Open Heart Surgery
Open heart surgery is a surgery in which the patient's heart is opened and surgery is performed on the internal structures of the heart. It was soon discovered by Dr. 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 Dr. C. Walton Lillehei and Dr. 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. During this surgery, the heart is exposed and the patient's blood is made to bypass it.
Surgeons realized 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. Dr. 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 Dr. 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'. Dr. 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.[10] In March, 1961, Zuhdi, Carey, and Greer, performed open heart surgery on a child, age 3½, using the total intentional hemodilution machine. In 1985 Dr. Zuhdi performed Oklahoma's first successful heart transplant on Nancy Rogers at Baptist Hospital. The transplant was successful, but Rogers, a cancer sufferer, died from an infection 54 days after surgery.[11]
Cardiac Surgery[edit | edit source]
The earliest operations on the pericardium (the sac that surrounds the heart) took place in the 19th century and were performed by Francisco Romero[1] Dominique Jean Larrey, Henry Dalton, and Daniel Hale Williams.[2] The first surgery on the heart itself was performed by Norwegian surgeon Axel Cappelen on the 4th of 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 axillae 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.[3][4] The first successful surgery of the heart, performed without any complications, was by Dr. Ludwig Rehn of Frankfurt, Germany, who repaired a stab wound to the right ventricle on September 7, 1896.[5][6]
Surgery in great vessels (aortic coarctation repair, Blalock-Taussig shunt creation, closure of patent ductus arteriosus), 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 (CABG), also known as "bypass surgery." In this procedure, vessels from elsewhere in the patient's body are most commonly harvested using a procedure known as EVH, and grafted to the coronary arteries to bypass blockages and improve the blood supply to the heart muscle. 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[7] but Souttar’s physician colleagues at that time decided the procedure was not justified and he could not continue.[8][9]
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 (1914–1948) of Charlotte, 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 (1910–1993) 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.[8][9]
In 1947 Thomas Holmes Sellors (1902–1987) 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.[8]
Cardiothoracic Surgery[edit | edit source]
Cardiothoracic surgery is the field of medicine involved in surgical treatment of diseases affecting organs inside the thorax (the chest)—generally treatment of conditions of the heart (heart disease) and lungs (lung disease). Cardiac surgery (involving the heart and great vessels) and thoracic surgery (involving the lungs) are separate surgical specialties, except in the USA, the UK, Australia and New Zealand.
Australia and New Zealand
The integrated advanced training program in Cardiothoracic Surgery is six years in duration with two of these years being devoted to experience in General Surgery, preferably during the first three years. 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 year in duration. 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 pathology, etc). Contemporary Canadian candidates completing general surgery and wishing to pursue cardiac surgery often complete a cardiothoracic surgery fellowship in the United States. However, the Royal College of Physicians and Surgeons of Canada affords 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. United States Surgeon operating.
Cardiac surgery training in the United States is combined with thoracic surgery and called cardiothoracic surgery. Cardiothoracic surgeons in the U.S. first complete a general surgery residency (typically 5-7 years), followed by a cardiothoracic surgery fellowship (typically 2-3 years). 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. Recently, however, options for an integrated 6-year cardiothoracic residency (in place of the general surgery residency plus cardiothoracic residency) have been established at several programs. Applicants match into these I-6 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 January 2011, there are now 14 approved programs, which include the following:
Medical College of Wisconsin Stanford University - 2 spots University of North Carolina University of Virginia Columbia University University of Pennsylvania University of Washington Northwestern University Mount Sinai Hospital, New York University of Maryland University of Texas Health Science Center at San Antonio Medical University of South Carolina
The American Board of Thoracic Surgery offers a special pathway certificate in congenital heart surgery which typically requires an additional year of fellowship. This formal certificate is unique because pediatric cardiac surgeons in other countries do not have formal evaluation and recognition of pediatric training by a licensing body.