By Jennifer Whitlock, RN, MSN, FN 

 Medically reviewed by David Hampton, MD

Cardiothoracic surgery is a field of surgery focused on organs in the thorax (chest), including the heart, lungs, and esophagus. It may be used to treat a wide range of issues, from heart failure to pulmonary embolism to esophageal cancer.1

Surgeons who perform cardiothoracic surgery may be specialists in pediatrics, oncology (cancer care), neurology, and more. The wide range of cardiothoracic procedures includes coronary artery bypass graft (CABG, which is the most common type of heart surgery), lung resection (removing tissue), and placing stents to keep blood vessels open.2

This article explains the types and reasons for cardiothoracic surgery, as well as the risks. It offers a step-by-step look at what to expect when you have the surgery and what recovery typically is like.

What Is Cardiothoracic Surgery?

Cardiothoracic surgeons have expertise in cardiovascular (heart and blood vessel) surgery and pulmonary (lung) surgery. Thoracic surgeons, by comparison, focus less on heart care.

These surgeries are used to diagnose and treat diseases and traumatic injuries of the heart and lungs, but also structures including:

• The trachea (windpipe)

• The esophagus (feeding tube)

• The diaphragm, a large muscle that assists with breathing)

• The thymus gland, which may be necessary when myasthenia gravis is diagnosed3

Cardiothoracic surgery is performed by a cardiothoracic surgeon. Some cardiothoracic surgeons specialize in highly sophisticated procedures such as heart and lung transplants.

A cardiothoracic surgeon is a healthcare provider trained as a general surgeon before adding another two to three years of fellowship training and certification by the American Board of Thoracic Surgeons.4

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

• Open, a traditional type of highly invasive surgery used for complex surgeries like open heart surgery. It may involve other structures, like the ribs.

• Endoscopic, with smaller incisions and laparoscopic or thoracoscopic instruments used to visualize tissue and perform procedures

• Robotic surgeries that are computer-assisted, often with evolving techniques and benefits3

Endoscopic and robotic surgeries are minimally invasive procedures with typically shorter recovery times than invasive surgeries. Most are inpatient procedures (requiring a hospital stay).

Some diagnostic procedures (like a lung biopsy), however, may be performed as an outpatient procedure.

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.

Why Someone Would Need Cardiothoracic Surgery

Cardiothoracic surgeries are used to diagnose and treat a vast range of lung and heart conditions, as well as gastrointestinal problems affecting the esophagus. They are indicated during a major heart attack, traumatic chest injury, or other emergency. With some diseases, like lung cancer, cardiovascular surgery is considered a standard of care.5

Cardiothoracic surgery can be performed on adults, children, and infants, and may even be completed using specialized in-utero procedures for fetal surgeries.6 The following chart presents various cardiothoracic surgeries and why they may be needed.

Cardiothoracic Surgery and Risk

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. Weighing the risks and benefits is especially important if:

• A cardiothoracic procedure is unlikely to extend life.

• A surgery candidate is extremely frail, which may affect some older adults.7

• A co-existing infection or disease presents additional challenges.

• The candidate cannot tolerate general anesthesia.

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.

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.

Cardiovascular Risks

Arrhythmia (abnormal heart rhythm)

Thrombosis (venous blood clots)

Heart failure

Stroke

Ischemic heart damage (caused by impaired blood flow)

Myocardial infarction (heart attack)

Cardiac tamponade (caused when blood fills the lining of the heart)

Acute kidney failure

Intestinal ischemia (also caused by impaired blood flow)

Pulmonary Risks

Atelectasis (collapsed lung due to deflation of the air sacs of the lungs)

Pneumothorax (collapsed lung due to a leak in the lungs)

Respiratory failure

Pulmonary embolism (blood clot in the lungs)

Empyema (a pocket of pus in the chest cavity)

Pleural effusion (fluid in the membranes surrounding the lungs)

Deep vein thrombosis

Atrial fibrillation (chaotic heart rate)

Pneumonia

Preparation Before Cardiothoracic Surgery

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.

Diagnostic Workup

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.8

With the diagnostic workup, 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:9

• 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:10

• 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

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).

What to Do Ahead of Surgery

There are things you need to do and know before your surgery. They include understanding the kind of facility you'll be in, whether or not you're planning an inpatient stay or need a driver to take you home, and other factors. These factors include the following:

• Food and drink restrictions intended to avoid the accidental aspiration of food or liquids into the lungs during surgery. They apply whether the surgery is minor or major, and you'll typically need to stop eating the day before your surgery. Be sure to follow your healthcare provider's instructions.

• Medications you need to stop taking. Common medications include anticoagulants, beta blockers, diabetes drugs, and nonsteroidal anti-inflammatory drugs (NSAIDs).11 High-dose vitamin E and oral corticosteroids like prednisone may also need to be stopped due to their effects on wound healing. But be sure to have medications that you need to take, too.

• Admissions paperwork. 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. Also, bring any instructions from your healthcare team.

• Clothing that will be comfortable after your procedure, such as avoiding pullover tops or choosing gowns to accommodate sutures and catheters. Pack enough for your entire stay, if possible.

Pre-Op Lifestyle Changes

Cigarette smoke causes prolonged vasoconstriction (the narrowing of blood vessels), which reduces the blood and oxygen supply that reaches surgical wounds. Smoking is associated with increased complications and slower healing times, including the risk of wound dehiscence in which an incision fails to close properly.12

Most cardiothoracic surgeons recommend smoking cessation (stopping) before and after surgery. The American Society of Anesthesiologists recommends at least one week before surgery, while other studies recommend up to four weeks of being smoke-free.1314

Surgery and Smoking

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. 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

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:

• 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

• Shaving: Your body may also need to be shaved at the surgical site. This is done by the nurse just before surgery. You do not need to do it yourself.

A healthcare provider also will record your weight and height. It is used to calculate your body mass index (BMI) so that the correct dosage of medications, including anesthesia, can be prescribed.

BMI is a dated, flawed measure. It does not take into account factors such as body composition, ethnicity, sex, race, and age. Even though it is a biased measure, BMI is still widely used in the medical community because it’s an inexpensive and quick way to analyze a person’s potential health status and outcomes.

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 MAC15

• General anesthesia: Typically used for more complex or longer surgeries to put you completely to sleep

A cardiothoracic surgery can take a few or many hours, depending on how extensive the procedure is. What happens next depends on the exact surgery you are having done and the technique being used to perform it.

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.

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.16

• 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.17

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.

Recovery from cardiothoracic surgery can improve significantly with the support of family and friends, as well as online or in-person support groups. Counseling and therapy may also be involved.18

Summary

A cardiothoracic surgeon is trained to perform procedures used to diagnose and treat conditions affecting the heart, lungs, and other organs in the chest, such as the esophagus. Some of these surgeries may be complex, involving inpatient hospital stays and longer recovery times. Others may be minimally invasive procedures completed on an outpatient basis.

Some of the preparation steps are similar. You'll likely need to stop eating and taking certain medications before your procedure. If you're a smoker, you may need to stop before the surgery can move forward. Your healthcare team will ensure you have the instructions for your situation.

Talk to your healthcare provider about your recovery time, too. You will likely have an extended recovery following major cardiothoracic surgery

Sources

1.Summa Health. Cardiothoracic Surgery.

2.Tiwari A, Sharma A, Jaswal S, Kaur SS, Thakur N. Assessing the Patient Outcomes and Performance of a Cardiothoracic and Vascular Surgery (CTVS) Unit During Its First Two Years in a Tier-2 City in India: A Comprehensive Audit and Analysis. Cureus. 2023 Aug 3;15(8):e42910. doi: 10.7759/cureus.42910.

3.Gonzalez-Rivas D, Manolache V, Bosinceanu ML, Gallego-Poveda J, Garcia-Perez A, de la Torre M, et al. Uniportal pure robotic-assisted thoracic surgery-technical aspects, tips and tricks. Ann Transl Med. 2023 Aug 30;11(10):362. doi: 10.21037/atm-22-1866.

4.American Board of Thoracic Surgery. Training and initial certification.

5.Lemjabbar-Alaoui H, Hassan OU, Yang YW, Buchanan P. Lung cancer: Biology and treatment options. Biochim Biophys Acta. 2015;1856(2):189-210. doi:10.1016/j.bbcan.2015.08.002

6.Benlamkaddem S, Berdai A, Labib S, Harandou M. A history case of cardiac surgery in pregnancy. Case Rep Obstet Gynecol. 2016;2016:7518697. doi:10.1155/2016/7518697

7.Castro ML, Alves M, Papoila AL, Botelho A, Fragata J. One-Year Survival after Cardiac Surgery in Frail Older People-Social Support Matters: A Prospective Cohort Study. J Clin Med. 2023 Jul 15;12(14):4702. doi: 10.3390/jcm12144702. 

8.Garcia-Valentin A, Mestres CA, Bernabeu E, et al. EuroSCORE and EuroSCORE II in the Spanish cardiac surgical population: a prospective, multicentre study. Eur J Cardio-Thoracic Surg. 2016 Feb;49(2):399-405. doi:10.1093/ejcts/ezv090

9.Roy PM. Preoperative pulmonary evaluation for lung resection. J Anaesthesiol Clin Pharmacol. 2018 Jul-Sep;34(3):296-300. doi:10.4103/joacp.JOACP_89_17

10.Seo HS, Choi M, Son SY, Kim MG, Han DS, Lee HH. Evidence-based practice guideline for surgical treatment of gastroesophageal reflux disease 2018. J Gastric Cancer. 2018;18(4):313-27. doi:10.5230/jgc.2018.18.e41

11.Sousa-Uva M, Head SJ, Milojevic M, et al. 2017 EACTS guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg. 2018;53(1):5-33. doi:10.1093/ejcts/ezx314

12.Yang L, Liao Z. Effect of Smoking on Cancer Surgery Outcomes and Recommendations for Perioperative Smoking Cessation Intervention. Sichuan Da Xue Xue Bao Yi Xue Ban. 2023 Nov 20; 54(6):1312-1316. Chinese. doi: 10.12182/20231160605.

13.United Nations. Smokers who quit one month before surgery reap benefits: UN health agency.

14.American Society of Anesthesiologists. Smoking.

15.Chakravarthy M. Regional analgesia in cardiothoracic surgery: A changing paradigm toward opioid-free anesthesia?. Ann Card Anaesth. 2018;21(3):225-7. doi:10.4103/aca.ACA_56_18

16.Bayly J, Fettes L, Douglas E, et al. Short-term integrated rehabilitation for people with newly diagnosed thoracic cancer: a multi-centre randomized controlled feasibility trial. Clin Rehabil. 2020;34(2):205-19. doi:10.1177/0269215519888794

17.McMahon SR, Ades PA, Thompson PD. The role of cardiac rehabilitation in patients with heart disease. Trends Cardiovasc Med. 2017;27(6):420-5. doi:10.1016/j.tcm.2017.02.005

18.Akbari M, Celik SS. The effects of discharge training and counseling on post-discharge problems in patients undergoing coronary artery bypass graft surgery. Iran J Nurs Midwifery Res. 2015 Jul-Aug; 20(4): 442–449. doi:10.4103/1735-9066.161007

By Jennifer Whitlock, RN, MSN, FN
Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.