Cardiovascular Medicine and Surgery in Singapore: The Next Lap

as described in this issue of the Annals. To cardiologists accustomed to the irreversibility of chronic atrial fibrillation in patients with long-standing valvular heart disease, the results of AF ablation surgery are impressive, with over 80% of patients maintaining sinus rhythm at 3 years. The development of off-pump techniques for coronary artery bypass grafting surgery promises to reduce the morbidity associated with cardiopulmonary bypass and is established firmly in cardiac surgical practice. Yet another development is the left ventricular assist device that sustains life in critically ill patients with cardiogenic shock, thus offering hope to those with life-threatening yet potentially reversible conditions, such as fulminant myocarditis. Besides transplantation and assist devices, there are major alternative surgical treatments of heart failure such as mitral valve repair 4 for cardiomyopathy, and the Saver procedure (Surgical anterior ventricular endocardial restoration) for ischaemic cardiomyopathy. 5 In non-invasive imaging, new modalities compete for attention. Positron emission tomography (PET), 6 often regarded as the “gold standard” for heart muscle viability, has arrived in Singapore. For patients with poor left ventricular function being considered for revascularisation, medical therapy or transplantation, tissue viability is often critical in decisionmaking. Yet another approach for viability assessment, albeit less well established, is cardiac magnetic resonance imaging, 7 which is now being developed locally. Further study is needed to determine the most cost-effective assessment modality. Multidisciplinary work between different specialties will spur the development of these new techniques. The above are but a few examples of how cardiology is developing, with an increasing reliance on a technology-based approach to intervention and imaging. We are fortunate in that Singapore has not lagged behind in acquiring the latest devices and techniques. The system of structured training and sub-specialisation established more than a decade ago has paid off in terms of depth of expertise, which in turn has helped us to rapidly absorb new advances. However, despite the potential for improved diagnosis and treatment, many challenges remain. The modernisation of Singapore, combined with an ageing population, has meant that coronary artery disease continues to dominate the leading causes of death, despite gradual reductions in the age-specific incidence of myocardial infarction and improved survival rates. 8 Indeed, improved treatment may have produced more survivors with residual left ventricular dysfunction and heart failure. The latter has become one of the major causes of hospital admissions. Large randomised trials have identified multiple drugs (e.g. beta-blockers, ACE inhibitors, angiotensin receptor blockers) that improve the outcome of heart failure. 9 More recently, biventricular pacing and implantable defibrillators have also been shown to improve clinical outcomes in subgroups of these patients. Left ventricular assist devices, developed as a bridge to transplantation, are now contemplated as destination therapy. Although effective, these treatments are not curative, and they are expensive. There can be little doubt that heart failure will continue to be a major challenge in the years to come. Management of heart failure is typical of a recurring dilemma that we face today: the availability of advanced treatments that improve quality of life or prognosis, or both, but at considerable cost. Resource limitations always occur in any