Cardiothoracic surgery also referred to as thoracic surgery is that field of surgery, which is involved in the surgical management of organs inside the thorax (Heart, Lung, Great Vessels, Chest wall and Mediastinum). In the surgical field, this speciality is pretty young. The 1st successful intra-cardiac open operation with the use of a heartlung machine for correction of a congenital heart defect using hypothermia was performed by C. Walton Lillehei and F. John Lewis at the University of Minnesota on 2nd September 1952. In India, Dr. Reeve Betz started the 1st cardiothoracic surgery department at Vellore in 1949. Dr. T. Thomas and Dr. Gopinath subsequently joined Dr. Betz and initiated the 1st open heart surgery program in 1960. The 1st Coronary Artery Bypass Graft (CABG) surgery was administered by Dr. K.M. Cherian in 1975 at Chennai, while the 1st ever heterologous cardiac transplant with a pig’s heart was done at K.E.M. Hospital, Mumbai by Dr. PK Sen. A cardiac surgery residency training programme can have a duration from three to six years relying on what stage you join the course (after MBBS or after MS General Surgery). Cardiac surgery training could also be combined with thoracic surgery called “Cardiothoracic Surgeon” (CT Surgeon), vascular surgery called “Cardiovascular Surgeon” (CV Surgeon) or both “Cardiovascular & Thoracic Surgeon” (CVT Surgeon).
In India after completion of general surgery residency there are two ways a candidate can become a cardiothoracic surgeon; either through MCH (Master of Chirurgieae) or DNB (Diplomate of National Board) programme, accredited by the National Board of Examination (NBE) (3/6 Year full-time programme). The NBE, found in 1975, runs a parallel system of postgraduate education, with uniform selection criteria, curriculum and examination format for training positions offered nationally. Aspiring medical students should understand that cardiothoracic surgery is very demanding. Along with the routine skills of a surgeon, it needs a special blend of skills and individual qualities like (1) Ability to stay calm in very stressful situations,(2) Practical skills like good hand-eye coordination, physical dexterity and visuospatial awareness, (3) Capacity to control developing situations, anticipate issues and to take initiative, (4) Ability to thrive under stress and pressure and resilience to deal with changing circumstances, (5) Excellent organizing and communication skills, (6) Good teamwork and the skill to lead and manage a team effectively, (7) Stamina to deal with potentially long hours in the operation theatre, (8) Ability to inspire confidence in others, (9) Emotional resilience and the ability to support your team in difficult circumstances. Prof. Kouchoukos rightly proposed the attributes of a perfect cardiothoracic surgeon, “Intelligence, drive, and stamina… loves challenges, diligence and positive outcomes…is result-oriented, loves working with their hands and brain simultaneously, enjoys caring for others and interacting with highly competent physicians and other healthcare professionals.” Thus the exemplary resident qualification manifesto encompasses the whole gamut of human occupational skills. No wonder cardiac surgeons are said to be one in a million! There are no shortcuts to success in CVTS, “Too much diligence” (confusion between work and life’s passion), “Late settlement in life” (but it’s about winning the war and not the battle), “Can’t work under someone or with a team” (man remains a social animal, despite willful denials). There are a few challenges that can’t be overlooked like, (1) The technical nature of the surgery, (2) Requirement of fine motor skills, (3) Long learning curve. For instance, an aortic valve replacement (AVR) has one hundred and twenty-two steps, which a trained surgeon is predicted to carry out in a precisely coordinated sequence. (As Dwight McGoon said, “Write it down twice, learn it & you will do well”). These challenges should be given with due respect, but they shouldn’t kill the aspirations of the budding surgeons. In one of my operation theatre doors, it had been written, “When going gets tough, the tough gets going”. It is true and it has happened occasionally. Every case is different and should never be underestimated neglected. Proper preoperative workup, counselling to the patient along with the bystander, availing consent for the high risk involved, detailed planning for the surgery, communication to the operation theatre staff and checking of all logistics required for the surgery. Not only that but for every surgery, there are always plans A, B and C. Once you begin a procedure and switch to the heart-lung machine, in the limited duration of the arrested heart, repair or replacement of the damaged part of the heart is to be done systematically and algorithmically. A cardiothoracic surgeon has to put in 100% of his/her skills, efforts, sweat and adrenaline. Interventional cardiology practiced by physicians has recently grown at a quick pace, but amidst this, there are several reasons which each student must understand as to why CVTS should never become redundant. The burden of cardiovascular diseases in India and across the planet is growing rapidly. Indian population has reached 136 Cr in 2020 and we have no more than 1500 active cardiothoracic surgeon as of today. Presently, 1,50,000 surgeries are performed yearly (130 cases per million population vs 850 cases per million in developed countries) and 1,40,000 Adult Cardiac Surgeries (1,00,000 CABG and 40,000 Valve Surgeries). Hypertension, Diabetes, Dyslipidemia, and smoking still are the major public health problems adding to the burden of CAD. Approximately 2,00,000 (half require some intervention) babies are born with congenital heart defects yearly, while only 25,000 pediatric cardiac surgeries (less than 50 specialized Pediatric CTS) are performed. Only a few centers in India and across the world can accommodate the management of cardiovascular & thoracic surgical procedures. There is a huge gap in academic institutions and personal health setup. In India for a patient burden of 20,000 yearly and fewer than 10 dedicated transplant units, only 300 heart transplants & 200 LVADs are performed with only two centers equipped for lung transplantation. Only a few centers have a genuine thoracic surgical or vascular surgical unit. Minimal Invasive Cardiac Surgery (MICS), Laparoscopic Surgery, Robotic Cardiothoracic Surgery, etc are routinely performed by only a few surgeons. Endovascular intervention procedures and percutaneous heart valve repair/replacement have a potentially huge market which remains untapped. Recent advancements related to this branch include Beating Heart Surgery, MICS, Heart Failure-Artificial Heart Replacement (ventricular assisted devices), Heart Transplantation, Endovascular Therapy, Percutaneous Heart Valve Implantation, Next Gen Heart Valves, Stem Cell Therapy and Gene Therapy. Also, there’s a parallel growth of other supportive specialities especially cardiovascular imaging with Computerized Scan and Magnetic Resonance Imaging. Instrumentation, imaging, staging and protocol-based therapy provide remarkable leads to Thoracoscopic surgery (VATS) and thoracic oncosurgery which wasn’t achievable till the last decade. After all, it’s us who decide what we want in life. With full determination, commitment and responsibility, one has to maintain the balance between work and life, create self-discipline and proper planning of not just days or weeks but for months. One must understand his or her shortcomings and limitations. For a successful life, you have to go with your core skills and realize the surgical areas where you’ll be able to give justice. Along with surgical skills, you will have to develop good communication with patients, relatives, team members and management. The internet and social media have deeply engulfed our lives in 2020. Surgeons should know computer operations beyond a basic level. Journal reading, paper writing and conference presentations are a must for academic positions and overseas job opportunities or fellowships. This career demands parallel physical development. Importance of yoga, meditation and physical training can’t be ignored. Diet and health are vital for the needed physical and mental skills. You would have to be focused on your goal without deviating or else you’ll lose since heart and lungs don’t offer you a second chance of surgery. CT surgeons have the chance to touch, hold and repair the most beautiful and strongest part of our body. The results are quick and long-lasting. Words cannot explain the sensation when a previously serious patient in the ICU improves after surgery and returns walking without any symptoms for follow up. Beating heart surgery is filled with thrill, excitement, adventure and an adrenaline rush. A heart arrested for repair within the chamber, resuming its activity on being disconnected from the heart-lung machine gives a special height of satisfaction.Today we are at the pinnacle of the future of cardiothoracic surgery. Refinement in surgical steps and hardware may be a requirement but it is still evolving. Presently, there’s an enormous gap in demand versus supply in this field. The cardiothoracic surgical community needs more skilled and erudite experts to serve. The technological boom in the field provides sufficient opportunities for a cutting-edge career path. Minimally invasive techniques and robotics offer exciting opportunities within the field with limitless prospects for innovations. Many untouched territories await within the fields of telesurgery and telementoring. The advancements in cardiology and catheter-based interventions shouldn’t be perceived as the death of open procedures, but the beginning of a new breed of evolved “hybrid surgeons”. Above all, the unique privilege to handle the heart, the most dynamic organ of our body is unparalleled. The altruistic heights that this career demands, allows the practitioner to seek out his alter-self, by losing himself within the care of the seat of the soul. Thus, beyond all rationalizations and odds, it would still be a right choice to walk this hard yet fulfilling path.