Cardiac surgery is a medical specialty focused on the surgical treatment of heart and thoracic aorta pathologies. This surgery has become a routine practice for many heart conditions, with the median sternotomy approach remaining the gold standard for most open-heart procedures. Since the 19th century, the field has seen significant advancements, including the development of cardiopulmonary bypass (CPB), coronary artery bypass grafting (CABG), valve repairs, and minimally invasive techniques.
Despite innovations, traditional methods remain crucial, especially in complex cases. Modern cardiac surgery addresses a wide range of conditions, from congenital heart defects to advanced coronary artery disease, necessitating interprofessional decision-making and careful patient selection to optimize outcomes. These advancements in cardiac surgery continue to evolve (see Image. Coronary Artery Bypass Surgery).
Evolution of Cardiac Surgery
Billroth performed the first pericardiectomy in 1882. The first successful treatment of cardiac trauma was achieved by Ludwig Rehn in 1896 when he operated on a cardiac stab wound, challenging the then-prevailing belief that the heart was not an organ suitable for surgery. The development of CPB became essential for accessing critical cardiac structures, driven by the high mortality rates of early cardiac operations, such as the first embolectomy performed by Trendelenburg.
Surgical revascularization is an option for relieving ischemic heart disease complicated by atherosclerosis. Vineberg implanted the left internal mammary artery (LIMA) into the anterior free wall without forming direct anastomoses to the coronary vessels. In earlier experiments, Vineberg observed that collaterals develop when ischemia is present. During the 1960s, several surgeons in different locations pioneered the first CABG operations. The era of reversing coronary artery disease started with the invention of cardiac catheterization by Forssman in 1929 and the injection of contrast media by Shirey in 1962 to visualize coronary vessels and locate stenosis. Bypass grafting and interventional revascularization are now the 2 primary options for treating ischemic heart disease, alongside drug therapy.
Surgical treatment of valvulopathies began with closed mitral commissurotomy, where a finger or instrument was passed through the narrow orifice of the mitral stenosis to dilate or cut it, a procedure first performed by Cutler in 1923. The first artificial valve, the Hufnagel cage-and-ball valve, was introduced in 1952 and was placed in the descending thoracic aorta to prevent blood flow reversal in aortic regurgitation. In 1967, a similarly structured valve, the Starr-Edwards cage-and-ball valve, was implanted 1000 times for mitral valve disease. Surgical techniques improved from early single-valve procedures to 4-valve replacement in 1992. Specialized techniques, such as the Ross procedure, were also introduced, which involved replacing the aortic valve with a pulmonic valve autograft. To treat proximal aortic dissection or aneurysm, Bentall developed a procedure that combines the implantation of an artificial aortic valve with an ascending aortic vessel prosthesis.
In 1944, cardiac surgeons Blalock, Taussig, and Thomas made their first venture into the field of congenital heart lesions by operating on a patient with tetralogy of Fallot—a cyanotic heart defect. Pulmonary stenosis is another cyanotic heart lesion. For cardiac arrhythmias, the Cox-Maze procedure provides a surgical treatment for atrial fibrillation. The development of cardiac pacemakers began with the application of external electrodes to stimulate the heart. Lillehei advanced this by placing electrodes directly into the heart during open-heart surgery. The first implanted pacemaker, however, lasted only 8 hours. Modern aggregates offer long-lasting solutions to diverse rhythm abnormalities.
In 1967, several surgical teams worldwide performed the first heart transplants—Barnard in South Africa; Shumway at Stanford, who improved posttransplant survival with the addition of immunosuppressive treatment; and Kantrowitz, who pioneered pediatric heart transplantation in New York. Some devices can supply mechanical circulatory support. Since 1963, the intra-aortic balloon pump has enhanced left ventricular function through counterpulsation. Open-heart surgery requires CPB to temporarily replace the function of the heart and lungs with an external circuit composed of pumps and an oxygenation membrane. Artificial hearts were first used extracorporeally in 1982, with subsequent devices enabling implantation.
Cardiac surgery carries high operative and perioperative risk, requiring professional staff and advanced equipment. Besides the diseases that require cardiac surgery, perioperative period often involves a range of complications, including systemic inflammatory response following CPB, myocardial stunning, low cardiac output syndrome, arrhythmias, massive transfusion needs, and multiorgan issues such as kidney injury, stroke, and respiratory distress.
With the rise of interventional and minimally invasive techniques for treating cardiac pathologies, both cardiology and cardiac surgery must adapt to these advancements. As Lytle and Mack described in their 2005 editorial, "The times they are changing," the field of cardiac surgery is undergoing a fundamental transformation. In his presidential address, Guyton stated, "If we do not embrace innovation, we will become its victims." Recent developments include the establishment of cardiac arrest centers, broader and more accessible use of extracorporeal membrane oxygenation (ECMO), system process improvements, fast-track hospital stay, collaborative decision-making by interprofessional cardiovascular teams, and challenges posed by an aging patient population.
Copyright © 2025, StatPearls Publishing LLC.