Cardiothoracic surgery is a specialized field dedicated to the surgical treatment of organs within the chest cavity, or thorax. This region primarily encompasses the heart, lungs, esophagus, and major blood vessels. The scope of practice is divided into cardiac surgery, focusing on the heart and great vessels, and general thoracic surgery, addressing the lungs, esophagus, and chest wall. Surgeons in this field manage complex conditions, from advanced heart disease to various forms of cancer.
Surgeries for Coronary and Structural Heart Disease
The primary procedure addressing blockages in the heart’s arteries is Coronary Artery Bypass Grafting (CABG). This operation reroutes blood flow around narrowed coronary arteries using healthy blood vessels harvested from elsewhere in the patient’s body, such as the internal mammary artery or the saphenous vein. The goal is to restore adequate oxygen supply to the heart muscle, preventing heart attacks and relieving symptoms like chest pain.
On-Pump vs. Off-Pump CABG
CABG can be performed using two main techniques. The traditional “on-pump” method involves stopping the heart and connecting the patient to a cardiopulmonary bypass machine, or heart-lung machine. This machine takes over gas exchange and blood circulation, providing a stable surgical field for the surgeon to sew the bypass grafts. The “off-pump” technique, also called beating-heart surgery, allows the surgeon to perform the procedure while the heart continues to beat, avoiding the use of the heart-lung machine entirely. This approach was developed to mitigate potential complications associated with the bypass machine.
Beyond revascularization, surgeons manage end-stage heart failure through the implantation of Ventricular Assist Devices (VADs). These mechanical pumps help the weakened heart ventricle move blood to the rest of the body, significantly improving survival and quality of life. VADs are used either as a “bridge to transplantation,” supporting the patient while they await a donor heart, or as “destination therapy” for patients who are not candidates for a transplant.
Heart transplantation remains the definitive treatment for end-stage heart failure, though it is limited by the scarcity of donor organs. Surgeons also address structural issues present since birth, known as adult congenital heart defects. This includes the surgical closure of holes in the heart’s walls, such as Atrial Septal Defects (ASD) or Ventricular Septal Defects (VSD). Repairing these defects prevents complications like heart failure or pulmonary hypertension later in life.
Procedures Focused on Valve Repair and Replacement
Dysfunction of the heart’s four valves—aortic, mitral, tricuspid, and pulmonary—can lead to stenosis (narrowing) or regurgitation (leaking). The surgical approach involves either repairing the patient’s native valve or replacing it with a prosthetic one. Repair, known as valvuloplasty, is often the preferred option, particularly for the mitral and tricuspid valves. Repair preserves the heart’s natural structure and may eliminate the need for lifelong blood thinner medication.
Valve replacement becomes necessary when the damage is too extensive for a durable repair, such as in cases of severe aortic stenosis. Surgeons choose between two primary types of prosthetic valves: mechanical or tissue.
Mechanical Valves
Mechanical valves are highly durable and designed to last the patient’s lifetime. However, their artificial surfaces necessitate the patient taking anticoagulant medication, such as warfarin, for the rest of their life. This medication prevents the formation of dangerous blood clots.
Tissue Valves
Tissue valves, also called bioprosthetic valves, are constructed from animal tissue. The significant advantage of these valves is that they generally do not require long-term blood thinners, which benefits patients with a higher risk of bleeding. The trade-off is their limited lifespan, as tissue valves typically require a re-replacement surgery after 10 to 20 years.
General Thoracic and Pulmonary Interventions
General thoracic surgery focuses on the lungs, chest wall, diaphragm, and esophagus. A substantial portion of this practice involves the surgical management of lung cancer. The type of operation is determined by the size and location of the tumor and the patient’s overall lung function.
A segmentectomy involves removing only one or more anatomical segments of a lung lobe, which is a lung-sparing technique often used for small, early-stage tumors. A lobectomy involves the removal of an entire lobe of the lung, and is the standard operation for many lung cancers. In rare cases of extensive disease, a pneumonectomy, which removes the entire lung, may be required.
Minimally invasive techniques have revolutionized thoracic surgery. Video-Assisted Thoracic Surgery (VATS) and robotic-assisted surgery utilize small incisions and specialized instruments. These approaches offer advantages like reduced post-operative pain, shorter hospital stays, and faster recovery compared to traditional open thoracotomy. Robotic surgery provides the surgeon with a magnified, three-dimensional view and instruments with a greater range of motion.
Thoracic surgeons also perform procedures on the esophagus, most notably esophagectomy. This is the removal of part or all of the esophagus, primarily for cancer or severe non-cancerous conditions. This complex operation often involves reconstructing the esophagus using a portion of the stomach or intestine.
Furthermore, they treat non-malignant conditions of the chest cavity, such as recurrent pneumothorax (a collapsed lung). Surgical procedures for pneumothorax, often performed with VATS, include pleurodesis to help the lung adhere to the chest wall. Surgeons also manage infectious conditions like empyema, which is a collection of pus around the lung, often requiring surgical drainage.