Training in Cardiovascular Surgery: Thoughts of a Key Opinion Leader

Dr Om P. Yadava, CEO and Chief Cardiac Surgeon of the National Heart Institute in New Delhi, India, and Editor-in-Chief of the Indian Journal of Thoracic and Cardiovascular Surgery, and Professor Rui Almeida, President of the Brazilian Society of Cardiovascular Surgery, discuss the reasons for a lack of trainee interest in the specialty of cardiovascular surgery and the steps that the Brazilian Society of Cardiovascular Surgery has taken to address this issue.

Professor Almeida discusses a lack of interest in trainees for the specialty of cardiovascular surgery and the potential for a worldwide shortage of cardiovascular surgeons in the near future (1). The main reasons for this include the long duration and complexities of the training required to become a cardiovascular surgeon. In Brazil, there is a 20% drop-off in residency positions in cardiovascular surgery. In India, almost 40% of training seats are going vacant. Professor Almeida discusses some of the steps that the Brazilian Society of Cardiovascular Surgery (BSCVS) has taken to bridge this gap, including invitations to medical students to form a national cardiovascular league that is joined with other national annual society meetings and the inclusion of residents, so that they can take an active part in it. The necessity of two-year general surgery training was waived off. Even the training schedule and curriculum has changed to include new technologies and techniques, especially endovascular, to excite the younger generation.

Professor Almeida notes that some interventional cardiologists don’t want cardiac surgeons to gain wire-based skills and are unlikely to help in the training schedule. On the other hand, a joint program between the Society of Interventional Cardiologists and the BSCVS is certifying their members in transcatheter aortic valve implantation (TAVI). In this context, most training should be simulation-based so that the cardiac surgeons can prepare themselves for percutaneous therapies, including hybrid surgeries, which are going to be necessary in the future. Besides that, a surgeon’s training schedule must include at least three months of cardiac catheterization lab posting, and every year there should be reinforcement through regular short-term postings in the catheterization lab during the entire training program.

In Brazil, at the end of five years of cardiothoracic and vascular surgery training, one-year training for subspecialities, such as pediatric cardiac surgery and heart transplant, is available. For hybrid procedures and transcatheter valves, certification is mandatory. Before getting certified, a surgeon has to do a minimum of ten cases and an interventional cardiologist a minimum of five cases. For alternative access only, the surgeon can be certified after doing five cases. Furthermore, both societies recommend that the two work together, and that in the future, only those who do so will be able to get reimbursed. This helps reinforce of concept of the heart-team and also ensures that surgeons are not left out as new therapies evolve.

Dr. Yadava notes that despite all the advantages that have been documented for valve repair over replacement, it has not filtered down to the average cardiac surgeon. Professor Almeida feels that it is because of the complexity of the valve repair, as compared to the replacement procedure, besides the other issues like non-availability of transesophageal echocardiography (TEE) in the operating room for intraoperative validation of repair and the reluctance of the anesthetists to take to TEE, because they are not reimbursed monetarily for their extra efforts. To bridge this gap, they are organizing hands-on workshops, which leading valve repair surgeons conduct at least once in a year, to help the rest of their colleagues take to the repair field. Professor Almeida opines that probably 25 repair procedures per year is the minimum for a cardiac surgeon to maintain proficiency.

Professor Almeida rues the fact that most cardiac centers, especially in the smaller cities of Brazil, are performing general cardiac surgery, and though they are jacks of all trades, they unfortunately are masters of none, a situation quite akin to India. Therefore, there is a need for creating “Centers of Excellence,” especially in major cities. To bridge the training gaps and to tide over the learning curve, they must have a system of vet labs and stimulation-based skills labs to complement the classic hands-on training on real-time patients. The industry plays an important role, as the society may not have all the fiscal resources to implement these programs. Industry should be leveraged, as they may have ulterior interests in training the younger generation of surgeons on mitral valve repair and percutaneous valve techniques. The needs of the specialty, and the gaps therein, can possibly be addressed by targeting the younger generation, just at the point when they are exiting medical school, and involving them in integrated programs.

Reference

1. Valooran G, Nair S. A Career in Cardiothoracic Surgery: A Passionate Choice. CTSNet. May 2015.