Cardiothoracic surgery

Cardiothoracic surgery is the field of medicine involved in surgical treatment of organs inside the thoracic cavity — generally treatment of conditions of the heart, lungs, and other pleural or mediastinal structures.
In most countries, cardiothoracic surgery is further subspecialized into cardiac surgery and thoracic surgery ; the exceptions are the United States, Australia, New Zealand, the United Kingdom, India and some European Union countries such as Portugal.

Training

A cardiac surgery residency typically comprises anywhere from four to six years of training to become a fully qualified surgeon. Cardiac surgery training may be combined with thoracic surgery and/or vascular surgery and called cardiovascular / cardiothoracic / cardiovascular thoracic surgery. Cardiac surgeons may enter a cardiac surgery residency directly from medical school, or first complete a general surgery residency followed by a fellowship. Cardiac surgeons may further sub-specialize cardiac surgery by doing a fellowship in a variety of topics including pediatric cardiac surgery, cardiac transplantation, adult-acquired heart disease, weak heart issues, and many more problems in the heart.

Australia and New Zealand

The highly competitive Surgical Education and Training 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 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 Royal Australasian College of Surgeons, denoting that they are qualified specialists. Trainees having completed a training program in General Surgery and have obtained their FRACS will have the option to complete fellowship training in Cardiothoracic Surgery of four years in duration, subject to college approval. It takes around eight to ten years minimum of post-graduate training to qualify as a cardiothoracic surgeon. Competition for training places and for public hospital places is very high currently, leading to concerns regarding workforce planning in Australia.

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. 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.
Thoracic surgery is its own separate 2–3 year fellowship of general or cardiac surgery in Canada.
Cardiac surgery programs in Canada:

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 United States is combined with general thoracic surgery and called cardiothoracic surgery or thoracic surgery. A cardiothoracic surgeon in the U.S. is a physician who first completes a general surgery residency, followed by a cardiothoracic surgery fellowship. The cardiothoracic surgery fellowship typically spans two or three years, but certification is based on the number of surgeries performed as the operating surgeon, not the time spent in the program, in addition to passing rigorous board certification tests. Two other pathways to shorten the duration of training have been developed: a combined general-thoracic surgery residency consisting of four years of general surgery training and three years of cardiothoracic training at the same institution and an integrated six-year cardiothoracic residency, which have each been established at many programs. Applicants match into the integrated six-year programs directly out of medical school, and the application process has been extremely competitive for these positions as there were approximately 160 applicants for 10 spots in the U.S. in 2010. As of May 2013, there are 20 approved programs, which include the following:
Integrated six-year Cardiothoracic Surgery programs in the United States:

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
University of California, Los Angeles 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

The earliest operations on the pericardium took place in the 19th century and were performed by Francisco Romero Dominique Jean Larrey, Henry Dalton, and Daniel Hale Williams. The first surgery on the heart itself was performed by Norwegian surgeon Axel Cappelen on 4 September 1895 at Rikshospitalet in Kristiania, now Oslo. He ligated a bleeding coronary artery in a 24-year-old man who had been stabbed in the left axilla and was in deep shock upon arrival. Access was through a left thoracotomy. The patient awoke and seemed fine for 24 hours, but became ill with increasing temperature and he ultimately died from what the post mortem proved to be mediastinitis on the third postoperative day. The first successful surgery of the heart, performed without any complications, was by Ludwig Rehn of Frankfurt, Germany, who repaired a stab wound to the right ventricle on September 7, 1896.
Surgery in great vessels became common after the turn of the century and falls in the domain of cardiac surgery, but technically cannot be considered heart surgery. One of the more commonly known cardiac surgery procedures is the coronary artery bypass graft, also known as "bypass surgery."

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 but Souttar's physician colleagues at that time decided the procedure was not justified and he could not continue.
Cardiac surgery changed significantly after World War II. In 1948 four surgeons carried out successful operations for mitral stenosis resulting from rheumatic fever. Horace Smithy revived an operation due to Dr Dwight Harken of the Peter Bent Brigham Hospital using a punch to remove a portion of the mitral valve. Charles Bailey at the Hahnemann Hospital, Philadelphia, Dwight Harken in Boston and Russell Brock at Guy's Hospital all adopted Souttar's method. All these men started work independently of each other, within a few months. This time Souttar's technique was widely adopted although there were modifications.
In 1947 Thomas Holmes Sellors of the Middlesex Hospital operated on a Fallot's Tetralogy patient with pulmonary stenosis and successfully divided the stenosed pulmonary valve. In 1948, Russell Brock, probably unaware of Sellor's work, used a specially designed dilator in three cases of pulmonary stenosis. Later in 1948 he designed a punch to resect the infundibular muscle stenosis which is often associated with Fallot's Tetralogy. Many thousands of these "blind" operations were performed until the introduction of heart bypass made direct surgery on valves possible.

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 Wilfred G. Bigelow of the University of Toronto that the repair of intracardiac pathologies was better done with a bloodless and motionless environment, which means that the heart should be stopped and drained of blood. The first successful intracardiac correction of a congenital heart defect using hypothermia was performed by C. Walton Lillehei and F. John Lewis at the University of Minnesota on September 2, 1952. The following year, Soviet surgeon Aleksandr Aleksandrovich Vishnevskiy conducted the first cardiac surgery under local anesthesia.
Surgeons realized that the limitations of hypothermia – complex intracardiac repairs take more time and the patient needs blood flow to the body, particularly to the brain. The patient needs the function of the heart and lungs provided by an artificial method, hence the term cardiopulmonary bypass. John Heysham Gibbon at Jefferson Medical School in Philadelphia reported in 1953 the first successful use of extracorporeal circulation by means of an oxygenator, but he abandoned the method, disappointed by subsequent failures. In 1954 Lillehei realized a successful series of operations with the controlled cross-circulation technique in which the patient's mother or father was used as a 'heart-lung machine'. John W. Kirklin at the Mayo Clinic in Rochester, Minnesota started using a Gibbon type pump-oxygenator in a series of successful operations, and was soon followed by surgeons in various parts of the world.
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. In March, 1961, Zuhdi, Carey, and Greer, performed open heart surgery on a child, age, 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.