ASA Monitor 12 2017, Vol.81, 44-45.
Christopher A. Troianos, M.D., FASE, is President, Society of Cardiovascular Anesthesiologists, and Professor and Chair of the Anesthesiology Institute, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University.
Adult cardiothoracic anesthesiology (ACTA) is now firmly established as a subspecialty within anesthesiology as it has been more than a decade since the Accreditation Council for Graduate Medical Education (ACGME) began accrediting training programs. Coincidently, the past decade has seen the developing concept of anesthesiologists assuming more responsibility for perioperative care beyond the O.R. and payment models that reward overall outcome, instead of merely collecting a fee for the service provided. Training requirements for ACTA specifically require demonstration of competence in preoperative patient evaluation and optimization of clinical status prior to the procedure, interpretation of cardiovascular and pulmonary diagnostic test data, hemodynamic and respiratory monitoring, pharmacological and mechanical hemodynamic support, and perioperative critical care, including ventilator support and perioperative pain management.1
The knowledge and skills expected of a cardiothoracic anesthesiologist are broadly applicable beyond the cardiac O.R.s, where perioperative care and optimization are arguably even more important during non-cardiac surgery, because the medical condition affecting the heart will not be improved with the planned surgical intervention. The expertise of a cardiothoracic (CT) anesthesiologist is well-suited to evaluating and optimizing these patients with cardiac, vascular and thoracic disease presenting for non-cardiac surgery. Graduates of an ACTA training program are expected to demonstrate and apply knowledge of noninvasive cardiovascular evaluation, including electrocardiography, transthoracic and transesophageal echocardiography, stress testing and cardiovascular imaging.1
A CT anesthesiologist should thus be well-suited to determine which tests are indicated, evaluating the results of those tests, and to formulate a plan for optimization as a part of a pre-anesthesia clinic evaluation and consultation. The value of an anesthesiologist in an episodic type of payment model becomes obvious as there may be a lesser need for other consultants if the optimization falls under the CT anesthesiologist’s area of expertise. A preoperative transthoracic echocardiography service led by CT anesthesologists is a model that has already been established and has been shown to be particularly useful for cardiovascular risk assessment for patients undergoing intermediate- or high-risk procedures.2
CT anesthesiologists are often consulted for intraoperative management of patients with cardiovascular disease undergoing non-cardiac surgery. Their expertise in establishing vascular access and complex monitoring, and their skill in performing andinterpreting transesophageal echocardiography (TEE), provide a valuable resource in the noncardiac O.R. setting. The benefit of TEE to diagnose the etiology of hemodynamic collapse can impact further management beyond implementation of advanced cardiac life support protocols.3 The combined expertise of a CT anesthesiologist in both diagnostic interventions and resuscitative efforts provides an added benefit in the care of patients who experience sudden unexpected cardiovascular compromise.
The role of CT anesthesiologists also extends to the care of patients having non-cardiac procedures outside of the operating rooms. The increasing prevalence of ventricular assist devices for patients with end-stage cardiomyopathies means it is not uncommon to encounter these patients in the gastroenterology or radiology suite. The increased survival of adult patients with congenital heart disease leads to an increased number of these patients presenting in the labor and delivery suites where management of the cardiac condition is complicated by the physiologic changes of pregnancy and labor. Anesthesiologists should therefore embrace their roles in coordinating the care of the patient beyond the operating room. Schonberger and colleagues showed that perioperative screening for hypertension is an opportunity for anesthesiologists to intervene and potentially reduce the risk of future cardiovascular morbidity and mortality.4 Although this opportunity is not limited to CT anesthesiologists, it is a great example of how anesthesiologists can impact care beyond the operating room.
CT anesthesiologists are commonly found managing patients in cardiovascular intensive care units after cardiac surgery. In order to care for the full range of physiologic derangements that are encountered in cardiac critical care units, training must include management of patients with extra-corporeal membrane oxygenation, ventricular assist devices, intra-aortic balloon counterpulsation and perioperative coagulopathy. CT anesthesiologists by virtue of their training and experience with cardiac surgical patients are familiar with managing these complex dilemmas and therefore play an important role in their care beyond the O.R.
The annual meeting of the Society of Cardiovascular Anesthesiologists is filled with topics and panels that address these clinical challenges of perioperative care. Come to learn more about perioperative care of the cardiac patient at our 40th anniversary meeting, which will be held April 28 – May 2, 2018 at the lovely JW Marriott Phoenix Desert Ridge Resort and Spa with world-class speakers and a fantastic venue.
1. Accreditation Council for Graduate Medical Education (ACGME). ACGME Program Requirements for Graduate Medical Education in Adult Cardiothoracic Anesthesiology. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/041_adult_cardiothoracic_anes_2017-07-01.pdf. ACGME-approved September 29, 2013. Revised and effective July 1, 2017. Last accessed October 6, 2017.
2. Shillcutt SK, Walsh DP, Thomas WR, et al. The implementation of a preoperative transthoracic echocardiography consult service by anesthesiologists [published online June 20, 2017]. Anesth Analg. doi: 10.1213/ANE.0000000000002156
3. Memtsoudis SG, Rosenberger P, Loffler M, et al. The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery. Anesth Analg. 2006;102(6):1653–1657.
4. Schonberger RB, Dai F, Brandt CA, Burg MM . Balancing model performance and simplicity to predict postoperative primary care blood pressure elevation. Anesth Analg. 2015;121(3):632–641.