Cardiothoracic Surgery: Everything You Need to Know

Cardiothoracic surgery, also known as thoracic surgery, is a field of surgery pertaining to organs in the thorax (chest), including the heart and lungs. It may be used to treat a wide range of issues, from heart failure to pulmonary embolism to esophageal cancer.

The body of cardiothoracic surgeries is diverse, including coronary artery bypass surgery, lung resection, vascular stenting, and many other procedures. Likewise, thoracic surgery numerous medical disciplines, including pediatrics, oncology, and neurology.

What Is Cardiothoracic Surgery?

Cardiothoracic surgery is comprised of cardiovascular (heart and blood vessel) surgery and pulmonary (lung) surgery. It is used to diagnose and treat diseases and traumatic injuries of the heart, lungs, and other allied structures, such as the trachea (windpipe), esophagus (feeding tube), and diaphragm.

Cardiothoracic surgery is performed by a cardiothoracic surgeon, a healthcare provider trained as a general surgeon before embarking on an additional two to three years of fellowship training and certification by the American Board of Thoracic Surgeons. Some cardiothoracic surgeons specialize in highly sophisticated procedures such as heart and lung transplants.

Depending on the procedure being performed, cardiothoracic surgery may be:

• Open:
• Endoscopic (a.k.a. laparoscopic or thoracoscopic)
• Robotic

Open surgery is generally used if an abnormality is hard to access, an injury is severe or complex, or the amount of tissue to be removed is extensive.

By contrast, endoscopic and robotic surgeries are minimally invasive and generally preferred to open surgery whenever possible. Because they involve one or more smaller incisions, recovery times are usually shorter.

Most are inpatient procedures requiring a hospital stay; because the incision is large and other structures may be affected (including the ribs and sternum), open surgery generally requires a longer hospital stay and recovery time.

Some diagnostic procedures (like a lung biopsy), however, may be performed as an outpatient procedure, allowing you to return home afterward.

Cardiothoracic surgery is widely considered to have started in 1896 by German surgeon Ludwig Rehn who successfully repaired the bleeding right ventricle of a man who had been stabbed in the chest.

Since then, the practice of cardiothoracic surgery has evolved to the point where open heart surgery is now considered commonplace, and the other, less invasive surgical techniques have become household names.

Contraindications

The contraindications to cardiothoracic surgery can vary by the type of procedure performed. Still, there are a few absolute contraindications to cardiothoracic surgery beyond those that apply to surgery in general.

A cardiothoracic procedure may not be pursued if it is unlikely to extend life or places a person at undue risk of harm due to extreme frailty, co-existing infection or disease, the inability to withstand general anesthesia, and other causes.

However, since cardiothoracic surgery tends to be limited to advanced cardiovascular and pulmonary diseases, the benefits of surgery as a "last option" tend to outweigh the risks.

Rigorous, individualized evaluation is needed before proceeding.

Potential Risks

All surgeries pose risks, but those involving the heart and lungs are especially concerning given the vital functions they carry out and the fact they are tied to those of the kidneys, liver, brain, and other organs. As such, complications that arise from cardiothoracic surgery can adversely impact these and other vital organ systems.

Beyond the general risks of surgery (including post-operative bleeding, post-operative infection, and the risks of anesthesia), there are specific risks and complications associated with cardiovascular or pulmonary surgery.

Purpose of Cardiothoracic Surgery

Cardiothoracic surgeries are used to diagnose and treat a vast range of pulmonary and cardiovascular diseases and disorders, as well as gastrointestinal problems affecting the esophagus.

It is indicated for medical emergencies (such as a major heart attack or traumatic chest injury) or scheduled procedures (when non-surgical options have been either exhausted or are considered inadequate). With some diseases, like lung cancer, cardiovascular surgery is considered a standard of care.

Cardiothoracic surgery can be performed on adults, children, and infants, and may even be pursued in unborn babies with specialized in-utero procedures. 

While an extensive list, the following is a sampling of cardiothoracic surgeries and when they may be performed:

Pre-Operative Evaluation

If cardiothoracic surgery is indicated, pre-operative tests will be performed to confirm that you are a candidate for surgery and to help direct the course of the procedure, including the type of anesthesia used.

There are different assessment tools used to determine an individual's risks for surgery, including EuroSCORE II, Parsonnet score, and Society of Thoracic Surgeons (STS) score. These can establish whether a person is at low, intermediate, or high risk of death following cardiothoracic surgery.

In addition, the cardiothoracic surgeon will conduct various tests and procedures to aid with surgical planning and identify vulnerabilities that may affect a person's response to anesthesia, risk of complications, or recovery.

Also known as the diagnostic workup, these pre-operative tests are ordered well in advance of surgery. They include blood tests to assess how well organs are functioning, including liver function tests (LFTs), kidney function tests, complete blood count (CBC), and blood coagulation tests. Imaging studies can help map the surgical approach and determine which surgical procedure is most appropriate.

The diagnostic workup for cardiovascular surgery may include:

• Cardiac catheterization to evaluate valve disorders
• Chest computed tomography (CT) for pre-operative planning
• Coronary angiogram to pinpoint blockages in blood vessels
• Echocardiography to evaluate coronary artery disease
• Electrocardiogram (ECG) to evaluate heartbeat irregularities
• Myocardial biopsy to characterize the cause of heart failure
• Nuclear stress testing to evaluate blood flow and characterize coronary artery disease
• Ultrasound of the neck vessels to evaluate stroke risk
• Ultrasound of lower extremity veins for possible grafts

The diagnostic workup for pulmonary surgery may include:

• Bronchoscopy to directly view tissues within the airways
• Chest X-ray or CT scans for pre-operative planning
• Endosonography to detect areas of inflammation (granulomatous lesions) within the airways
• Lymph node biopsy to help determine whether lung cancer is curable
• Magnetic resonance imaging (MRI) to better characterize soft tissue injuries or abnormalities
• Pulmonary function tests (PFTs) to establish how functional the lungs are
• Positron emission tomography (PET) to pinpoint areas of cancer activity, including metastases

The diagnostic workup for esophageal surgery may include:

• Barium swallow with X-ray to aid with pre-operative planning of a hiatal hernia
• Esophageal endoscopy to directly view the esophagus and esophageal sphincters
• Gastric emptying studies to determine the causes of GERD
• Manometry to characterize problems with movement and pressure within the esophagus

How to Prepare

The surgeon will meet with you to review your pre-operative test results and discuss what is involved with the surgery, including pre-operative preparations and post-operative recovery.

Ask as many questions as you need to fully understand the benefits and risks of surgery. This includes asking how often the surgeon has performed the surgery and why this procedure was chosen over others (such as open vs. video-assisted surgery).

Location

Cardiothoracic surgery is most commonly performed in the operating room of a hospital. It is standardly equipped with an ECG machine, anesthesia machine, mechanical ventilator, and "crash cart" to use in a cardiac emergency. Video-assisted surgeries involve a narrow fiber-optic scope, called an endoscope, that is inserted into a small incision to view the surgical site on a video monitor.

The majority of these surgeries require hospitalization, even relatively minor ones.

You will need to organize for someone to take you home after your hospital stay. Most hospitals will not discharge patients unless a friend or family (or, at the very least, a car service) is there to drive them home.

Food and Drink

Cardiothoracic surgery typically involves general anesthesia, regional blocks with intravenous sedation, or local anesthesia with intravenous sedation. In all three cases, there are food and drink restrictions.

Food and drink restrictions are intended to avoid the accidental aspiration of food or liquids into the lungs during surgery. They apply whether the surgery is minor or major.

In most cases, you will need to stop eating anything after midnight the night before your surgery. The next morning, you are allowed a few sips of water to take any medications your healthcare provider approves of. Within four hours of surgery, nothing should be taken by mouth, including water, ice chips, gum, or breath mints.

Medications

Your surgeon will provide you a list of medications you need to stop prior to cardiothoracic surgery. These include drugs that promote bleeding, impair blood clotting, affect blood sugar levels, or enhance the effects of anesthesia.

The drugs most commonly affected include:

• Anticoagulants: Usually stopped three to five days before surgery, including the drugs Coumadin (warfarin) and Plavix (clopidogrel)
• Aspirin (acetylsalicylic acid): Usually stopped five days before surgery
• Beta-blockers: Usually stopped two to three days before surgery, including the drugs Lopressor (metoprolol) and Inderal (propranolol)
• Diabetes medications: Usually stopped on the day of surgery, including insulin
• Nonsteroidal anti-inflammatory drugs (NSAIDs): Usually stopped five to seven days before surgery and restarted within four days of surgery, including Advil (ibuprofen), Aleve (naproxen), and Celebrex (celecoxib)

High-dose vitamin E and oral corticosteroids like prednisone may also need to be stopped prior to and after surgery due to their effect on wound healing.

What to Bring

For hospital admissions, you will need to bring a government photo ID (such as a driver's license), your insurance card, and an approved form of payment if copay or coinsurance costs are required upfront.

Given that most cardiothoracic surgeries are inpatient, you will need to pack accordingly based on the length of your stay and to bring clothing appropriate to your procedure. For instance:

• You may want to bring buttoned tops rather than pullovers to avoid having to reach over the head or disrupt sutures, stitches, or surgical drains.
• Women may benefit from purchasing a post-surgery bra with front closures that are easier to put on and don't place stress on surgical wounds.
• Nightshirts and nightdresses may be easier to wear if a post-surgical urinary catheter is needed.

Don't forget necessary toiletries, a change of underwear and socks, a robe and slippers, and things to read and entertain yourself with. Don't overpack since you won't have a lot of room to store your belongings. Leave any valuables at home.

You will also need to bring an ample supply of your chronic medications, which may be taken by the nursing staff upon your arrival and dispensed with other medications prescribed by your surgeon.

Pre-Op Lifestyle Changes

Cigarette smoke causes prolonged vasoconstriction (the narrowing of blood vessels), which can impede healing by reducing the amount of blood and oxygen that reaches surgical wounds. Smoking is also associated with an increased risk of wound dehiscence in which an incision fails to close properly.

Because of this, most cardiothoracic surgeons recommend the cessation of smoking at least five days before and five days after surgery, no matter the reason it is being done.

That said, people with heart or lung disease are routinely advised to stop smoking altogether to avoid the progression of the disease. If cardiothoracic surgery is indicated, there is likely no greater reason to stop smoking for good.

To reduce nicotine cravings and improve your chances of quitting, ask your healthcare provider about prescription smoking cessation aids, many of which are fully covered by insurance under the Affordable Care Act.

What to Expect on the Day of Surgery

On the day of surgery, you will be asked to wash thoroughly with an antimicrobial surgical body wash, such as Hibiclens, and to avoid putting any lotion, ointment, fragrance, or makeup on the skin.

Once you have checked in at hospital admissions, you will need to fill out a medical information sheet and a consent form stating that you understand the aims and risks of the surgery.

Depending on the surgery, you are led either to a pre-operative procedure room or directly admitted to a hospital room where you will be prepped for surgery.

Before the Surgery

There are standard procedures a patient will undergo before cardiothoracic surgery. Once you have changed into a hospital gown, a nurse will:

• Record your weight and height: Used to calculate your body mass index (BMI) so that the correct dosage of medications, including anesthesia, can be prescribed
• Take your vital signs: Including temperature, blood pressure, and heart rate
• Draw blood for blood tests: Including a CBC, comprehensive metabolic panel (CMP), and arterial blood gasses (ABG) to evaluate your blood chemistry
• Set up ECG monitoring: Involving the attachment of electrodes to your chest so that your heart rate can be monitored during surgery
• Set up pulse oximetry: Involving a device that is clamped to a finger to monitor your blood oxygen saturation levels during surgery
• Place an intravenous catheter: Involving the insertion of a flexible tube, called an intravenous (IV) catheter, into a vein in your arm to deliver medications and fluids, including IV sedation and antibiotics

During the Surgery

Anesthesia is selected and administered by the anesthesiologist to render a safe and comfortable surgery with the minimum of risk. The possibilities include the following, and the procedure you are having is what mainly dictates what is used:

• Local anesthesia: Involving one or several injections into the surgical site and typically accompanied by monitored anesthesia care (MAC), a form of IV sedation to used to induce "twilight sleep"
• Regional anesthesia: A form of anesthesia that blocks nerve pain signals (such as a spinal or pectoral epidural), used with or without MAC
• General anesthesia: Typically used for more complex or longer surgeries to put you completely to sleep

Once anesthetized, the surgery can begin. What happens next depends on the exact surgery you are having done and the technique being used to perform it. There are many possibilities given that there are numerous procedures a cardiothoracic surgeon is qualified to perform.

For example, surgery for tracheal stenosis (narrowing) will involve the placement of a stent to keep the airway open, while a lobectomy will involve surgically removing a lobe of the lung.

Some surgeries require the placement of a temporary chest tube to help drain accumulated fluids from the chest cavity and/or help reinflate the lungs after lung surgery.

A cardiothoracic surgery can take a few or many hours, depending on how extensive the procedure is.

After Surgery

You will either be taken to the post-anesthesia care unit (PACU) where you will be monitored until you are fully recovered from anesthesia, or directly to the intensive care unit (ICU) if major surgery is performed.

The duration of hospitalization can vary by surgery and may involve a short stay for observational purposes (i.e., to ensure that complications don't occur or determine whether a response has been achieved) or a prolonged stay for in-hospital recovery and rehabilitation.

Recovery

Cardiothoracic surgery invariably involves a period of recovery and, more often than not, a structured rehabilitation program.

The rehabilitative efforts are often overseen by a physical therapist specializing in cardiopulmonary diseases. Some of the procedures are performed in-office, while others are conducted at home, often on an ongoing basis.

• Pulmonary rehabilitation typically involves progressive aerobic and strength training combined with breathing exercises to expand the volume and strength of inhalations and exhalations. In addition, efforts are made to remedy weight loss that often occurs after major lung surgeries under the direction of a certified dietitian.
• Cardiac rehabilitation is standardly performed in four parts in people who have undergone major heart surgery, including the acute phase (performed in-hospital), subacute phase (performed in an outpatient facility), intensive outpatient phase (outpatient and in-home), and independent ongoing conditioning phase.

In addition, you will need to see your surgeon for scheduled visits to ensure that you are healing properly, as well as your cardiologist, pulmonologist, gastroenterologist, or oncologist to ensure ongoing management of the treated condition.

A Word From Verywell

Being referred to a cardiothoracic surgeon doesn't mean that your condition is necessarily serious. It simply means that it will benefit from the skills of a surgeon specially trained in the structure, function, and diseases of the heart, lungs, and other organs of the chest.

If cardiothoracic surgery is recommended, ask as many questions as you need to make an informed choice. If you are not getting the answers you need, do not hesitate to get a second opinion as long as the delay in treatment does not compromise your health.