June 2016

“Keeping a baby alive through a heart operation is a wonderful experience.”

Thierry Carrel is one of the most renowned heart surgeons in Switzerland. In the interview with Senso, the director of the University Hospital at the Inselspital Bern tells us why he is so fascinated by heart surgery, why the oldest patients benefit most from state-of-the-art technology and why Swiss university hospitals lead the way when it comes to cardiovascular research.

Carrel
Mr. Carrel is a Professor and Head of Cardiovascular Surgery at the Inselspital Bern and Co-Head of Heart Surgery at the Hirslanden Klinik Aarau.

Thierry Carrel, how important is the heart to you?

The heart is an extremely interesting vital organ weighing 350 grams. In the operating theatre, however, the heart is just like any other organ, a lot of which can be repaired or reconstructed. Time is of the essence here. During the operation, there is no room for emotions or philosophical thoughts.

And outside the operating theatre?

The symbolism surrounding the heart is fascinating and has been passed down from generation to generation and from civilisation to civilisation. One interesting fact is that you apparently feel the heart more consciously than the lungs, for example, even though you are constantly breathing and can also feel your breath directly. However, people feel their heart in a very special way and, last but not least, there is also a religious element to it. Nevertheless, I unfortunately have to disappoint those who want to see the heart as housing the soul: I am yet to come across a soul during one of my many heart operations, but then they do say the soul is invisible.

What makes operating on hearts so special?

Every day, I have the privilege of stopping, draining and opening up hearts. Although it is now a routine task for me, it really is a fine art. We can replace or reconstruct worn valves in the heart. Patients usually recover quickly after the operation and their life expectancy is much higher afterwards. This is not the case in many other surgical disciplines. It is a wonderful experience for everyone involved to give the gift of life to a baby through a heart operation, so that he or she can perhaps have a healthy life for 80 years.

Is that also the reason why you decided to become a heart surgeon?

It was also a bit of a coincidence that I became a heart surgeon and not a general surgeon or an orthopaedic surgeon. I was already fascinated by surgery during my studies. To me, it is the perfect interplay between a manual activity, intellectual considerations and the use of cutting-edge technology. I need to be well prepared for an operation, develop solutions in advance and be aware of different approaches in case any complications arise. There have been and will continue to be huge technological advances, but at the same time these present us with major challenges.

What are they?

Technology has played a particularly crucial role in developing the specialist field of surgery. However, progress is so rapid that it is becoming increasingly difficult to keep the big picture in mind in order to check what is usable and what it would be better to steer clear of.

Could you give us an example?

A good example was laser surgery in the mid-1990s. The marketing campaigns of the industry and clinics that used lasers were huge: those clinics which did not offer laser surgery were considered old-fashioned. However, the lasers disappeared quietly after a couple of years because nobody was able to show why laser technology was actually needed.

How can you avoid being taken for a ride with unnecessary innovations?

The team needs to study a lot of professional literature and have lots of discussions. We are exceptionally good at doing so at Inselspital: it is one of our strengths. We inform ourselves at congresses, as well as exchanging information and experiences. However, even that is no guarantee that you are always right. It is often the case that you can only determine several years later whether it was a wise move to pursue a particular innovation.

That also costs you a pretty penny, doesn’t it?

Costs are an important topic these days. The doctor needs to be convinced that what is being offered will have a positive effect, that due consideration has been given to cost-effectiveness and that the patient will benefit from the process in the long term. It is now possible to document this much better than it was 25 years ago. These questions are also important because we are increasingly treating more fragile patients, or in other words more elderly patients. The costly procedures need to be even better prepared and thought through.

Does that mean the average age of cardiovascular patients is now higher than it used to be?

The figure has increased by 10 to 15 years over the last 25 years. A 65-year-old patient used to already be considered old. Nowadays, this only applies to 80 year olds.

Are cardiovascular diseases now generally occurring later in life?

There has not been a drop in 40 to 60-year-old patients, even though people now know about preventive measures and aftercare following an initial incident, i.e. a heart attack, stent or bypass operation. However, these days our patients are older on average when they have their first operation because medication or catheter interventions can delay the need for a heart operation. And since we live longer now than we used to, cardiovascular patients are also getting older and older.

Does the same apply to women?

The risk factors apply to both genders. There is also no difference where the treatment offered is concerned. However, the menopause presents women with an additional risk due to the fluctuation in female hormones. Furthermore, women’s coronary vessels are often smaller, making deposits more of a serious issue. More men are affected in the 40 to 60 age group, but things even out between the ages of 60 and 80.

You said that in spite of prevention strategies, the number of cardiovascular patients has not dropped. So could you do away with prevention all together?

Prevention is just one piece of the puzzle. Getting enough exercise, having a healthy diet, not smoking and if possible, not being overweight – however, you already need to start doing so between the ages of 20 and 30, and not only once you turn 60.

Why is that not the case?

Valve procedures are comparatively rare in young patients, so it is hardly worth spending money on research and developing innovative products. This is one of the sad truths of a free market economy. Not much is implemented for a small group of patients. On the other hand, there is a huge market for older patients and hence also lots of services.

Will new procedures reduce these costs in future?

Yes, I am convinced that we are in for many new developments which we haven't even thought about yet. Life scientists, engineers and IT specialists are very active in the health sector because the healthcare market is lucrative. For instance, specialists are thinking about how organs or parts thereof could be bred. Another major area of research is understanding our genetic make-up. There is great potential here, for example personalised medicine. However, you also need to consider the risks.

Which ones spring to mind?

Lots of data is required if you want to obtain and make use of important information from the genotype. And anyone who has lots of data needs to think about protecting this data. This would enable customised medicine for many illnesses such as tumours and high blood pressure. Prevention could also benefit from this.

It would open up completely new doors.

Exactly. Just imagine if you could treat illnesses that either were caused or will be caused by gene defects before they do any damage. It is a fascinating prospect. After all, cardiovascular problems are frequently genetically inherited. That would open up a totally new possibility in medicine. This would also be extremely interesting from a research perspective.

What stage is Switzerland actually at where cardiovascular research is concerned?

Based on the size of the population, the output of the five universities and the Federal Institutes of Technology including their valuable publications is above average. It is much higher than in the USA, for example. As far as inventions and patents are concerned, we are very well positioned, especially also in pharmaceutical research. Our strong networking creates the ideal conditions for successful research and internationally renowned innovations.

What are they?

For example, the invention of the balloon catheter by Andreas Grüntzig in Zurich in 1977. Or the first heart transplant, which was performed by Åke Senning at the University Hospital Zurich in 1969. Or the invention of ciclosporin – which is used to prevent rejections after transplants – in the early 1970s at Sandoz by Jean-François Borel and his team. Many renowned doctors find the ideal conditions here for their work and research because the medicine is at a very high level. However, successes in cardiovascular medicine have also led to people making light of the diseases and taking the attitude of: I don’t have to make an effort; after all, there are very good solutions available if I get sick.

What do you mean by that?

Nowadays, people already almost assume that cardiovascular diseases are always curable. And this is correct in the majority of cases: a heart attack can now be well treated, with operations enabling a new and generally complaint-free phase of life. However, a successful heart operation is only the beginning. What happens afterwards is also an important factor.

Are you referring to post-operative care?

Yes, treatment only makes sense if it has a positive after-effect. However, since treatment has now become so commonplace and simple, some patients have the feeling that a bit of vascular calcification is like tartar. You simply have another operation when it is necessary again. However, personal responsibility is an important part of post-operative care: why every patient must make an effort: for example, anyone who immediately stops smoking quickly progresses to the same area of risk as a non-smoker.

What role do factors like stress and workload play?

Good question, because you cannot just measure these factors and say what they cause. Stress factors definitely have an influence on our health, but we need positive stress in turn in order to be productive and perhaps also happy.

You are a very busy person. What is your personal strategy for dealing with stress?

Yes, I work a lot, but I myself determine what the limits are. That is important. I determine how many talks I hold or how many projects I get involved in. I get positive energy from these activities. Moreover, I also consciously allow myself short breaks.

And how about your prevention strategy? Do you have time for sport?

For a long time, I didn’t do much sport and sacrificed almost everything for my job, but I realised that things couldn’t continue like this. After all, to me it is a question of credibility not just to tell my patients to live healthy lives but also to actually do so myself. I lost 25 kilograms thanks to a healthy diet and sport. I also have a check-up every few years. I want to be a role model where prevention is concerned – not just to my patients but also to my team.

How important is teamwork and exchanging ideas with colleagues to you?

Very important. After all, the hospital doesn't rely solely on me. I am also very proud of the junior doctors who frequently contribute to our positive team spirit and experiences. We have trained the largest number of heat surgeons in Bern over the last 15 years: some colleagues have secured a senior consultant position at a university hospital – for example in Basel and Geneva – while others work at one of the Hirslanden clinics. I also enjoy exchanging ideas with colleagues and discussing special operating techniques with colleagues from abroad at congresses.

Do you also refer your patients to colleagues for a second opinion?

It happens relatively rarely but a different viewpoint can be valuable. It becomes problematic if the patient is given different opinions from several doctors and then loses trust in them. That is why I also like to allow enough time to talk about my patients’ doubts or fears with them.

In general, what role does the psyche play when it comes to treating cardiovascular problems?

Cardiac patients also frequently suffer from non-physical complaints. Cardiac psychology is therefore an important part of our treatment. Patients who are waiting for a donor heart can suffer psychologically because they have to live with great uncertainty. They ask themselves if they will actually still be alive by the time they have the operation and whether or not a suitable heart will ever be found. And then they ask themselves who their heart once belonged to. They need psychological support in these cases. Or also when somebody survives a cardiac arrest and then wakes up in a hospital bed with a cut in their chest not knowing what has happened to them. That can be very taxing, which is why our work isn’t done after the operation.

Interview: Daliah Kremer