Cardiothoracic surgery is a surgical specialty dedicated to surgery of the chest. It is a new specialty which came into its own in the 1950’s with the expansion of lung surgery for tuberculosis. Soon these chest surgeons were to develop heart surgery first in children for congenital heart disease and later in adults for heart valve disease and coronary artery disease. The development of heart surgery way greatly facilitated by two key developments in which UK surgeons played a major role. The first was the development of a heart-lung machine to take over the function of the heart during surgery. This meant that the heart could be handled more easily and also emptied of blood so it could be opened. The second was the discovery in the UK of chemical means of stopping the heart beating during an operation. These two developments meant that surgeons could operate on a still heart without blood in the way. This paved the way for heart valve replacements in the 1960’s and the advent of coronary surgery in the 1970’s.

There are now four main sub-specialities in cardiothoracic surgery:
 Adult cardiac surgery – surgery for angina and heart valve disease
 Paediatric surgery – surgery for children with heart problems
 Transplantation -        Heart and Lung transplantation
 Thoracic Surgery – surgery on the lungs and the oesophagus (gullet)

Surgery of the heart is the most extensively studied branch of surgery. As a result of it’s demonstrable benefit to patients both in terms of relieving their symptoms and prolonging life there has been a rapid expansion. Similarly, surgery of the lungs and gullet is very successful in the right patients, particularly for cancer. As a result the specialty has grown quickly.

 Nearly 35,000 adult cardiac operations were carried out in Great Britain last year
 Around 3500 major lung operations were undertaken for Lung Cancer
 Just under 4000 heart operations were performed on children
 There are 220 Consultant Cardiothoracic Surgeons in the UK
 There are just over 90 surgeons training to be consultant cardiothoracic surgeons
 There are 37 cardiothoracic units in Great Britain treating adults

This is a complex branch of surgery which is highly demanding both in and out of the operating theatre. A consultant cardiothoracic surgeon’s work includes:

• Operating

• Management of patients on the intensive care after their operation

• Ward rounds

• Out patients clinics

• Teaching and Training

• Administration

• Audit

• Continuing medical education

• Regular On call duties  

The Society of Cardiothoracic Surgeons of Great Britain and Ireland was set up by the profession to develop cardiothoracic surgery. It is often referred to as the Society or SCTS. It represents the views of Cardiothoracic surgeons on all major topics of interest in the specialty. It develops guidelines on clinical management, working practices

The Society has taken a lead in data collection and analysis for over 25 years. Cardiothoracic surgery is the only medical or surgical specialty in the UK to have comprehensive data on activity and outcomes.

With the Royal College of Surgeons the Society helps monitor standards and investigate problems that are highlighted by this. It has taken the lead in developing a system of Quality Assurance for the Hospitals involved in Cardiothoracic Surgery.

Why all the interest in heart surgery outcomes?

After Bristol, the quality and safety of heart surgery has attracted much attention. The media and the public, as well as the profession, have started to look quite carefully at the outcome of heart operations. Heart surgery is exceptional amongst medical specialties in three ways:

• Most heart surgery consists of a handful of operations, and over half of these are just one type of operation: coronary artery bypass grafting or CABG.

• Because these are big operations, which carry some risk of death, it is relatively easy to produce figures for the death rate of certain procedures.

• Death is a very solid, objective outcome (no-one can argue about it)

For these reasons, heart surgery lends itself easily to analysis, even by amateurs. It is not surprising that the specialty has become the first focus of initiatives to measure quality of medical treatment.

This depends on the quality of the league tables and the information from which they are constructed. It is easy to place hospitals in order of death rate after a particular operation, but it is much more difficult to interpret such league tables intelligently.

The most important feature in any league table is that the data on which it is based are accurate and complete, and, sadly, this is rarely the case. The second most important feature is that the data should be risk-stratified (in other words, a measure of how old and sick the patients are should be included) so that the league table is fair and does not penalise hospitals, which are prepared to accept high-risk patients.

League tables, even if they are accurate and risk-stratified, invariably mean that there is always a hospital at the bottom of the league. If we decide to shut this hospital down, the next hospital will end up as the bottom hospital and, if we carry this argument to its logical conclusion, there will only be one hospital (perhaps only one surgeon!) left to carry the country's heart surgery workload, an impossible task.

Another feature of league tables is that the easiest way to move up the table is to refuse high-risk patients, but this is bad for patients because it is often these very patients who stand to gain most from operations. Although league tables are in vogue, with ever-increasing demands for public disclosure of data and greater openness, it is important that their limitations and inherent problems are recognized.

Most patients are probably not interested in where exactly their hospital is in the league table, but they are interested, and rightly so, in knowing that their hospital constantly monitors its performance and acts immediately if there is evidence that it is not doing well.

To achieve, a hospital needs to have accurate information on the number of operations it caries out, who does them, their nature and their outcome (at the very least survival rates). The hospital also needs to have some risk information about its patients, and agreed limits for acceptable performance. Once a hospital has all this information readily available, it must continuously monitor its results to ensure that the standard is met or exceeded. Finally, the hospital should have a robust mechanism for dealing with and swiftly correcting any underperformance that may occur.

In other words, this approach would build quality monitoring into the local fabric of the hospital management. If all hospitals had these mechanisms in place, league tables would become largely unnecessary. The Society of Cardiothoracic Surgeons of Great Britain & Ireland (SCTS) has begun such a programme, which can be accessed at scst (website here?).

The Department of Health has Hospital Episode Statistics in which which were designed for measuring clinical activity in hospitals. It collects basic information such as age, postcode, diagnosis and treatment or operation and whether the patient was discharged alive or dead from hospital. The system was not designed to collect detailed clinical data. Nevertheless it can be used for measuring basic performance. Unfortunately because people with more of a clerical than clinical training collect the information and hospital notes can be difficult to interpret, the HES data can be quite inaccurate when complex procedures are coded in the system. Nevertheless it provides a basic tool for the Department of Health and organizations like Dr Foster to scan hospital results. Dr Foster try to compensate for differences in patient populations at different hospitals by taking into account the effects of age, gender, urgency of operation and social status or deprivation which is the best that can be expected from the data available, but many other conditions such as underlying heart function, lung function, smoking history, diabetes, obesity, high blood pressure, kidney function and other vascular conditions all have an impact on the risk of a heart operation. These factors must all be taken into account when calculating surgical risk, particularly if meaningful comparisons between units or surgeons are to be made. 

The SCTS monitors the outcome of a number of key operations in both adult cardiac, adult thoracic and paediatric cardiac surgery. This is done by hospital and also by consultant surgeon. When under performance is detected, the hospital is informed of this so that action can be taken. The SCTS usually helps identify the sources of the problem and ways to correct the problem. This monitoring is continuous.

The most important feature is that risk stratification helps guide the surgeon and the patient towards deciding whether or not to go ahead with surgery. Decisions about an operation can only be made if you know the likely risk and the benefit of the operation so that you can "weigh them up" against each other. For example, if you have angina, and you know that the benefit of an operation will be to get rid of the angina and help protect you against a heart attack, you might well wish to proceed with surgery if your risk of dying is 3%, but you may have second thoughts if your risk is, say, 30%.  Understanding risk is also important in knowing which hospital or surgeon you choose. League tables may place hospitals (and, soon, surgeons) in the order of their outcome results (death after a procedure). To make sense of such tables, having an idea of risk is essential.

Remember none of these are perfect and when applied to an individual patient can only allow an educated ‘guesstimate’ of risk compared to a theoretical average patient.

If you answer Yes to any of these question then you may face a greater risk, however you may also have more to gain. The greater the number of affirmative answers (Yes) will mean an increased risk.
Are you over 70?
Are you female?
Do you have high blood pressure?
Are you significantly overweight?
Do you have lung problems?
Do you get short of breath on minimal exercise?
Have you had a stroke?
Do you have problems with the circulation in your legs?
Are you kidneys damaged?
Are you in-hospital with bad angina?
Have you had a heart attack in the last 90 days?

There are two main reasons for undergoing coronary artery surgery:

• To prolong life

• To reduce or abolish the symptoms of angina and breathlessness

A good outcome from cardiac surgery can be measured in these terms but will vary from patient to patient.  It is important to discuss this before surgery so that you have realistic expectations and do not expect the impossible.  This is why you see the surgeon in the Out Patient Clinic.

Overall, results compare favourably with any in the world. It is an achievement that despite operating on older and sicker patients, the death rate for first time coronary artery bypass is only 2.1% for the nation, and in no hospital does it exceed 4.3%. Hospital results obviously will differ from each other, and there are many reasons for this, ranging from different patient risk profiles, to genuine differences in hospital performances. Nevertheless, the current outcomes are very satisfactory indeed, and the risk of major open-heart surgery now compares quite favourably with the risk of relatively less complex general surgical and orthopaedic procedures.

Heart surgery is, without any doubt, the most studied, monitored and audited specialty. The current monitoring systems, though not perfect, make it very unlikely that poor performance will go undetected for any length of time. The profession has learnt the lessons of Bristol and efforts are constantly made to improve quality control in the specialty.

First it is important to realise that the outcome of cardiac surgery is not simply related to the skill of the surgeon undertaking the operation.  The outcome of any operation is the end point of a complex interaction between at least 3 often 4 Consultants (Cardiology, Anaesthesia, Surgery and Intensive Care), many different environments (the Ward, Theatres & ITU) and many differing doctors, nurses and physiotherapists.  Cardiac surgery should be teamwork par excellence.  If there good results then the surgeon should take the credit along with everyone else and if there are genuine concerns about results it may be nothing to do with the surgery.  This is know as the system approach and is supported by the Chief Medical Officer, The Bristol Inquiry and the Secretary of State for Health, the Rt. Hon Mr Alan Milburn.

Secondly why not just talk to your surgeon? He is obliged to tell you his own results. However, sometimes he may not know and should tell you so. This is occurs when he is doing an uncommon operation or operating on someone very ill. In both cases there will be some degree of uncertainty which should be openly discussed.