Cardiothoracic surgery
Occupation | |
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Names |
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Occupation type | Specialty |
Activity sectors | Medicine, Surgery |
Description | |
Education required |
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Fields of employment | Hospitals, Clinics |
Cardiothoracic surgery is the
In most countries, cardiothoracic surgery is further subspecialized into cardiac surgery (involving the heart and the great vessels) and thoracic surgery (involving the lungs, esophagus, thymus, etc.); the exceptions are the United States, Australia, New Zealand, the United Kingdom, India and some European Union countries such as Portugal.[1]
Training
A cardiac surgery
Australia and New Zealand
The highly competitive Surgical Education and Training (SET) program in Cardiothoracic Surgery is six years in duration, usually commencing several years after completing medical school. Training is administered and supervised via a bi-national (Australia and New Zealand) training program. Multiple examinations take place throughout the course of training, culminating in a final fellowship exam in the final year of training. Upon completion of training, surgeons are awarded a Fellowship of the
Canada
Historically, cardiac surgeons in Canada completed general surgery followed by a fellowship in CV / CT / CVT. During the 1990s, the Canadian cardiac surgery training programs changed to six-year "direct-entry" programs following medical school. The direct-entry format provides residents with experience related to cardiac surgery they would not receive in a general surgery program (e.g. echocardiography, coronary care unit, cardiac catheterization etc.). Residents in this program will also spend time training in thoracic and vascular surgery. Typically, this is followed by a fellowship in either Adult Cardiac Surgery, Heart Failure/Transplant, Minimally Invasive Cardiac Surgery, Aortic Surgery, Thoracic Surgery, Pediatric Cardiac Surgery or Cardiac ICU. Contemporary Canadian candidates completing general surgery and wishing to pursue cardiac surgery often complete a cardiothoracic surgery fellowship in the United States. The Royal College of Physicians and Surgeons of Canada also provides a three-year cardiac surgery fellowship for qualified general surgeons that is offered at several training sites including the University of Alberta, the University of British Columbia and the University of Toronto.[citation needed]
Thoracic surgery is its own separate 2–3 year fellowship of general or cardiac surgery in Canada.
Cardiac surgery programs in Canada:[citation needed]
- University of Alberta – 1 position
- University of British Columbia – 1 position
- University of Calgary – 1 position
- Dalhousie University – 1 position every other year
- Université Laval – 1 position every three years
- University of Manitoba – 1 position
- McGill University – 1 position every three years
- McMaster University – 1 position every other year
- Université de Montréal – 1 position every three years
- University of Ottawa – 1 position
- University of Toronto – 1 position
- Western University – 1 position
United States
Cardiac surgery training in the
Integrated six-year Cardiothoracic Surgery programs in the United States:[citation needed]
- Medical College of Wisconsin
- Stanford University – two positions
- University of North Carolina at Chapel Hill
- University of Virginia
- Columbia University – two positions
- University of Pennsylvania
- University of Pittsburgh – two positions
- University of Washington
- Northwestern University
- Mount Sinai Hospital, New York
- University of Maryland
- UCLA– two resident positions, one Transplant Fellowship; one Congenital resident position
- University of Texas Health Science Center at San Antonio
- Medical University of South Carolina
- University of Southern California – two positions
- University of Rochester
- University of California, Davis
- Indiana University
- University of Kentucky
- Emory University
- University of Michigan
- Yale University
The American Board of Thoracic Surgery offers a special pathway certificate in congenital cardiac surgery which typically requires an additional year of fellowship. This formal certificate is unique because congenital cardiac surgeons in other countries do not have formal evaluation and recognition of pediatric training by a licensing body.
Cardiac surgery
Cardiac surgery | |
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ICD-9-CM | 35–37 |
MeSH | D006348 |
OPS-301 code | 5-35...5-37 |
The earliest operations on the
Surgery in
Early approaches to heart malformations
In 1925 operations on the heart valves were unknown. Henry Souttar operated successfully on a young woman with mitral stenosis. He made an opening in the appendage of the left atrium and inserted a finger into this chamber in order to palpate and explore the damaged mitral valve. The patient survived for several years[10] but Souttar's physician colleagues at that time decided the procedure was not justified and he could not continue.[11][12]
Cardiac surgery changed significantly after
In 1947
Open heart surgery
Open heart surgery is a procedure in which the patient's heart is opened and surgery is performed on the internal structures of the heart. It was discovered by
Surgeons realized the limitations of hypothermia – complex intracardiac repairs take more time and the patient needs blood flow to the body, particularly to the
Nazih Zuhdi performed the first total intentional hemodilution open heart surgery on Terry Gene Nix, age 7, on February 25, 1960, at Mercy Hospital, Oklahoma City, OK. The operation was a success; however, Nix died three years later in 1963.[13] In March, 1961, Zuhdi, Carey, and Greer, performed open heart surgery on a child, age 3+1⁄2, using the total intentional hemodilution machine. In 1985 Zuhdi performed Oklahoma's first successful heart transplant on Nancy Rogers at Baptist Hospital. The transplant was successful, but Rogers, who had cancer, died from an infection 54 days after surgery.[14]
Modern beating-heart surgery
Since the 1990s, surgeons have begun to perform "
Some researchers believe that the off-pump approach results in fewer post-operative complications, such as postperfusion syndrome, and better overall results. Study results are controversial as of 2007, the surgeon's preference and hospital results still play a major role.[citation needed]
Minimally invasive surgery
A new form of heart surgery that has grown in popularity is
Pediatric cardiovascular surgery
Pediatric cardiovascular surgery is surgery of the heart of children. The first operations to repair cardio-vascular[15] defects in children were performed by Clarence Crafoord in Sweden when he repaired coarctation of the aorta in a 12-year-old boy.[16] The first attempts to palliate congenital heart disease were performed by Alfred Blalock with the assistance of William Longmire, Denton Cooley, and Blalock's experienced technician, Vivien Thomas in 1944 at Johns Hopkins Hospital.[17] Techniques for repair of congenital heart defects without the use of a bypass machine were developed in the late 1940s and early 1950s. Among them was an open repair of an atrial septal defect using hypothermia, inflow occlusion and direct vision in a 5-year-old child performed in 1952 by Lewis and Tauffe. C. Walter Lillihei used cross-circulation between a boy and his father to maintain perfusion while performing a direct repair of a ventricular septal defect in a 4-year-old child in 1954.[18] He continued to use cross-circulation and performed the first corrections of tetralogy of Fallot and presented those results in 1955 at the American Surgical Association. In the long-run, pediatric cardiovascular surgery would rely on the cardiopulmonary bypass machine developed by Gibbon and Lillehei as noted above.[citation needed]
Risks of cardiac surgery
The development of cardiac surgery and cardiopulmonary bypass techniques has reduced the mortality rates of these surgeries to relatively low ranks. For instance, repairs of congenital heart defects are currently estimated to have 4–6% mortality rates.
In order to assess the performance of surgical units and individual surgeons, a popular risk model has been created called the EuroSCORE. This takes a number of health factors from a patient and using precalculated logistic regression coefficients attempts to give a percentage chance of survival to discharge. Within the UK this EuroSCORE was used to give a breakdown of all the centres for cardiothoracic surgery and to give some indication of whether the units and their individuals surgeons performed within an acceptable range. The results are available on the CQC website.[24] The precise methodology used has however not been published to date nor has the raw data on which the results are based.[citation needed]
Infection represents the primary non-cardiac complication from cardiothoracic surgery. Infections can include mediastinitis, infectious myo- or pericarditis, endocarditis, cardiac device infection, pneumonia, empyema, and bloodstream infections. Clostridium difficile colitis can also develop when prophylactic or post-operative antibiotics are used.
Post operative patients of cardiothoracic surgery are at risk of nausea, vomiting, dysphagia and aspiration pneumonia.[25]
Thoracic surgery
A pleurectomy is a surgical procedures in which part of the
Lung volume reduction surgery
Lung volume reduction surgery, or LVRS, can improve the quality of life for certain patients with COPD of emphysematous type, when other treatment options are not enough. Parts of the lung that are particularly damaged by emphysema are removed, allowing the remaining, relatively good lung to expand and work more efficiently. The beneficial effects are correlated with the achieved reduction in residual volume.[27] Conventional LVRS involves resection of the most severely affected areas of emphysematous, non-bullous lung (aim is for 20–30%). This is a surgical option involving a mini-thoracotomy for patients in end stage COPD due to underlying emphysema, and can improve lung elastic recoil as well as diaphragmatic function.[citation needed]
The National Emphysema Treatment Trial (NETT) was a large multicentre study (N = 1218) comparing LVRS with non-surgical treatment. Results suggested that there was no overall survival advantage in the LVRS group, except for mainly upper-lobe emphysema + poor exercise capacity, and significant improvements were seen in exercise capacity in the LVRS group.[28] Later studies have shown a wider scope of treatment with better outcomes.[29]
Possible complications of LVRS include prolonged air leak (mean duration post surgery until all chest tubes removed is 10.9 ± 8.0 days.[30]
In people who have a predominantly upper lobe emphysema, lung volume reduction surgery could result in better health status and lung function, though it also increases the risk of early mortality and adverse events.[31]
LVRS is used widely in Europe, though its application in the United States is mostly experimental.[32]
A less invasive treatment is available as a bronchoscopic lung volume reduction procedure.[33]
Lung cancer surgery
Not all lung cancers are suitable for surgery. The stage, location and cell type are important limiting factors. In addition, people who are very ill with a poor performance status or who have inadequate pulmonary reserve would be unlikely to survive. Even with careful selection, the overall operative death rate is about 4.4%.[34]
In
Pulmonary reserve is measured by
There is weak evidence to indicate that participation in exercise programs before lung cancer surgery may reduce the risk of complications after surgery.[37]
Complications
A prolonged air leak (PAL) can occur in 8–25% of people following lung cancer surgery.[38][39] This complication delays chest tube removal and is associated with an increased length of hospital stay following a lung resection (lung cancer surgery).[40][41] The use of surgical sealants may reduce the incidence of prolonged air leaks, however, this intervention alone has not been shown to results in a decreased length of hospital stay following lung cancer surgery.[42]
There is no strong evidence to support using
Types
- Lobectomy (removal of a lobe of the lung)[44]
- Sublobar resection (removal of part of lobe of the lung)
- Segmentectomy (removal of an anatomic division of a particular lobe of the lung)
- Pneumonectomy (removal of an entire lung)
- Wedge resection
- Sleeve/bronchoplastic resection (removal of an associated tubular section of the associated main bronchial passage during lobectomy with subsequent reconstruction of the bronchial passage)
- VATS lobectomy (minimally invasive approach to lobectomy that may allow for diminished pain, quicker return to full activity, and diminished hospital costs)[45][46]
- esophagectomy (removal of the esophagus)
See also
- Annals of Thoracic Surgery
- European Journal of Cardio-Thoracic Surgery
- Journal of Thoracic and Cardiovascular Surgery
References
- ^ "Portuguese Ordem dos Médicos – Medical specialties" (in Portuguese). Archived from the original on 23 January 2012.
- ^ "Thoracic Surgery Specialty Description". American Medical Association. Retrieved 28 September 2020.
- ^ "Integrated Thoracic Surgery Residency Programs – TSDA". www.tsda.org. Archived from the original on 31 January 2018. Retrieved 8 May 2018.
- PMID 9307502.
- ^ "Pioneers in Academic Surgery – Opening Doors: Contemporary African American Academic Surgeons". Archived from the original on 29 March 2016. Retrieved 12 February 2016. Pioneers in Academic Surgery, U.S. National Library of Medicine
- ISBN 1-899066-54-3
- PMID 31592616.
- ^ Absolon KB, Naficy MA (2002). First successful cardiac operation in a human, 1896: a documentation: the life, the times, and the work of Ludwig Rehn (1849–1930). Rockville, MD : Kabel, 2002
- ^ Johnson SL (1970). History of Cardiac Surgery, 1896–1955. Baltimore: Johns Hopkins Press. p. 5.
- ^ Dictionary of National Biography – Henry Souttar (2004–08)
- ^ a b c Harold Ellis (2000) A History of Surgery, page 223+
- ^ a b Lawrence H Cohn (2007), Cardiac Surgery in the Adult, page 6+
- ^ Warren, Cliff, Dr. Nazih Zuhdi – His Scientific Work Made All Paths Lead to Oklahoma City, in Distinctly Oklahoma, November, 2007, p. 30–33
- ^ "NDepth: Dr.Nazih Zuhdi, the Legendary Heart Surgeon | Newsok.com". Archived from the original on 25 April 2012. Retrieved 16 April 2012. Dr. Nazih Zuhdi, the Legendary Heart Surgeon, The Oklahoman, Jan 2010
- ^ Wikipedia: Coarctation of the Aorta. Coarctation is not cardiac (i.e., heart) but is a narrowing of the aorta, a great vessel near the heart
- .
- .
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{{cite journal}}
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- ^ "Heart Surgery in United Kingdom". Archived from the original on 5 November 2011. Retrieved 2011-10-21. CQC website for heart surgery outcomes in the UK for 3 years ending March 2009
- ^ Ford C., McCormick D., Parkosewich J., et al. Safety and effectiveness of early oral hydration in patients after cardiothoracic surgery. Am. J. Crit. Care. 2020;29(4):292–300. doi:10.4037/ajcc2020841
- ^ Aziz, Fahad (7 January 2017). "Pleurectomy". Medscape. Archived from the original on 6 October 2017. Retrieved 4 October 2017.
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- ^ Kronemyer, Bob (February 2018). "Four COPD Treatments to Watch". DrugTopics. 162 (2): 18.
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External links
- The Cardiothoracic Surgery Network
- The Society of Thoracic Surgeons
- American Association for Thoracic Surgery
- International Society for Minimally Invasive Cardiothoracic Surgery