To the Editor
Cardiovascular disease continues to be the leading cause of death in the United States.1 While the volume of cardiac surgery to repair cardiac disease has decreased over time, the prevalence of patients with critical cardiac disease (eg, severe valvular heart disease, mechanical circulatory support [MCS] devices) presenting for noncardiac surgery has increased.2,3 A study examining trends in cardiovascular disease among patients undergoing noncardiac surgery from 2004 to 2013 found the prevalence of cardiac risk factors and atherosclerotic cardiovascular disease (ASCVD) increased over the study period.3 Heart failure (HF) currently affects approximately 7 million people in the United States and the prevalence is projected to rise to 3% of the population by 2030.4 Many patients with HF develop conditions requiring noncardiac surgery. HF increases the risk for perioperative complications as well as perioperative mortality.5 In a cohort of 38,047 patients undergoing major or minor noncardiac surgery, Van Diepen and colleagues found unadjusted 30-day postoperative mortality rates of 9.3% in patients with nonischemic HF, 9.2% in patients with ischemic HF, 6.4% in patients with coronary artery disease (CAD), and 2.9% in patients with atrial fibrillation without CAD or HF.6
Anesthesiology training prepares graduates to care for patients undergoing a diverse array of surgical procedures and there is an expectation that graduates (ie, anesthesiologists) be entrustable with perioperative management of complex patients for general and subspecialty procedures of all types. Notwithstanding, when considering management of patients with HF presenting for noncardiac surgery, there is often the question of whether care should be managed by cardiac or critical care subspecialty-trained anesthesiologists. Though HF patients are at higher risk for mortality and perioperative complications, there are no data to show that outcomes are improved when the anesthetic is administered by an adult cardiothoracic anesthesiology (ACTA)-trained or Critical Care-trained anesthesiologist.
During residency training, cardiothoracic anesthesiology subspecialty rotations present the most focused medium for exposure and experience in the intraoperative management and care of patients with complex cardiac disease including HF. The Accreditation Council for Graduate Medical Education (ACGME)-accredited anesthesiology residency programs require trainees to spend 2 months rotating in cardiothoracic anesthesiology, where they will perform a minimum of 20 cardiac cases, 10 of which must involve cardiopulmonary bypass (CPB). There are no requirements listed for the management of patients on other MCS. ACGME also requires experience with transesophageal echocardiography (TEE) allowing the acquisition and interpretation of standard views to evaluate myocardial function and basic pathology.7 The origin and basis for the ACGME requirements are not clear, but they have changed minimally since the inception of accreditation in 2006 despite the increased prevalence of cardiac disease.2,3 There are also no current data to indicate whether the mandated minimum number of cardiac cases is sufficient to establish competency in the management of patients with critical cardiac disease or HF. Additionally, the severity and exposure to cardiovascular disease varies across academic departments. To develop competence in the care of patients with HF, trainees must have adequate exposure to the disease and experience in caring for these patients when they undergo noncardiac surgery. Currently, there is no mandate from the ACGME regarding case numbers for patients with HF.
Due to the increasing prevalence of HF, it is imperative that anesthesiology graduates be well equipped to care for patients on pharmacological and mechanical support, presenting for noncardiac surgery. To ensure this, we suggest that training requirements be updated and regularly assessed. While there are no clear data on number of cases needed to attain proficiency, we may begin with previously prescribed ACGME minimums, eg 20 patients with left ventricular ejection fraction less than 30%, on mechanical support devices presenting for cardiac or noncardiac surgery. While not all training programs offer a high level of exposure, adjunctive simulation training can be utilized to bridge the gap.
Finally, it is challenging to obtain accurate data on frequency of management by case type. The current system relies on resident self-reporting, which permits inaccuracies. For example, residents often stop reporting once they achieve the required minimums. To accurately characterize exposure by case type and complexity, automated, likely artificial intelligence-driven tools are needed to collect this data. Hence, to ensure that graduating anesthesiology residents are prepared to competently manage patients with critical cardiac disease in the current era, it is imperative that we (1) update the training requirements to include meaningful exposure to and experience with management of contemporary mechanical support devices; (2) further investigate thresholds of exposure during training that confer proficiency in the management of these patients; and (3) develop tools that improve accuracy of case type reporting.
Abimbola O. Faloye, MD
Department of Anesthesiology
Emory University
Atlanta, Georgia
Beth Ladlie MD, MPH
Department of Anesthesiology and Perioperative Medicine
Mayo Clinic
Jacksonville, Florida
Jochen D. Muehlschlegel, MD, MMSc, MBA
Department of Anesthesiology and Critical Care Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland
Linda Shore-Lesserson, MD
Department of Anesthesiology
Northwell Health
New Hyde Park, New York
Christopher A. Troianos, MD, FASE, FASA
Department of Anesthesiology
Cleveland Clinic
Cleveland, Ohio
Adam J. Milam, MD, PhD
Department of Anesthesiology and Perioperative Medicine
Mayo Clinic
Phoenix, Arizona
milam.adam@mayo.edu