Author: Chase Doyle
Case volume for cardiac anesthesiologists is on the rise, and it’s not limited to just cardiac surgical procedures. Rather, according to a recent retrospective analysis, cardiac anesthesiology care is increasingly requested for cases traditionally covered by general anesthesiologists. Over the course of six months at a single academic institution, the most common reasons for referral for noncardiac procedures were pulmonary hypertension, the presence of adult congenital heart disease (CHD), severe valvular pathology, ejection fraction below 30% and cardiac tamponade.
“All anesthesiologists are trained very well in the skills to manage complex patients, but we’re starting to see a subset in which the cardiac anesthesiology skill set is being requested. And our informal discussions with other institutions show that they’re feeling the same thing,” said Michael G. Fitzsimons, MD, an anesthesiologist at Massachusetts General Hospital, in Boston. “This survey highlights the perceived notion that cardiac anesthesiologists are frequently requested by surgeons, cardiologists and general anesthesiologists to provide anesthesia care for more complex patients.”
For this study, Dr. Fitzsimons and his colleagues collected all requests to the cardiac anesthesiology group at their quaternary care academic institution to manage cases generally covered by noncardiac anesthesiologists. Over a six-month period, the researchers examined the type of case referred, the requesting department, cardiac pathologies and comorbidities, intraoperative monitoring and management, and 30-day postoperative mortality. Referrals for reprogramming of pacemakers alone, perioperative performance of transesophageal echocardiography (TEE) alone, or management of patients with ventricular assist devices were excluded from the analysis.
In addition, data showed that 30-day postoperative mortality was 21%. There were no interoperative deaths, noted Dr. Fitzsimons, but the high 30-day mortality may reflect the illness of the patient population. Findings also demonstrated that TEE was used only in 26% of the cases.
“Cardiac anesthesiologists are recognized as experts in echocardiography, so it was interesting to see that this skill was not used in the majority of these cases,” Dr. Fitzsimons said. “This shows that we often rely on our clinical acumen rather than merely resort to echocardiography, and that we’re frequently called upon to manage complex hemodynamic challenges.”
Researchers noted, for example, that a few patients in the study had right ventricular systolic pressure in the range of 90 mm Hg, one patient had two prior heart transplants, and two patients needed an intra-aortic balloon pump before their noncardiac surgery. Several patients in this study also had severe valvular diseases requiring urgent noncardiac surgery.
A Growing Trend
As Dr. Fitzsimons explained, there are existing studies and guidelines on how to manage patients with ventricular assist devices and pacemakers/defibrillators during noncardiac surgery. However, no current studies address the reasons, management or outcomes when cardiac anesthesiologists are summoned to deliver specialized care outside the cardiac operating room and services generally covered by other providers or teams.
“Traditionally, cardiac anesthesiologists have stepped outside of the cardiac operating rooms and covered patients who have ventricular assist devices or balloon pumps or may be on extracorporeal membrane oxygenation, but we’re now hearing from our colleagues at other institutions that we’re really stepping beyond that realm,” Dr. Fitzsimons said.
While this study’s findings may be limited to a single institution, Dr. Fitzsimons and his colleagues view these data as reflective of a larger trend: more and more patients with increasingly complex needs that are driving the demand for cardiac anesthesiologists.
“We think that the growing demand for our services is related to the fact that patients seem to be doing better with systolic heart failure,” Dr. Fitzsimons said. “Patients who have poor ejection fractions and other medical conditions are living longer and living [with] their diseases to more complex states. As more and more patients are surviving with significant cardiac dysfunction, we expect the demand for cardiac anesthesiology care outside of cardiac surgery will only increase.”
According to Dr. Fitzsimons, this additional workload is ultimately beneficial for the specialty. Nevertheless, covering more general surgery cases with complex patients presents its own challenges.
“With cardiac surgery, anesthesiologists often have the luxury of getting patients to cardiopulmonary bypass, fixing the problems, and then the patients do very well,” he explained. “For these complex cases, however, we don’t have the luxury of cardiopulmonary bypass. We need to merely get them through the procedure. Some of these procedures are done in preparation for cardiac surgery, but in others, they’re just procedures that need to get done on complex patients.”
These findings will be used to design a referral system at Massachusetts General for resource planning and staffing the main operating rooms. Additionally, Dr. Fitzsimons said, this pilot study may be expanded to review such requested cases in other institutions and regions. Following presentation of these data, Dr. Tran said she received comments from cardiac anesthesiologists from around the country noting a rise of referrals in their respective hospitals.
“Many audience members discussed that, depending on the day, staffing of these noncardiac cases could be challenging for the cardiac anesthesiology groups,” Dr. Tran observed. “However, if given advance notice and mobilization of resources, cardiac anesthesiology groups were better able to manage resources.”
This study highlights an important trend for cardiac anesthesiologists and their patients, said Jacques Neelankavil, MD, an anesthesiologist at the Ronald Reagan UCLA Medical Center, in Los Angeles, in an interview with Anesthesiology News.
“Recently, our scope of practice has expanded from the cardiac operating room to more broadly include patients with significant cardiovascular disease presenting for a myriad of surgeries,” said Dr. Neelankavil, who noted that a large percentage of these requested cases include patients with a history of CHD. “Surgical repair of CHD has improved over the last few decades, and our congenital heart disease patients are presenting on labor and delivery for obstetric care in addition to arrhythmia management in the electrophysiology lab.”
Not all patients with CHD or pulmonary hypertension need to be managed by a cardiac anesthesiologist, as many general anesthesiologists are extremely skilled at caring for patients with severe cardiovascular comorbidities, explained Dr. Neelankavil, who was not involved with the study. However, this abstract could help start a discussion that many cardiac anesthesia groups are having individually.
“The identification of the types of patient comorbid conditions that trigger a consult for a cardiac anesthesiologist may help us further with preoperative risk stratification,” he observed. “The next steps could include a scoring system that would help identify high-risk patients and high-risk surgeries that would benefit from cardiac anesthesia care coordination. Even if we are not the primary anesthesia provider, we can help our patients and our colleagues by coordinating the perioperative care of these complex patients.”