Download cardiothoracic surgery

CARDIOTHORACIC
SURGERY
5th grade research project
By Gracie Guerin
“Dr Richmond you’re needed on the second floor” The speakers
shout up and down the hallways. My pager goes off and I start running.
When I get to the room I ask the nurse what happened. She says that Mr
Kent had started babbling nonsense. I thought quickly and inspected the
color of his skin and his lips and saw that they looked blue. I told them
that we needed to get him into an OR immediately. When the nurse
asked me why, I said that Mr Kent had pericardial effusion. We then
raced him down the hallway and into the O.R.
Scenarios like that happen every day. But without the expertise
and quick thinking of cardiothoracic surgeons people like Mr. Kent would
be dead. It takes years of training, talented people and hard work but
without those people what would we do?
From rocks to laser beams, heart surgery has changed a lot over
the short period of time that it has been around. People have worked
their whole lives to try and save lives.
What is the heart?
The heart is a pump in your chest about the size of your fist. It never
gets tired. There are two pumps on each side- the atrium and
ventricle. The circulation process of blood
takes about one minute to go through your entire
body. At the start of the process the right atrium
fills with used blood that then travels to the lungs
to get oxygen. The left atrium then fills with good
blood that came from the lungs that then
circulates around the body. But be careful
because your heart is not invincible, obesity, fatty foods and many other
things can contribute to heart problems. But if you exercise regularly and
eat a healthy diet you can try and stay free of heart conditions.
What are cardiothoracic surgeons?
Cardiothoracic surgeons (sometimes referred to as Ct Surgeons)
are specialists both men and women, who have expertise in disorders of
the heart, lungs, esophagus and major blood vessels of the chest cavity.
Within the specialty, one can develop skills in adult heart surgery,
children’s heart surgery, and general thoracic surgery (of the lungs and
esophagus).
Instruments-Scalpels
Scalpels were invented around 3000 B.C.E. The scalpel has been the
surgeon’s most effective tool for 5000 years. Evidence of the first
known surgical tools has been found
among Sumerian archaeological remains
from 3000 B.C.E. This is now modern Iraq.
The Egyptian surgeons removed
abscesses and tumors with the scalpel.
Scalpels are used to cut through skin,
remove objects or for precise little cuts.
-Iron Lung Machine
The Iron lung machine is a machine from
1926 that was used to help polio victims.
Polio is a disease that paralyses the
nerves that controls the limbs and lungs.
To help you breath they would put you into
a big box (the iron lung machine) that
pushed air into your lungs and sucked it
out again. Today only a facemask and
ventilator are used to help you breath.
-Laser Beams
Modern surgeons use laser beams in surgery.
They cut through skin with more precise
movements. They are best used for eye surgery.
1962 was when laser beams were first used in
surgery.
Transplants
In December 1967, South African doctor, Christaan Barnard did a
heart transplant on a patient. He lived for 18 days until the powerful
drugs used to fight rejection weakened him and he died of pneumonia.
The second to get a heart transplant by Dr. Barnard lived for 18 months.
But the triumph was shortly crushed as patient began dying of infection
and rejection. By 1971, 146 of the 170 heart transplant patients had
died, turning this into a disaster. Everybody admitted defeat.
Immuno suppressant
A fungus was found in Hardaangerfjord (a lake in Norway) that
contained a substance called cyclosporine which contained excellent
immuno suppressant properties that controlled organ rejection without
completely shutting down your immunity to infection. Hospitals began reopening their heart transplant units and patients were living after
surgery. This was the end to the surgical difficulties with heart
transplants. To figure out when to give the cyclosporine to the patients
Dr. Norman Shumway gathered a team to scientifically tackle this
problem. They came up with a way to insert a catheter into the heart and
remove a piece of heart for examination. When signs of rejection were
spotted the immuno suppressant doses increased.
World War II
During World War II, military doctors made advances in antibiotics,
anesthesia and blood
transfusions. The revolution
to gain access to the heart
was started by a Dr. Dwight
Harken, a young US army
surgeon. Many of his
patients were young soldiers
that had shell fragments and
bullets lodged into their
chests or heart. Dr. Harken
was developing a technique
that would let him cut into
the wall of a still beating
heart, insert a finger, located
the bullet or shell fragment and remove it. All of the first 14 animals died.
In the second group of 14 only half died. And in the last group of 14, only
2 died. He then did the procedure on humans and they all lived. People
now knew that the heart could be operated on. Sadly they could only
operate for four minutes.
Hypothermic treatment
Dr. Bill Bigelow from the University of Minnesota had noticed how
hibernating animals survived long, hard and especially cold winters.
They would slow down their heart beats, allowing them to survive
without food. Bigelow began animal experiments and discovered that
when dogs are chilled, they can survive open heart surgery for much
longer than four minutes. He said that when you are colder, the tissues
of the brain and body don’t need as much oxygen and could live without
oxygen in their blood for much longer.
On September 2nd 1952, Dr. Walton
Lillehei and Dr. John Lewis tried
doing the first open heart surgery on
a 5 year old girl that was born with a
hole in her heart. The girl was
cooled so that her body temperature
was 81 degrees F. When she is that
cold, she can survive without a
working heart for ten minutes.
Clamping the flow of blood into the
heart so that it emptied, Lewis and
Lillehei cut open her heart, and
quickly sewed up the hole. They put
her in a bath of warm water until her body temp reached normal again. It
was a success.
The history of heart surgery is quite short compared to other
specialties. We still have a lot to discover, cure, research and develop,
and were just getting started.
Many people have done many things to help evolve cardiothoracic
surgery. People research, they investigate, and spend their lives making
sure that surgeons have the knowledge that they need. When everybody
tries, even the smallest achievement can mean a lot.
Timeline
Ludwig Rehn was the first person to ever successfully do a suture repair
of a stab wound to the heart, he did this is 1896. In
1924 Martin Kirschner did the first
successful pulmonary embolectomy. In
1944 Alfred Blalock did the first subclavian
pulmonary anastomosis for tetralogy of
fallot, the blue baby operation. The blue
baby was a big step for surgeons. I will
ALFRED BLALOCK
explain the blue baby operation more
fully in the conditions section. The next person is Dwight
Harken. In 1943 to 1945 he was the first person to
DWIGHT
HARKEN
successfully remove foreign bodies from the heart. These two talented
surgeons helped start the era of open-heart surgery.
In 1952, John Lewis did the first successful open heart closure of an
atrial defect using hypothermia. This is called hypothermia or
hypothermic treatment, which I explained, in the history section. We
jump all the way to 1960 when Albert Starr successfully replaced the
mitral valve with an artificial valve. Albert Starr did some very stunning
work on the mitral valve and I will explain more about his life and the
process of making the mitral valve in this section, later on. We stay in
1960 when James Jude and William Kouwenhaven did the first closed
chest resuscitation for cardiac arrest (CPR).
After James Hardy tried to transplant a
chimpanzees heart into a humans body and it
failed, Christaan Barnard, who will come up
later, did a heart transplant from a human into
a human. Sadly the patient only lived 18 days
before the massive amount of drugs given to
him to fight the possibility of rejection killed
him. His first attempt was in 1967; in 1968 he
tried again this time with the patient living 18
months (593 days).
After that massive breakthrough people started trying to
transplant the lungs with the heart. It took more than 10 years, but in
1981, the first successful heart-lung transplant was
performed by Bruce Reitz and Norman Shumway. It
made a change in many people’s lives that couldn’t
just have their hearts being
transplanted.
For a while, artificial hearts
were trying to be developed.
But without having an
artificial valve constructed
they couldn’t make it. So
when Albert Starr made the artificial mitral valve,
and it worked, people went to work on making an
artificial heart. In 2001 Laman Grey made the first
working artificial heart.
TH E H EAR T A ND
LU NGS
AR TIFIC IA L HEAR T
CO MPA RED TO A R EAL HEA RT
Michael DeBakey, MD
Michael DeBakey was born in Lake Charles, Louisiana in
1908. He did his undergraduate degree at Tulane University.
He then did his Bachelors degree and medical degree in 6
years. He did his internship and residency under Dr.
Ochsner. He went to Europe for two years and studied one
year under Dr. Rene Leriche at the university of Strasbourg
and the other year with Dr. Kirschner at the university of Heidelberg.
After that he came back to Tulane where he was made assistant
professor. He worked a few months at the Ochsner clinic, which Dr.
Ochsner had started. In 1942 Michael DeBakey went into the army
medical corps. Fred Rankin was the chief surgical consultant in
Washington. He asked that Dr. DeBakey would come up to Washington.
Dr. DeBakey was then assigned to the surgical general's office in
Washington. In 1948 he went to Houston to be the chairman of the
department of surgery at Baylor College of medicine. He ended taking
over the old navy hospital and the local county hospital soon came into
business with them. In 1952 Baylor did their first abdominal aortic
aneurysm. They thought they were the
first but they ended up being the second with a
school in Paris being the first. Once he did the
abdominal aneurysm, Dr. DeBakey thought it could
be applied to the thoracic aneurysm. He tried
doing a thoracic aneurysm with the same idea as
the
abdominal aneurysm and it went well. When he
was a junior medical school student, his faculty
AB DOM INAL AO RTIC advisor asked him to get a pump that could pump
AN EUR YSM
fluid. He went everywhere and while he was
searching he found out that in the mid nineteenth
century rubber tubing was developed for the first time.
That was what gave him the idea to
invent the roller pump. In those
days blood transfusions were rare
because they didn’t have anywhere
to store the blood (blood banks). But with the roller
RO LLER PU MP
pump he
was able to directly pump blood from the donor into the TH ORA CIC AORT IC
patient. Dr. DeBakey soon became an expert in blood
AN EUR YSM
transfusions. He went town to town doing blood
transfusions. Dr. DeBakey died on July 11th 2008. He had a long and
very rewarding career.
Albert Starr, MD
Albert Starr was born in 1926 and grew up in New York City. He went to
Columbia University in 1945. He graduated Columbia and entered
medical school. In his senior year at medical school he applied for
surgical internships at Massachusetts general and john Hopkins. He got
accepted at John Hopkins and went there. He was so busy in his
internship that he forgot to apply for a residency position at John
Hopkins so instead he did it at New York Presbyterian. But then the
Korean War started and he was drafted. He went to Korea and was
placed as a battalion surgeon in the first Calvary division. He worked
there for about 6 months. He was pulled back and put in a mobile
surgical hospital where he spent the next year. To him, it was a great
experience. In total he had a year and a half in Korea. He spent another
6 months in Fort Meade in Maryland. He went back to New York
Presbyterian, where he continued his residency. Dr. Berry told him that
he should go into thoracic surgery, but Dr. Starr was only a two-year
resident. Berry said that in his fourth year he could start in thoracic
surgery. He finished general surgery in 3 years and at the end of 5 years
had qualifications in both boards (tests you take at the end of your
residency). In 1955 and 1956 they were starting to do open heart
surgery in New York. He was hired in the department of pediatrics and
his job was to start cardiac surgery in the next 6 months to a year in
Oregon. The first 6 months he spent gathering all the materials and
equipment necessary. He arrived in Oregon in 1957 and they did their
first open heart surgery. He then met Lowell
Edwards who told him that
he wanted to create an artificial heart. Dr. Starr
told him that it wasn’t possible because in order
to make an artificial heart, you need to be able to
make an artificial valve. So they started
brainstorming ideas for making an artificial mitral
valve. The first prototype that they made worked
well the first day but on the second or third day
THE M IT RAL VA LVES
LO CATION O N TH E
they would die of pulmonary edema, and the
HE ART
valve would thrombus. It would begin at the
suture line and spread out to the leaflets. In early 1959 they started
putting caged ball valves in the dogs. But even after that
their problem was still thrombosis. When they used the
ball valve on the first dog it worked splendid and the dog
lived for many years after that. But after that dog it all
went downhill. The dogs were dying in a matter of
weeks. The valve would thrombus, but this time it would
spread from the suture line to the orifice. To solve this
they put a circular shield around the valve. The dogs
were living and they were ready for human implanting.
TH E A RTIFICIAL MITR AL On the first human they didn’t add the circular shield.
VA LVE W ITH C IR CUL AR
The first patient was done on September of 1960. The
SH IE LD
patient died of a massive air embolism, but they kept on
trying and eventually the patients were living after having the implant.
The valve was working and it kept on evolving.
Christaan Barnard
Christaan Barnard went to the university of Cape Town
and studied general surgery in 1957. He then went to
Minneapolis. At that time Vince Gott was working on the
heart-lung machine. One day Christaan Barnard scrubbed
in and he were immediately fascinated. He switched from
general surgery to cardiac surgery.
When he was a senior resident he finished his PhD with an intestinal
atresia. At the same time he was working on his masters degree with a
thesis on aortic valves. He left Minneapolis in 1958 and went to South
Africa.
Some problems with heart transplants in those days were the use of a
human donor and the problem with rejection. The technique was easy
and Dr. Barnard never had a problem with it. People were already doing
kidney and liver transplants. In 1967 he got a position in Richmond,
Virginia with Dr. Hume. He got this position to study kidney transplants
for a few months. During his time in Richmond, Dr. Richard Lower was
doing heart transplants on dogs and he went to go and watch him in the
experimental lab. He spent half and hour in the lab and decided to go
back to South Africa and assemble a transplant team. They did a kidney
transplant, which was the first one in South Africa.
A good thing about South African law is that you only need two doctors
to pronounce someone dead that would then be used as a donor. One of
the doctors had to be qualified for over five years and they were not
allowed to be a part of the transplant team. The first kidney transplant
went well with the patient living for 23 years with that kidney. The next
problem was to select a patient for the heart transplant. They chose Mr.
Washkansky, a 53-year-old male with extensive damage from multiple
attacks and were also diabetic. On December of 1967 they had a young
girl killed in an automobile accident. The girl was pronounced brain
dead. The operation went smoothly but
Mr. Washkansky only lived for 18 days
until he died from pneumonia. Although
the patient died, when they did the
autopsy they found that the heart had
little signs of rejection. They realized that
they could in fact, do the operation. Their
next patient Dr. Phillip Blaiberg lived for
18 months after the operation. The third
patient lived for 12 years and the
A PIGG IE D B ACK H EAR T
seventh lived for 23 years. With the still
remaining problem of infection he changed the procedure so that they
wouldn’t take out that original heart, but piggyback the new heart on to it.
Even though some people try their whole lives, they don’t achieve
anything ‘big’. Some people get results in a matter of months. No matter
how big your achievement or how hard you tried, always remember the
people that began you on that path.
Imagine if somebody told you that you had a heart condition. You would
be upset right? Before you freak out you should get information about it
and actually know if it is that serious. There are different conditions and
different levels of intensity, and with the right thinking they can all be
cured.
Pulmonary Embolism
A pulmonary embolism is a blood clot on
your lung that usually appears because
there is a clot in another part of the body
(usually leg or arm). It gets clogged up in
the lungs causing the blood to clot in the
lungs.
Causes
Causes can be from extensive rest such
after surgery or sitting for long periods of time. It can be caused by a
family history of clots, too. It can happen if you have cancer and are
receiving chemotherapy. More include being overweight, history of heart
failure or stroke, recently had trauma, had given birth in the last 6 weeks
or if you are taking birth control pills.
Symptoms
Symptoms can be sudden shortness of breath, pale bluish clammy skin,
fast heartbeat, cough, excessive sweating, lightheadedness, fainting, or
wheezing.
Treatment
The treatment depends on the level of intensity. If the case is life
threatening then surgery will b done. Other treatments are blood thinner
medication or compression socks.
Prevention
To help prevent pulmonary embolisms try
exercising daily, drinking lots of fluids, don’t
smoke, try not to sit with your legs crossed, don’t
wear tight fitting cloths, loose weight (only if
overweight) and elevate your feet for 30 minutes
CO MPR ESSION
SO CKS
twice a day.
Gastroesophogeal reflux disorder (GERD)
When you eat food, your food goes down your
throat, through your esophagus and down to your
stomach. There is a muscle called the lower
esophageal sphincter that controls the opening
between the esophagus and the stomach. It
remains tightly closed except when food comes
down. When the muscle doesn’t close the acid
contents of the stomach can come back up to the
esophagus. This movement is called reflux.
Treatments
Raise the head of your bead by 6 inches to let
gravity help keep the acid down. Eat meals a few
hours before going to bed and avoid having
‘midnight snacks’. Try to eat smaller meals and
moderate portions of food. Maintain a healthy
weight and try to limit intake of fatty foods, chocolate, peppermint,
coffee, tea and alcohol. Try to give up smoking and wear loose clothing
and belts. Try to avoid tomatoes, citrus foods and juices because they
will make additional acid. This disorder is not that serious.
Subclavian Pulmonary Anastomosis (blue baby)
If you are a blue baby then that means that the babies’ blood does not
have enough oxygen in it. In a healthy normal heart the blood goes into
the heart, goes into the lungs to get oxygen, goes back to the heart to go
out into the body. The people that live have hard lives. They can only
take a few steps before getting tired.
Children mainly sit in their beds
with their head to knees because
they say it helps them breath. Their
toes, fingertips and nose can be
tinged blue
Alfred Blalock with assist from Helen
Taussig and Vivien Thomas found a
way to move an artery and sew it to
a blood vessel so that instead of the
blood first going into the heart it
would go directly into the lungs, so it gets more oxygen.
Pericardial Effusion
A pericardial effusion is a buildup of fluid
between the pericardium, which is the outer
lining of the heart.
Causes
Causes can be from infections such as
viruses, bacterial or tuberculosis. It could be
from inflammatory disorders such as lupus.
Cancer could have spread to that region or
A PER IC ARD IA L E FFUSION X RA Y
kidney failure with excessive levels of
nitrogen can also result in a pericardial
effusion.
Is It Serious?
The seriousness really depends on the cause of it. It can
also depend on whether it can be treated. If it came to be
because of an infections can be treated and the patient will
remain free of pericardial effusions. Rapid fluid can cause
cardiac tamponade which compresses the heart, impaling
its ability to function. This can be life threatening.
Symptoms
A CA RDIAC TA MPO NAD E
X-RA Y
Many patients don’t have symptoms. Usually it is found by
a chest x-ray that was performed for a different reason. Signs and
symptoms may not occur until a large amount of fluid has collected.
Symptoms might occur if the patient has heart failure. This happens
because the heart cannot relax after each breath because of the added
pressure from the fluid. If the patient does show symptoms they may
include chest pressure or pain, shortness of breath, nausea, abdominal
fullness or difficulty swallowing. If it is causing cardiac tamponade
symptoms may include blue tinged lips and skin, change in mental
status or shock.
There is always a possibility of somebody finding a cure today, tomorrow
or in ten years. But they always will find a cure.
Surgeons save millions of people a year. A surgeons training is long and
hard, but without them what would we do?
Why become a cardiothoracic surgeon?
Now that I’ve said all this stuff about cardiothoracic surgeons, why
should you become one?
Cardiothoracic surgery is a very rewarding career if you have stamina,
intelligence, if you enjoy working with people and loves challenges you
will go far. Financially you are solid in cardiothoracic surgery with the
average yearly pay being $360,000. You get to interact with interesting
people such as patients, nurses, anesthesiologists and many other
different staff. They also save people’s lives. Imagine if you could save
somebodies life every day. True, there is also the liability that you could
kill someone. But sometimes it isn’t your fault; At least you tried, right?
Becoming a cardiothoracic surgeon has many hard and challenging
steps. But when you become one there are many great things about it.
College
First you go to college. In undergraduate years, a student can major in
any field of study as long as they take the necessary prerequisite
courses to get into medical school. This
includes one year of general biology, general
chemistry, organic chemistry, physics and
calculus. Most medical schools require the
medical college admissions test (MCAT) which
is usually taken in the spring of junior year in
college. Most students will take a MCAT prep course for several months
before taking the test.
Medical school
Typically med school is 2 years of study in the basic sciences and intro
to clinical medicine. Then you do one year
of exposure to all of the major clinical
disciplines. The final year is additional
clinical exposure and electives. During
student’s senior year in med school, he/she
will work on applying for a general surgery
internship at a hospital. They will work on
this through their senior year.
Residency in general surgery
The application for a general surgery residency is done in a student’s
senior year. Ideally the student should have a surgery faculty advisor to
give advice throughout the
application and decision
making process. This
relationship is very important
because the advisor can
provide information about
different programs that could
be of interest. They can also write letters of recommendation. The
applications are sent to accredited programs through the Electronic
Residency Application Services (ERAS). In general surgery training
which is usually 5 years of clinical rotation through various surgical
disciplines, the student is usually exposed to cardiothoracic surgery in
their early and middle years of their training. Many academic based
programs require or try to encourage one or two years in additional
experience in some type of research endeavor. In the fourth year of
clinical general surgery the student can complete the application process
to get a residency position in cardiothoracic surgery.
Clinical Training in Cardiothoracic Surgery
Clinical training in cardiothoracic surgery is between two and three
years. Some programs give special training with an
emphasis in general thoracic surgery. In training the
student goes through carefully planned and
supervised step progression of experience and will
develop increasing knowledge, skill, technical ability,
responsibility and judgment. After the successful completion of an
accredited program’s training, the student will be able to sit the American
board of thoracic surgery.
4+3 Plan
In recent years different methods to get training in cardiothoracic
surgery have come out. A new pathway to residency in cardiothoracic
surgery is to first complete a training program in vascular surgery
followed by two or three years of training in cardiothoracic surgery.
There are now many training programs that give the offer of a 4+3 plan,
so that when you are doing the 4 years of general surgery training, the
resident has the opportunity to spend more time in cardiothoracic
surgery. When completed training the resident is eligible to become
certified by the American board of surgery and the American board of
thoracic surgery. Some programs now offer an intergraded 6 year
clinical program that will match medical students directly into the path of
cardiothoracic surgery.
The training process for a cardiothoracic surgeon is very long and very
difficult. But when you come down to it, without the rigorous training the
people wouldn’t be as good as they are.
The lights flash on. “Mr. Kent, are you awake?” Dr. Richmond asks.
“Yeah, what happened? Oww, my chest hurts!” He says cringing in pain.
“You went into surgery” the doctor says “you had something called a
pericardial effusion. It’s something in your lung, but it’s gone now, we
fixed it” He says while checking Mr. Kent’s temperature.
“Thank you so much, doc” Mr. Kent says as he drifts back into sleep.
Millions of people rely on surgeons and hospitals in general, to fix them.
You might think that surgery isn’t worth it because it’s expensive, or
because it leaves a scar. But when your loved one is sick, any amount of
money is worth it to see them safely home. Surgeons help people live. It
takes years of training, talented people and hard work, but without those
people, what would we do?
www.pbs.org
Pioneers of cardiac surgery-2008
Heart man- Edwin Brit Wyckoff
Medicine- Paul Dowswell
http://my.clevelandclinic.org
the road to becoming a cardiothoracic surgeon-www.sts.org
why become a cardiothoracic surgeon?- Nicholas Kouchoukos
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