The entire discipline dealing with the surgical treatment of congenital heart disease is unique in retaining much of its original awesomeness. Perhaps this is because the act of opening a child's chest to manipulate in or about the heart still evokes the feeling that this is an incredibly impertinent thing to do. Even after all these years, the act seems to fly in the face of that which is natural and possible. Perhaps it is because of the great gravity of the procedure, the sometimes narrow margin between failure and success, with an entire unlived lifetime in the balance. Or perhaps it is because the surgical capability to invade the heart developed more recently than for any other organ—indeed, within the professional lifetime of some of its still-pioneering pioneers.
It is unquestionably true of each of the surgical disciplines that success or failure is related to the availability of fundamental knowledge, advanced technology and artistic skill. But perhaps those who are involved in surgery of congenital heart defects could be forgiven for observing that this axiom relates most particularly of all to this discipline. The structural complexity and functional intricacy of the cardiovascular system are exceeded by only one other, the central nervous system, which is so exalted in these respects as to remain relatively intractable to all but ablative surgical interventions. Of all other systems, with regard to complexity, none seem to compare embryologically, anatomically, physiologically, or electronically with the heart. And within the cardiovascular system itself, the subclass of conditions which has a congenital aetiology greatly surpasses other forms of heart disease with respect to multiplicity of pathological presentations, diversity of combinations of associated lesions, and requirements for ingenuity and precision of surgical technique and patient care.
The congenitally deformed heart poses special obstacles to corrective operation. The necessity for growth is particularly important, especially when prosthetic valves or conduits are required, and true also for cardiac transplantation or perhaps ultimately the use of an artificial heart. Pertinent also, is the problem of secondary effects of the congenital anomaly on pulmonary or peripheral vasculature, or on the myocardium itself.
A situation par excellence which demonstrates the necessity of sophisticated teamwork in modern medical practice is provided by groups which are successful in the management of patients with congenital heart disease. Collaboration, coordination, communication, cross-fertilization and mutual esteem should be in evidence among participants of this team, which includes a cardiologist, radiologist, physiologist, pathologist, anaesthetist, nurse, technician, surgeon and several other partners. Perhaps as well as being the most ''incisive'', the surgeon's role in this team is also highly decisive. It is necessarily upon the surgeon's shoulders that the principal burden of the operative intervention must primarily rest. He or she must feel the weight of having accepted from the parent that strongest of all possible human obligations—the profound, primordial, instinctive identification and responsibility for an offspring. Surely no more depth of sincerity can be imagined than that expressed in the ''Thank you'' of a parent for a safe and successful surgical endeavour, nor more pain, frustation and despair if the outcome should be the opposite. By virtue of the complexity of the many problems to be dealt with, the precision required during all phases of patient care, and the immense parental trust resting upon them, the team dealing with congenital heart disease sometimes finds the demands on reserves of physical, emotional and spiritual strength almost overwhelming. Yet the incomparable sense of reward which is frequently achieved compensates and justifies all.
Some 40-45 years are all that have been required for progression from that first adventure of cardiac surgery to the present when virtually every anomaly is amenable to some form of surgical intervention. During this time, the advance of one ingenious approach after another has stirred excitement and expectation, and the prospect of further refinements and innovations continues. However, at this point, one senses that a landmark may have been reached. Techniques, approaches, results and remaining issues of concern all seem to have reached a tentative landing on the staircase of progress. This pause presents, perhaps for the first time, a splendid opportunity to survey the subject broadly and thoroughly. The authors of this book are well suited to the task from the standpoint of their multi-disciplinary diversity, their uniformly superb qualifications and their substantial individual contributions to this body of knowledge. The challenge of condensing the mass of information surrounding each aspect and anomaly, while retaining comprehensiveness, has, I think, been expertly accomplished.
It gives me honour to have the opportunity to present these reflections as a preliminary to this fine text. It gives me pleasure to congratulate all of those who contributed in either small or large measure to the remarkable achievements to which it attests. To its authors, I heartily extend my respect and gratitude.
DWIGHT C. McGOON, M.D. Mayo Clinic, Rochester, Minnesota, USA
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