VOLUME 29, ISSUE 2

In the preamble section, the authors make the following statement: “The ACC/AHA practice guidelines are intended to assist clinicians in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circum- stances. The ultimate judgment about care of a particular patient must be made by the clinician and patient in light of all the circumstances presented by that patient. As a result, situations may arise in which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. “¹

A new addition to the guidelines, section 15 “Noncardiac Surgery in Patients With VHD,” is relevant to practicing anesthesiologists. This section details how patients with VHD should be managed for elective and emergent surgery. In regards to emergent noncardiac surgery, the taskforce suggests in the supportive text that patients with severe left sided valvular stenosis “should be managed by a cardiovascular anesthesiologist with invasive hemodynamic or TEE imaging monitoring intraoperatively and remain in an intensive monitoring setting for 48 to 72 hours postoperatively.” The taskforce goes into greater detail in their recommendations for patients with VHD undergoing elective noncardiac surgery. The taskforce gives a Class IIa (Benefit outweighs risk, additional studies needed.) recommendation for performing moderate-risk noncardiac surgery with appropriate intraoperative and postoperative monitoring in patients with asymptomatic severe aortic stenosis, aortic regurgitation with a normal left ventricular ejection fraction, and mitral regurgitation (Level of evidence: B, C and C respectively). Moderate-risk elective noncardiac surgery in patients with asymptomatic severe mitral stenosis in patients not amenable to percutaneous balloon mitral commissurotomy was given a Class IIb recommendation with appropriate intraoperative and postoperative monitoring (Level of evidence C). ¹

The collaboration among cardiac anesthesiologists, cardiologists, and other physicians in creating these thoughtful recommendations was invaluable. From the perspective of a cardiovascular anesthesiologist, it is reasonable to appreciate the value of subspecialty training and experience to manage these challenging patients. However, as an anesthesiologist, I wonder if we are undervaluing the skills and training of all anesthesiologists, regardless of subspecialization. Indeed, as the taskforce wisely mentioned in the above quoted text, “ultimate judgment” about the care of the patient must be made by the clinician. A consultant in anesthesiology is trained to assess a patient and decide the best plan for anesthesia care and monitoring for that patient whether it is an emergency or an elective case.

Guidelines and recommendations help physicians care for patients in an evidence-based fashion. Suggesting certain patients be cared for by subspecialists or implying that adverse outcomes can be avoided by utilizing invasive arterial and venous monitoring, following wedge pressures, and/or using TEE (which may limit who can care for these patients) based on limited evidence (Level B: evidence derived from a single randomized trial or nonrandomized studies, Level C: only case studies or expert opinions.), potentially limits our ability to care for these patients. As consultants in anesthesia, we need to continue to be able to evaluate each patient and develop the appropriate anesthetic plan based on the available evidence. As anesthesiologists evolve into perioperative clinicians, we need continued collaboration with our medical and surgical colleagues, as we did with these guidelines, to ensure that the breadth of our field is represented.