Cardiac anesthesia and TAVR

[Nivens]

What do we think? Seems like the cardiac people I talk to all think we are going to play a critical role, while all the noncardiac people say we won't be needed.

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[deleted171991]

What do we think? Seems like the cardiac people I talk to all think we are going to play a critical role, while all the noncardiac people say we won't be needed.

Cardiac anesthesiologists will play a critical role in the beginning, until cardiologists become really good at it, at which point any anesthesia or sedation provider will suffice. Kind of like in the cath lab.

Cardiac surgery is a dying field. It's just dying slowly so, unless there is some revolutionary treatment for coronary disease, it will take decades. Expect more transcatheter treatments for valvular diseases in the future; we are just scratching the surface, like when stents first appeared.

 

[Direct Laryngoscopy]

Maybe when the SHTF we will be appreciated and needed thereafter. Some places pride themselves on minimally invasive techniques (unsecured airway, no TEE), but in a lot of cases these patients are sick with mutiple co-morbidities. And all it takes is 1 case where there is an unwanted outcome, and the Monday morning QB M and M, then you may see changes.

I personally like a secure airway and TEE. Doesn't mean someone else's technique is better, wrong or otherwise. I feel that although sometimes less is more in these sick pts, I like having a secure airway and TEE may be in the patient's best interest.


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[AdmiralChz]

Cardiac anesthesiologists will play a critical role in the beginning, until cardiologists become really good at it, at which point any anesthesia or sedation provider will suffice. Kind of like in the cath lab.

Cardiac surgery is a dying field. It's just dying slowly so, unless there is some revolutionary treatment for coronary disease, it will take decades.

Perhaps, but people have been saying cardiac surgery has been dying since the '80s. With so many universities and major hospitals building cardiac pavilions with specialized ORs I am not sure.

Also a record number (by a significant margin, although specific data isn't yet out) of cardiac fellowship applicants this year would argue many others feel it's a good career / professional development path.

 

[Mman]

Perhaps, but people have been saying cardiac surgery has been dying since the '80s. With so many universities and major hospitals building cardiac pavilions with specialized ORs I am not sure.

It is decreasing in volume despite a growing and aging population. From 2001-2008, there was a decrease in the number of CABGs performed in the US from 1700 per 1,000,000 adults to 1000 per 1,000,000 adults.

Cardiac surgery isn't dead, but it's continuing to be less common over time.

 

[OB1🤙]

Cardiac anesthesiologists are indispensable for these cases.

We do them with MAC. No dedicated lines, no Foley, no TEE.

It's all hunky dory until the excrement hits the rotational cooling device.

Then we are absolutely necessary.

So you could them with any schmoe in the case with a cardiac person sitting around on standby doing nothing waiting for a disaster, but that would be pretty inefficient.

Note that when I say "cardiac person," I mean an anesthesiologist comfortable with doing hearts and comfortable with resuscitating this cohort of patients.

 

[OB1🤙]

in a lot of cases these patients are sick with mutiple co-morbidities.

These are the folks who benefit the most from MAC.

 

[Nivens]

Speaking of CABG, is there a trend toward off-pump procedures at all? Seems like that would be sketchy-er for sure from our end.

 

[BLADEMDA]

SEPTEMBER 1, 2016
For TAVR, Lower Mortality Using Moderate Sedation Versus General Anesthesia


Is moderate sedation safer than general anesthesia for transcatheter aortic valve replacement (TAVR), or is it that lower-risk patients are more likely to receive moderate sedation? That is the question raised by a new 11,000-patient study that found 30-day mortality rates were 38% lower among TAVR patients who received moderate sedation than those who were administered general anesthesia.

“These results support our hypothesis that moderate sedation can lead to better clinical outcomes, and could have significant implications for patient care and for the process of the TAVR procedure,” said senior author Jay Giri, MD, MPH, assistant professor in the Cardiovascular Medicine Division at the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia.

http://www.anesthesiologynews.com/C...tion-Versus-General-Anesthesia/37676/ses=ogst

 

[pgg]

SEPTEMBER 1, 2016
For TAVR, Lower Mortality Using Moderate Sedation Versus General Anesthesia


Is moderate sedation safer than general anesthesia for transcatheter aortic valve replacement (TAVR), or is it that lower-risk patients are more likely to receive moderate sedation? That is the question raised by a new 11,000-patient study that found 30-day mortality rates were 38% lower among TAVR patients who received moderate sedation than those who were administered general anesthesia.

“These results support our hypothesis that moderate sedation can lead to better clinical outcomes, and could have significant implications for patient care and for the process of the TAVR procedure,” said senior author Jay Giri, MD, MPH, assistant professor in the Cardiovascular Medicine Division at the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia.

http://www.anesthesiologynews.com/C...tion-Versus-General-Anesthesia/37676/ses=ogst

Wake me up when they do something prospective and randomized. There are multiple reasons why the GA group in a retrospective chart crawl would have a higher mortality rate. All the statistical massaging in the world can't erase selection bias that doesn't make it into the chart as a hard number.

 

[AdmiralChz]

Interestingly, at our institution have had a series of TAVRs gone quite poorly. If the CT anesthesia team wasn't in the room the patients 100% would have died, and we are a high-volume TAVR center. When things go poorly everyone just sort of looks at each other debating whether to crack the chest - only those at the head of the bed are actively supporting hemodynamics. Would you trust that to a cath lab sedation RN?

 

[Man o War]

Interestingly, at our institution have had a series of TAVRs gone quite poorly. If the CT anesthesia team wasn't in the room the patients 100% would have died, and we are a high-volume TAVR center. When things go poorly everyone just sort of looks at each other debating whether to crack the chest - only those at the head of the bed are actively supporting hemodynamics. Would you trust that to a cath lab sedation RN?

Yep. These can and do go sideways on a regular basis if you do enough of them.

 

[Planktonmd]

Interestingly, at our institution have had a series of TAVRs gone quite poorly. If the CT anesthesia team wasn't in the room the patients 100% would have died, and we are a high-volume TAVR center. When things go poorly everyone just sort of looks at each other debating whether to crack the chest - only those at the head of the bed are actively supporting hemodynamics. Would you trust that to a cath lab sedation RN?

Are you implying that only anesthesiologists who sit in cardiac rooms doing nothing while people have surgery on bypass can resuscitate a patient with acute valve injury?
The other anesthesiologists are just dangerous *****s aren't they?

 

[caligas]

Are you implying that only anesthesiologists who sit in cardiac rooms doing nothing while people have surgery on bypass can resuscitate a patient with acute valve injury?
The other anesthesiologists are just dangerous *****s aren't they?

Wow, that's a leap from what he said.

 

[AdmiralChz]

Wow, that's a leap from what he said.

Thanks, Plankton read my post again. Was mostly saying anesthesiology involvement was an improvement over RN-led sedation as in a traditional cath lab. But interpret as you will I suppose.

 

[Notorious T.E.E.]

Are you implying that only anesthesiologists who sit in cardiac rooms doing nothing while people have surgery on bypass can resuscitate a patient with acute valve injury?
The other anesthesiologists are just dangerous *****s aren't they?

While I don't think he was saying anyone was a dangerous ***** (other than a cath lab sedation RN) I think that I would agree that when a TAVR turns into an emergent AVR, a cardiac anesthesiologist will be the best choice. The question is how often that will happen. In the cath lab when a pericardial effusion or coronary dissection turns the case into a CABG a cardiac anesthesiologist is the best choice, but it isn't practical to have one for every cath. TAVRs will likely go this same route over time.

 

[Planktonmd]

I guess I am a little fed up with that pompous attitude of some "subspecialists" who convinced themselves that doing a year's worth of certain type of cases under direct supervision, has made them so much smarter than the rest of us!
Sorry for the knee jerk reaction.