The Current State and Challenges in Cardiothoracic Surgery in Latin America

Latin America’s cardiothoracic landscape is marked by stark contrasts. While high-volume centers achieve outcomes comparable to high-income nations, systemic inequities persist. The region faces a critical workforce shortage (<1 surgeon per million population), with training programs concentrated in larger urban hubs like Sao Paulo, Buenos Aires, and Mexico City, leaving rural areas underserved.¹ Access to advanced therapies such as transcatheter aortic valve replacement and left ventricular assist devices remains limited by funding disparities—Peru’s transplant programs, for example, operate at 59% capacity due to reliance on philanthropic support.² Gender gaps further compound these challenges, with women representing only 4.8% of surgeons. The Latin American Association of Cardiac and Endovascular Surgery (LACES) has unified regional education efforts, but broader reforms are needed to standardize training, expand infrastructure, and leverage telemedicine for equitable care delivery. Without addressing these foundational gaps, technological advancements risk benefiting only a privileged few.

Advances in Cardiothoracic Surgery: A Regional Perspective

Progress in Valve Repair and Reconstruction

Mitral valve (MV) pathology in low- and middle-income countries is primarily due to rheumatic heart disease. In Brazil, a nationwide cohort of 78,808 patients (2001-2007) reported MV stenosis as the most common lesion (38.9%), with a rheumatic etiology in 94.7% of cases.³ Brazil, Argentina, and Chile collectively reported outcomes of 330 rheumatic MV repairs, with in-hospital mortality ranging from 0.9% to 2.3%; an 87% repair rate in cases of MV regurgitation; survival rates of 91%, 78%, 71%, and 50% at 5, 10, 15, and 20 years, respectively; and overall, 86.4% 20-year survival and 95.6% freedom from reoperation—highlighting the long-term durability and effectiveness of native valve preservation in rheumatic heart disease.³ For aortic valve repair with the David technique, Brazil and Colombia reported 164 aortic root reconstructions with 1.9% 30-day mortality, 4.9% overall mortality, 5.6% in conduit, and 2.6% in valve-sparing cases.⁴

Minimally Invasive Cardiac Surgery: Growth And Limitations

Minimally invasive cardiac surgery (MICS) has gained traction across Latin America as a viable alternative to traditional sternotomy, especially in valve procedures. In Brazil, data from the Brazilian registry of adult patients undergoing cardiovascular surgery (BYPASS Registry) reported a modest MICS adoption rate of 1.6% among 920 valve surgeries, indicating the early stages of widespread implementation.^5,6 More advanced programs have demonstrated favorable outcomes; for instance, Poffo and colleagues⁵ detailed 214 periareolar surgeries for MV disease with no access-related complications or mortality over an 8-year follow-up, and later expanded their series to 39 robotic-assisted cases, reporting only a 5% early complication rate. In Argentina, the Hospital Italiano de Buenos Aires performed MICS in 63 MV surgeries, noting a 30-day mortality of 4.4% and only 1 conversion to sternotomy; in a separate cohort, the same center conducted 10 MICS-Bentall procedures with no mortality.⁶ Conversely, barriers to MICS programs in Latin America are closely linked to postoperative management and continuity of care. Limited access to intensive care units, specialized recovery nursing, and step-down monitoring can compromise patient safety after complex procedures. Additionally, inadequate availability of minimally invasive instruments, platforms, and maintenance support affects both intraoperative efficiency and postoperative outcomes.⁵ These factors collectively restrict case volume, hinder adoption of new techniques, and reduce equitable access to minimally invasive procedures, particularly in resource-limited public hospitals.

Transcatheter Aortic Valve Replacement: A Slow But Steady Rise

Despite notable advancements, TAVR remains underutilized in Latin America, especially by cardiovascular surgeons. A regional multicenter study revealed a notable disparity in access and procedural frequency, with fewer than 10 TAVR procedures per million inhabitants, starkly contrasting with rates exceeding 100 per million in high-income nations.⁷ Nevertheless, the region has witnessed gradual progress; a comparative analysis between 2015 and 2020 showed an increase from 29 to 46 active centers, reflecting a growing commitment to less invasive cardiovascular interventions. In Brazil, data from the national TAVR registry comprising 3194 patients demonstrated a marked decline in in-hospital mortality—from 8.6% in early experience to 3.7% in more recent cases—suggesting that procedural outcomes improve significantly with institutional and operator expertise.⁸

Heart Transplantation and Left Ventricular Assist Device: Progress Amid Constraints

Latin America recorded 12,374 heart transplantations across 16 countries (1968-2022), with Brazil, Argentina, and Colombia accounting for 84% of procedures. Brazil alone performs approximately 350 heart transplantations annually, predominantly in São Paulo.² At Incor (São Paulo), Chagas disease (36%) and dilated cardiomyopathy (35%) were the main indications, with 72.25% 1-year posttransplant survival—lower than global benchmarks—reflecting intensive care unit bottlenecks, inconsistent immunosuppression access, and fragmented follow-up.² In Peru, economic constraints stem from underfunded public hospitals; only 3 centers perform heart transplants regularly, relying on foreign device donations. However, it reported better outcomes (87.5% 1-year survival in 83 patients), but only 59% of 166 identified centers remained operational by 2022 due to economic constraints and workforce shortages. Brazil’s left ventricular assist device hub-spoke model—achieving 90% 1-year survival—succeeded through centralized expertise, standardized protocols, and telemedicine-enabled follow-up at spoke sites.⁹ Key to its scalability is public funding (covering 60% of costs) and partnerships with regional hospitals for patient selection. However, reliance on philanthropic support for devices limits expansion. These models highlight a critical lesson: Success depends on combining centralized excellence with decentralized outreach, but sustainability requires government investment in infrastructure and training.

On the other hand, postoperative management is a critical barrier for cardiac transplant programs. Patients require continuous access to immunosuppressive medications, frequent laboratory monitoring, and specialized outpatient follow-up to prevent graft rejection and infection. Many centers face shortages of drugs, limited intensive care unit capacity, and insufficient trained staff to manage complex postoperative care. These constraints reduce patient survival, restrict program growth, and exacerbate inequities between private and public institutions. As a result, access to safe, high-quality transplant care remains uneven, limiting the broader implementation of cardiac transplantation across Latin America. In other words, many programs remain scarce and dependent on institutional/philanthropic funding.⁹ While demonstrating advanced capabilities, disparities persist in access and resource distribution across the region.

Persistent Challenges

Innovation, Accessibility, Geography, Language, Gender, and Economic Barriers

Latin America faces persistent challenges in cardiothoracic care access, with severe surgeon shortages (<1 per million people) and limited training programs concentrated in urban centers.¹ This geographic imbalance forces patients and trainees to travel long distances, restricting access to advanced procedures. The lack of regional data on center distribution further complicates efforts to address care gaps. Language barriers also hinder progress, as most global surgical resources are in English, while Spanish/Portuguese dominate the region. While LACES has begun translating materials, broader multilingual support on platforms like CTSNet remains crucial for knowledge sharing. Gender disparities persist, with women constituting just 4.8% of cardiac surgeons in Latin America, below the already low global average of 8%.¹⁰ LACES's Women's Committee is making strides through networking and research initiatives, but systemic change requires sustained mentorship and policy reforms to achieve true equity in our specialty.

On the other hand, economic and institutional constraints continue to limit access to cardiothoracic surgery throughout Latin America. In Colombia, about one third of patients with cardiovascular disease will require surgery at some point, yet fewer than a quarter can access care when needed.¹¹ Most cardiac surgery centers are private—nearly 80%—and often have only 1 or tw2o operating rooms, performing between 11 and 50 adult procedures per month. Although the cost-effectiveness of these programs is generally positive, sustaining advanced services such as heart transplantation, extracorporeal support, and ventricular assist devices demands significant investment. Similarly, in the Caribbean, government-funded hospitals hire surgeons to cover a wide range of thoracic and cardiac pathologies, requiring flexibility and often external support for complex cases.¹² These examples illustrate a broader reality across Latin America: Economic disparities and limited resources directly affect surgical access, the organization of services, and the capacity to maintain high-quality cardiothoracic care.

Pathways to Progress: Strategic Solutions With Laces as Catalyst

The Role of LACES in Strengthening Cardiothoracic Surgery in Latin America

Before 2019, Latin American collaboration in cardiothoracic surgery was limited, with no clear networking. The creation of LACES in Uruguay changed this, fostering regional excellence through education, research, and global partnerships. This event solidified a platform for knowledge exchange, specialized workshops, and international training opportunities. LACES also partners with major societies like The Society of Thoracic Surgeons (STS), European Association for Cardio-Thoracic Surgery (EACTS), and American Association for Thoracic Surgery (AATS), promoting cutting-edge research and best practices. Additionally, LACES contributes to global clinical guidelines, such as those on coronary revascularization and aortic valve management, ensuring evidence-based, accessible cardiovascular care for the region. Its growing influence continues to elevate surgical standards across Latin America.

On the other hand, training gaps persist despite LACES’s efforts. Only 40% of residency spots are filled in Mexico and Colombia, attributed to low salaries (∼$20,000/year) and migration to private practice.¹ Chile’s "rural surgeon" incentives—loan forgiveness for remote service—have improved retention and could be replicated. Language barriers further hinder progress; while LACES translates STS guidelines, 70% of Latin American trainees lack English proficiency to access global resources. Proposed solutions include expanding LACES-sponsored residencies with stipends, regional simulation centers, and mandatory rural rotations. Without these steps, the workforce shortage will worsen as demand grows.

Expanding Global Networks: Collaboration With International Societies

International societies such as STS, EACTS, and AATS, and surgical platforms like CTSNet (which offers several advances with surgical videos, surgeon profiles, and newsletters) are providing a channel for knowledge for surgeons worldwide, although requiring proficiency in English to fully benefit from most opportunities. The international collaboration between the Latin American community and these societies is opening the door to travel fellowship programs in prestigious cardiovascular centers worldwide, such as the yearly Francis Fontan Fellowships. Several Latin American surgeons are also receiving advanced cardiothoracic surgery mentorship and hands-on training courses, mainly in European and North American countries. Despite LACES’s strong partnership with several global organizations, we believe there are others with whom we have not achieved successful collaboration, and that would reinforce our networking strategies and work together (Figure 1).

Figure 1.

The value of LACES's (The Latin American Association of Cardiac and Endovascular Surgery) local and global societal partnerships with major international institutions in cardiothoracic surgery, including STS (The Society of Thoracic Surgeons), AATS (American Association for Thoracic Surgery), EACTS (European Association for Cardio-Thoracic Surgery), ESCVS (The European Society for Cardiovascular Surgery), PASCaTS (The Pan-African Society for Cardiothoracic Surgery), ANZSCTS (The Australian and New Zealand Society of Cardiac and Thoracic Surgeons), ASCVTS (The Asian Society for Cardiovascular and Thoracic Surgery), WSPCHS (World Society for Pediatric and Congenital Heart Surgery), ASPCHS (African Society for Pediatric and Congenital Heart Surgery), CHSS (Congenital Heart Surgeons' Society), ECHSA (The European Congenital Heart Surgeons Association), and AAPCHS (Asian Association for Pediatric and Congenital Heart Surgery).

Opportunities for Future Growth and Innovation

New opportunities for innovation and collaboration are transforming cardiothoracic care in Latin America. Virtual surgical training platforms can overcome geographical barriers, allowing surgeons to learn from global experts. Meanwhile, initiatives like the STS/EACTS scholarships and LACES partnerships—such as The Thoracic Surgery Foundation / Francis Fontan Fellowships Traveling Fellowship and Evarts A. Graham Memorial Fellowship—provide hands-on training and financial support. Despite these advances, challenges remain. While fellowships and international exchanges foster expertise, they still fall short of addressing Latin America’s vast training needs. Strengthening these programs is crucial to bridging gaps in surgical education and ensuring access to cutting-edge techniques for the next generation of surgeons.

Regional institutions are leading multicenter studies on coronary disease, aortic valve replacement, and minimally invasive surgery, boosting Latin America’s global research presence. Yet more funding and formal training are needed. While robotic and transcatheter techniques advance, limited funding and training hinder adoption. Though LACES lacks dedicated programs, partnerships with global societies, like the STS Robotic Surgery Scholarship and Transcatheter Aortic Valve Implantation Fellowships, are expanding access to cutting-edge training.

Conclusion

Latin America's cardiothoracic surgery stands at a critical juncture, boasting world-class clinical achievements yet facing persistent inequities in access and resources. The region must now transition from isolated excellence to systemic reform by empowering LACES as a unifying force for education and policy advocacy; prioritizing strategic investments in training and technology to bridge gaps; and implementing initiatives like the LATAM-CTS Registry to standardize outcomes and guide resource allocation (Figure 2). Through coordinated collaboration—regionally and globally—Latin America can transform its surgical landscape, ensuring that innovation benefits all populations equitably. The next decade demands decisive action to build a sustainable, world-class cardiothoracic care ecosystem.

Figure 2.

Latin America's cardiothoracic surgery revolution: Current practices and future directions with potential registry. (HTx, heart transplantation; LACES, Latin American Association of Cardiac and Endovascular Surgery; LATAM-CTS, Latin American-Cardiothoracic Surgery; LVAD, left ventricular assist device; MICS, minimally invasive cardiac surgery.)