Year : 2022  |  Volume : 25  |  Issue : 3  |  Page : 251--253

Changing paradigms in the practice of cardiac anesthesiology


Mukul C Kapoor 
 Department of Anaesthesiology and Surgical ICUs, Amrita Hospital, Faridabad, Haryana, India

Correspondence Address:
Mukul C Kapoor
6 Dayanand Vihar, Delhi - 110 092
India




How to cite this article:
Kapoor MC. Changing paradigms in the practice of cardiac anesthesiology.Ann Card Anaesth 2022;25:251-253


How to cite this URL:
Kapoor MC. Changing paradigms in the practice of cardiac anesthesiology. Ann Card Anaesth [serial online] 2022 [cited 2022 Aug 19 ];25:251-253
Available from: https://www.annals.in/text.asp?2022/25/3/251/349916


Full Text



The evolution of anesthesia for cardiothoracic surgery has been dramatic. In the last quarter of the 20th century, the specialty emerged from the shadows of the cardiothoracic surgeon to develop into an independent, self-sufficient, and fiercely competitive specialty. Within no time, cardiothoracic anesthesiologists gained expertize in vascular access and mastered patient hemodynamic management. They were much sought after to manage dire emergencies. Today, cardiac anesthesiologists are considered tech-savvy wizards of echocardiography. They are master manipulators of the trans-esophageal echocardiography (TEE) probe and guide the cardiac surgeon to improve patient outcomes.

Cardiac surgery was limited to repairing simple congenital heart defects until cardiopulmonary bypass (CPB) advent. The horizon of cardiac anesthesiology widened with the development of safe CPB. The complexities of anesthetic management are too compounded. The emergence of coronary artery bypass brought in a larger volume of patients, and the scope of the specialty widened. Cardiac anesthesiology prospered as a specialty and attracted the best of talent. A large number of anesthesiologists joined this emerging stream. The specialty of cardiac anesthesiology emerged out of its shell and became one of the most sought-after fields.

Cardiac surgery patients are often very high risk, with multiple comorbid conditions such as pulmonary, cardiac, renal, endocrine, and systemic disorders.[1] Anesthetic management of such patients demands intensive knowledge and dedication. Handling the heart and the lungs during surgery may cause significant physiologic disruption.

Anesthetic technique shifted from a high-dose narcotic to a balanced technique using moderate-dose narcotics, shorter-acting muscle relaxants, and volatile anesthetics. The specialty matured, and patient outcomes improved. The reach of cardiac surgery widened exponentially, and it was available in the developing world before the end of the 20th century.

Thoracic surgery developed at a slower pace. The surgical profile remained restricted to routine lobectomies and pneumonectomies for quite some time. Several new therapeutic modalities emerged in the last two to three decades for complex lung cancer, esophageal cancer, mediastinal masses excision, tracheal surgery, and thoracic trauma surgical techniques. The advent of video-assisted thoracoscopic surgery made the field more popular and brought recognition to it as an independent specialty. The surgical and anesthetic requirements of thoracic surgery varied significantly from cardiac surgery. This advance led to the weaning off of thoracic anesthesiology from cardiothoracic anesthesiology. Thoracic anesthesiology is now a proud independent specialty. Thoracic Anesthesiologists no longer practice cardiac anesthesiology. New technologies in lung separation are making thoracic anesthesia safer. Granell M et al.[2] present the benefits of VivaSight double-lumen tubes in this issue.

Cardiac Anesthesiologists soon occupied leadership positions in the academic anesthesiology world. Their extrovert personalities and penchant for research, knowledge and clinical expertize were possibly responsible for this sterling growth. With the complexities of surgeries increasing with time, cardiac anesthesiologists also took over the cardiac intensive care space. Their prowess in understanding cardio-respiratory physiology helped improve outcomes in complex surgeries like an arterial switch, complicated congenital heart disease, heart/lung transplant, and major vascular surgeries.

Anesthesiologists seized the opportunity offered by newly developed TEE probes and their miniaturization. Cardiologists were reluctant to restrict their clinical and intervention practice by spending precious time in the confines of the operating room. Anesthesiologists were quick to learn echocardiography and soon excelled in TEE. TEE machines were soon commonplace in cardiac operating rooms, and now their use is almost mandatory for all cardiac surgeries.

The paradigm shift to shorter-acting drugs led to a renewed interest in the fast-track recovery of patients. Multimodal analgesia with regional blocks, intrathecal morphine, and nonsteroidal anti-inflammatory drugs gained popularity. New weaning protocols and intensive observation disrupted the traditional intensive care model. Patients were extubated early in the recovery room and rapidly discharged to specialized postcardiac surgical recovery units. Fast-track cardiac anesthesia is today the default management mode in most parts of the world. With fast-tracking gaining popularity and its revenue advantage, conventional high-dose narcotic anesthesia is restricted to a few very high-risk cases today.

There has also been a significant shift in treatment modalities for many cardiac lesions, earlier in the domain of the surgeons to the cardiac catheterization laboratory. Endovascular options became more readily available. Transcatheter aortic valve implantation, mitral clips, and device closure of shunts/defects shifted into the domain of the cardiologists. However, the complexity of these procedures ensured that they remained under the care of cardiac anesthesiologists. The ever-growing expertize of cardiac anesthesiologists matched the technological advances. In this issue, Beydoun N et al.[3] present the relationship between preoperative heart rate variability and clinical outcomes. Vascular surgery made significant forays in the endovascular field, and hybrid operating rooms became common.

The use of ultrasound-guided regional blocks has significantly increased in anesthesiology practice. Cardiac anesthesiologists were hesitant to accept this changing paradigm and remained restricted to epidural and intravenous analgesia. Today, Cardiac anesthesiologists administer multiple fascial plane blocks. In this issue, Toscano A et al.[4] compare continuous erector spinae plane block with serrates anterior plane block for mitral valve surgery by mini-thoracotomy. The current trend indicates that fascial plane blocks will be the standard of care in the next few years.

The popularity of cardiac surgery as a profession has taken a significant hit. Cardiac anesthesiology, too, lost some of its sheens. Several training vacancies are lying vacant. We need to be proactive to attract the right talent to the specialty. The specialty must offer better professional satisfaction to attract the young. There is a need to move from mundane techniques and routine TEE to more challenging research and techniques. There is a need to innovate and disrupt the current status.

India has possibly the most revenue-friendly cardiac surgery program in the world. The rates charged for complex surgeries are perhaps the lowest in the world. We have a large number of technically competent cardiac anesthesiologists in the country. Unfortunately, many cardiac anesthesiologists are still not members of the Indian Association of Cardiovascular Thoracic Anaesthesiologist (IACTA). All practitioners of cardiac anesthesiology in the country should join the IACTA to benefit from its academic activities.

The academic organ of the IACTAs, the 'Annals of Cardiac Anaesthesia' has kept pace with the changing paradigms of cardiac anesthesiology and possibly played a significant role in promoting the change. The variety of topics covered in this issue reflects the different paradigms of the specialty today. The journal has gained a large international readership and regularly receives contributions from all parts of the world.

It is an honor to take over the reins of the Annals of Cardiac Anaesthesia as its Chief Editor. The past editors toiled hard to improve the value and image of the journal, and we are indebted to them. They have handed over a very vibrant journal. The new editorial board hopes to maintain the set standards and scale the journal to greater heights.

References

1Clough RA, Leavitt BJ, Morton JR, Plume SK, Hernandez F, Nugent W, et al. The effect of comorbid illness on mortality outcomes in cardiac surgery. Arch Surg 2002;137:428-32; discussion 432-3.
2Granell M, Petrini G, Kot P, Murcia M, Morales J, Guijarro R, et al. Intubation with VivaSight double-lumen tube versus conventional double-lumen tube in adult patients undergoing lung resection: A retrospective analysis. Ann Card Anaesth 2022;25:279-85.
3Beydoun N, Quraishi SA, Tolman E, Battarjee W, Weintraub A, Cobey F, et al. Association of preprocedural ultrashort-term heart rate variability with clinical outcomes after transcatheter aortic valve replacement: A nested, case-control, pilot study. Ann Cardiac Anaesth 2022;25:318-22.
4Toscano A, Capuano P, Costamagna A, Canavosio FG, Ferrero D, Alessandrini EM, et al. Is continuous erector spinae plane block (ESPB) better than continuous serratus anterior plane block (SAPB) for mitral valve surgery via mini-thoracotomy? Results from a prospective observational study. Ann Card Anaesth 2022;25:286-92.