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Congenital Cardiac Surgery
Surgery on the heart first began in 1896 when a stab wound to the heart was sutured preventing death from haemorrhage. However little progress occurred over the next 50 years due to the difficulty of operating inside the heart without stopping it.
Heart surgery today is divided into 2 fields, congenital and acquired. Congenital surgery deals with defects that are present at birth while acquired deals with defects that occur in a previously normal heart. The 2 are sometimes referred to as paediatric (congenital) and adult cardiac surgery but that definition is less accurate since many children operated on are surviving into adulthood sometimes needing further surgery. Occasionally a defect present at birth may not declare itself until adult life and is best operated by a surgeon trained in the recognition and correction of such problems. A few children born with normal hearts may develop diseases of the heart that require an operation and this will come under the care of a congenital (paediatric) cardiac surgeon.
All heart surgery is divided into either closed or open. Closed heart surgery refers to any operation on the heart that does not need a pump to take over the function of the heart while it is being operated. Open heart surgery is any operation on the heart where a pump (Heart-Lung Bypass Machine) is used. About 80% of surgery is thus defined as open.
Congenital heart surgery began in 1939 when a surgeon in Boston USA tied off a persistent arterial duct (PDA). It was followed in 1944 by an operation to relieve Coarctation of the aorta (Craaford in Stockholm), and the Blalock-Taussig shunt at Johns Hopkins Hospital in Baltimore. Later in 1947/8 Brock and Holmes-Sellors in London performed operations to treat stenosed (narrowed) valves. All these operations were enormous steps at the time but were limited by the unavailability of the heart lung machine so were closed heart operations.
In 1953 the first operation inside the heart was accomplished when John Gibbons in Philadelphia successfully closed an ASD utilising a heart lung machine that he had developed. However the machine was not reliable and he was unable to repeat the success. Other surgeons persisted with research and development until in 1955 a machine was available to allow open heart surgery to become a reality. This introduced a period of massive and rapid progress such that today there is virtually no baby born with a heart defect for whom some sort of operation is possible. However at the same time many defects are so complex that the operations can never achieve a normal circulation. Approximately 5,500 operations for congenital heart defects are performed each year in the UK and Ireland of which about 1,000 are over 16 years old. Every operation is reported to a central monitoring organisation, NICOR (National Institute for Cardiovascular Outcomes Research) to ensure standards are maintained at a high level. Currently 30-day survival is just over 97% irrespective of the underlying condition making the UK and Ireland one of the safest places in the World to have such surgery.
Training in Congenital heart surgery
In the UK following graduation from medical school a doctor must spend 2 years as a “Foundation” trainee. This is followed by a year or 2 as a “Core Trainee”. By now many will have made a decision on their career and those that wish to become a surgical specialist must take further exams toward a qualification MRCS (Member of the Royal College of Surgeons). This is a 2 part exam and details are available at The Royal College of Surgeons of England website.
MRCS is essential to progress into higher surgical training where the doctor has chosen a specialty. All aspiring congenital heart surgeons must pass through the same basic training in cardiothoracic surgery as those who wish to become adult cardiac or thoracic (lung and chest) surgeons. This is a 6 year training program with selection by interview held once a year as a national recruitment into the specialty. Successful applicants will be allocated to a training program and given a NTN (National Training Number). Each year they are assessed before being allowed to progress to the next year. An exam is taken after at least 4 years which will confer the diploma FRCS(CTh) (Fellow of the Royal College of Surgeons; Cardiothoracic).
Those who wish to become congenital cardiac surgeons may, in the first 4 years, spend some time in that branch of heart surgery within their regional programme, but most of the early training is in adult cardiac surgery and at least a year must be spent in thoracic surgery training. Formal training in congenital surgery requires a good basic understanding and competence in adult cardiac surgery.
Congenital Cardiac Surgery is now a formal Sub-Specialty of Cardiothoracic Surgery. This means that trainee surgeons who wish to pursue a career in Congenital will need to spend at least two years of their final training within a dedicated Congenital Programme. Trainees must have passed their FRCS(CTh) and hold an NTN in Cardiothoracic Surgery. They must then apply for one of the UK training programmes for Sub-Specialty Training. All consist of two paired centres with the trainee spending one year in each. The posts are interviewed for at the same time as national recruitment, once a year. Currently, the recognised programmes are (a) Great Ormond Street and Birmingham Children’s Hospital, (b) Evelina (Guy’s and St Thomas’) and the Royal Brompton Hospital and (c) Alder Hey Liverpool and Freeman, Newcastle.
After 6 years in training and having passed the FRCS(CTh) the trainee will be awarded a CCT (Certificate of Completion of Training) which will allow them to enter the GMC register as a “Specialist”. Without that specialist registration they cannot be appointed to a NHS consultant position. If pursuing a career in Congenital Cardiac Surgery the trainee will have also completed their two-year Sub-Specialty training and will receive their CCT in not only cardiothoracic surgery in general, but also in the Sub-Specialty of Congenital. Thus, trainees in congenital heart surgery will usually have a slightly longer period in specialist training since most will not sit the FRCS exam until their 5th year and then spend years 6 and 7 in the sub-specialty training.
In summary anyone wishing to become a congenital cardiac surgeon will spend at least 10 years after graduation from medical school before they become a consultant in the NHS. At present there are about 40 consultant congenital cardiac surgeons in the UK and Ireland. A significant increase in that number is unlikely given that no patients are un-operated due to lack of a surgeon and an increase in the number of babies born with heart defects is not anticipated. Thus approximately 3 surgeons need to be trained every 2 years to replace current consultants as they retire.
As with a lot of things a crystal ball is needed. However the increasing survival into adulthood of children with complex cardiac defects has brought new challenges. For some the heart may begin to fail early. For them an operation may enable recovery but for others if medication does not help then cardiac transplant may be the only option. That is limited by donor organ availability which already cannot meet national need. One possibility may be genetic modulation of other mammalian hearts though that has been disappointing thus far. A more realistic solution may be the development of a totally artificial heart that can be implanted. The current success of heart surgery owes a great deal to the technological advances in material science and diagnostics as it does to the greater knowledge of cardiac physiology and biochemistry. These technological advances may well overcome the current difficulties that prevent widespread application of totally implantable artificial hearts.
[Content provided by Professor David Anderson, Consultant Heart Surgeon and Professor of Children's Heart Surgery, St Thomas' Hospital - last updated 6 March 2017]
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