CT Surgery

[Jdp00921]

Hey All!

Firstly, I apologize if this is in the wrong thread category. Given the recent threads on matching due to the recent match, I figured I would post this here.

Anyway, I was just wondering what the consensus is on CT surgery and the integrated CT surgery residencies. I rarely see them on match lists and in addition, rarely see posts on here with an interest in CT surg. I like to think that's one of the most interesting fields to me right now (I recognize I have little experience as I don't begin medical school until August, and my interest may change drastically, but I have shadowed the field and loved it). I have read a few different website articles/SDN posts in the past that note some type of "takeover" by interventional cardiology - likely being the reason for a drop in interest (?). However, I have also read (I don't remember exactly where I found the article, maybe it was SDN, IDK) that CT is *sort-of* making a comeback?

Anyway, to get to the direct question, is CT surgery going to be possible for me to enter by the time I graduate in several years (if my interest remains the same)? I know a definitive answer isn't possible, but what is the consensus? What's the thought on the future of CT? Will there be jobs available or will interventional methods overrun open-heart methods?

Thanks!

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[Donald Juan]

Yes, CT surgery as a field is not going to implode in the next 4 years.

 

[LebronManning]

No one really knows for sure but CT Surgery is definitely not safe. If you want to be safe, think about Interventional Cardiology because for some time and into the future these guys are the leaders in heart pathology and treatment. CT Surgery has become 2nd fiddle.

IC currently dominates the CAD market.
With that said, there certainly still is room for CT Surgery even in CAD but unsure of how that will progress. In fact, I shadowed an interventional cardiologist yesterday. He did a couple elective caths but we also got 2 MIs, an NSTEMI and STEMI. For the STEMI, he put in 3 stents and it was done. The NSTEMI patient had 4 vessel disease and so was referred to CT for CABG. Before I got there, he also had a patient with a left main that was referred to CT for CABG. So clearly CT Surgeons still have work even in CAD but I asked the cardiologist how this may progress. He agrees that this may not be the case forever as stents will improve like they have been improving. Also remember that medical therapy has huge scope to be improved and that is likely the most useful thing in a systemic stenosis problem such as CAD. The beauty of IC is that you are also a cardiologist and thus aren't losing any business when medical therapies start to improve. I believe the future of CAD will be medical therapy maybe in conjunction with some sort of intervention. That intervention won't be open heart surgery.

Valves are also primarily in the domain of CT Surgery, for now. Currently, percutaneous valve intervention (TAVR or MitraClip) only happens if the CT Surgeon denies the patient. However, the trends favor Interventional Cards. Recently TAVR was approved for moderate risk patients only whereas first it was only approved for high risk. I think the common consensus among cardiologists is that within 10 years time TAVR will be approved for anyone and it will not even require a CT surgeon in the room. This was told to me by the cardiologist, I'm sure the CT Surgeon has a different POV. But guess what? The cardiologist controls the patient and the referral pattern.

VADs currently are 100% CT Surgery market but again, with increasing technology, who's to deny the prospect of percutaneous VADs? They already have Impella which is not a long term solution, but my point is that there's no reason technology won't be able to create a highly functional pVAD in the future.

Heart transplant and Congenital cardiac surgery will always be in the realm of CT Surgery but I'm not sure there will be enough volume for these diseases.

 

[CUatthefinishline]

I think I've read exactly the same past SDN threads on CT surgery as you. I'm secretly (see: just happy to be becoming a doctor lol) interested in it too, & have been since I was a kid. These are good questions & thanks for asking

 

[Jdp00921]

No one really knows for sure but CT Surgery is definitely not safe. If you want to be safe, think about Interventional Cardiology because for some time and into the future these guys are the leaders in heart pathology and treatment. CT Surgery has become 2nd fiddle.

IC currently dominates the CAD market.
With that said, there certainly still is room for CT Surgery even in CAD but unsure of how that will progress. In fact, I shadowed an interventional cardiologist yesterday. He did a couple elective caths but we also got 2 MIs, an NSTEMI and STEMI. For the STEMI, he put in 3 stents and it was done. The NSTEMI patient had 4 vessel disease and so was referred to CT for CABG. Before I got there, he also had a patient with a left main that was referred to CT for CABG. So clearly CT Surgeons still have work even in CAD but I asked the cardiologist how this may progress. He agrees that this may not be the case forever as stents will improve like they have been improving. Also remember that medical therapy has huge scope to be improved and that is likely the most useful thing in a systemic stenosis problem such as CAD. The beauty of IC is that you are also a cardiologist and thus aren't losing any business when medical therapies start to improve. I believe the future of CAD will be medical therapy maybe in conjunction with some sort of intervention. That intervention won't be open heart surgery.

Valves are also primarily in the domain of CT Surgery, for now. Currently, percutaneous valve intervention (TAVR or MitraClip) only happens if the CT Surgeon denies the patient. However, the trends favor Interventional Cards. Recently TAVR was approved for moderate risk patients only whereas first it was only approved for high risk. I think the common consensus among cardiologists is that within 10 years time TAVR will be approved for anyone and it will not even require a CT surgeon in the room. This was told to me by the cardiologist, I'm sure the CT Surgeon has a different POV. But guess what? The cardiologist controls the patient and the referral pattern.

VADs currently are 100% CT Surgery market but again, with increasing technology, who's to deny the prospect of percutaneous VADs? They already have Impella which is not a long term solution, but my point is that there's no reason technology won't be able to create a highly functional pVAD in the future.

Heart transplant and Congenital cardiac surgery will always be in the realm of CT Surgery but I'm not sure there will be enough volume for these diseases.

Thank you for the really detailed answer - exactly what I was looking for! I never really gave interventional cards too much thought because I always figured I'd do something surgery related. While I recognize interventional cards is procedure-heavy (I assume as much at least), I was under the impression it really didn't involve any "true" surgeries. Again, this can all be dead wrong. I have no experience with IC at all. I'll have to do some research into IC for myself.

Thank you again for the reply!

 

[Jdp00921]

I think I've read exactly the same past SDN threads on CT surgery as you. I'm secretly (see: just happy to be becoming a doctor lol) interested in it too, & have been since I was a kid. These are good questions & thanks for asking

Well I certainly wasn't into CT since I was a kid (I'm a non-trad., wasn't even into medicine as a kid lol), but I definitely liked it the most out of everything I had exposure to so far (which is limited exposure to say the least). I never made a thread on the topic so I figured it couldn't hurt. Glad to see it answered someone else's question(s)!

 

[VascularMan]

From my experience in medical school, CT surgery gets the really sick patients that interventional cardiologists cant handle with minimally invasive surgery alone, and thus the outcomes and complications with those patients are much much worse. There will be plenty of sick patients in coming years with our aging population, but it's mainly cardiology driven and less in the hands of cardiac surgeons.

 

[TypeADissection]

CTS is a field that truly has to be experienced to make those decisions to further pursue it. It's easy to become superficially enamored by cardiac surgery, but it is so much more than that. You have to like the lung and esophageal work as well. Most importantly, you have to live through the pages about sick crashing patients on LVADs and ECMOs. Scrub through long cases. See all the complications that come through the door. Etc. After that, you get a good idea whether or not this is your jam and worth investing your professional life into.

I'd recommend by just starting to shadow some surgeons while being as unobtrusive as possible. Then maybe pick up a project and sit through the M&Ms. Go from there. It was during those VATS, mediastinoscopies and esophageal stuff, that I decided it wasn't for me personally. Cheers.

 

[CTFellowMD]

I have read a few different website articles/SDN posts in the past that note some type of "takeover" by interventional cardiology - likely being the reason for a drop in interest (?).

Most of the things said in earlier replies are correct. Not going to get into the whole IC vs CT debate, and if CT is going to survive. It is, and there is plenty of work to go around.

Just wanted to point out that there is not a drop in interest in CT. For traditional fellowships, it's the most competitive that it's been in several decades. Starting in the 2014 application cycle, interest shot up. There haven't really been any open spots post match for about 4 years now, and about 25-30% of applicants don't match. The integrated fellowships have always been competitive.

Not trying to discourage, but there is still this incorrect belief that CT is an easy fellowship to match into, and it's just not the case anymore.

 

[Jdp00921]

CTS is a field that truly has to be experienced to make those decisions to further pursue it. It's easy to become superficially enamored by cardiac surgery, but it is so much more than that. You have to like the lung and esophageal work as well. Most importantly, you have to live through the pages about sick crashing patients on LVADs and ECMOs. Scrub through long cases. See all the complications that come through the door. Etc. After that, you get a good idea whether or not this is your jam and worth investing your professional life into.

I'd recommend by just starting to shadow some surgeons while being as unobtrusive as possible. Then maybe pick up a project and sit through the M&Ms. Go from there. It was during those VATS, mediastinoscopies and esophageal stuff, that I decided it wasn't for me personally. Cheers.

I really do only have a small amount shadowing experience in the field - maybe 50 hours or so. I watched a couple valve replacements and a few other procedures. Overall, I thought it to be very interesting but as you mention, I haven't got to see those other aspects that made you less interested in the field. I guess it's something I just have to explore more in the future! Thanks for the reply though!

 

[ka0]

Speaking to one of the senior attendings at my hospital, its definitely going to change from what it used to be. He thinks the field is heading more and more towards taking care of sicker patients like complications from endovascular procedures (stenting, ruptures, valves etc), LVADs and ECMOs - The days of schedules being full of CABGs and AVRs are probably over. Not to say that it's not exciting still - robotic and minimally invasive CT surgery still might have a role. According to him - basically every hospital doing VRs endovascularly is going to need to keep a CT surgeon on staff for the eventual complications.