Since joining the Heart Institute in 2002, Dr. Ruel has been a pioneer and advocate of minimally invasive cardiac surgery. He has taught his minimally invasive cardiac bypass technique to surgeons from across North America and around the world.
When not in the operating room, Dr. Ruel is an active researcher, running the Regenerative Therapies Laboratory. In collaboration with the Cardiovascular Tissue Engineering Laboratory, led by Erik Suuronen, PhD, Dr. Ruel’s lab looks for new ways to harness the body’s own stem cells and regenerative mechanisms to repair damaged heart tissue.
Dr. Ruel spoke with The Beat about the future of surgical research at the Heart Institute, the changing role of surgery in cardiac care, and the opportunities and challenges presented by new technologies.
The Beat: How do you see surgical practice at the Heart Institute evolving in coming years?
Dr. Ruel: Technical innovation has been a brilliant area for us. It’s helped our patients and has put us on the forefront of the international stage. Some of us have gone all over the world to teach the operations that we’ve invented or taken on. We receive patients here for minimally invasive coronary surgery from coast to coast, even from the U.S. sometimes. This innovation is definitely something that we want to continue. It enhances our program and helps us serve our patients and community better.
We also want to be able to provide the very best teaching to the doctors who come here to learn surgical techniques. That’s the medium-term impact of what we do. In a nutshell, clinical excellence is a short-term benefit, research is long-term and education is a medium-term benefit to society at large. The residents, fellows and outside surgeons we instruct at the Heart Institute can go back to their own centres and provide the very best care to their patients. That’s part of our mission!
Once an operation is completed and the patient has left the Intensive Care Unit, where our anesthesiology colleagues provide top-notch care, we also want to develop a more integrated model of care with nurses and other health personnel, such as physiotherapists. We want to develop the use of protocols that reduce variability when there’s a routine medical decision to be made, for instance with anticoagulation prescriptions, fluid over-load, or dealing with fast heart rates after surgery, which are fairly common. We believe that, by having protocols that are developed in conjunction with the nurses, we will improve efficiency and reduce the opportunity for errors. One of our surgeons, Dr. Khanh Lam, has great interest in this.
The Beat: You are both a surgeon and a researcher—how do you see Cardiac Surgery at the Heart Institute embracing and expanding its research program going forward?
Dr. Ruel: Our research has been very strong within the arena of cardiac surgery; in terms of an international presence, I’d say we’re in the top 10. But we don’t yet have a formal research structure: Essentially, we’re a group of surgeons that operates a lot and does significant research on the side. And that may not be a sustainable way to do things. Our future recruitments will aim at a surgeon who has a dedicated research role. So far, we haven’t had anyone like that in the division.
We want to continue our work in the regeneration of the heart and its blood vessels—that’s the translational science we participate in, and we’re planning for expansion in this area, which Erik Suuronen leads.
We also want to develop our ability to follow more of our patients over the long term. There’s a move now at the Heart Institute, which has been in part initiated by Surgery, to be able to obtain long-term follow-up data for all patients who come through our doors. That vision was there 30 years ago, when Dr. Wilbert Keon, Dr. Pierre Bédard and, later on, Dr. Roy Masters and their teams decided to follow every single patient who had a valve replacement. Thanks to that effort, we now have one of the richest long-term follow-up data sets available to understand the outcomes of these patients who have lived 10, 20, even 30 years with a replacement valve. These data also allow us to better understand, through research, what works well and what works less well. It’s helped us provide the best valve care available.
What I think would be important now is to expand this to every cardiac surgical patient or, even better, to every Heart Institute patient. Patients who come into the Heart Institute probably would be happy to engage in a process that would not only help to optimize their care but also the care for other patients. Getting this follow-up is difficult, but it’s incredibly useful for present and future patients.
We also want to build up our clinical trial culture even more. Dr. Fraser Rubens and I have engaged in this, and as a division, we want to be in a position where our new techniques can be validated and where we can find what exactly is the best approach for a given patient, not just the best operation. This also implies doing clinical trials and research with our colleagues in cardiology and anesthesia, which I call trans-specialty trials.
The Beat: In 2017, the Heart Institute will have a new building with expanded facilities, including a hybrid operating room. What new capabilities will that give your team?
Dr. Ruel: There are two advantages to having a hybrid OR. One is preparation and planning of the operation, at the time of the operation. With CT-like imaging capabilities in the OR, we can get a road map then and there of exactly where the anatomical structures are for a given patient. This will allow us to determine exactly where a minimally invasive incision would optimally be placed so that we can reduce the invasiveness as much as possible. It will give us the best outcome for the patient and the easiest operation for the surgeon.
The other advantage of a hybrid OR is enhanced quality assurance. The results of all the coronary and aortic operations could be instantly validated by measuring the perfusion in the OR and by looking at the radiologic appearance of the grafts or the reconstruction or the repair of a valve. In fact, we’re already doing this for valves, and it has changed practice quite considerably. I think that for aortic surgery, for coronary surgery, this is coming and should be part of modern, routine practice.
The Beat: How do you see cardiac surgery evolving over the next decade?
Dr. Ruel: I think cardiac surgery is thriving. Though, like all advanced surgical specialties, it is toward the end of the spectrum for our patients—the end of the line in the cardiovascular journey after other treatments and interventions have been considered and either exhausted or not been sufficient. I think that the amount of time and resources that will be devoted to cardiac surgery will continue to increase.
However, a number of routine operations, very common first-line types of therapies, are going to decrease. And that’s a good thing. That is the evolution of surgery, and I think that’s a beautiful thing. I think that simple diseases should be handled by disciplines other than surgery, unless the disease becomes advanced, is severe, or is complicated and other attempts have failed or are not as effective.
Cardiac surgery is also expanding at the minimally invasive level. And at the other end, it is expanding in terms of the complexity and scope of the conditions we can treat. This is largely because of our colleagues in anesthesia and critical care, who are so instrumental in being able to allow us to perform intricate operations with complete safety. We’ve been able to expand the scope of the difficult operations, including on patients with very poor cardiac function. Even five years ago, these types of operations would not have been possible.
So I think there’s going to be less routine surgery but more minimally invasive surgery and more extreme types of presentations that will require advanced cardiac surgery. I expect that the demands on our division and the demands on the cardiac surgery teams, including anesthesia and nursing, are going to increase.
As a division, we are uniquely placed to provide a wide scope, encompassing top-notch care, education and research. Our team has a vast array of competence, with each surgeon having a particular focus, including but not limited to: Drs. Mesana and Vincent Chan in mitral valve surgery, Dr. Rubens in pulmonary thromboendarterectomy surgery and education, Dr. Munir Boodhwani in aortic repair surgery, Dr. Buu-Khanh Lam in arrhythmia surgery, Dr. Masters in aortic valve surgery and Canadian Society leadership, and Dr. Paul Hendry in heart failure surgery and education. Although it represents a lot of work, it’s a great privilege and honour to be leading this very fine team!