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Ann Thorac Surg 1998;65:903-904
© 1998 The Society of Thoracic Surgeons

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Editorials

International Aspects of Cardiac Surgery

^a Division of Cardiothoracic Surgery, Saint Vincent Hospital, Worcester, Massachusetts, USA

Address reprint requests to Dr Pezzella, Division of Cardiothoracic Surgery, Saint Vincent Hospital, 25 Winthrop St, Worcester, MA 01604-4593

"Ce n’est pas la souffrance de l’enfant qui est révoltante, en elle même, mais le fait qu’elle n’est pas justifiée."

Albert Camus

"... service is the rent we pay for the privilege of living in this world."

Stephen R. Covey

As the global community draws closer together politically, economically, socially, and culturally, the transfer of technology, goods, and services becomes increasingly feasible and practical. In fact, it is almost necessary for sustained growth and development.

Nowhere is this more evident than in health care. Historically the developed countries sent health care to the indigent areas of the world in the form of medical missionaries, be they secular or religious. Colonial powers introduced health care systems primarily to care for government and corporate workers. Medical development was achieved in the preventive and curative areas. Medical education followed with sustained indigenous involvement. In this century small and large nongovernment organizations and private voluntary organizations have played an increasing role in foreign health care. At the government level many countries have provided health care loans and aid to developing countries. The United Nations through the World Health Organization has been the principal provider and catalyst for global health concerns, particularly in health care planning and strategies. Their monumental efforts in smallpox eradication and other infectious diseases are well known.

Within this macrocosm of global health care lies our small area or microcosm, namely, cardiac disease. In the developed world, coronary artery disease remains the principal disease we deal with, whereas in the developing world congenital and acquired (principally rheumatic) heart disease is more prevalent.

In recent years cardiac surgery has become more widespread and available. This is primarily related to improved results and decreased costs. Advances in anesthesia, surgical technique, critical care, and training have greatly enhanced cardiac surgery worldwide. The widespread growth internationally is mirrored in the increased number of articles from around the world being published in both The Annals of Thoracic Surgery and the Journal of Thoracic and Cardiovascular Surgery.

Approximately 500,000 open heart operations, in more than 900 centers, by more than 3,500 cardiac surgeons are performed in the United States annually. Another 500,000 operations at a similar number of centers, by an equal number of surgeons, are performed in the rest of the world. Half of these are performed in Western Europe. Yet with 5.5 billion people on the planet in more than 200 countries, this represents an obvious mismatch, with 270 million Americans having access to half the world’s resources in cardiac surgery. Certainly the growth factor favors the remainder of the world. As economies develop and political fronts stabilize, the infrastructure grows accordingly. Within this framework all social aspects grow, especially health care.

With this as background, considerable effort is beginning to take place in extending cardiac surgery worldwide. At the corporate level this is already occurring. Sales of equipment and supplies continue to grow. In certain growth areas, like India and Eastern Europe, marketing through local distributors has advanced to regional managers and representatives. This is especially true in heart valves. There is no doubt that the growth of valve surgery is in the developing countries. Congenital heart surgery will also grow, yet this area remains very expensive, with little compensation from government or private sources. Neonatal cardiac surgery will remain last in development in most evolving programs. Coronary artery surgery along with invasive cardiology will grow as the Western vices of smoking and high-cholesterol diets consume the rest of the world.

The United States and other developed countries are the major resource in providing the strategy and framework for global development of cardiac surgery. The following suggestions hopefully will generate thought, debate, and constructive criticism.

1. Establishment of an international database containing the countries, number of programs, annual caseload, and the number of surgeons along with surgeon profile: The Society of Thoracic Surgeons has already established the framework for this on the Internet. The European Association for Cardio-Thoracic Surgery has also embarked on an annual European database. These efforts will certainly be a great asset for the international strategy.
   
2. Further collaboration of the major thoracic surgical societies to include broadening of international membership and international meeting sites: Doctor Robert Replogle has previously described his work in extending the international society to include international as well as regional societies [1]. The Society of Thoracic Surgeons under the direction of Dr Gerald Rainer has established an Ad Hoc Committee on International Relations to study and collate information and strategies regarding international issues.
   
3. Establishment of a broad-based United States database of surgeons, programs, and organization with previous or ongoing experience in international cardiac surgery: A reference source is invaluable for those wishing to embark on this type of activity. Heart Link^* in Minneapolis, Minnesota, has already developed a reference list including surgeons and programs with experience or interest in global development. Previous examples of foreign program initiatives have already been published [2–4].
   
4. Program development can be achieved at varying levels: university relations abroad with other interested institutions to share teaching, clinical, or research activities; individual surgeons going abroad for part-time (1 to 2 weeks) or long term (1 to 2 years); cardiac surgery teams augmenting an existing unit or developing a new program (however, a considerable amount of planning and research is necessary for a successful long-term project); and emphasis on larger strategies involving teaching. Already in China, a broad-based initiative to standardize cardiac surgery training is taking place [5].
   

Regarding the development or augmentation of an open heart program abroad, the following recommendations are offered:

1. Contact with the host individual, group, or program regarding an open heart project.
   
2. Background check of previous experiences in that area.
   
3. On-site visit to assess the feasibility of the project.
   
4. At least 1 year is required before starting the open heart program:
   
   1. Training of foreign personnel in the United States is helpful with a 1- to 2-month rotation.
      
   2. During gathering of equipment and supplies, both purchased and donated, shipment by air or sea requires logistical planning and cooperation to ensure that everything arrives safely and undamaged.
      
   3. On-site initiation of the project requires a minimum of 2 weeks. The minimum basic personnel include a cardiac surgeon, anesthesiologist, operating room technician, intensive care unit nurse, perfusionist, and biomedical engineer.
      
   
   
5. Funding is a major concern with individual, group, and corporate participation.
   
6. Success usually requires a 3- to 5-year commitment with sustained growth directly proportional to local economic and political development.
   

In summary, there are exciting opportunities from both a humanitarian and a corporate mode internationally. Information and communication, especially via the Internet, will open new vistas in cardiac surgery worldwide, with a resultant explosive increase in number of programs, operations, training opportunities, and research activities. New programs in developing countries ready to embark on cardiac surgery will gain tremendous benefit. Enhancement of existing training programs will also result. Clinical and basic research will undoubtedly grow.

Viable job opportunities abroad for United States-trained cardiac surgeons will certainly increase and develop. The possibilities are endless. This area deserves increased attention and discussion. The motives for participation in this endeavor range from boredom and frustration with the American system to career change, travel, adventure, and humanitarian concerns. No doubt this editorial will generate discussion, debate, and controversy. I encourage others to comment.

Footnotes

^* Children’s Heart Link, 5075 Arcadia Ave, Minneapolis, MN 55436-2306; telephone: (612) 928-4860, ext 19; fax: (612) 928-4859; e-mail: chl@mtn.org; http://www.childrensheartlink.org.

References

1. Replogle R.L. The international community of cardiothoracic surgeons [Editorial]. Ann Thorac Surg 1996;62:635.[Free Full Text]
2. McGrath L.B. Establishing a pediatric cardiac surgical unit in the Commonwealth of Independent States (formerly the Soviet Union) [Letter]. J Thorac Cardiovasc Surg 1992;104:1758-1759.[Medline]
3. Lansing A.M. Heart surgery in underdeveloped countries. Success in Panama and Romania [Letter]. Ann Thorac Surg 1993;56:1439-1440.[Medline]
4. Pezzella A.T. Introduction to the reports from Vietnam [Editorial]. Tex Heart Inst J 1995;22:317-319.[Medline]
5. Cheung D.L. Postgraduate training in cardiothoracic surgery: the Asian setting [Editorial]. Asian Cardiovasc Thorac Ann 1997;5:129.

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