some 180,000 Britons and 800,000 Americans experience each year, a blockage in an artery can cut off the supply of oxygenated blood, triggering a heart attack.

When cardiac surgery finally emerged it became one of the most prestigious and well-rewarded branches of medicine

Cardiac surgeons try to fix these conditions. This is tricky work. The heart sustains everything else; break it and the patient dies. Until the late 19th century surgeons were convinced that the organ was so delicate that even touching it would cause death. The heart is more robust than they thought, but the demands it makes of a surgeon are still considerable, necessitating mastery of sophisticated technology, the ability to work under time pressure (the longer a patient is kept "on bypass", the higher the risk of damage to the heart, brain or kidneys), and the capacity to deal psychologically with the high-stakes nature of the operations. Unsurprisingly, when cardiac surgery finally emerged between the 1940s and 1960s it quickly became one of the most prestigious and well-rewarded branches of medicine, dominated by vaunting men who gloried in their power to save those doomed to die.

Surgery can save lives, but it is also physiologically and psychologically traumatic, and can take months to recover from. Today, many heart problems are treatable without it. Running catheters into the heart through blood vessels has become a mainstream approach for dealing with both blockages in the coronary arteries and problems with the heart valves. In Britain, such procedures are generally not carried out by heart surgeons, but by so-called "interventional" cardiologists, who work in a distinct speciality. Their success rolling out new procedures over the past few decades has been staggering. In 2008-09, the number of heart operations taking place in Britain reached an all-time high of over 41,000. By 2019-20 it had fallen to just over 31,000. By contrast, the number of just one type of minimally invasive procedure – the implantation of stents (short tubes or meshes that keep arteries open) – increased from around 10,000 in 1991 to just over 100,000 in 2019-20. The long-term trend has been similar in America. Though the number of consultant heart surgeons in Britain has been largely static – 257 at last count – there is ever less work to go around.

"For the patient's sake that has to be a good thing," says Stephen Westaby, a retired heart surgeon from the John Radcliffe Hospital in Oxford. "Cardiac surgery…takes a long time to get over…and modern technology is able to do things as well, with less risk." But for heart surgeons, the rise of interventional cardiology is depriving them of patients, threatening their job security and their ability to strike it rich through private work. When I asked Dincer Aktuerk, a consultant surgeon recently appointed at Barts – as St Bartholomew's is known – what he thought about the future of his profession, he was blunt: "I don't think that the conventional cardiac surgeon, as we know it, will exist in a few years’ time."

Kulvinder Lall was born to parents who emigrated to Britain in the decades after the second world war. His father hailed from Punjab, and his mother had grown up as a member of the Sikh Punjabi minority in Nairobi. Like many first-generation immigrant parents, they expected their son to find a respectable job. With money that Lall's father earned from his small construction firm, the couple managed to send their son to a fee-paying school, where Lall excelled. After acing his A-levels, he began studying medicine at King's College London.

Medicine during the 1980s and 1990s, when Lall did his training, was very different in atmosphere from today. Lall once worked for one surgeon who would throw an assistant out of the operating theatre every half an hour and summon a replacement. ("Nothing to do with the assistant, just because he was out of his comfort zone, shouting and stuff," Lall explained.) This generation of consultants had carried out some of the earliest and most dangerous operations on the heart. Even in the 1970s, mortality rates for certain risky surgeries were as high as 25%. "Can you imagine losing patient after patient after patient after patient?" Lall remarked. Surgeons "must have been so single-minded, and so bloody-minded almost, to get through those days".

Westaby, the retired heart surgeon, told me that he was only able to survive in the world of heart surgery thanks to a brain injury he sustained while playing rugby, which he claims granted him psychopathic qualities. He acquired the nickname "Jaws" during his surgical training for the speed with which he could amputate a leg. After he’d moved on to hearts, he was once summoned from the pub to repair an aorta torn in a car crash. "The problem wasn't so much the amount of alcohol – we were used to that – more the volume of urine to pass during a four-hour operation," Westaby later wrote. Too proud to go to the toilet mid-operation, he catheterised himself with rubber tubing and let the urine run into his surgical boot, coughing to disguise the squelch.

"Cardiac surgery is highly invasive. Modern technology is able to do things as well, with less risk"

Lall graduated from medical school in 1989, and after several years joined the Royal Brompton Hospital in London to work for a famous Anglo-Egyptian surgeon called Magdi Yacoub. Yacoub had established an extremely influential heart-transplant programme in the 1980s. Lall told me he respected Yacoub as an innovator, but also remembers behaviour that would be unacceptable today. Yacoub barely slept, and held clinics in the middle of the night. Patients, attached to bypass machines, would sometimes wait for hours for him to arrive. On one occasion Yacoub called the hospital and told them to begin surgery as he was "at the airport", only for it to transpire that he was still in Paris. (Yacoub, now 87, declined an interview, and did not respond to an invitation to comment.)

By the time Lall became a consultant in 2003, the culture among heart surgeons was changing. In the mid-1990s, a scandal had emerged at the Bristol Royal Infirmary, where babies were dying after cardiac surgery at noticeably high rates. A public inquiry in 2001 blamed numerous factors: a lack of leadership, a clubby culture among doctors, a lax approach to safety and secrecy about performance.

In response, the British medical authorities ramped up scrutiny. Most significantly, the National Health Service (NHS) began to publish mortality rates for individual heart surgeons. Whereas surgeons had previously made their name by seeking out particularly difficult or pioneering operations, the new era of transparency inverted the incentives. Publishing stats made surgeons wary of taking on risky cases. In the space of a single generation, heart surgery was transformed from a discipline of daring innovation and overbearing personalities to one of tried-and-tested procedures. It became "a profession of marginal gains", Thomas Morris, author of a history of heart surgery, told me.

The increased scrutiny improved outcomes for most patients. A study in 2009 found that mortality rates after coronary-artery surgery in Britain had fallen by 21% in the preceding five years; those for surgery on isolated valves saw a reduction of a third. Yet publication of mortality rates created unintended consequences. Some surgeons gamed the system, by registering a higher number of risk factors for certain patients so that it appeared that they were harder to operate on. To combat this, the NHS switched to publishing outcomes for heart surgery by unit, rather than by individual surgeon, in 2020. The hope is that this will increase surgeons’ willingness to take on complex cases.

Lall will retire in less than a decade. When I spoke with him about the changes in his field his responses reflected a mixture of the heart surgeon's classic self-assurance and the perspective of someone whose own professional position is secure. He suggested that there was still plenty of innovation within heart surgery – he pointed in particular to new, less intrusive ways of harvesting veins and opening chests. But he admitted that greater oversight than in the past did mean things move more slowly. "We’re not allowed to kill people while in the learning curve. So everything has to go at a much more sedate pace."

In between stints in Lall's operating theatre, I spent time in another department of Barts – the catheter lab, or "cath lab". There I witnessed the less invasive procedures that were supplanting the work of the surgeons. One autumn day, Mike Mullen, a 57-year-old interventional cardiologist, stood in his lab, preparing to get to work. To protect himself from radiation, he wore a lead-lined apron depicting dalmatians gallivanting on a blood-red field ("It's more fun than boring monotone," he explained). In the centre of the room stood a large X-ray machine, and inside lay 88-year-old Shirley Rodwell, who, like most of Mullen's patients, would remain awake for the procedure. Rodwell had aortic stenosis, a narrowing of one of the heart's valves, usually caused in older patients by a build-up of calcium deposits. A narrowed valve reduces the volume of oxygenated blood circulating through the body, often resulting in shortness of breath and the chest pain known as angina. In severe cases, aortic stenosis can lead to heart failure and death.

Traditionally this condition, which affects around one in 30 British adults over 75, has required an operation. A surgeon opens the chest and replaces the diseased valve with an artificial substitute or one made from cow, pig or human tissue. But Rodwell was having a different procedure: TAVI, which stands for transcatheter aortic valve implantation. (It's known as TAVR in America, where the R stands for "replacement".) No big incisions would be needed. The valve, made from cow tissue, would be compressed onto a balloon on the tip of a catheter. The cardiologist would guide the balloon to the narrowed aortic valve by means of a wire inserted into a blood vessel, where it would be inflated with fluid, locking the new valve in place without having to cut open Rodwell's chest.

"I don't think that the conventional cardiac surgeon, as we know him, will exist in a few years’ time"

When TAVI debuted in Britain in 2007, the procedure was exclusively offered to frailer patients like Rodwell, who were too old to withstand open-heart surgery. Today, it is increasingly provided to stronger patients too. In 2014-15, TAVI accounted for 17% of all aortic-valve replacements. By 2020-21 that figure had risen to around 70%.

Before her TAVI, Rodwell was apprehensive. Her husband Wilfred had open-heart surgery in 1994 to repair his own aortic valve. Magdi Yacoub, the surgeon who trained Kulvinder Lall, conducted the operation before a medical audience to demonstrate a new kind of replacement valve. Wilfred survived, but the experience was brutal: his heart stopped beating twice during the eight-hour ordeal, and he remained in a coma for several days after the operation. Rodwell was determined to avoid a similar experience.

Mullen injected Rodwell's right thigh with local anaesthetic, then punctured her femoral artery with a hollow needle. Feeding the guide wire into the needle, he pushed it all the way up to the narrowed aortic valve in her heart. He then strung the new valve onto the wire, and began guiding it into place with X-ray and ultrasound, toggling between two- and three-dimensional views on a nearby monitor.

TAVI was first successfully attempted on a pig in 1989. Thirteen years later, a French cardiologist pulled off the procedure on a human. Early patients were put under general anaesthetic, but now they are usually conscious throughout the process, and given only minor painkillers. Today, doctors told me, TAVI is relatively painless, though Rodwell's reaction suggested otherwise. "Ow, ow, ow," she moaned, as the machines beeped remorselessly. When the team sped up her heartbeat – to stabilise the balloon used to expand the valve – she began to whimper. Eventually, Mullen finished replacing the valve and extracted the blood-spattered catheter. The whole process had taken under an hour.

Heart surgery has been transformed from a discipline of daring innovation and overbearing personalities to one of routine procedures

Rodwell stayed in the cath lab for 30 minutes of observation, and was then taken to a ward. The following day, she was propped up in bed at the hospital and ready to talk. "It really is a very uncomfortable thing," she said. But everything had seemingly turned out well. She went home hours later.

​​Several months later, in her timber-framed house in north London, Rodwell had forgotten whatever discomfort she experienced during the procedure. In fact, she had no recollection at all of what it had felt like. When I asked her if she felt better in general, she replied, "Definitely."

Over the past 20 years, cardiologists have driven innovation in much the same way as surgeons did in the 1960s and 1970s. They no longer paddle in a staid medical backwater prescribing pills for hypertension, but perform TAVIs, stent implants and other procedures that are swiftly replacing traditional surgical techniques.

Mullen himself originally wanted to be a surgeon, but grew disillusioned with the field while working with breast-cancer patients in northern England in the 1980s, when treatment was, compared with today at least, crude. "The surgical approach didn't inspire me," he said. Shortly after, he switched to cardiology, initially treating congenital heart defects. Then, in 2006, at a medical conference in Washington, DC, he saw a TAVI procedure. "Very avant-garde then," Mullen recalled, "A man-landing-on-the-Moon type of moment."

Mullen persuaded the company that made the device to supply catheter kits to the Brompton Hospital in London, and he performed some early procedures as part of a Europe-wide clinical trial. "Mike is a total swashbuckler of medicine," explained Guy Lloyd, the head of cardiac imaging at Barts. "He will fly in and do things that other people just wouldn't do." I suggested to Mullen that the state of interventional cardiology today sounded like early heart surgery, but he replied that cardiology, too, now felt less buccaneering because of increased oversight. "It doesn't have the same free spirit," he told me. "In the early days of cardiac surgery, it was largely data-free. So good data was very hard to get. Now, everything we do is driven by data and clinical trials."

Whatever the similarities between their respective fields, however, Mullen and Lall repeatedly criticised the other's discipline during our conversations. "Kulvinder Lall and myself, we lock horns on a fairly regular basis," Mullen told me. He suggested the surgeons were practitioners of a dying trade, unable to accept that cutting open chests was going the way of leeches and bloodletting. Mullen claimed that Lall, whose career was well-established, was leading his juniors into a future of precarity. "They’ve got guys sitting there who are in their mid-40s, who still haven't got a consultant's job," Mullen told me. Simon Kennon, another Barts cardiologist, told me that when Lall started as a registrar, his consultants "would’ve been earning, quite literally, footballer salaries". "That's all been taken away by us," he added. "So there is that simmering resentment in the background."

Lall didn't deny that there was a difficult road ahead for young surgeons. But he believed that Mullen was an evangelical advocate for unproven wire techniques that lack long-term data. As far as Lall was concerned, interventional cardiologists had grown too cosy with the medical-device manufacturers that developed their gadgets.

Nonetheless, Lall told me, he and Mullen almost always agreed on which procedure was right for a particular patient. It was clear that the pair also liked and respected each other personally. In the multi-disciplinary team meetings, where decisions are made jointly by surgeons and cardiologists, they would sit next to each other in their green scrubs, bantering like schoolboys. On one occasion, Lall texted Mullen to ask if he could perform a TAVI on his aunt. Mullen happily obliged.

No one wants to have heart surgery unless it is absolutely necessary. But the question of whether minimally invasive methods are an adequate replacement for it remains hotly contested. Take, for instance, the case of a trial conducted in 2010 and funded by Abbott, an American stent manufacturer. The trial, called EXCEL, recruited nearly 2,000 patients: some had undergone bypass surgery; others had been treated with stents. The organisers tracked them for three years to compare the efficacy of each procedure.

Cardiologists no longer paddle in a staid medical backwater prescribing pills for hypertension

EXCEL's early findings suggested that outcomes for the two populations were roughly similar, and in response the European Society of Cardiology revised its guidelines to declare stents as effective as bypass surgery for treating disease of the left main coronary artery. Critics, however, alleged that the EXCEL scientists had relied on a misleadingly narrow definition of heart attack. Had they used the more generally accepted definition, the trial would have demonstrated that patients treated with stents were almost twice as likely to suffer a heart attack as those who underwent bypass surgery. Moreover, while mortality figures were relatively similar between the two groups after three years, they began to diverge after five, with stent patients dying at a higher rate.

The editors at the prestigious New England Journal of Medicine (NEJM), which was publishing the trial's results, pressed the organisers to include the five-year data. So too did David Taggart, a heart surgeon who chaired the trial's surgical committee. But the EXCEL team did not follow this advice, and in autumn 2019 they published a paper concluding that the treatments were equally effective at five years. Taggart asked to have his name removed from the study. At a meeting of surgeons in October 2019 he described the actions of the EXCEL organisers as "an absolute outrage". "In my 30 years of medical practice", he said, "I have never witnessed such an attempt to distort what a paper actually looks like."

After underlying data from the trial was leaked to Deborah Cohen, a BBC journalist, things got even messier. When approached by Cohen, trial organisers initially denied that the data existed to begin with, before backtracking. Nick Freemantle, who directs the clinical-trial unit at University College London, analysed the EXCEL data for the BBC in 2019 and concluded that the organisers had manipulated the results to their liking. In the plan of the trial, they had included the universal definition of a heart attack as a "secondary outcome" to be measured, Freemantle told me, but omitted it when the three-year results were first published in 2016. "You simply cannot cherry-pick the outcomes you choose to report," he said. In 2020, under pressure following the BBC's reporting, the EXCEL trial organisers eventually published the results using the universal definition. These looked radically different, showing a 79% greater chance of a heart attack after a stent implant than after a bypass after three years.

Gregg Stone, the leader of the trial, told me that a more recent analysis of several different trials, published in the Lancet in November 2021, supported EXCEL's initial findings, but critics like Taggart remain unconvinced. He believes the meta-analysis diluted the results of EXCEL with "smaller, weaker, older" studies to make the mortality benefit of surgery over wire procedures "disappear".

Amid this uncertainty, however, a few things seem to be clear. New trial data published in 2019 showed TAVI matching or outperforming surgery for low-risk patients in the two years following the treatment. (There was a standing ovation at the American College of Cardiology meeting when the results of one of these trials was announced.) On that basis America's Food and Drug Administration approved TAVI/TAVR for low-risk patients. In 2019 TAVI numbers in America outmatched all forms of surgical valve replacement for the first time. But there is still uncertainty as to TAVI's long-term effectiveness.

Diseased aortic valves always require replacement one way or the other. But some heart conditions may not require any form of intrusive intervention. Some studies have suggested that medication and lifestyle changes are just as effective at treating coronary heart disease as either stents or bypass surgery. As Anthony Mathur, another cardiologist at Barts, explained it to me, both surgeons and cardiologists have a propensity to put their training to use at every opportunity. They find it hard not to intervene. "They have a skill set that allows them to deliver high-tech procedures," he told me, "so funnily enough that's what they’ll do."

The history of medicine is littered with kinds of surgery that were abandoned with the advancement of technology. In the 1940s, the advent of antibiotics swiftly ended alarming procedures to cut out sections of lungs infected with tuberculosis. In the 1970s, the arrival of H2 receptor blockers, which inhibit the production of gastric acid, revolutionised the treatment of ulcers in the stomach and intestine, which had previously been operated on.

But even as some surgeries began to disappear, other operations became possible, such as bariatric surgery for weight loss and more sophisticated cancer treatments. "There was never a question of surgeons becoming redundant as they no longer needed to do a particular operation," said Roland Valori, a British gastroenterologist. Yet the youngest generation of heart surgeons clearly feels that things are changing – and that they have to change too.

Mullen suggested the surgeons were practitioners of a dying trade, unable to accept that cutting open chests was going the way of leeches and bloodletting

Between operations at Barts I sat in a messy common room with Urszula Simoniuk, one of Kulvinder Lall's assistants. She explained to me that her interest in surgery was sparked by a cancer she developed near her shoulder at the age of 13, when she was growing up in Poland. As Simoniuk underwent treatment, the doctors explained that she could lose her arm. "If I’m going to keep my hand and I’m doing fine, I’m going to do something useful with my hands," she told herself. She avoided amputation, and kept her vow.

Simoniuk has responded to cardiologists’ encroachment on heart surgery by looking to plant a foot in both camps. She wants to learn how to use a catheter as well as performing conventional operations. "In the next few years I would like to learn TAVI," she told me. "So when patients, for example, are referred by cardiology, I can potentially offer two procedures." The training system does not accommodate this approach – there is no mandatory rotation on wire skills for surgeons, and a one-year fellowship available at the end of training is not long enough to qualify for TAVI. But Simoniuk seems determined to find a way, and she has found an endovascular surgeon at Barts who can train her in basic wire skills.

Other prospective surgeons go elsewhere. Months after I’d met him in theatre, I spoke with Richard Galloway, the other surgical trainee. I reminded him of the question he asked Lall about whether cardiothoracics was still a good trade. Galloway was keen to emphasise that he had felt torn at the time. Along with the nagging concern for the future of the discipline, he had been overawed by Lall's physical dexterity during the bypass.

Nonetheless, Galloway's concerns about heart surgery's future were real. The threat was not only from cardiology. Galloway mentioned interventional radiology, another speciality, which focuses targeted radiation at problems inside the body, and which may further cannibalise surgery. "The cardiothoracic, cardiology thing…it is not just within those two groups where this massive change is happening," Miles Walkden, an interventional radiologist at University College London Hospital, told me. "It's across medicine."

For his part, Galloway had chosen to focus on orthopaedics – fixing musculoskeletal injuries – a branch he knew from his own slew of rugby injuries. As the war between the surgeons and cardiologists raged, it seemed like a more practical choice. "Everyone's going to need knee replacements," Galloway said. "You’re in good business there." ■

Simon Akam (@simonakam) is a British writer. He has previously written for 1843 magazine on the covid pandemic and a plane-crash mystery in the Alps. His first book, "The Changing of the Guard", was published in 2021 and he co-hosts the writing podcast "Always Take Notes".


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