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Page 2 of 12 Mestres et al. Vessel Plus 2019;3:38 I http://dx.doi.org/10.20517/2574-1209.2019.20
[5]
circulation and DeWall in the beginning of the fifties of the twentieth century have to be seen with the
perspective of time as ground-breaking events that could probably be difficult to replicate in current times.

Cardiac Surgery has undergone impactful changes since it became a medical specialty. It has been
associated with the development of specialties within the chest and related to the cardiovascular surgery.
The name has also undergone changes and different terms have been used over time. Cardiac Surgery,
cardiovascular surgery, cardiothoracic surgery, have been associated to innovation. The approach chosen by
[1]
Gibbon was innovative at that time. The idea of oxygenating the blood while circulating through artificial
tubes out of the body was an outstanding example of innovation. This followed the original studies of Max
[6]
von Frey at the Carl Ludwig Leipzig Physiological Institute at the end of the 1890s’ , who also innovated
at that time by developing a system for blood oxygenation. Since its inception as an independent specialty,
inclusive of name changing, Cardiac Surgery has also been associated to education. Education is the
foundation of the individual and the society. Education in Cardiac Surgery is a dynamic process and is
considered as one of the most important activities in the Specialty. This has been highlighted over the years
by many. Every department, every scientific society allocates resources and budget to cope with the needs
[7,8]
of those who will deliver high-quality services and is highlighted in their respective mottos .
As time goes by, it is evident that our Specialty changes. What it was done in the early developmental
phases, does not apply in current times. The introduction of the HLM represented a breakthrough in
surgery as it allowed to repair or palliate a number of previously unaddressed pathologies. Over the past
70 years, we witnessed the evolution of the techniques, the consolidation of the specialty, the improvement
in clinical results, thus resulting in the benefit of the community. This has been extensively recorded in the
literature [9-13] .

There have been substantial changes over time in the perception and action in the Specialty. Coronary
artery surgery continues to be the gold standard in the treatment of triple-vessel disease, with or without
[14]
left main lesions . Despite the advent of the newer transcatheter techniques that are later discussed,
[16]
[15]
[17]
mitral valve repair for degenerative disease , surgery for infective endocarditis , aortic valve repair ,
[19]
[18]
obstructive cardiomyopathy and aortic surgery , to name just a few, are well-established and routine
[20]
procedures all over. On the contrary, cardiac pacing, a surgical activity for decades , including all sorts
[21]
of pacemakers and implantable cardioverter defibrillators was slowly taken over by cardiologists almost
everywhere. The improvement and miniaturization of hardware, the easiness of implantation and other
factors, progressively shifted pacing towards Cardiology.
Cardiac Surgery currently faces new challenges. This is well known, as challenges are always out there and
are the foundation for development. This means Cardiac Surgery is continuously evolving as the surgeons
do. It is not to be forgotten that surgery, despite its etymology, is not a manual activity, it is an intellectual
activity. The surgeon does a manual work, surgery -from the Greek, χεῖρ cheîr “hand” y ἔργον érgon
[22]
“work” , which is intellectually driven. Here we tried to understand which are the current challenges
in Cardiac Surgery, where the frontiers for future development are and what we need to do to overcome
difficulties in an adaptive process.

THE CHALLENGES AND THE FRONTIER
Adaptive changes result from challenges. Darwin understood that species undergo adaptive changes
[23]
as a response to environmental challenges , a theory that has also been challenged. The technological
breakthrough of the HLM was challenged by a number of technological and biological umprecedented
problems related to the new interactions between machines and the human body. New materials and new
technology resulted in sophisticated devices incorporating better pump heads, biocompatible surfaces for
[24]
cardiopulmonary bypass tubing aiming at reducing inflammatory response , multiple in-line sensors for