Cardiothoracic surgery is a specialty that performs surgeries of the chest, also called the thorax. Cardiothoracic surgeons operate on the heart, lungs, esophagus, and other organs of the chest (The Society of Thoracic Surgeons).
To become a board-certified cardiothoracic surgeon in the United States, a student must complete four years of undergraduate university work, four years of medical school, five years of a general surgery residency, and two to three years of a cardiothoracic surgery residency. There are opportunities for fellowships to further specialize in fields such as adult heart surgery, children’s heart surgery, heart transplantation, and disorders of the lungs and esophagus if desired. Some new integrated programs offer a six year clinical program that allows students to go more directly to cardiothoracic surgery (The Society of Thoracic Surgeons). To become board certified, candidates must successfully complete residency requirements and pass an examination. To maintain board-certified status with the American Board of Thoracic Surgery, doctors must complete at least 30 hours of continuing medical education (CME) yearly, retake the examination every ten years, and submit letters from peers regarding their clinical abilities. They must also participate in a practice quality improvement project every five years and take a course on patient safety every five years (American Board of Thoracic Surgery).
History of Cardiothoracic surgery?
Francisco Romero (exact dates of birth and death unknown)
Francisco Romero was a Catalonian physician who is considered the first heart surgeon. After he completed medical school, he spent time working with the military, where he encountered many cases of a condition called pericardial effusions (Aris, 1997). The pericardium is a fluid filled membrane that encloses the heart. A pericardial effusion is when there is too much fluid in the sac. The excess fluid presses on the heart which negatively affects heart function. The condition is potentially life-threatening if left untreated (Mayo Clinic). Romero became frustrated with the medical treatment being employed at that time, so he decided to try a surgical approach. In 1801, Romero treated the condition by making a small incision between the ribs and draining the excess fluid from the pericardium. Five pounds of fluid were removed and the patient recovered enough to return to work in four months. The patient’s only complaint three years later was some pain around the original incision site. Romero also drained pleural effusions (too much fluid around the lungs) in a similar open manner. Romero presented his work to the Society of the School of Medicine in Paris in 1815, but the approach was rejected as too aggressive by the society and his work was silenced (Aris, 1997).
Ludwig Rehn (1849-1930)
Ludwig Rehn was a German surgeon known for performing the first successful suture of a wound to the heart (called a cardiorrhaphy) in 1896. At that time, the prevailing opinion was the heart was considered a sacred organ and surgery for it, especially to repair a wound, was taboo.
The patient was a 22-year-old man with a history of irregular heartbeat who had been stabbed. When Rehn arrived at his bedside, the patient was near death due to blood loss, and Rehn felt he had no option other than to perform surgery. He opened the chest cavity and eventually discovered the cause of blood loss: a 1.5 cm wound to the heart itself. He placed three stitches into the heart muscle. The patient eventually recovered.
Rehn presented a report of this success to the German Society of Surgeons. Cardiorrhaphy become more accepted and thus performed more, and the mortality rates from wounds to the heart, which had been nearly 100% before this surgery, began to decrease (Blatchford, 1985).
Ernst Ferdinand Sauerbruch (1875-1951)
Ferdinand Sauerbruch was a German physician who developed a pressure-differential chamber for thoracic surgery in 1904. Before that time, surgeries on the chest were always fatal due to complications from lung collapse when the chest cavity was opened. Sauerbruch realized that the negative pressure in the chest needed for normal breathing must be equalized with negative atmospheric pressure so that the lung would not collapse during the surgery. He devised a chamber that allowed this to occur, successfully tested it on dogs, then successfully tested it on a human patient. The pressure-differential chamber allowed for successful surgeries on the lungs, esophagus, mediastinum, and other structures of the chest. Sauerbruch also invented new tools to make the surgeries easier, and new methods for performing surgery. For his contributions, Sauerbruch is considered a pioneer of thoracic surgery (Cherian, 2001).
Alexis Carrel (1873-1944)
Alexis Carrel was a French surgeon whose experiments made advances in cardiothoracic surgery and anesthesia possible. For his development of innovative suturing techniques that allowed blood vessels to be sewn together, Carrel was awarded the 1912 Nobel Prize in Medicine or Physiology. This laid the groundwork for the development of successful organ transplantation in the future.
Carrel also served in the French Medical Corps during World War I, at which time he and a colleague, American chemist Henry Dakin, developed a method of caring for wounds that decreased the need for limb amputations due to infection. This method included cleansing of the wound, surgical debridement, and irrigation of wounds with an antiseptic solution, now called Dakin’s solution, which is still in use today.
Carrel then teamed up with American engineer Charles Lindbergh (who was also a famous pilot) to create the first pump oxygenator which allowed for long term perfusion of organs in 1935. This would allow many types of future surgeries to be done, including heart valve repairs, cardiac bypass, and transplantation (Dente, 2005).
Robert E. Gross (1905-1988)
Robert E. Gross was an American pediatric surgeon who is best known for performing the first successful ligation of a patent ductus arteriosus (PDA) on a child in 1938 (Murray et al., 2013). The normal heart has four distinct chambers with valves that open to allow blood flow into the chamber of the heart and close to prevent blood flow backwards. PDA is a congenital (meaning someone is born with it) malformation of the heart where there is an extra opening between two chambers of the heart. This opening is a part of normal development of the fetus while in the mother’s uterus but is supposed to close before birth. If it does not close, it allows poorly oxygenated blood to flow in the wrong direction. This causes overworking of the heart muscle which can lead to heart failure and death (Mayo Clinic). At the time Gross performed the surgery, children with this malformation of the heart were not expected to live past adolescence. Gross cured the problem in his seven-year-old patient by simply tying off the extra vessel so that blood could no longer flow through it. The operation was successful and the child grew into a woman. During her first pregnancy, her doctor was concerned she could have problems with her heart, and she was sent back to Dr. Gross. From that day until Dr. Gross’ death, she sent him a card every Valentine’s Day and they remained in contact. As of 2013, the patient was still living and a great-grandmother, the world’s longest known survivor of heart surgery.
Dr. Gross is considered a pioneer of congenital cardiac surgery, a specialty field of cardiothoracic surgery (Murray et al., 2013)
Rudolf Nissen (1896-1981)
Rudolf Nissen was a German surgeon known for his advances in thoracic surgery. He performed the first successful total pneumonectomy (removal of a lung) in 1931. The patient was an eleven-year-old girl who was hit by a vehicle which caused the collapse of a lung. The lung was re-inflated, but she developed a severe infection. Nissen realized the only way to save her life was to remove the infected lung. Later uses for removal of a whole or part of a lung include treatment for tuberculosis, lung cancer, trauma to the lung, and other conditions.
He later developed a surgical method for treating gastroesophageal reflux disease, which commonly presents as heartburn. This involved wrapping a small portion of the stomach around the esophagus and suturing it in place. This procedure is still widely performed laparoscopically today and bears his name: the Nissen fundoplication (Fults, 2011).
Christiaan Barnard (1922-2001)
Christiaan Barnard was a South African surgeon best known for performing the first successful human heart transplantation in 1967 (Hoffenberg, 2001). The patient was a 55-year-old man named Louis Washkansky who was dying of heart failure. The donor was a 25-year-old woman who had died in an automobile accident (Columbia University Medical Center). Washkansky lived eighteen more days, then died of pneumonia in both lungs. The operation was still deemed a success (Hoffenberg, 2001). Barnard’s second transplant was performed two weeks later, with the patient living 19 months afterward (Altman, 2001). Barnard became internationally famous overnight.
The successful transplantation of the heart brought up some important legal and ethical questions about when someone could be declared dead and their still beating heart be removed from their body. This eventually brought about the term “brain dead” (Hoffenberg, 2001). Barnard’s decision to use a brain dead donor for both of his operations opened the door for transplantation of organs in addition to the heart from patients who were deemed brain dead (Altman, 2001).
Examples of diseases treated with cardiothoracic surgery
In adults
Coronary artery disease: This is a disease of the arteries that supply blood to the heart. When plaque builds up over time in the arteries, it restricts blood flow, which can cause symptoms of chest pain or shortness of breath. Risk factors for coronary artery disease include a family history of coronary artery disease, cigarette smoking, aging, being overweight or obese, having high blood pressure, or having diabetes. If the artery becomes completely blocked, it can cause a heart attack. (Mayo Clinic). Cardiothoracic surgeons perform an operation called coronary artery bypass grafting surgery (often abbreviated CABG) to treat coronary artery disease. During this surgery, a healthy vein or artery from another part of the body is removed and then connected to the arteries of the heart. This creates a “bypass” around the diseased artery, which allows blood flow to return to normal (The Society of Thoracic Surgeons).
Valvular disease: The normal anatomy of the human heart includes four valves between each chamber of the heart. Each valve normally opens wide enough to allow enough blood to pass through and closes tightly enough that the blood cannot flow backwards. When a valve doesn’t function properly, it usually causes one of two conditions: stenosis or regurgitation. Stenosis is when the valve doesn’t open wide enough to allow enough blood through. Regurgitation is when the valve doesn’t close correctly and blood flows backward instead of forward. Valvular disease can be congenital, acquired from an infection, or caused by the aging process. Cardiothoracic surgeons may either repair diseased valves or replace them completely (The Society of Thoracic Surgeons, 2016).
Thoracic aortic aneurysm: The aorta is the large artery that the heart pumps freshly oxygenated blood into so that it can be delivered to the rest of the body. The aorta is divided into two parts anatomically: the thoracic aorta, which is in the chest, and the abdominal aorta, which is in the abdomen. An aortic aneurysm is when the wall of the aorta begins to weaken and inflate like a balloon. This can be caused by genetic factors, high blood pressure, and hardening of the arteries with aging. If the aorta becomes so weak that it bursts, a patient may bleed out internally. If the aneurysm is small when it’s detected, monitoring with regular imaging may be recommended. If it’s larger, surgery may be recommended. Cardiothoracic surgeons repair thoracic aortic aneurysms using either grafts or stents to reinforce the weakened area (The Society of Thoracic Surgeons, 2016).
Congestive Heart Failure: Often abbreviated as CHF, this is a condition where the heart muscle has weakened and is no longer working as efficiently to pump blood. Chronic congestive heart failure (heart failure that progresses over time) is usually caused by other diseases, such as uncontrolled high blood pressure, coronary artery disease, and diabetes, though there are also some genetic causes. Other risk factors include obesity, smoking, and high stress. Acute heart failure can occur as a result of a heart attack or problems with heart valves. Congestive heart failure is often managed with medication and lifestyle changes. When this is not enough, surgery may be the best option. The type of surgery depends on the underlying cause of heart failure. Options include surgery on heart valves, a CABG, or implantation of a medical device such as a defibrillator. If there are no other options available, heart transplantation may be the best choice (The Society of Thoracic Surgeons, 2016).
Lung cancer: Lung cancer is most common in people who are current or past smokers (including cigar and pipe smoking), though some people get lung cancer without ever smoking. Exposure to certain environmental toxins can also increase the risk of getting lung cancer. Lung cancer is usually an incidental finding on imaging that was ordered for another reason, although a low-dose CT scan is now available for screening people at higher risk. When cancer is suspected based on imaging, a biopsy is usually done to confirm the diagnosis, then staging is done to determine whether the cancer has spread. If surgery is the best option for treatment, there are three types available: a lobectomy (removal of a portion, or lobe, of the lung), a segmentectomy or wedge resection (removal of only the cancerous portion of the lobe of the lung), or pneumonectomy (removal of the entire lung) (The Society of Thoracic Surgeons, 2016).
Esophageal cancer: The esophagus is the tube that connects the mouth to the stomach. Risk factors for esophageal cancer include chronic gastroesophageal reflux disease (GERD), smoking, heavy alcohol use, and other esophageal disorders. Early esophageal cancer is found incidentally on imaging ordered for other reasons. Later esophageal cancer may present with symptoms such as difficulty swallowing, hoarseness, or weight loss. The most common treatment for esophageal cancer is a surgical procedure called an esophagectomy. In this procedure, most of the esophagus, including the cancerous portion, is removed, and the remaining esophagus is attached to the stomach (The Society of Thoracic Surgeons, 2016).
Mesothelioma: Mesothelioma is a rare cancer that affects the tissue lining the lungs, heart, chest cavity, and abdominal organs. It is caused by repeated exposure to asbestos, a material previously used in various construction, plumbing, and manufacturing jobs. If mesothelioma is suspected, it must be confirmed with a tissue diagnosis and staging, as with other cancers. If surgery is the best option, there are three types available, depending on where in the body the disease is. Extrapleural pneumonectomy is when the affected lung and affected areas of the heart lining, chest lining, and diaphragm are removed. Man-made materials are then used to reconstruct the heart lining and diaphragm. Pleurectomy/decortication removes the lining surrounding one lung and the affected lining of the chest cavity. This allows the patient to keep the lung. Debulking, also called a partial pleurectomy, is similar to the pleurectomy/decortication described above, but with less tissue removed. The patient is still able to keep the lung (The Society of Thoracic Surgeons, 2016).
In children
Congenital heart disease: Depending on the specific defect with which a child was born, cardiothoracic surgeons specially trained in pediatric congenital heart disease will perform surgery to correct it (The Society of Thoracic Surgeons, 2016).
Transplantation
Heart transplantation: Heart transplantation is considered when other methods of controlling heart disease have been exhausted. An extensive pre-transplant work up is performed, including tests to make sure the patient doesn’t have cancer or other diseases that would significantly limit survival in spite of the transplant. Patients who qualify are then placed on a national list. Placement on the list depends on how sick the patient is and whether their condition deteriorates over time. When a donor organ becomes available, the patient must travel to the transplant center quickly so that the surgery may be performed. The transplant itself is a 3-4 hour surgery performed by a team headed by a cardiothoracic surgeon who has specialized in heart transplants. The chest is opened and the diseased heart is removed, then the new heart is sewn into place. During the surgery, the patient is placed on a heart-lung machine which temporarily does the job of the heart and lungs until the operation is complete. When the surgery is finished, the new heart begins beating on its own, often aided by medications and sometimes an electric shock. Transplant patients will have to take antirejection medication for the rest of their lives so that the body does not reject the transplanted heart.
Pediatric heart transplants proceed in much the same way as adult transplants. With children, the donor heart must be the correct size for the child and will grow with the child (The Society of Thoracic Surgeons).
Lung transplantation: Like heart transplantation, lung transplantation is considered when other methods of controlling lung disease have been exhausted. Either one or both lungs can be transplanted. The process for lung transplant is similar to that of heart transplants. When a donor organ becomes available, the patient must travel to the transplant center quickly. The transplant surgery for one lung takes 4-8 hours. The transplant surgery for both lungs takes 6-12 hours. The patient will have to stay on antirejection medications for the rest of their life so that the body does not reject the transplanted organ.
Pediatric lung transplants are performed in a similar manner to adult lung transplants (The Society of Thoracic Surgeons).
Current research in cardiothoracic surgery
Current studies from the National Heart, Lung, and Blood Institute are focusing on two areas: cell biology and bioengineering. The cell biology section is studying the use of stem cells to help replace damaged cells in the heart following a heart attack. Current studies are being done in pigs and once successful, human trials will take place. The bioengineering section is interested in new minimally invasive techniques for performing cardiothoracic surgery, including the development of new devices and tools to make surgery easier and give better outcomes for the patient. Current projects are looking at heart valve replacement surgeries and CABG (National Heart, Lung, and Blood Institute).
Professors at Yale School of Medicine are conducting studies on left ventricular assist devices. These devices help the left ventricle of the heart (the heart chamber responsible for pumping blood to the rest of the body) when it is failing. One type of device is implanted into the body and runs using a battery outside the body. The second type is completely outside the body and usually only used for very ill patients in a critical care unit inside the hospital. They are also researching wireless energy transfer to artificial heart pumps so that a battery unit would not need to be attached to the patient for the pump to work (Yale School of Medicine).
The Pediatric Cardiac Surgery Lab associated with Stanford University’s Department of Cardiothoracic Surgery is looking for ways to correct heart structure abnormalities present in children while the child is still in the mother’s uterus. They are also trying to make artificial heart valves that grow with the child (Stanford Medicine).
Researchers in Columbia University’s Cardiothoracic Surgery Research Lab are looking for ways to predict the development of thickening of the heart muscle leading to heart failure after heart transplantation (termed cardiac allograft hypertrophy). The development of cardiac allograft hypertrophy has been associated with worse clinical outcomes and a decreased survival rate. Researchers hope that by finding ways to predict when it will occur, they can then put measures in place to prevent or delay its occurrence in patients (Columbia University Department of Surgery).
Cardiothoracic surgery is a thriving surgical subspecialty in terms of innovation and patients helped, thanks to the work of early pioneers and current researchers.
Aris, A. (1997). Francisco Romero, the First Heart Surgeon. The Annals of Thoracic Surgery,64(3), 870-871. doi:10.1016/s0003-4975(97)00760-1.
Blatchford, J. W. (1985). Ludwig Rehn: The First Successful Cardiorrhaphy. The Annals of Thoracic Surgery,39(5), 492-495. doi:10.1016/s0003-4975(10)61972-8.
Cherian, S. M., Nicks, R., & Lord, R. S. (2001). Ernst Ferdinand Sauerbruch: Rise and Fall of the Pioneer of Thoracic Surgery. World Journal of Surgery,25(8), 1012-1020. doi:10.1007/s00268-001-0072-x.
Fults, D. W., & Taussky, P. (2011). The Life of Rudolf Nissen: Advancing Surgery Through Science and Principle. World Journal of Surgery,35(6), 1402-1408. doi:10.1007/s00268-011-1047-1.
Hoffenberg, R. (2002). Christiaan Barnard: his first transplants and their impact on concepts of death. Bmj,324(7335), 1478-1480. doi:10.1136/bmj.324.7335.465/b.
Murray, L., Hendren, W. H., Mayer, J. E., & Rockoff, M. A. (2013). “A Thrill of Extreme Magnety”: Robert E. Gross and the Beginnings of Cardiac Surgery. Journal of Pediatric Surgery,48(8), 1822-1825. doi:10.1016/j.jpedsurg.2013.06.008.
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