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Robots can’t replace surgeons – heart surgeon

Technology promises to stave off old age, as scientists work to increase the durability of our organs, including the most vital – the heart. What’s changing? And what does the future hold for healthcare in general? World-renowned heart surgeon Dr. Leo Bokeria shares his thoughts.

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Sophie Shevardnadze: Dr Leo Bokeria, I’m so happy to see you. We haven’t seen each other for so long, and so much has happened. I’d just like to discuss all the changes that have happened in the past 10 years, including in your field of expertise. I just can’t seem to solve the puzzle. Medical science and technology have advanced. Methods of diagnosis are getting better, medication is more effective and targeted today. And still you say that heart diseases are the plague of the 21st century, while Americans say that by 2030, the mortality rate will reach 23 million people. I don’t really understand how that’s possible. 

Leo Bokeria: At this point, medical science and pharmacology just can’t keep up. We’re talking about the entire world, you see, and there are developed countries that have managed to significantly reduce the risks. In Russia, people say myocardial infarction now occurs in younger people, but it’s the opposite – the average age has even risen a little. Let me give you some figures that made me happy, even though it’s not about our country; I’m part of the Dartmouth Dialogue – you know, the format that started back in Eisenhower’s time, when relations between our leaders were strained. Then Yevgeny Primakov and Henry Kissinger revived it – so there was this figure: 137,000 people in the U.S. that are over 100 years old. By 2040, that number is expected to reach almost 400,000. 

SS: Wow.

LB: What does that tell us? That there are very many people who are now 90, or 95, or 85 years old, and the state of their health indicates a good chance that many of them will live to be 100 or more. It’s changing the social structure. Today we perform a lot of open-heart surgeries in Russia on patients aged between 75 and 80. To put that in perspective: just twenty years ago, we wouldn’t operate on a 50-year old patient. That’s with regard to your question about technological advances.

SS: We haven’t seen each other for ten years. A lot has changed in medicine and technology. I have compiled a list of things I want to go through with you, item by item. Some of these things sound like science fiction, some not, and it would be great to hear your professional opinion. For instance, in 2016, the U.S. saw the first surgery performed entirely using a surgical robot. The advantages are clear: robots don’t have shaky hands, can do precision work and use finer tools, making the smallest incisions. But the surgeon is still directing the entire procedure. I’ve been thinking, since we live in a time of rapid change and technological breakthroughs, is it possible that one day all surgeries will be robot-assisted?

LB: Originally, the idea was to use robots as assistants to medical professionals who have to work under challenging conditions, in a variety of emergency situations – on submarines, aircraft, in the mountains. That’s what robots were created for. When robots started trending, they started to develop them further, giving them three arms, then four arms, and so on, like the da Vinci Surgical System. People have always strived for enhanced surgical precision, using magnifying lenses and microscopes. It is important because there are surgeries, especially in pediatrics, where you can make a patient permanently disabled if you miss a cut by a millimeter. Or, you can give a patient a heart attack by puncturing a tiny vessel with a stich. I can speak about that, because I have experienced all of it as a surgeon. Also, robot-assisted surgery is extremely costly, in all respects. The robots are expensive, and operating them is also expensive. In the United States, which has the highest number of robot-assisted surgeries, people are refusing robotic surgeries for many reasons, which I won’t go into.

SS: You mean the patients are refusing?

LB: I mean both patients and surgeons.

SS: There’s a lot of talk about the so-called 5G revolution. They say that it will give us high-performance connections never seen before so that, say, the genius surgeon Dr Bokeria would be able to operate on patients virtually anywhere in the world, without even leaving the office.

LB: Yes, that’s exactly what I said. That was the original idea behind robotic surgery. To have, say, the da Vinci Surgical System in every city and town so that one surgeon would be able to help an operating surgeon on site. The surgeon would first open the patient’s chest and put the patient on a bypass, and when that’s done, the surgeon working from another city, say Moscow, could take over and perform the procedures using robotic hands. But let’s say, you are performing a coronary artery bypass surgery, the procedure performed most often. The surgical thread we use in such procedures is either 8/0 or 9/0. It is almost invisible, and a surgeon’s tactile perception, as well as his or her eyesight, helps a lot. Because you need to make sure you don’t break the thread while placing the sutures. And robotic “hands” can’t do that – not now, and I believe, not ever. You can write software for the machine, but you cannot give it human tactile perception that allows you to tie 7 to 8 knots to secure your suture. So when we talk about robotic surgery, yes, it is justified in some cases. But I can guarantee you 100% that robotic technologies will never take over surgery and cardiac surgery in particular.

SS: Because robots lack tactile perception?

LB: No, that’s just one of the reasons. You see, cardiac surgery requires the participation of a whole team of professionals. Every surgery with a cardiac bypass is performed by a surgical team, and we perform, say, 150,000 such surgeries every year. To do that, you need to have all these people properly trained. And even out of them, only the most experienced can be put in charge of robot-assisted or minimally invasive techniques – otherwise, you risk fatalities and other misfortunes. 

SS: So you don’t believe that full robotic surgery, without human involvement, will ever be possible?

LB: No, absolutely not. A robot can break a ‘leg’, or a ‘hand’, but you can’t imagine a robot putting some iodine on the wound or scrubbing hands before surgery, can you? Or putting all these sterilised robes on, examining the scope of work...

SS: I think I understand. Another innovation I wanted to ask you about is something I find almost unbelievable. These are so-called nano-robots – how real is that? If I understand it correctly, we’re talking about molecule-sized robots that can enter blood vessels, even the smallest ones, where they can repair tissues or destroy pathogens on command, and so on. How real is that? And if it is, what happens to this tiny bot when it’s done with whatever it was doing, how does it get out?

LB: Is it clean? I’ll explain. As soon as any foreign object or agent enters a human body it gets literally covered with all types of tissues, because that is how our system protects itself from intruders. So if we consider this idea, the way you just told me, I find it very unlikely that any robot could just move about freely inside a human body. It sounds very much like all those people recommending you use herbal medicine only. Garlic, herbs, chamomile, and so on. Let me tell you how it works. In every pill, there are active agents that are carried by the bloodstream to the area where they are needed. It gets there with the blood, it’s the only way. Thanks to the mechanism of the blood pressure gradient, they can reach the infected or otherwise affected area and do their job. However, when people decide they want a herbal remedy, it could contain next to zero quantities of such useful agents, while also increasing the load on the stomach, the liver, and so on. So by analogy, if we talk about these nano-robots, even if the bloodstream takes them to the affected area, that’s just half of the problem. The other half is that these robots need to be designed in such a way that they wouldn’t form a clot. It’s very serious. I can give you loads of examples on this topic.

SS: Got it! Let’s talk about the artificial heart. It’s also something that’s brought up a lot. Would you say it’s something like a pacemaker?

LB: No, it’s not. I can tell you what it is.

SS: Great! You know, the first thing I thought of, what happens if it breaks?

LB: The artificial heart is something very different. It’s basically a pump that performs the functions of a human heart, fully or partially. I have personally installed a large number and variety of these pumps. I believe this technology has a promising future. To give you an example, half a million people in the United States are in a heart failure risk group. We won’t find that many transplants, for one. Secondly, not all of them can have a transplant because of their age. And thirdly, it’s very expensive and not covered by regular insurance. So the left ventricle gets only half of the 3.5 or 4 liters of blood that it has to pump out per minute. With this lessened strain, it starts functioning better and can even regenerate to some extent. It’s the left ventricle that’s responsible for our arterial pressure. At this point, unfortunately, it turns out that heat exchange is still an issue. Now, what does that mean? The temperature of blood is 36.6 °C, it’s warm. And the device is placed right next to the lung, which is hot, so it gets clotted. I think that together, all of us – developers and doctors – will figure it out, and then people will certainly be able to live very long lives. It’s a very small surgery: put one cannula in the left atrium via a small incision, and attach another cannula to, say, an artery. And that’s it. So I’m definitely all for it...

SS: This pump you described, does it recharge on its own? Does it need charging?

LB: Yes, it needs charging. For now, unfortunately, the device is powered by a battery. The charger is external, very light and so on. 

SS: Is it possible in theory that this artificial heart would recharge simply through movement? Like a good mechanical Swiss watch – it doesn’t need a battery, does it? Something like that.

LB: I can answer that. There’s a professor called Olga Bokeria, who created an epicardial electronic pacemaker. Now, how does that work? When we implant pacemakers – we now have tens of thousands of people going about their lives with pacemakers – there’s always a small chance of electrode thrombosis or infection. In addition, the electrodes go through the tricuspid valve and can, to an extent, depending on its exact position, it can prevent the tricuspid valve from closing all the way. So she got a grant from the Ministry of Education and Science and created an epicardial electrode that can be put directly on the heart through thoracoscopy, which involves a very small incision. The device is 18mm in diameter, and it works just as well.

Now they’re finishing with their second grant research. Initially, the pacemaker has a battery of course, a tiny one, but now they’re finishing up with their research aimed at using the energy of the heart contractions to recharge it. 

SS: You said there aren’t enough heart donors for everyone. Apart from artificial human hearts, there’s a lot of talk about transplanting pig’s hearts as an alternative. As far as I know, in China they already grow these genetically modified pigs. I don’t know though, is a pig’s heart a suitable replacement?    

LB: In 1964, three years before Dr Christiaan Barnard performed the first human-to-human heart transplant, American surgeon Dr Hardy transplanted the heart of a chimpanzee into a dying patient. At first, everything was going fine, but in about 24 hours the heart gave out. So, you see, of course, there are interspecies differences, but a heart is essentially a pump. You need to understand that if a person weighs 80 kilos and has this little heart, it will start wearing out unless the weight is dropped to 60 kilos. The day before yesterday, we had surgery and we were looking for a heart donor patient. When we learned there was a donor, we choose a patient about the same size. So, all that talk about transplantation remains on paper – at least for now. That’s why I focus mainly on artificial hearts. 

SS: Now, people also talk about 3D printers, which allegedly can work miracles. Just a week ago, I read about a neighborhood in Mexico that was entirely 3D-printed. And in Israel, they printed a heart with human tissue – a tiny heart, for sure, but still. Is it possible that a patient won’t have to wait for a donor heart or an animal transplant? You’ll just have a 3D printer at your hospital and print hearts.

LB: What am I supposed to make a living heart from?   

SS: They say it can be made from living tissue but I don’t really know what that means. Is that fiction, or it theoretically possible?

LB: I don’t know that. However, having spent all my life working in the field of cardiovascular surgery, I can say that this would be the end for my field. If they manage to do that, there will be nothing else left to learn.

SS: But for now, it’s fiction, and we shouldn’t take that seriously, right?

LB: Let’s be real. Every day we see real people who are ill. Lots of them. Everything that there is to try – we’ve tried all of it. And things that have been proven to work have become ‘standard procedure’. Unfortunately, there is nothing better than a donor heart.

SS: In 2016, a team of researchers in the U.S. successfully grew heart tissue from stem cells. Is that possible?

LB: Look, right now you’re inside the building that has seen more stem cell research than any other place in the world. Some 20 years ago, Americans came here with their stem cells which could be implanted in anyone, a human or a dog – that’s how pure they were. So, I got all the necessary permissions and implanted those stem cells in several patients with coronary artery disease. One of them died a couple years after that. We examined the body and saw that those cells took well. However, they didn’t fully assimilate but formed a strip of sorts. The cells simply didn’t connect to the cardiac muscle. Later, I discussed this case with my colleagues, and everyone agreed with my conclusion, including those who brought those cells. These cells have no nerves and no blood supply. That is why we now use a mixture of cells to ensure innervation. Some children are born with one artery – I mean, they have two, but one of them stems from the pulmonary artery. This artery carries venous blood, the one that’s blue. As a result, that child may develop extensive myocardial infarction at the age of only 4 months. And we have to do the same kind of surgery as we do with people of any other age. The problem is that there is very little cardiac tissue to work with. That’s why I wanted to try stem cells, and the results that we got were quite impressive. Since then, the way surgeries are done on such children have changed drastically, it has improved. Today, we don’t use stem cells for that but we did experiment with them in the past. When it comes to children, I know how it happens, their bodies are growing, they are very responsive to all kinds of interventions and adapt easily. As for adults, stem cells work differently and you have to be extremely cautious.

SS: I’d like to ask you about gadgets. All these devices – smart watches, phones, etc. They can now count your steps, even monitor your heart rate. Before, it was all seen as a gimmick, but just recently, an elderly lady in New York got a smart watch as a present from her grandchildren, and it actually helped her avoid a heart attack by analysing her condition. I thought to myself, this can’t be real. You no longer need to go for a check-up, you can self-diagnose at home and then go to a doctor for treatment if needed. Is that so?

LB: This really is a breakthrough, because it can have a massive impact. You can buy a blood pressure monitor and check your blood pressure twice a day to see whether there are any spikes. That may help you with adjusting the dosage of a particular drug, so that you would take as much as you really need, not as much as prescribed. Devices like the one you mentioned have revolutionised our lives. I am all for them. Here’s what I can tell you, my close friend’s son designed a device that can measure and record your heart’s activity not for one day but for a week. It’s like a Holter monitor. You can wear it for one day, for three days or for a week. But in this case, it’s on a watch. Gadgets like these allow people who are worried about their health to take action. That’s how I see this. I don’t think that everyone should be wearing these devices. You see your heart rate go up, you get alarmed, that raises your heart rate even further, and so on. So, it’s a huge step forward with these devices, and now lots of companies are working on smartwatches or similar devices to monitor users’ health. It’s a good thing.

SS: And then there’s genetic engineering. I don’t know how you’d react to it, but they’re now saying that you can identify a heart disease-related gene that was passed to a child and replace it so that the child won’t suffer from any heart problems in the future. 

LB: There’s no practical implementation yet. Of course, there is a lot of research, and we welcome it, because you won’t find a solution if you don’t look for it. But I don’t think it’s that easy. To be able to diagnose it, a lab has to have the necessary time-tested equipment and qualified specialists. And ordinary doctors have to know about it, so they could refer their patients there. We’ll be patiently waiting for it.

SS: I just know that in France, they reduced the number of children born with Down syndrome to almost zero, because they can determine it all in advance. So I thought, maybe it was possible [for heart disease too].

LB: Here’s what I have to say on the subject. About 15 or maybe 20 years ago, the UK wanted to forbid births of children with hypoplastic left heart syndrome, regardless of the gestational age. And French doctors actively supported them. Well, we didn’t have any effective methods of treating it back then. What is hypoplastic left heart syndrome? It means the heart only has the right ventricle, while the left one is virtually non-existent, and there is no mitral valve, no aorta – only 2mm long. So ideally, the child would have to undergo three operations in their first year of its life. Of course, with three operations, adverse outcomes are quite common. Together with Americans, we convinced them not to proceed with this ban on women giving birth to children like that. For me, the best argument was the mothers whose children with HLHS grew up. There was a book – I’ve read it twice, I think – it was just incredible. These children are very attached to their parents, because the parents dote on them. So they probably mean these children, and the French probably managed to push this law and make it mandatory for a woman pregnant with a child who has HLHS to get an induced abortion. I remember it very well, because I was strongly against what our UK colleagues were doing at the time. They later congratulated me on winning this battle. 

SS: Thank you so much for this educational and really insightful talk. I’ve learned so many new things. Please take care. With you, we have nothing to fear. Thanks a lot again.

LB: Happy to hear it. Thank you very much.