Our world is rapidly changing. There has been an explosive growth of technology and knowledge combined with a rapidly aging population. By the year 2040, there will be over 77 million people aged 65 and older in the United States alone. People are living longer and more people will be seeking medical treatment to enhance their quality of life.
In spite of these statistics, the number of open heart surgeries performed each year has been steadily declining. While this is partly due to the decreased incidence of cardiovascular disease, it is also because of the large-scale application of percutaneous coronary interventions. Technology now allows interventional cardiologists to go where only cardiothoracic surgeons went in the past. Traditionally invasive cardiac surgery is being replaced by transcatheter and endovascular procedures; to the point that it is something patients have come to expect. Most patients expect to undergo minimally invasive procedures with no incision and to leave the hospital within a day or two. Where does the role of the cardiac surgeon fit into this rapidly changing field of medicine and patient expectation? Quite simply, it has to evolve.
Evolution is nothing new for cardiothoracic surgery. It is a relatively new field that has been around for about 50 years. It wasnt until the late 1950s that the heart lung bypass machine was perfected enough to be used in surgery. For the first time, surgeons had time to work on a heart that was not only empty of blood, but which wasn’t moving. Surgeons could actually go “inside” the heart for hours at a time to perform intricate life-saving surgeries. What followed was a period of explosive growth and rapid advancement in the treatment of heart conditions.
Until about 25 years ago, most cardiothoracic surgeons operated out of university settings. This changed in the early 1980s. As the demand increased, universities were overloaded from a volume and financial perspective due to the high acuity of these patients. Community hospitals began building open-heart surgery programs. More and more hospitals wanted to offer this cutting edge technology and invested large amounts of money in building operating suites and attracting highly trained surgeons and ancillary staff members. Until the mid-1990s cardiac surgery continued to enjoy solid growth.
As we approach the end of another decade, cardiac surgery is evolving again. While there will always be a demand for cardiothoracic surgeons, some areas of cardiac surgery are being replaced by percutaneous and endovascular procedures performed by interventional cardiologists and vascular surgeons. This includes a substantial portion of coronary surgery, aortic, mitral and pulmonary stenosis surgery, arrhythmia surgery (pacemaker and defibrillator implants have been taken over by electrophysiologically trained interventionists), and atrial septal defect. Even thoracic aortic aneurysms are being treated with endovascular procedures.
Even with these advances, open surgery is still the only option in certain cases and the skill of experienced surgeons remains indispensable. Unfortunately, due to declining volumes, fewer physicians are electing to pursue the additional education and training necessary to specialize in cardiac surgery. Hospitals are finding it harder to recruit and retain not only cardiac surgeons, but also the paramedical staff needed to sustain a quality cardiac program. In order to remain competitive, hospitals will need to be proactive and invest in new technology and treatment protocols and develop market niches. Cardiac surgeons and interventionists will need to adjust to a team approach. As technology drives changes, there will be no room for solo endeavors. Each specialty will become more dependent on the other with the safety of the patient always being of paramount importance.
The convenience of a cardiothoracic surgeon at the community level will become increasingly rare and it is also likely we will see a more regionalized approach for complex cardiac care. While community hospitals will continue to experience growth in percutaneous and endovascular cases, more complex cases will be referred to regional centers which will have the expertise of the entire cardiac team, including the surgeon, interventionist, and paramedical support staff.
Our world is rapidly changing. There has been an explosive growth of technology and knowledge combined with a rapidly aging population. By the year 2040, there will be over 77 million people aged 65 and older in the United States alone. People are living longer and more people will be seeking medical treatment to enhance their quality of life. 
