Download Cardiothoracic Surgery - an insight for medical students

The major sub-specialities are congenital, thoracic and adult cardiac, each with its own
characteristics. Some surgeons have a mixed practice across thoracic and adult cardiac but
most specialise in one of these areas.
Thoracic surgery is, of course, dominated by the treatment of malignant disease, but this
is not confined to bronchial carcinoma for important changes have occurred in the
management of metastases and sarcomas. Problems of the pleural space such as
pneumothorax, empyema and malignant pleural effusions are the daily fare of a thoracic
surgeon. Mediastinal tumours and tracheal surgery are highly specialised areas.
Oesophageal surgery is a challenging sub-speciality of thoracic surgery but a few talented
surgeons have made this an absorbing career. Nowadays, thoracic surgeons collaborate
with general surgeons and gastroenterologists in upper GI units.
Arguably the most fascinating area of cardiac surgery is congenital practice because the
challenges are significant both intellectually and technically but the rewards for successful
repair of defects can be great. Many of these children, often neonates with complex
defects, require further procedures later in life and so may come to be operated upon as
adults. Hybrid procedures between interventional cardiologists and surgeons, for example,
pulmonary valve replacement, are being developed in many centres. This is the most
demanding type of cardiothoracic surgery and only a small group of highly talented
surgeons perform these types of operations. In recent years the intensity of public and
institutional scrutiny has increased markedly.
Adult cardiac surgery is dominated by coronary heart disease but in an ageing population
the requirement for valve surgery is rising fast. Coronary artery surgery is probably the
most studied operation of all time. It is a big procedure but relatively safe with an early
hospital mortality of 2%. This has been achieved despite the increasing age and comorbidity of patients undergoing the procedure. There continue to be innovations in valve
surgery mainly in the area of tissue valves seeking to improve their durability. As the
population of elderly patients increases, surgery of the thoracic aorta, including the aortic
arch is expanding and provides opportunities to develop skills in endovascular stenting and
to collaborate with vascular surgeons and interventional radiologists. The other major
area is heart failure for which there are a range of surgical treatments from transplantation
and ventricular assist devices to high risk coronary artery surgery, mitral valve repair and
ventricular restraint devices.
Surgeons in cardiothoracic surgery work closely with cardiologists or thoracic physicians.
Attention to detail is essential as mistakes are not forgiven and may easily lead to the
death of the patient during the operation. This feature distinguishes cardiac surgery in
particular, from other branches of surgery.
There have been three eras in cardiac surgery. In the first 20 years after 1950 surgeons
were preoccupied in making cardiac surgery safe. Attention then turned to evaluating
outcomes and analysing data to a very high level of sophistication. We are now in a third
era concerned to reduce the morbidity of our operations by the use of minimal invasive
techniques and to enable patients to benefit from the explosion of basic science research in
vascular biology, tissue engineering, stem cells and many other areas. The surgeon at the
bedside is in a very privileged position at the interface between the laboratory and the
patient.