cardiac and regional in practice?

[sandwiches9]

Hi, I'm a CA-2 resident trying to decide what to do with the rest of my life. I enjoy cardiac and would like to do the fellowship, but I would also like to practice regional as part of my career. Is that something that is actually possible in the real world? (private practice-- I'm assuming in academics I would be pigeonholed into hearts only..) Or are people pigeonholed into their fellowship sub-specialty no matter what?

Unrelated - is it true that cardiac anesthesia is less in-demand because procedures are increasingly interventional as opposed to open, and the incidence of cardiac disease is going down because of better primary care? Is regional the new hot thing that everyone wants? I know I'm just supposed to do whatever I really really want to do and fellowship costs a year of attending salary etc etc.. just trying to get a feel for what the zeitgeist is.

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[T-burglar]

Ironically a cardiac fellowship may open up more private practice doors for you. Doors to practices that do lots of regional as well, since regional is kind of bread and butter private practice. I wouldn’t have my job in my current group where I do everything if I wasn’t able to do cardiac.

Also ironically, the explosion of structural trancatheter interventions and complicated EP like lead extractions and VT ablation is creating a lot of demand for the cardiac subsection in my private group.

 

[Dexmetaketapropofol]

My practice is actually mimicking the same interests you have. I work in the Southeast US, so we get a lot of snowbirds. It is private practice, but all the attendings are cardiac trained, so cardiac call and general call is the same person. We practice heavy on cardiothoracic, ortho, vascular, structural heart, etc. (all the old people surgeries). A common day for me is to supervise 3-4 rooms: 1 open heart, 2 general, 1 ortho. If I'm doing structural heart, then I'll mainly focus on that as the TEE. Or ortho day which can be 2 ortho rooms, etc. Plenty of regional and cardiac to go around.

Your time is better spent doing the cardiac fellowship IMHO to help with the structural heart cases and complex echo. Regional is really not that complicated for the vast majority of blocks to warrant an entire fellowship year in it IMO.

 

[nimbus]

Some of our cardiac guys are also our most prolific blockers.

 

[B-Bone]

I work in a practice like this. I did not do a fellowship, but do cardiac cases. Most days, I just do a general mix of cases (everything except sick kids and transplant). The other day I did a CAB in the morning, with a bunch of ortho/general surgery in the afternoon. I ended up doing 3 interscalenes, two adductors, 5 spinals, two labor epidurals, and a thoracic epidural before I went home. Long day. I think my group is pretty unique though, and we have hired a few CT-trained folks over the past few years. Going forward, probably best to to CT fellowship if you want to do hearts. At least in market, the CT people all do general OR cases in PP. Just not that many hearts to go around. In academics, I think more people do hearts ONLY, but I still know several academic CT guys that do a wide variety of stuff (though mostly hearts).

 

[deleted171991]

Hi, I'm a CA-2 resident trying to decide what to do with the rest of my life. I enjoy cardiac and would like to do the fellowship, but I would also like to practice regional as part of my career. Is that something that is actually possible in the real world? (private practice-- I'm assuming in academics I would be pigeonholed into hearts only..) Or are people pigeonholed into their fellowship sub-specialty no matter what?

Unrelated - is it true that cardiac anesthesia is less in-demand because procedures are increasingly interventional as opposed to open, and the incidence of cardiac disease is going down because of better primary care? Is regional the new hot thing that everyone wants? I know I'm just supposed to do whatever I really really want to do and fellowship costs a year of attending salary etc etc.. just trying to get a feel for what the zeitgeist is.

Disclaimer: I am not a cardiac anesthesiologist, but I have worked in PP. To answer your questions:

Do a cardiac fellowship. THAT's worth it. Skip the regional one. THAT's usually useless, as in you can easily learn all the blocks you need with some initial handholding from your partners. (You should have actually chosen your residency based on a decent exposure to regional anesthesia, too; it IS the shiny new thing, especially in the non-opiate era.) You will be able to practice both regional and cardiac in PP.

Current cardiac anesthesia demand WILL disappear, with a more than 50% probability, but it may take decades. Once these interventional procedures become everyday, with low risk of complications, they will be done by any anesthesia provider, as all the EP lab procedures already are. Open heart surgeries are here to stay for a while; cardiac disease is going up, not down, with the "healthy" lifestyle and diet of the American people and their longer lives. Stents don't fix everything, and don't work forever. Even if cardiac surgery volume dropped, cardiac anesthesiologists are uniquely prepared to deal with the worst anesthesia catastrophes, so they will always have a job, as long as they are open to learning new skills (such as regional).

 

[sandwiches9]

Thanks everyone for your replies! This was very helpful.

 

[T-burglar]

Current cardiac anesthesia demand WILL disappear, with a more than 50% probability, but it may take decades. Once these interventional procedures become everyday, with low risk of complications, they will be done by any anesthesia provider, as all the EP lab procedures already are. Open heart surgeries are here to stay for a while; cardiac disease is going up, not down, with the "healthy" lifestyle and diet of the American people and their longer lives. Stents don't fix everything, and don't work forever. Even if cardiac surgery volume dropped, cardiac anesthesiologists are uniquely prepared to deal with the worst anesthesia catastrophes, so they will always have a job, as long as they are open to learning new skills (such as regional).

This is maybe applicable to TAVR, which can be done with fluoro and a transthoracic in MOST cases. But complicated and alternative access TAVR will usually require TEE. Transcatheter interventions on the atrial septum, ventricular septum, mitral and tricuspid, atrial appendage etc. are PRIMARILY TEE guided and it doesnt matter if you can otherwise do them with local and some benadryl for sedation (you can't) because someone will have to be there guiding the procedure with TEE. Likewise with high risk lead extractions and wireless pacers, TEE is needed if you care about your patients. There is even work being done on total endovascular bentall procedures. The sky is apparently the limit on TEE guided procedures.

The real question is, will interventional echo ever become lucrative enough by itself that cardiology will want to do it. Because as it stands, they don't, and they love having CT anes around to do it.

 

[AdmiralChz]

This is maybe applicable to TAVR, which can be done with fluoro and a transthoracic in MOST cases. But complicated and alternative access TAVR will usually require TEE. Transcatheter interventions on the atrial septum, ventricular septum, mitral and tricuspid, atrial appendage etc. are PRIMARILY TEE guided and it doesnt matter if you can otherwise do them with local and some benadryl for sedation (you can't) because someone will have to be there guiding the procedure with TEE. Likewise with high risk lead extractions and wireless pacers, TEE is needed if you care about your patients. There is even work being done on total endovascular bentall procedures. The sky is apparently the limit on TEE guided procedures.

The real question is, will interventional echo ever become lucrative enough by itself that cardiology will want to do it. Because as it stands, they don't, and they love having CT anes around to do it.

Eh, I’ve been underwhelmed by structural (cath lab) TEE-guided procedures. They’re cool cases, but the TEE isn’t much more than a “yeah, you’re on the right track” or “nope not there.” I’m really underwhelmed by the reimbursement, which isn’t measurably more than for a general case. Happy to let the cardiology folks do it, just doesn’t move the needle much for us.

 

[psychbender]

It's also interesting in seeing regional trends on the newer transcatheter procedures, and who is doing the TEE. Where I did CCM fellowship, the CT anesthesia fellows were almost never involved in TAVR, MitraClip, etc cases. So, for residents thinking about the future, not all fellowships are created equal. If your future job will include these cases, then train somewhere that you will actually be involved with these cases.

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[sevoflurane]

Hi, I'm a CA-2 resident trying to decide what to do with the rest of my life. I enjoy cardiac and would like to do the fellowship, but I would also like to practice regional as part of my career. Is that something that is actually possible in the real world? (private practice-- I'm assuming in academics I would be pigeonholed into hearts only..) Or are people pigeonholed into their fellowship sub-specialty no matter what?

Unrelated - is it true that cardiac anesthesia is less in-demand because procedures are increasingly interventional as opposed to open, and the incidence of cardiac disease is going down because of better primary care? Is regional the new hot thing that everyone wants? I know I'm just supposed to do whatever I really really want to do and fellowship costs a year of attending salary etc etc.. just trying to get a feel for what the zeitgeist is.

Do the CT fellowship. Focus on structural. TAVR, mitral clip, watchmen, MVIV, perc septal procedures and lots of surgical valves.

I’m 40% cardiac, 40% regional, 20% OB/trauma/spine/ped/gen surgery.

A long day of SSB and Catheters is def. busier than 2-3 hearts.

Great mix IMO.

 

[narcotics999]

My practice is actually mimicking the same interests you have. I work in the Southeast US, so we get a lot of snowbirds. It is private practice, but all the attendings are cardiac trained, so cardiac call and general call is the same person. We practice heavy on cardiothoracic, ortho, vascular, structural heart, etc. (all the old people surgeries). A common day for me is to supervise 3-4 rooms: 1 open heart, 2 general, 1 ortho. If I'm doing structural heart, then I'll mainly focus on that as the TEE. Or ortho day which can be 2 ortho rooms, etc. Plenty of regional and cardiac to go around.

Your time is better spent doing the cardiac fellowship IMHO to help with the structural heart cases and complex echo. Regional is really not that complicated for the vast majority of blocks to warrant an entire fellowship year in it IMO.

1:4 supervision including a open heart room?

 

[sevoflurane]

Eh, I’ve been underwhelmed by structural (cath lab) TEE-guided procedures. They’re cool cases, but the TEE isn’t much more than a “yeah, you’re on the right track” or “nope not there.” I’m really underwhelmed by the reimbursement, which isn’t measurably more than for a general case. Happy to let the cardiology folks do it, just doesn’t move the needle much for us.

You ever done a mitral clip?

 

[T-burglar]

Eh, I’ve been underwhelmed by structural (cath lab) TEE-guided procedures. They’re cool cases, but the TEE isn’t much more than a “yeah, you’re on the right track” or “nope not there.” I’m really underwhelmed by the reimbursement, which isn’t measurably more than for a general case. Happy to let the cardiology folks do it, just doesn’t move the needle much for us.

Theeeeeres a little more to it than that. And a 4 TAVR day is 60 units before time and lines.

 

[GA8314]

Aren't the cardiologists doing the TEE's for the TAVRs and mitral clips??

 

[Dexmetaketapropofol]

1:4 supervision including a open heart room?

Depends, usually 3, sometimes 4 if it's busy during winter season

 

[AdmiralChz]

You ever done a mitral clip?

Yeah, not my favorite. We have much better results from our mini mitrals and they go home in 3 days.

Theeeeeres a little more to it than that. And a 4 TAVR day is 60 units before time and lines.

EDIT: I wasn’t referring to TAVRs, which pay reasonably well (we don’t get that many units though?) especially if we have the odd patient with commercial insurance. Although it was much more lucrative I’m told when it was GA, A-line, CVL and TEE. Now we do MAC/a-line only. I was talking more about watchman, ASDs and other true structural which do no more for us than bronchs and EP work.

All about your insurance. Add in no commercial insurance / Medicare which is 80+% of cath lab and it’s a downer when you hit the books.

I’m just talking from a strictly business/practice standpoint, not really an anesthesia point of view. We recently acquired a lot of these cath lab procedures from another fading practice... and we’re having somewhat of buyers remorse. The previous group did it MD only, which we are doing for now.

 

[deleted171991]

1:4 supervision including a open heart room?

That's the real (as in GREEDY) world for you. If you can still find a mostly 1:2 job, count yourself blessed.

Btw, we, the bad guys, the pessimists, the losers, the you name it, have been predicting this, despite all the insults and the naysayers. In my area, 1:3 is becoming the norm, even in academia.

What kind of a joke of supervision can happen with 1:4 coverage, especially if one is a heart room? Welcome to the anesthesia fire station of the future, with quasi-independent CRNA practice, the worst of both worlds.

 

[Dexmetaketapropofol]

Well, I won't take it as an insult, as you're implying my practice to be "a joke." Instead, I'll just tell you how I do 1:4 with a heart room. I've been doing it for years and I'm quite happy with the practice.

645: Preop the heart
650-710: Preop the next 2 cases which will have staggered starts ranging from 8 to 830am
715: Start the heart with performing the lines and TEE
800: Start the other 2 cases I saw earlier, often easy rooms requiring LMA or GETA, spinal for hips or knees if ortho
900: Start the 4th case

The vast majority of the time after induction, the anesthetic plan is discussed and everything is uneventful. This is with me doing all the invasive lines or blocks. IF I need to do a preop block then I'll adjust accordingly (shoulder, adductor canal, etc) in the AM. If it is a high turnover room, we don't include that with our heart rooms. If it's a TAVR, Mitraclip, Structural room, we just do that one room until the cases are done as the TEE jockey.

All the CRNAs I work with follow the plan we discuss and I am present for emergence and extubation as well. It's a busy day, no doubt about it. One thing it is not, however, is a joke...

 

[pjl]

Today I did a cardiac case, 2 peds cases and an ortho case with block.
Normally my day is less of a grab bag, but we definitely have a chance to do both cardiac and regional.

That is at a generalist PP spot. We have cardiac fellowship people, but not everyone who does hearts did a fellowship. Cardiac is definitely the fellowship we would prefer in applicants though, but no fellowship is required.

 

[sevoflurane]

Aren't the cardiologists doing the TEE's for the TAVRs and mitral clips??

Not around here.

 

[sevoflurane]

Yeah, not my favorite. We have much better results from our mini mitrals and they go home in 3 days.

My point is that Mitral Clips are exceptionally TEE dependent.

 

[T-burglar]

My point is that Mitral Clips are exceptionally TEE dependent.

Yes they are not just TEE dependent they are TEE mandatory and all the stuff coming down the pipeline for the tricuspid and mitral space will all be TEE mandatory. And the regulatory bodies have already conceded that the TEE component should be a 7unit unbundled reimbursable component , it’s just taking a long time to finalize with insurance companies or whatever. Structural rooms pay really well if you have operators that can bang out a couple in reasonable time. And are poised to provide even more capturable income for your group from the structural TEE cot code if you take control of the TEEs in your shop.

 

[Robotic Wis-Hipple]

My point is that Mitral Clips are exceptionally TEE dependent.

Not to mention we aren’t comparing results of a MitraClip and a surgical repair. Just not the same endpoints

 

[Dexmetaketapropofol]

Not around here.

One of my most favorite days at work was watching our TEE cardiologist "guru" fumble through a Mitraclip. He had no concept of directing the catheter or getting unconventional views that would aid in visualization. Needlesstosay, he never came back to do them after that day again, lol

 

[sevoflurane]

One of my most favorite days at work was watching our TEE cardiologist "guru" fumble through a Mitraclip. He had no concept of directing the catheter or getting unconventional views that would aid in visualization. Needlesstosay, he never came back to do them after that day again, lol

Yeah man. I am a firm believer that we should own structural heart tee. As a specialty we need to push for it.

Knowing anterior/posterior, lateral/medial orientation and septal puncture height should be fast and easy for us to determine. If not, then we look bad and are not helping.

 

[Dexmetaketapropofol]

We're doing a lot more tricuspid position clips and having to get a little creative with the views. With the one I had today, The biatrial enlargement was approx 7cm, causing a lot of rotation. Trying to avoid overshadowing artifact using some transgastric views, we got the job done. It was fun!

 

[sevoflurane]

Nice...
Sounds fun... even more so if HVF normalized.

 

[Dexmetaketapropofol]

Didn't normalize, but went from reversal to blunting. Which was a helluva difference, so mission accomplished!

 

[sevoflurane]

Didn't normalize, but went from reversal to blunting. Which was a helluva difference, so mission accomplished!

Yeah buddy. Love that $hit.
Nice work.

 

[sevoflurane]

Since we are talking echo on this board... any of you young studs want to take a guess at what we are looking at here?

TTE:

TEE:

Kind of a zebra... but echo nerdiness at its best.

 

[Dexmetaketapropofol]

I'll take a stab at the risk of looking silly...

I don't see any obvious identifiable cardiac structures. Depending on how you're rotating the probe, I would guess pleural effusion with compressive atelectasis and likely loculated pleural effusion vs empyema in your measurement sector.

I could be totally wrong, but it's a still image with no omniplane angle and the image is cutting out the near sector proximal to the probe...

 

[Man o War]

Since we are talking echo on this board... any of you young studs want to take a guess at what we are looking at here?

TTE:

TEE:

Kind of a zebra... but echo nerdiness at its best.

Hmmm toughie from the static picture.
Pseudo aneurysm of the aortic root?

 

[Dexmetaketapropofol]

Hmmm toughie from the static picture.
Pseudo aneurysm of the aortic root?

I didn't even see that he wrote TTE and TEE! I thought they were both TEE pictures... Ok assuming that's LVOT then yes, there's clearly Ao root pathology anterior to the RCC in the long axis view...my bad. Would be nice to see color flow! Cool pictures

 

[sevoflurane]

@Man o War , @Dexmetaketapropofol

Pretty close...

@pgg @Hawaiian Bruin @sethco
@nimbus

Maybe the cath will help a little.

 

[sevoflurane]

(Might have to follow the link)

 

[Man o War]

(Might have to follow the link)

I’ve only seen a couple in my entire career, but my next guess would be a right coronary artery aneurysm. Would definitely call that a zebra.
Good post.

 

[deleted171991]

Well, I won't take it as an insult, as you're implying my practice to be "a joke." Instead, I'll just tell you how I do 1:4 with a heart room. I've been doing it for years and I'm quite happy with the practice.

645: Preop the heart
650-710: Preop the next 2 cases which will have staggered starts ranging from 8 to 830am
715: Start the heart with performing the lines and TEE
800: Start the other 2 cases I saw earlier, often easy rooms requiring LMA or GETA, spinal for hips or knees if ortho
900: Start the 4th case

The vast majority of the time after induction, the anesthetic plan is discussed and everything is uneventful. This is with me doing all the invasive lines or blocks. IF I need to do a preop block then I'll adjust accordingly (shoulder, adductor canal, etc) in the AM. If it is a high turnover room, we don't include that with our heart rooms. If it's a TAVR, Mitraclip, Structural room, we just do that one room until the cases are done as the TEE jockey.

All the CRNAs I work with follow the plan we discuss and I am present for emergence and extubation as well. It's a busy day, no doubt about it. One thing it is not, however, is a joke...

My disrespect is not for your volume of work; on the contrary, you have my deepest appreciation. It's for the concept of 1:4 medical direction. Just because nothing bad happens to the patients doesn't mean they get excellent care, no offense, and I am talking about all those little things a good anesthesiologist is anal about and most CRNAs aren't.

 

[nimbus]

I’ve only seen a couple in my entire career, but my next guess would be a right coronary artery aneurysm. Would definitely call that a zebra.
Good post.

Wild guess...aortic root pseudoaneurysm. It fills late and there’s no distal coronary runoff.

Edit:..didn’t see your first guess

 

[Dexmetaketapropofol]

My disrespect is not for your volume of work; on the contrary, you have my deepest appreciation. It's for the concept of 1:4 medical direction. Just because nothing bad happens to the patients doesn't mean they get excellent care, no offense, and I am talking about all those little things a good anesthesiologist is anal about and most CRNAs aren't.

There is truth in missing the nuances when supervising at that ratio. I try to mitigate it by creating these small cards when a new CRNA starts to work with me. I'm sure when they get them from me on the first day they think I'm crazy, but after a while, they appreciate the practice.

The cards include when they absolutely need to call me and not try to troubleshoot on their own. They include things such as eye care, ETT securing, mouth care in prone position, TIVA, tons of stuff. The new CRNAs end up learning a lot. The old ones I'm sure get offended. When they get offended by saying things like "this isn't my first rodeo" I openly tell them and the entire population of the OR that if a case goes to litigation, I'm sure my bill will be higher than theirs so I get it my way.

I actually prefer getting a bright eyed CRNA straight from training who is insecure about everything than an CRNA who thinks they can intubate anyone...

 

[sethco]

Had this happen a couple weeks ago on call

@sevoflurane Am I getting close

 

[deleted171991]

There is truth in missing the nuances when supervising at that ratio. I try to mitigate it by creating these small cards when a new CRNA starts to work with me. I'm sure when they get them from me on the first day they think I'm crazy, but after a while, they appreciate the practice.

The cards include when they absolutely need to call me and not try to troubleshoot on their own. They include things such as eye care, ETT securing, mouth care in prone position, TIVA, tons of stuff. The new CRNAs end up learning a lot. The old ones I'm sure get offended. When they get offended by saying things like "this isn't my first rodeo" I openly tell them and the entire population of the OR that if a case goes to litigation, I'm sure my bill will be higher than theirs so I get it my way.

I actually prefer getting a bright eyed CRNA straight from training who is insecure about everything than an CRNA who thinks they can intubate anyone...

Wow!!! I would LOVE to be able to do the same thing. I remember even mentioning it on the forum, years ago, using the concept of preference cards for the surgeons. I can also tell you that 95% of the practices I know would kick me out if I did this. It's much harder to hire a CRNA than an anesthesiologist, so gods forbid you upset the syndicate. Where I work now it's as close to a team effort as I have seen, and militant CRNAs are encouraged to leave, but gods forbid one comes close to micromanaging them. Whenever I tried to do that in my less than 10 years of practice, I was on the losing end.

 

[sevoflurane]

View attachment 240683

Had this happen a couple weeks ago on call

@sevoflurane Am I getting close

Very close...

 

[Dexmetaketapropofol]

Wow!!! I would LOVE to be able to do the same thing. I remember even mentioning it on the forum, years ago, using the concept of preference cards for the surgeons. I can also tell you that 95% of the practices I know would kick me out if I did this. It's much harder to hire a CRNA than an anesthesiologist, so gods forbid you upset the syndicate. Where I work now it's as close to a team effort as I have seen, and militant CRNAs are encouraged to leave, but gods forbid one comes close to micromanaging them. Whenever I tried to do that in my less than 10 years of practice, I was on the losing end.

It's not even close to 100% effective, but it works. For example, when I get a CRNA who gives inadequate muscle relaxant or over does the opioids, or extubates prematurely or does anything inadequate or harmful, I publish the case to a private google groups account for our practice so all the other attendings and CRNAs see it. I keep the providers anonymous and ask input from the others about what they would do differently. We then discuss what approaches would have been more effective.

It ends up showing the involved CRNA what went wrong and how their own peers react and would do things differently, instead of hearing it from a physician. All the mechanisms of action, pharmacokinetics and evidence based practice may not be discussed each time, but the message gets across.

This has been the only way I've seen seasoned CRNAs see what they do wrong and try it a different way without attitude. Another thing I also strive to push is attitude and humility. There will always be people who go against the grain, but they sure feel awkward when everyone else flies the other direction together.

 

[anbuitachi]

Since we are talking echo on this board... any of you young studs want to take a guess at what we are looking at here?

TTE:

TEE:

Kind of a zebra... but echo nerdiness at its best.

that's clearly a fetus

 

[AdmiralChz]

Sinus of valsalva aneurysm?

 

[DM27]

I second sinus of valsalva.

 

[sevoflurane]

Bingo!

Nice job guys.

This is the absolute biggest SOVA I have ever seen. It was a monster.

Most common SOVA (congenital or acquired) is that of the right SOV which we see here.

Mine was not ruptured, but @sethco might have been.

Repair was almost identical to this:



Amazing the stuff you see in this field.

 

[Arch Guillotti]

The cards include when they absolutely need to call me and not try to troubleshoot on their own. They include things such as eye care, ETT securing, mouth care in prone position, TIVA, tons of stuff.

Serious questions:

Where are you when they put the ET tube in?

Why do they need to call you to secure an ET tube?

 

[sethco]

Bingo!

Nice job guys.

This is the absolute biggest SOVA I have ever seen. It was a monster.

Most common SOVA (congenital or acquired) is that of the right SOV which we see here.

Mine was not ruptured, but @sethco might have been.

Repair was almost identical to this:



Amazing the stuff you see in this field.

Nice.

I couldn't get the Cath images to load on my phone. My guess would have been either SOV Aneurysm, RCA Aneurysm, or Abscess/Fistula.

My image above was a CABG X 1 emergency for the worst RCA Aneurysm I have ever seen