The Daily Dose • Saturday, March 19, 2022
Cardiovascular Anesthesia Care Across the World: Consistent Considerations, Varying Resources, and Approaches to Care
A panel of experts reviewed common considerations in cardiac care, the range of resources available to perform cardiac surgeries in different settings, and an approach to specialized care for cardiac procedures during the IARS and World Federation of Societies of Anesthesiologists session, “Modern Perioperative Concepts in Patients with Cardiovascular Risk” on Saturday, March 19 at the IARS 2022 Annual Meeting. The pathophysiology and clinical implications of right heart failure along with treatment strategies, the specific challenges of high-complexity care in a low-resource environment and the implications of anesthesia care in patients undergoing transcatheter valve replacements were discussed in detail by Drs. Muralidhar Kanchi, Cornelius Sedagire, and Vera von Dossow.
Muralidhar Kanchi, MBBS, MD, MBA, Narayana Institute of Cardiac Sciences, NH health city, Bangalore, India, started the panel with a discussion of right ventricular (RV) failure and the implications of RV failure. He emphasized that the RV is particularly sensitive to acute increases in afterload, and that RV failure is common and associated with significantly worse outcomes. He outlined that the assessment strategies for RV function can be challenging since they often use invasive monitors. Strategies to assess RV function include measurement of cardiac filling pressures, Pulmonary Artery Pulsatility index (PAPi), pulmonary vascular resistance, transpulmonary gradient, diastolic pulmonary gradient, RV stroke work, RV stroke work index, pulmonary artery (PA) compliance and PA elastance. Deterioration in RV function can also be seen by assessing the waveform of RV pressure loops and echocardiography measurements including tricuspid annular plane systolic excursion (TAPSE), RA area, eccentricity index, RV longitudinal strain (RV LSS), and RV fractional area of change (RV FAC). To improve RV function in patients with severe RV failure, Dr. Kanchi explained that triggering factors should be treated as infection, arrhythmias and thrombosis. This improves RV perfusion, lower RV afterload, optimize RV preload and increase RV contractility by using inhaled pulmonary vasodilators, inotropes, and vasopressors, but when all else fails, mechanical circulatory support is indicated. Options for mechanical circulatory support for acute RV failure include the Impella RP, Tandem RVAD, Protek Duo and VA-ECMO. Dr. Kanchi emphasized that RV function should be a priority in the care of cardiac patients, and considerations to optimize RV function should be made to avoid RV failure and the associated morbidity and mortality.
The next panelist Cornelius Sedagire, MBChB, M.Med, FCA (ECSA), a Cardiac Anesthesiologist and Intensivist at the Uganda Heart Institute and a Lecturer in the Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences and the Secretary-General of the Association of Anesthesiologists of Uganda, presented a talk entitled, “The Challenges of Cardiac Anesthesia in a Low-Resource Country – A Ugandan Experience.” He provided an engaging overview of the Mulago Specialized Referral Hospital in Kampala, Uganda, which includes the Uganda Heart Institute. They have performed over 5,000 cardiac catheterization lab procedures, and have performed over 1,000 open-heart surgeries in the one cardiac OR supported by 3 ICU beds. The types of cardiac cases performed on adults at the Uganda Heart Institute include cardiac catheterizations, percutaneous coronary interventions, electrophysiology procedures, valve surgery, coronary artery bypass grafts, and vascular abdominal aortic aneurysm grafts. For pediatric patients, they have operated on an array of conditions including patent ductus arteriosus (PDA) device closures, diagnostic catheterizations, atrial septal defect (ASD) and ventricular septal defect (VSD) device closures, ASD, VSD, partial anomalous pulmonary venous return /total anomalous pulmonary venous return repairs, tetralogy of Fallot and single ventricle repairs, PDA ligations and coarctation of the aorta repairs. Notably, this one operating room and one catheterization lab center serves all of Uganda, with a population of 45 million people.
Dr. Sedagire emphasized that the World Health Organization (WHO) recommends that for every 2 million people, 1 cardiac center performing 300-500 pediatric cardiac operations annually should be present (Yacoub, 2007). However, in Uganda, one cardiac center performs 100 open-heart surgeries and 200 catheterization procedures annually and supports a population of 45 million people. This highlights a significant access issue for cardiac services in Uganda. This discordant population-to-cardiac care ratio is also an issue with anesthesiologist support for these procedures since there is only one anesthesiologist for every half million people in Uganda, significantly lower than the WHO recommendations of one anesthesiologist for every 100,000 people. The team that serves this cardiac surgical care center comprises a nurse dedicated to the anesthesia team, 2 pediatric cardiac surgeons, 3 adult cardiac surgeons, cardiologists, 5 cardiac OR nurses, 2 perfusionists and 3 biomedical technicians.
He also described additional patient-related, space-related, staff-related, and system-related challenges. Specifically, equipment resource limitations and blood transfusion resources are major roadblocks to productivity and often require the cancellation of cases. With the waitlist reaching up to 300 patients, patient selection is very challenging in this setting of scarce resources. A multidisciplinary team must tackle this issue. Systemic inefficiencies limit the productivity of the group, including the lack of patient database and palliative care services and limited cardiac rehabilitation programs. Dr. Sedagire closed by emphasizing that this major cardiac care access issue in Uganda is multifactorial, but hope, commitment, leadership and partnerships to support the growth of the program has made a considerable impact.
Vera von Dossow, MD, Professor at the Ruhr-University Bochum and Director of the Institute of Anesthesiology and Pain Medicine at Heart and Diabetescenter Bad Oeynhausen, Ruhr-University Bochum in Germany, presented, “Anesthetic Considerations in Patients Undergoing Transcatheter Valve Replacements (TAVR).” She emphasized the importance of a multidisciplinary team of highly skilled individuals including cardiac anesthesiologists. Since 2002, over 50,000 transcatheter aortic valve cases have been performed worldwide. This will only increase due to the burden of the disease and poor prognosis of severe aortic stenosis without therapy of 75% mortality within 3 years of the first symptoms.
Regarding the patient populations for which TAVR is recommended, the ACC/AHA 2020 Guidelines for the Management of Patients With Valvular Heart Disease gave clear recommendations for the open surgical approach for patients younger than 65 years, but recommended either open surgery or TAVR for patients between 65 and 80 years of age. For patients older than 80 years, they recommend TAVR. However, the age thresholds risk categories and associated recommendations are still under debate. The 2021 ESC/EACTS Guidelines recommended that patients younger than 75 years at low risk undergo open surgery, all patients older than 75 years or high risk and suitable for TAVR undergo TAVR, and all other patients undergo either open surgery or TAVR after shared decision-making. Dr. von Dossow went on to explain the key steps of the TAVR procedure and outlined the many complications are possible throughout the procedure including arrhythmia, cardiac shock, bleeding, ventricular rupture, stroke, aortic dissection, and malposition of the graft. To maintain patient safety, the anesthesia management is key including risk evaluation, prophylaxis, monitoring and intervention of hemodynamic instability or complications. Dr. von Dossow also highlighted the risk of delirium postoperatively and the importance of the preoperative risk assessment. She cited a study (Assmann et al., 2016) associating frailty with postoperative delirium and mortality after TAVR to emphasize the importance of preoperative assessment and risk stratification. She then explained how her group has formed the Early Risk Stratification and Strategy Group (ERSAS-Group) to focus on risk stratification, craft a patient-individualized pathway, standardize intraoperative care and manage delirium postoperatively to help optimize and prepare for frail patients.
The Q&A to follow supported a stimulating discussion. Moderator Christian Werner, MD, from Medical Center of Johannes Gutenberg-Universität, Mainz, Germany, moderated the session and opened with a question to Dr. Sedagire. Dr. Sedagire described the Uganda Heart Institute’s procedural program trajectory of growth over time and how the Ugandan government has provided financial support through scholarships for training in anesthesia. Dr. Werner then asked Dr. von Dossow about the trends in TAVR procedures to be even less invasive with monitors and anesthetic techniques and whether an anesthesiologist may even be present for these procedures in the future. Dr. von Dossow replied that items such as central venous access may be another invasive component that may fall by the wayside. However, for patient safety, she asserted that these patients are so high risk that she doesn’t envision safe care not involving anesthesiologists. Dr. Sedagire then answered a question from Dr. Werner regarding the day-to-day resource challenges he and his team face. He said that one of the biggest challenges is drug availability, which can prevent a scheduled case from being performed. He said that to avoid medications expiring and to help ensure supplies are in stock, they aim to have a consistent rate of 7-10 cases being performed per week to better anticipate stock supplies and reduce waste. He also said a main reason for case cancellation is lack of adequate transfusion supplies available for specific blood types. Dr. Werner asked specifically what the WFSA could do to help support safe cardiac surgery in Uganda. Dr. Sedagire explained that the WFSA could provide opportunities for interactions with cardiac anesthesiologists abroad from higher-volume programs and add programs where Ugandan cardiac anesthesiologists can shadow and learn from higher-volume programs.
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