Ir J Med Sci DOI 10.1007/s11845-014-1193-1
REVIEW ARTICLE
The 100 most cited publications in cardiac surgery: a bibliometric analysis K. E. O’Sullivan • J. C. Kelly • J. P. Hurley
Received: 22 May 2014 / Accepted: 2 September 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Introduction This study is a citation analysis of the top 100 most cited papers in adult cardiac surgery. Bibliometric analyses are viewed as a proxy marker of a paper’s influence and, therefore, an analysis of the most influential papers published in recent decades. Methods Impact factor ranking as of 2012 was used to decide which journals to include in our searches. The Thompson Reuters Web of Knowledge was used to search for citations of all papers relevant to cardiac surgery within selected journals. Journals in the areas of surgery, cardiothoracic surgery, general medicine, anaesthesia, perfusion and pathology were included. Results The most frequently cited paper was found to be that of Nashef et al. (Eur J Cardiothorac Surg 16(1):9–13, 1999) introducing the EuroSCORE operative risk evaluation system. A number of authors including Alderman, Carpentier and Cox had more than one paper in the top 100. Conclusion Despite the potential flaws with bibliometric analysis, and its application to cardiac surgery, there is inherent merit in an analysis of this type. Keywords
Cardiac Surgery Bibliometric analysis
K. E. O’Sullivan (&) J. C. Kelly J. P. Hurley Mater Misericordiae University Hospital, Eccles St., Dublin 7, Ireland e-mail: [email protected] K. E. O’Sullivan J. C. Kelly J. P. Hurley Mater Private Hospital, Eccles St., Dublin 7, Ireland
Introduction Cardiac surgery has grown and evolved due to the work and courage of many pioneering surgeons who have pushed beyond the barriers of convention. The operative techniques and concepts they introduced have shaped development of the specialty. Whilst some would argue the specialty is still in its infancy, cardiac surgery has grown exponentially in recent years due to technical and technological advances, which have enabled progress to occur at a rapid rate. Research within the field has been carried out with vigor and a vast body of published literature has added to our understanding of the field. To our knowledge this is the first study to quantify and analyze the most frequently cited papers in the history of cardiac surgery as a surrogate measure of their impact within the specialty. A citation is defined as an abbreviated alphanumeric expression embedded within a body of intellectual work that acknowledges the relevance of the work to that carried out by others. It is an act of intellectual honesty [1]. Citation analysis is the bibliometric process used to examine the citation history of a particular paper by examining the citations attributed to that publication. It is one of the most widely used methods of bibliometrics and used to determine impact factor of a journal. Impact factor is a measure of the frequency with which the average article in a journal has been cited in a particular year. Whilst these methods are not without potential bias, there is no perfect method of assessing the merit of a scientific paper and impact factor and citation number generally accepted as the best [2]. A number of other surgical specialties have recently published bibliometric analyses on the most cited papers in their specialty. These include general surgery, orthopaedics, otolaryngology and plastic surgery [1, 3–9]. The analyses
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performed within these publications have postulated a better understanding of the influential papers in a number of fields since the commencement of the widespread dissemination of medical and scientific literature. The purpose of this article is to examine and rank cardiac surgery publications using the number of citations as a proxy marker of influence on practice and then question the validity of this method in the context of cardiac surgery specifically.
Methods Impact factor ranking as of 2012 was used to decide which journals to include in our searches. For this, Journal Citation Reports database was used. Journals from a number of specialties were included to ensure that all relevant publications were included for consideration. Specifically journals in the areas of surgery, cardiothoracic surgery, general medicine, anaesthesia, perfusion and pathology were searched. The Thompson Reuters Web of Knowledge is an online platform providing bibliographic database services. It details science citation indexes from 1970 to present. This was used to search for citations of all papers relevant to cardiac surgery within selected journals (Table 1). The search limits and sorting options in the Web of Knowledge were used to rank all articles from each individual journal according to the number of citations. These were then hand searched for articles pertaining to cardiac surgery. A number of exclusions were applied: case reports, consensus or guideline documents and papers describing paediatric cardiac surgery or transplantation. In addition, papers describing the pathogenesis of conditions such as atherosclerosis were excluded and articles were limited to those describing operative technique, outcomes or complications. Articles from each journal with greater than 100 citations were then combined into a database, which allowed them to be ranked according to citation number. When the top 100 most cited articles were identified these were assessed further and title, authorship, journal of publication, country and institution of origin, year of publication and number of citations were recorded. For the purposes of this analysis it was not possible to assess the ‘lead’ author of each paper, therefore, we considered the first name author to be the primary contributor.
Results Thirty-four journals were included in the search (Table 1). Searches yielded a total of 5,462 articles, which were ranked in order of citation number. Of journals searched, only the top seven were included in the top 100 (Table 2). Number of citations ranged from 1,252 to 271 (Table 3)
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Table 1 Journals included in bibliometric analysis searches Journal
Impact factor
New England Journal of Medicine
51.7
Lancet
39.1
JAMA
30.0
British Medical Journal
17.2
PLOS Medicine
15.3
Circulation
15.2
Annals of Internal Medicine
14.0
BMC Medicine
6.7
Canadian Medical Association Journal
6.5
Journal of Internal Medicine
6.5
Annals of Surgery Mayo Clinic Proceedings
6.3 5.8
Pain
5.6
Anaesthesiology
5.2
Annals of Medicine
5.1
Heart
5.0
American Journal of Surgical Pathology
4.9
British Journal of Surgery
4.8
American Journal of Medicine
4.8
Journal of the American College of Surgeons
4.5
British Journal of Anaesthesia
4.2
Surgery of Obesity Related Diseases
4.1
Annals of Surgical Oncology
4.1
Journal of Thoracic and Cardiovascular Surgery
3.5
Anaesthesia
3.5
Regional Anaesthetic Pain Management
3.5
Annals of Thoracic Surgery Surgery
3.5 3.4
Anaesthesiology and Anaesthesia
3.3
European Journal of Pain
3.1
European Journal of Cardiothoracic Surgery
2.7
Journal of Cardiovascular Surgery
1.5
Journal of Cardiac Surgery
1.5
Thoracic and Cardiovascular Surgery
0.9
Table 2 Journals included in the top 100 citations Rank
Journal
Number of articles included
1
Journal of Thoracic and Cardiovascular Surgery
27
2 3
New England Journal of Medicine Circulation
25 19
4
Annals of Thoracic Surgery
15
5
Lancet
8
6
Annals of Surgery
3
7
European Journal of Cardiothoracic Surgery
3
Ir J Med Sci Table 3 The top 100 citations in cardiac surgery Rank
First author
Citations
Rank
First author
Citations
Rank
First author
Citations
1
Nashef [10]
1252
34
Rahimtoola [46]
448
2
Roach [48]
1035
35
McFalls [49]
447
67
van de Watering [47]
321
68
Thomas [50]
3
Yusuf [51]
1023
36
Ross [52]
436
320
69
Cox [25]
319
4
Leon [13]
1013
37
Debakey [53]
435
5
Serruys [54]
999
38
Ross [55]
431
70
Angelini [50]
316
71
Hannan [56]
6
Kirklin [35]
942
39
Furnary [57]
428
72
315
Buckberg [58]
312
7
Chenoweth [59]
921
40
Acar [60]
427
73
Gardner [61]
312
8
Carpentier [22]
898
41
Cox [26]
413
74
Tamburino [16]
311
9
Alderman [19]
878
42
Lytle [33]
411
75
Guiraudon [62]
311
10
Newman [63]
845
43
Bidstrup [36]
410
76
Ferguson [64]
309
11 12
Mishra [65] Inoue [68]
770 750
44 45
Buffolo [66] Carpentier [23]
409 407
77 78
Griepp [67] Lichtenstein [17]
304 303
13
Smith [69]
701
46
Loop [31]
395
79
Khan [70]
302
14
Roques [71]
672
47
Hamm [72]
394
80
Kolessov [45]
299 298
15
Lytle [28]
661
48
Calafiore [73]
386
81
Puskas [40]
16
Steingart [74]
652
49
Parsonnet [75]
384
82
Shroyer [76]
296
17
Alderman [20]
581
50
Kennedy [77]
381
83
Vanoeveren [78]
294
18
Takaro [79]
572
51
Fergusson [80]
378
84
Hampton [38]
293
19
Serruys [81]
557
52
Peterson [82]
377
85
Mangano [83]
292
20
Mangano [84]
554
53
Pocock [85]
371
86
Webb [18]
292
21
Nussmeier [86]
551
54
Bruins [87]
369
87
Cremer [88]
288
22
Cox [27]
546
55
Bolling [89]
359
88
Cosgrove [32]
286
23
Butler [90]
539
56
Lie [91]
346
89
Dake [92]
285
24
Webb [14]
537
57
Waldo [93]
345
90
Daoud [94]
282
25
Bigger [95]
536
58
Zerr [96]
345
91
Almassi [97]
280
26
King [98]
530
59
Svennson [99]
343
92
Chamberlain [100]
280
27 28
Bigelow [34] Motwani [29]
523 522
60 61
Alderman [21] Fisher [102]
340 340
93 94
Hammer Schmidt [101] Carpentier [24]
280 280
29
Aranki [103]
520
62
Alderman [104]
339
95
Paperella [105]
279
30
Koch [30]
515
63
Salzman [106]
334
96
Hennein [107]
277
31
Furnary [37]
507
64
van Dijk [108]
329
97
Frazier [109]
277
32
Shake [110]
465
65
Bigelow [12]
328
98
Kennedy [111]
275
33
David [39]
449
66
Murphy [112]
325
99
Shlafer [113]
273
Kodali 11]
271
100
[10, 11]. Mean number of citations for papers included was 457. Pre-dating the advent of cardiopulmonary bypass, the oldest paper on the list was ranked position 65 by Bigelow et al. [12] describing the use of general hypothermia as a means of reducing the oxygen requirements of the body sufficiently to allow intracardiac surgery and was cited 328 times. The most recently published paper was that by Kodali et al. [11] in the New England Journal of Medicine reporting the 2 years outcomes of transcatheter aortic valve replacement compared with surgical valve replacement from the PARTNER Trial. Analyzing the list by decade published, most of the papers in the top 100 were published in the 1990s (Fig. 1).
The journal most frequently represented was the Journal of Thoracic and Cardiovascular Surgery with 27 articles (Table 2). The second most represented journal was the New England Journal of Medicine with 25 articles and third was Circulation with 19. The top-ranking article overall was published in 1999 by Nashef et al. [10] in the European Journal of Cardiothoracic Surgery entitled ‘European system for cardiac operative risk evaluation (EuroSCORE)’ (Table 3). Topics covered in the top ranking papers were wide ranging (Table 4). The most common topics listed were coronary artery bypass grafting (40 papers) and post-cardiac surgery complications including sternal wound
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Ir J Med Sci Table 5 Authors with more than one of the most frequently cited papers
Fig. 1 Analysis of the number of articles in the top 100 by decade Table 4 Topics described by the top 100 papers Rank
Topic
Number of articles
1
Coronary Artery Bypass Grafting
40
2
Post Cardiac Surgery Complication
19
3
Cardiopulmonary Bypass
8
4
Transcatheter Aortic Valve Implantation
8
5
Cardiac Surgery Risk Scoring
4
6
Hypothermia
4
7
Mitral Valve Repair
4
8
Surgical Management of Afib
4
9
Aortic Dissection
10 11 12
Rank
Author
Institution
Number of papers
1
Alderman
Stanford University School of Medicine, California
4
2
Carpentier
Georges Pompidou Hospital, France
3
3
Cox
Washington University School of Medicine, Barnes Hospital
3
4
Bigelow
University of Toronto, Canada
2
Furnary
Providence St Vincent Medical Center, Oregon
2
Kennedy Lytle
University of Washington, Seattle Cleveland Clinic Foundation, Ohio
2 2
Mangano
Ischemia Research and Education Foundation, San Bruno, California
2
Ross
National Heart Hospital and the Institute of Cardiology, London
2
Serruys
Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
2
Webb
St. Paul’s Hospital, Vancouver, Canada
2
Table 6 Countries of origin of the most cited papers
Rank
Country
Number of papers
2
1
USA
60
Basic Science
2
2
UK
12
Ross Procedure Aortic Aneurysm
2 1
3
Canada
8
4
Netherlands
6
13
David Procedure
1
5
Italy
2
14
Ventricular Assist Device
1
6
Germany
2
7
Russia
1
8
Japan
1
9
Brazil
1
infections, atrial fibrillation and bleeding (19 papers) and cardiopulmonary bypass (8 papers) (Table 5). Interestingly, transcatheter aortic valve implantation (TAVI) ranked at number 4 reflecting its significant impact on the specialty in recent years [11, 13–18]. A number of first authors were represented more than once on the list with E. L. Alderman ranking first having published 4 papers on the topic of coronary artery bypass grafting in Circulation and the New England Journal of Medicine with a cumulative citation number of 2,138 [19–21]. The second ranking author was A. Carpentier who published 3 of the top ranking papers on mitral valve repair including ‘‘Cardiac Valve Surgery-The French Correction’’ [22–24]. J. L Cox ranked third, publishing three papers on the surgical management of atrial fibrillation and the Cox Maze procedure [25–27]. Eight remaining authors; Bigelow, Furnary, Kennedy, Lytle, Mangano, Ross, Serruys and Webb contributed two papers to the top 100 citations (Table 5).
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Examining the list based on country of origin, the majority of the identified papers came from the United States with the United Kingdom and Canada ranking next (Table 6). A total of 64 different institutions were represented, of those 14 more than once. The institution with the greatest number of papers was the Cleveland Clinic, which was credited with 6 papers from multiple authors [28–33]. The two institutions ranking next are the University of Toronto and Stanford University (Table 7).
Discussion Bibliometric analysis of cardiac surgery to date offers the reader some interesting insights into the specialty; its
Ir J Med Sci Table 7 Top ranking institutions Rank
Institution
Number of papers
1
The Cleveland Clinic Foundation
6
2
University of Toronto, Toronto, Canada
4
3
Stanford University School of Medicine, California Hoˆpital Europe´en Georges Pompidou, Paris
4
5
Columbia University Medical Center and New York Presbyterian Hospital
3
6
Washington University School of Medicine, Barnes Hospital
3
7
University of Alabama in Birmingham, Alabama
2
8
The Johns Hopkins Medical Institutions, Baltimore, Maryland
2
9
Ischemia Research and Education Foundation, San Francisco
2
10
National heart hospital and the institute of cardiology, London, UK
2
11
Emory University School of Medicine, Atlanta
2
12
Duke University Medical Center, Durham
2
13
Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
2
14
Department of Surgery, Beth Israel Hospital, Boston
2
4
3
history and how it is currently evolving. The most frequently cited article in our analysis was the landmark paper by Nashef et al. [10] which introduced the EuroSCORE; a risk stratification tool for predicting operative mortality in cardiac surgery. The EuroSCORE is based on a logistic regression model, from data recording 97 risk factors collected from 20,000 patients in eight European countries. This groundbreaking risk index is now the most widely used in cardiac surgery and is accepted to have contributed significantly to improvements in operative morbidity and mortality witnessed in recent years. Interestingly, the paper was published relatively recently in 1999 and exceeds the 2nd ranking publication by 217 citations. Viewed in isolation, it is reasonable to acknowledge this paper’s broadreaching and specialty-altering contribution. It has truly improved daily clinical practice in cardiac surgery and the decision-making processes within cardiac surgery. Examining the publications by decade reveals some interesting patterns. Papers in the 1950s pre-date cardiopulmonary bypass and describe the experimental use of hypothermia, a technique which has persisted [12, 34]. Papers from the 1980s are largely focused on understanding the effects of cardiopulmonary bypass and activation of the complement cascade, the debate over coronary artery bypass grafting versus coronary stenting began in with the publication of a number of randomized controlled trials,
aprotonin was described for reduction in bleeding following cardiopulmonary bypass and the technique of mitral valve repair was introduced by Alain Carpentier [20, 22, 35, 36]. Papers from the 1990s describe the surgical management of atrial fibrillation, the David procedure, demonstration of the importance of glycaemic control in the development of sternal wound infections and the debate regarding PCI vs CABG continue with further RCTs examining patient subsets [27, 37–39]. Papers published after 2000 first describe TAVI and compare off-pump with on-pump coronary artery bypass surgery [13, 40]. When considering a list of this nature, we must ask ourselves how best the true impact of a piece of research is measured. Is a citation analysis the best manner to assess the true impact of a research paper? There are many measures of scientific impact, however, citation-based measures are thought to provide a substitute measure of a discovery’s importance or an author’s standing in the research community [2]. Despite this growth in the popularity of citation analyses, there are a number of limitations to discuss. A recently published analysis indicated significant discrepancies in citation practices across disciplines [2]. Also, the number of citations collected by a paper are often influenced by the paper’s age, resulting in a bias towards older papers and more established investigators [41]. This trend is mirrored by our findings with the majority of papers in the top 100 published in the 1990s. The United States dominates the top 100 list with 60 contributions. Unsurprisingly, a number of key institutions were represented multiple times. Research funding has been demonstrated to drive the ‘scholarly impact’ of publications in a particular area [42]. The unpredictable pattern of citations across all scientific disciplines has resulted in an effect described as ‘impact disparity’, whereby a limited number of papers earn the largest share of citations [43]. Furthermore, it has led a number of researchers to question whether or not authors are overly reliant on ‘crowd sourcing’ to identify important literature. Considering this in the context of our results, the effect of impact disparity is undoubtedly seen. The first successful cardiac surgery was performed by Ludwig Rehn of Frankfurt in 1896 with the repair of a stab wound to the heart, heralding the beginning of an era of exponential growth within a new field of surgery [44]. Reflecting on the origins of cardiac surgery in the context of this list, it is clear that many of the seminal developments within the discipline were achieved prior to the establishment of publications dedicated to the field, and long before the era of digital dissemination. Milestones such as the first surgery on the aortic valve (Theodore Tuffier, Paris 1912), surgery on the mitral valve (Elliot Cutter, Boston 1923), implantation of a substitute cardiac valve (Charles Hufnagel, Georgetown, 1952) and open heart surgery (John Gibbon, Boston 1953) are notably
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absent from a list of this nature and will never be captured by an analysis of this type. Another notable feature when considering this list is the fact that coronary artery bypass grafting is the most frequently published topic yet the paper first describing its use ranks in only 81st position [45]. This emphasizes one important flaw with bibliometric analyses; the ‘obliteration by incorporation’ phenomenon [1]. This describes the process whereby information from a truly classic paper is less frequently cited as the body of information becomes integrated into current knowledge such that it is no longer cited. Such discoveries move from the theoretical to the factual, transitioning from published literature into textbooks as accepted techniques. Despite the potential flaws with bibliometric analyses, there is inherent merit in an analysis of this type. First, it stimulates discussion and allows an overview of the influential papers published in recent decades with clarification of patterns, themes and eras represented in the literature [4]. Although this article omits the earliest papers, it provides a valuable perspective for those currently contributing to the body of cardiac surgical literature, practicing cardiac surgery and trainees within the specialty. It remains a somewhat rhetorical question whether or not an understanding of history is crucial in the maturation and continued education of a cardiac surgeon. It does, however, illustrate the direction in which the specialty has progressed in recent years.
Conclusion Many key developments in cardiac surgery pre-date an analysis of this type. Using citation analysis as a proxy marker, the most influential papers published within cardiac surgery in the modern era are consistently published by a limited number countries and a number of key institutions. The highest-ranking paper on the list was published in 1999 by Nashef et al. in the European Journal of Cardiothoracic Surgery and introduced the now ubiquitous EuroSCORE into daily clinical practice. Citation analyses, although impaired by certain limitations, do offer an interesting overview of the key papers within a discipline and in this instance demonstrate the direction in which cardiac surgery has progressed in recent decades. Conflict of interest
None.
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REVIEW ARTICLE
The 100 most cited publications in cardiac surgery: a bibliometric analysis K. E. O’Sullivan • J. C. Kelly • J. P. Hurley
Received: 22 May 2014 / Accepted: 2 September 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Introduction This study is a citation analysis of the top 100 most cited papers in adult cardiac surgery. Bibliometric analyses are viewed as a proxy marker of a paper’s influence and, therefore, an analysis of the most influential papers published in recent decades. Methods Impact factor ranking as of 2012 was used to decide which journals to include in our searches. The Thompson Reuters Web of Knowledge was used to search for citations of all papers relevant to cardiac surgery within selected journals. Journals in the areas of surgery, cardiothoracic surgery, general medicine, anaesthesia, perfusion and pathology were included. Results The most frequently cited paper was found to be that of Nashef et al. (Eur J Cardiothorac Surg 16(1):9–13, 1999) introducing the EuroSCORE operative risk evaluation system. A number of authors including Alderman, Carpentier and Cox had more than one paper in the top 100. Conclusion Despite the potential flaws with bibliometric analysis, and its application to cardiac surgery, there is inherent merit in an analysis of this type. Keywords
Cardiac Surgery Bibliometric analysis
K. E. O’Sullivan (&) J. C. Kelly J. P. Hurley Mater Misericordiae University Hospital, Eccles St., Dublin 7, Ireland e-mail: [email protected] K. E. O’Sullivan J. C. Kelly J. P. Hurley Mater Private Hospital, Eccles St., Dublin 7, Ireland
Introduction Cardiac surgery has grown and evolved due to the work and courage of many pioneering surgeons who have pushed beyond the barriers of convention. The operative techniques and concepts they introduced have shaped development of the specialty. Whilst some would argue the specialty is still in its infancy, cardiac surgery has grown exponentially in recent years due to technical and technological advances, which have enabled progress to occur at a rapid rate. Research within the field has been carried out with vigor and a vast body of published literature has added to our understanding of the field. To our knowledge this is the first study to quantify and analyze the most frequently cited papers in the history of cardiac surgery as a surrogate measure of their impact within the specialty. A citation is defined as an abbreviated alphanumeric expression embedded within a body of intellectual work that acknowledges the relevance of the work to that carried out by others. It is an act of intellectual honesty [1]. Citation analysis is the bibliometric process used to examine the citation history of a particular paper by examining the citations attributed to that publication. It is one of the most widely used methods of bibliometrics and used to determine impact factor of a journal. Impact factor is a measure of the frequency with which the average article in a journal has been cited in a particular year. Whilst these methods are not without potential bias, there is no perfect method of assessing the merit of a scientific paper and impact factor and citation number generally accepted as the best [2]. A number of other surgical specialties have recently published bibliometric analyses on the most cited papers in their specialty. These include general surgery, orthopaedics, otolaryngology and plastic surgery [1, 3–9]. The analyses
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performed within these publications have postulated a better understanding of the influential papers in a number of fields since the commencement of the widespread dissemination of medical and scientific literature. The purpose of this article is to examine and rank cardiac surgery publications using the number of citations as a proxy marker of influence on practice and then question the validity of this method in the context of cardiac surgery specifically.
Methods Impact factor ranking as of 2012 was used to decide which journals to include in our searches. For this, Journal Citation Reports database was used. Journals from a number of specialties were included to ensure that all relevant publications were included for consideration. Specifically journals in the areas of surgery, cardiothoracic surgery, general medicine, anaesthesia, perfusion and pathology were searched. The Thompson Reuters Web of Knowledge is an online platform providing bibliographic database services. It details science citation indexes from 1970 to present. This was used to search for citations of all papers relevant to cardiac surgery within selected journals (Table 1). The search limits and sorting options in the Web of Knowledge were used to rank all articles from each individual journal according to the number of citations. These were then hand searched for articles pertaining to cardiac surgery. A number of exclusions were applied: case reports, consensus or guideline documents and papers describing paediatric cardiac surgery or transplantation. In addition, papers describing the pathogenesis of conditions such as atherosclerosis were excluded and articles were limited to those describing operative technique, outcomes or complications. Articles from each journal with greater than 100 citations were then combined into a database, which allowed them to be ranked according to citation number. When the top 100 most cited articles were identified these were assessed further and title, authorship, journal of publication, country and institution of origin, year of publication and number of citations were recorded. For the purposes of this analysis it was not possible to assess the ‘lead’ author of each paper, therefore, we considered the first name author to be the primary contributor.
Results Thirty-four journals were included in the search (Table 1). Searches yielded a total of 5,462 articles, which were ranked in order of citation number. Of journals searched, only the top seven were included in the top 100 (Table 2). Number of citations ranged from 1,252 to 271 (Table 3)
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Table 1 Journals included in bibliometric analysis searches Journal
Impact factor
New England Journal of Medicine
51.7
Lancet
39.1
JAMA
30.0
British Medical Journal
17.2
PLOS Medicine
15.3
Circulation
15.2
Annals of Internal Medicine
14.0
BMC Medicine
6.7
Canadian Medical Association Journal
6.5
Journal of Internal Medicine
6.5
Annals of Surgery Mayo Clinic Proceedings
6.3 5.8
Pain
5.6
Anaesthesiology
5.2
Annals of Medicine
5.1
Heart
5.0
American Journal of Surgical Pathology
4.9
British Journal of Surgery
4.8
American Journal of Medicine
4.8
Journal of the American College of Surgeons
4.5
British Journal of Anaesthesia
4.2
Surgery of Obesity Related Diseases
4.1
Annals of Surgical Oncology
4.1
Journal of Thoracic and Cardiovascular Surgery
3.5
Anaesthesia
3.5
Regional Anaesthetic Pain Management
3.5
Annals of Thoracic Surgery Surgery
3.5 3.4
Anaesthesiology and Anaesthesia
3.3
European Journal of Pain
3.1
European Journal of Cardiothoracic Surgery
2.7
Journal of Cardiovascular Surgery
1.5
Journal of Cardiac Surgery
1.5
Thoracic and Cardiovascular Surgery
0.9
Table 2 Journals included in the top 100 citations Rank
Journal
Number of articles included
1
Journal of Thoracic and Cardiovascular Surgery
27
2 3
New England Journal of Medicine Circulation
25 19
4
Annals of Thoracic Surgery
15
5
Lancet
8
6
Annals of Surgery
3
7
European Journal of Cardiothoracic Surgery
3
Ir J Med Sci Table 3 The top 100 citations in cardiac surgery Rank
First author
Citations
Rank
First author
Citations
Rank
First author
Citations
1
Nashef [10]
1252
34
Rahimtoola [46]
448
2
Roach [48]
1035
35
McFalls [49]
447
67
van de Watering [47]
321
68
Thomas [50]
3
Yusuf [51]
1023
36
Ross [52]
436
320
69
Cox [25]
319
4
Leon [13]
1013
37
Debakey [53]
435
5
Serruys [54]
999
38
Ross [55]
431
70
Angelini [50]
316
71
Hannan [56]
6
Kirklin [35]
942
39
Furnary [57]
428
72
315
Buckberg [58]
312
7
Chenoweth [59]
921
40
Acar [60]
427
73
Gardner [61]
312
8
Carpentier [22]
898
41
Cox [26]
413
74
Tamburino [16]
311
9
Alderman [19]
878
42
Lytle [33]
411
75
Guiraudon [62]
311
10
Newman [63]
845
43
Bidstrup [36]
410
76
Ferguson [64]
309
11 12
Mishra [65] Inoue [68]
770 750
44 45
Buffolo [66] Carpentier [23]
409 407
77 78
Griepp [67] Lichtenstein [17]
304 303
13
Smith [69]
701
46
Loop [31]
395
79
Khan [70]
302
14
Roques [71]
672
47
Hamm [72]
394
80
Kolessov [45]
299 298
15
Lytle [28]
661
48
Calafiore [73]
386
81
Puskas [40]
16
Steingart [74]
652
49
Parsonnet [75]
384
82
Shroyer [76]
296
17
Alderman [20]
581
50
Kennedy [77]
381
83
Vanoeveren [78]
294
18
Takaro [79]
572
51
Fergusson [80]
378
84
Hampton [38]
293
19
Serruys [81]
557
52
Peterson [82]
377
85
Mangano [83]
292
20
Mangano [84]
554
53
Pocock [85]
371
86
Webb [18]
292
21
Nussmeier [86]
551
54
Bruins [87]
369
87
Cremer [88]
288
22
Cox [27]
546
55
Bolling [89]
359
88
Cosgrove [32]
286
23
Butler [90]
539
56
Lie [91]
346
89
Dake [92]
285
24
Webb [14]
537
57
Waldo [93]
345
90
Daoud [94]
282
25
Bigger [95]
536
58
Zerr [96]
345
91
Almassi [97]
280
26
King [98]
530
59
Svennson [99]
343
92
Chamberlain [100]
280
27 28
Bigelow [34] Motwani [29]
523 522
60 61
Alderman [21] Fisher [102]
340 340
93 94
Hammer Schmidt [101] Carpentier [24]
280 280
29
Aranki [103]
520
62
Alderman [104]
339
95
Paperella [105]
279
30
Koch [30]
515
63
Salzman [106]
334
96
Hennein [107]
277
31
Furnary [37]
507
64
van Dijk [108]
329
97
Frazier [109]
277
32
Shake [110]
465
65
Bigelow [12]
328
98
Kennedy [111]
275
33
David [39]
449
66
Murphy [112]
325
99
Shlafer [113]
273
Kodali 11]
271
100
[10, 11]. Mean number of citations for papers included was 457. Pre-dating the advent of cardiopulmonary bypass, the oldest paper on the list was ranked position 65 by Bigelow et al. [12] describing the use of general hypothermia as a means of reducing the oxygen requirements of the body sufficiently to allow intracardiac surgery and was cited 328 times. The most recently published paper was that by Kodali et al. [11] in the New England Journal of Medicine reporting the 2 years outcomes of transcatheter aortic valve replacement compared with surgical valve replacement from the PARTNER Trial. Analyzing the list by decade published, most of the papers in the top 100 were published in the 1990s (Fig. 1).
The journal most frequently represented was the Journal of Thoracic and Cardiovascular Surgery with 27 articles (Table 2). The second most represented journal was the New England Journal of Medicine with 25 articles and third was Circulation with 19. The top-ranking article overall was published in 1999 by Nashef et al. [10] in the European Journal of Cardiothoracic Surgery entitled ‘European system for cardiac operative risk evaluation (EuroSCORE)’ (Table 3). Topics covered in the top ranking papers were wide ranging (Table 4). The most common topics listed were coronary artery bypass grafting (40 papers) and post-cardiac surgery complications including sternal wound
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Ir J Med Sci Table 5 Authors with more than one of the most frequently cited papers
Fig. 1 Analysis of the number of articles in the top 100 by decade Table 4 Topics described by the top 100 papers Rank
Topic
Number of articles
1
Coronary Artery Bypass Grafting
40
2
Post Cardiac Surgery Complication
19
3
Cardiopulmonary Bypass
8
4
Transcatheter Aortic Valve Implantation
8
5
Cardiac Surgery Risk Scoring
4
6
Hypothermia
4
7
Mitral Valve Repair
4
8
Surgical Management of Afib
4
9
Aortic Dissection
10 11 12
Rank
Author
Institution
Number of papers
1
Alderman
Stanford University School of Medicine, California
4
2
Carpentier
Georges Pompidou Hospital, France
3
3
Cox
Washington University School of Medicine, Barnes Hospital
3
4
Bigelow
University of Toronto, Canada
2
Furnary
Providence St Vincent Medical Center, Oregon
2
Kennedy Lytle
University of Washington, Seattle Cleveland Clinic Foundation, Ohio
2 2
Mangano
Ischemia Research and Education Foundation, San Bruno, California
2
Ross
National Heart Hospital and the Institute of Cardiology, London
2
Serruys
Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
2
Webb
St. Paul’s Hospital, Vancouver, Canada
2
Table 6 Countries of origin of the most cited papers
Rank
Country
Number of papers
2
1
USA
60
Basic Science
2
2
UK
12
Ross Procedure Aortic Aneurysm
2 1
3
Canada
8
4
Netherlands
6
13
David Procedure
1
5
Italy
2
14
Ventricular Assist Device
1
6
Germany
2
7
Russia
1
8
Japan
1
9
Brazil
1
infections, atrial fibrillation and bleeding (19 papers) and cardiopulmonary bypass (8 papers) (Table 5). Interestingly, transcatheter aortic valve implantation (TAVI) ranked at number 4 reflecting its significant impact on the specialty in recent years [11, 13–18]. A number of first authors were represented more than once on the list with E. L. Alderman ranking first having published 4 papers on the topic of coronary artery bypass grafting in Circulation and the New England Journal of Medicine with a cumulative citation number of 2,138 [19–21]. The second ranking author was A. Carpentier who published 3 of the top ranking papers on mitral valve repair including ‘‘Cardiac Valve Surgery-The French Correction’’ [22–24]. J. L Cox ranked third, publishing three papers on the surgical management of atrial fibrillation and the Cox Maze procedure [25–27]. Eight remaining authors; Bigelow, Furnary, Kennedy, Lytle, Mangano, Ross, Serruys and Webb contributed two papers to the top 100 citations (Table 5).
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Examining the list based on country of origin, the majority of the identified papers came from the United States with the United Kingdom and Canada ranking next (Table 6). A total of 64 different institutions were represented, of those 14 more than once. The institution with the greatest number of papers was the Cleveland Clinic, which was credited with 6 papers from multiple authors [28–33]. The two institutions ranking next are the University of Toronto and Stanford University (Table 7).
Discussion Bibliometric analysis of cardiac surgery to date offers the reader some interesting insights into the specialty; its
Ir J Med Sci Table 7 Top ranking institutions Rank
Institution
Number of papers
1
The Cleveland Clinic Foundation
6
2
University of Toronto, Toronto, Canada
4
3
Stanford University School of Medicine, California Hoˆpital Europe´en Georges Pompidou, Paris
4
5
Columbia University Medical Center and New York Presbyterian Hospital
3
6
Washington University School of Medicine, Barnes Hospital
3
7
University of Alabama in Birmingham, Alabama
2
8
The Johns Hopkins Medical Institutions, Baltimore, Maryland
2
9
Ischemia Research and Education Foundation, San Francisco
2
10
National heart hospital and the institute of cardiology, London, UK
2
11
Emory University School of Medicine, Atlanta
2
12
Duke University Medical Center, Durham
2
13
Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
2
14
Department of Surgery, Beth Israel Hospital, Boston
2
4
3
history and how it is currently evolving. The most frequently cited article in our analysis was the landmark paper by Nashef et al. [10] which introduced the EuroSCORE; a risk stratification tool for predicting operative mortality in cardiac surgery. The EuroSCORE is based on a logistic regression model, from data recording 97 risk factors collected from 20,000 patients in eight European countries. This groundbreaking risk index is now the most widely used in cardiac surgery and is accepted to have contributed significantly to improvements in operative morbidity and mortality witnessed in recent years. Interestingly, the paper was published relatively recently in 1999 and exceeds the 2nd ranking publication by 217 citations. Viewed in isolation, it is reasonable to acknowledge this paper’s broadreaching and specialty-altering contribution. It has truly improved daily clinical practice in cardiac surgery and the decision-making processes within cardiac surgery. Examining the publications by decade reveals some interesting patterns. Papers in the 1950s pre-date cardiopulmonary bypass and describe the experimental use of hypothermia, a technique which has persisted [12, 34]. Papers from the 1980s are largely focused on understanding the effects of cardiopulmonary bypass and activation of the complement cascade, the debate over coronary artery bypass grafting versus coronary stenting began in with the publication of a number of randomized controlled trials,
aprotonin was described for reduction in bleeding following cardiopulmonary bypass and the technique of mitral valve repair was introduced by Alain Carpentier [20, 22, 35, 36]. Papers from the 1990s describe the surgical management of atrial fibrillation, the David procedure, demonstration of the importance of glycaemic control in the development of sternal wound infections and the debate regarding PCI vs CABG continue with further RCTs examining patient subsets [27, 37–39]. Papers published after 2000 first describe TAVI and compare off-pump with on-pump coronary artery bypass surgery [13, 40]. When considering a list of this nature, we must ask ourselves how best the true impact of a piece of research is measured. Is a citation analysis the best manner to assess the true impact of a research paper? There are many measures of scientific impact, however, citation-based measures are thought to provide a substitute measure of a discovery’s importance or an author’s standing in the research community [2]. Despite this growth in the popularity of citation analyses, there are a number of limitations to discuss. A recently published analysis indicated significant discrepancies in citation practices across disciplines [2]. Also, the number of citations collected by a paper are often influenced by the paper’s age, resulting in a bias towards older papers and more established investigators [41]. This trend is mirrored by our findings with the majority of papers in the top 100 published in the 1990s. The United States dominates the top 100 list with 60 contributions. Unsurprisingly, a number of key institutions were represented multiple times. Research funding has been demonstrated to drive the ‘scholarly impact’ of publications in a particular area [42]. The unpredictable pattern of citations across all scientific disciplines has resulted in an effect described as ‘impact disparity’, whereby a limited number of papers earn the largest share of citations [43]. Furthermore, it has led a number of researchers to question whether or not authors are overly reliant on ‘crowd sourcing’ to identify important literature. Considering this in the context of our results, the effect of impact disparity is undoubtedly seen. The first successful cardiac surgery was performed by Ludwig Rehn of Frankfurt in 1896 with the repair of a stab wound to the heart, heralding the beginning of an era of exponential growth within a new field of surgery [44]. Reflecting on the origins of cardiac surgery in the context of this list, it is clear that many of the seminal developments within the discipline were achieved prior to the establishment of publications dedicated to the field, and long before the era of digital dissemination. Milestones such as the first surgery on the aortic valve (Theodore Tuffier, Paris 1912), surgery on the mitral valve (Elliot Cutter, Boston 1923), implantation of a substitute cardiac valve (Charles Hufnagel, Georgetown, 1952) and open heart surgery (John Gibbon, Boston 1953) are notably
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absent from a list of this nature and will never be captured by an analysis of this type. Another notable feature when considering this list is the fact that coronary artery bypass grafting is the most frequently published topic yet the paper first describing its use ranks in only 81st position [45]. This emphasizes one important flaw with bibliometric analyses; the ‘obliteration by incorporation’ phenomenon [1]. This describes the process whereby information from a truly classic paper is less frequently cited as the body of information becomes integrated into current knowledge such that it is no longer cited. Such discoveries move from the theoretical to the factual, transitioning from published literature into textbooks as accepted techniques. Despite the potential flaws with bibliometric analyses, there is inherent merit in an analysis of this type. First, it stimulates discussion and allows an overview of the influential papers published in recent decades with clarification of patterns, themes and eras represented in the literature [4]. Although this article omits the earliest papers, it provides a valuable perspective for those currently contributing to the body of cardiac surgical literature, practicing cardiac surgery and trainees within the specialty. It remains a somewhat rhetorical question whether or not an understanding of history is crucial in the maturation and continued education of a cardiac surgeon. It does, however, illustrate the direction in which the specialty has progressed in recent years.
Conclusion Many key developments in cardiac surgery pre-date an analysis of this type. Using citation analysis as a proxy marker, the most influential papers published within cardiac surgery in the modern era are consistently published by a limited number countries and a number of key institutions. The highest-ranking paper on the list was published in 1999 by Nashef et al. in the European Journal of Cardiothoracic Surgery and introduced the now ubiquitous EuroSCORE into daily clinical practice. Citation analyses, although impaired by certain limitations, do offer an interesting overview of the key papers within a discipline and in this instance demonstrate the direction in which cardiac surgery has progressed in recent decades. Conflict of interest
None.
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