Advances in heart surgery .sx The Chair of Cardiac Surgery at the Royal Postgraduate Medical School , University of London is held by Professor Ken Taylor .sx He reviews the progress of cardiac surgery over the last 30 years and forecasts ways in which it can be assisted by new drugs and techniques .sx " There's nothing magical about surgery on the heart but the heart-lung bypass machine is a unique feature which keeps the patient alive during the operation by taking over the function of the heart and lungs .sx " Professor Taylor's speciality is the technology associated with the heart-lung machine .sx In the 1950s open heart surgery was in its infancy .sx Once a consensus had emerged in the late 60s of a reasonably reliable and safe way of using heart-lung bypass machinery , there was an explosion in the number of operations for valve replacement , coronary artery surgery and the correction of deformities in the hearts of babies and young children .sx In the 70s the emphasis turned to the development of surgical techniques with a corresponding reduction in the mortality rate .sx Within the last ten years there has been intense activity with new techniques emerging almost every month and the question has been how to get rid of all the risks associated with surgery .sx " The problem now " , says Professor Taylor , " is not mortality but morbidity .sx When blood passes over artificial materials a cascade of changes takes place , producing abnormal functions in many bodily systems .sx The impetus now is to make the support machinery as near to normal physiology - the way the body works - as possible .sx " .sx Basic scientific research is being carried out in several areas .sx One is the effect on blood cells of artificial materials .sx The cells tend to react in a defensive way and cause inflammation throughout the body .sx The effects of that inflammation response are seen in various parts of the body including the lungs , the brain and in blood-clotting processes .sx Bio-materials are being developed which , it is hoped , will not be recognised by blood cells as being artificial .sx Drugs to block the inflammatory process are being developed and the use of Aprotinin in this context , pioneered at Hammersmith Hospital in 1985 , is used in 80% of all heart operations in Germany .sx It is now being licensed throughout the world .sx " It is profoundly effective in its ability to reduce blood loss following cardiac surgery and consequently blood transfusion is becoming less necessary , reducing the risk of transmitting viral diseases .sx " .sx Research is also focusing on brain functions during cardiac surgery .sx BHF-funded research has revealed that the eye is a useful and accurate indicator of cerebral circulation before , during and after surgery .sx " It's a window on the circulation of the whole brain " , says Professor Taylor .sx The blood supply to the retina is an integral part of the brain's own blood supply .sx Studies have shown that within a few moments of the patient being connected to the heart-lung machine , the small blood vessels in the retina begin to become blocked .sx To prevent the blockage a new type of artificial lung is used which reduces the visible abnormality in the retinal circulation from 100% of patients to less than 50% .sx Professor Taylor says :sx " Any patient of any age anywhere who has a heart operation goes on a heart-lung machine which has been developed from research funded by BHF .sx " The Hammersmith team are confident that continuing research in this area will make cardiac surgery even safer for patients by helping to achieve bio-compatibility between the artificial lung and the patient's physiology .sx It has also been discovered that arteries are far stronger than veins when used in coronary grafting .sx " They seem to last indefinitely " , says Professor Taylor .sx There are now moves towards looking at long-term results in various categories of patients .sx A unit set up by the Department of Health in 1986 at Hammersmith Hospital registers every artificial heart valve in use in the UK and is able to make comparisons between the ways different countries use their valves , select their patients and use their resources .sx Fifteen years ago Professor Taylor received his first research funding from the British Heart Foundation and eight years ago he was appointed to the Chair of Cardiac Surgery .sx He says :sx " The Junior Research Fellowship option funded by the Foundation is a superb way of introducing bright young research trainees to cardiac surgery .sx I think it's an absolutely excellent scheme .sx The techniques which are being pioneered here are being used in many parts of the world today .sx " .sx Genetics - the medicine of tomorrow .sx Professor John Burn , Director of the Northern Region Genetics Service at the University of Newcastle upon Tyne , looks at 30 years of development in one of the most dynamically growing disciplines in medicine .sx The changing pattern of disease has combined with dramatic scientific advances over the last 30 years to bring clinical genetics to the fore .sx In 1961 centres around the world were rushing to apply the new technique which made it possible to show that children with Down's syndrome had an extra small chromosome .sx In that year several other syndromes involving heart malformation were shown to be due to a chromosome fault .sx " In the 70s new banding techniques made possible the recognition of faults within chromosomes and cases where the fault might recur in the family .sx Meanwhile obstetricians began to develop in the mid-70s the techniques to allow prenatal diagnosis of these faults " , explains Professor Burn .sx " In the 60s dozens of new rare diseases were identified caused by failure of individual genes to produce essential enzyme catalysts .sx Since then the chemical pathways of the body have yielded many of their secrets and we understand more clearly how , for example , the body handles fats or causes the blood to clot at the right and wrong times .sx Very often genetic faults are discovered , such as the variety of faults in the lipoprotein receptor , which lead to familial hypercholesterolaemia .sx The ability to diagnose and in some cases treat such single gene faults has been made possible by the revolution in molecular genetics which , particularly in the 80s , allowed us to study individual genes and learn all about their structure and function .sx " A major challenge for our own unit in the coming decade will be to use these latest techniques alongside traditional clinical studies to learn why over 4,000 children are born each year with a malformed heart .sx Thanks to surgical advances 30 years ago , we now have a growing number of young adults whose heart defects have been successfully treated , but many of them fear for the health of their children .sx We have traced 750 young adults operated on around Britain for the most serious heart defects to see what happened to their children .sx Four per cent of their children have heart malformations and the chance is higher if the mother has the heart defect .sx This may be because the genes inherited in the egg play a greater role in the heart development than those from the father .sx This variation between the parents is called imprinting and may be one reason why genetic faults which cause heart defects do not show themselves every time .sx Chance factors may also decide whether someone with a faulty gene will have a heart defect .sx " When we identify families with several affected members we are comparing their DNA to see which genes they have in common .sx This process is more feasible when we have a candidate gene - one which we know can cause the heart to develop incorrectly .sx Our main interest at present is in a small area of chromosome 22 which is usually missing in children with a rare pattern of problems called Di-George syndrome .sx This pattern was first recognised in 1965 and combines faults in the immune system and low calcium levels due to a hormone fault .sx The heart is often malformed .sx In collaboration with colleagues at St Mary's Hospital , London , we are seeking the faulty gene and using the new genetic techniques to see whether faults at this point on chromosome 22 can cause similar heart defects without the other features of the syndrome .sx This project , like our 'offspring' study , is funded by the British Heart Foundation which is the major 'shareholder' in our cardiovascular research team .sx Learning why so many children are born with heart defects will take a long time .sx Thanks to the vision of BHF we have made a beginning .sx I hope the next 30 years will bring us some answers to the question 'why ?sx ' for only then will true prevention become possible .sx " .sx Clotbusters Professor Keith Fox , holder of The Duke of Edinburgh Chair of Cardiology at the University of Edinburgh , has seen substantial changes in cardiology over the last decade .sx Here , with Dr Rudolf Riemersma , Senior Lecturer in Cardiovascular biochemistry , he reviews progress in the treatment of coronary artery disease and looks to the future with confidence .sx " My predecessor Professor Michael Oliver and Professor Desmond Julian , who is now Consultant Medical Director to the British Heart Foundation , set up the first European Coronary Care Unit ( CCU ) here in Scotland in 1966 .sx They were prompted to do so because Scotland has a record for heart disease which is the worst in the world .sx We are still trying to find out why .sx " .sx In the last 30 years two main areas of progress can be identified .sx These are defibrillation and the new 'clotbuster' treatments for heart attack .sx Defibrillation and coronary care have played a major part in increasing the survival rates of patients suffering from heart attacks .sx Now that every frontline ambulance in Scotland has a defibrillator , a programme is in hand to improve further the chances of survival of patients with heart attack .sx Meanwhile , there has been a resurgence of interest in thrombolytic 'clotbusting' research and treatment in the last ten years , preliminary clinical tests having first been carried out in the 40s .sx While in the United States Professor Fox and colleagues undertook the original experimental studies with new-generation thrombolytic agents in 1981 .sx The important 'clotbusters' still carry a risk of reclosure of the artery after drug treatment and we need to know more so that the treatment can be maximised and the harmful effect minimised .sx There is a need now to find out what happens before the vessel becomes blocked .sx It is very important that patients at high risk are identified by their blood-borne markers , the platelets which clot the blood , in conjunction with the use of electrocardiograms and angiography .sx Research is now progressing in the development of anti-platelet agents .sx " In 1986 very few people with clear-cut symptoms were being treated with thrombolytics - only about 4% " , says Professor Fox .sx " Today they are the treatment of choice in more than 70% .sx The emphasis on thrombolysis has increased our awareness of what happens before the clot develops .sx " .sx Of the contribution made by the British Heart Foundation to his department's work , he says :sx " BHF is not just supporting research which would otherwise be underfunded ; it is permitting the development of new areas of research .sx Without this support academic cardiology in Britain would be in a disastrous situation .sx " .sx The Cardiovascular Research Unit has been specialising in the problems of heart disease in Scotland .sx In 1978 the first inkling came that diet might in some way affect the incidence of heart disease and in 1984 a study discovered that people who had less linoleic acid in their body and diets were more prone to coronary heart disease .sx In 1987 firm data from a huge study of 6,000 patients confirmed the theory .sx " We discovered that people with low levels of linoleic acid eat less of this essential fatty acid and are more likely to smoke and drink more .sx There has been a general change and an improvement in diet over the last 12 years .sx Plant oils , such as those found in sunflower margarine , are rich in linoleic acid and are much more available - supermarkets have played a big part .sx The health education message has got through to the better-educated sector of the public and we have to hope that it will eventually filter through to all sectors of the community .sx " .sx