Re: Lange R, Hoerer J, Schreiber C. What are the Obstacles to Training in Surgery for Congenital Heart Disease in Germany? Thorac Cardiovasc Surg 2013; 61: 273-277

We would like to comment on the article “What are the obstacles to training in surgery for congenital heart disease in Germany?” by R. Lange and colleagues from Munich.

According to the authors, in the future there will be a lack of fully trained congenital cardiac surgeons in Germany, mainly for two reasons. First, there are many centers with low case load not allowing for sufficient training. Second, the requirements for the German board certificate of cardiac surgery do not consider the special needs of congenital cardiac surgeons.

So, how many specialized surgeons do we really need in Germany? Considering that we perform ∼5500 operations per year and that the workload of a specialized surgeon should be around 125 cases per year, we need 44 surgeons. Currently, more than 50 surgeons in Germany are certified for congenital cardiac surgery. Since we do not all retire at the same time or tend to go abroad, it is difficult to calculate the real (annual) need for the future. Reliable data are missing, but are necessary to do this calculation.

Do centers with a low case load allow for sufficient training? What is low? The consensus statement for optimal/ideal structures of a unit by the EACTS and later that of the DGTHG state a minimum of 250 cases per year. Taking this into account, only seven centers of 31 fit into this range, leaving 24 centers with lower than optimal/ideal case loads. However, less than 20% of the certified congenital cardiac surgeons in Germany trained at high volume centers! How does this match? Theoretically, a higher case load offers more training opportunities, but if these opportunities will turn into real training depends on more than numbers: From our point of view and personal experience training in our field is very much related to the dedication of the mentor, the structures in the respective unit and the personal enrollment of the trainee. Reality shows that sufficient training and education are offered also in low-volume-centers.

Do the requirements for the German board certificate of cardiac surgery consider the special needs of congenital cardiac surgeons? The current German training catalogue for cardiac surgery (Weiterbildungsordnung), which is a general requirement to become a congenital cardiac surgeon later, is almost exclusively focused on acquired heart disease. Taking into account that this training often takes more than eight years and that training for congenital cardiac surgery needs to be done “on top” of this, it is no wonder that the threshold for a young surgeon is quite high to commit him- or herself to our field. Our current training requirements are a major issue.

Considering all this, we do not know exactly how many congenital cardiac surgeons we will need in future. We do not know what the ideal case load for training is. From our point of view, we believe that dedicated mentoring is probably the most important factor to provide good training and to inspire young surgeons for our field. We fully agree that an adaptation of the current requirements for training in cardiac surgery to our needs is of utmost importance.