VOLUME 30, ISSUE 1

I am about to retire from full time practice and have been asked what my thoughts are concerning my over 40 year association with cardiovascular anesthesiology (CVA). Honored by this request, I pondered, well, what do I think; what have I seen?

First, I have always been grateful for the seemingly happenstance events that let me be a part of the progression of the subspecialty. These were primarily an association with certain people with one association leading to another in a seemingly random but fortuitous (for me) pattern. The first of these events was meeting Dr. James Arens, who is well known for his many accomplishments in Texas and beyond and someone I have frequently attempted to emulate. As an admirer of many things Arens, and being a fellow in Jim’s program at the University of Mississippi, I found a direct lead into an association with Arthur Keats, Steven Slogoff, Denton Cooley and the Texas Heart Institute (THI). This was first as a rotating fellow in 1975 and then as a faculty member of the Division of Cardiovascular Anesthesia in 1978. I have remained at Texas Heart up to the present. This has afforded me a somewhat unique and involved perspective on the evolution of CVA. The following represent a few of the observations I have made.

In the mid 1970’s CVA was just beginning to be thought of as a subspecialty. While In the 1960s, “hearts” were restricted to valve replacements, congenital operations, thoracic aneurysms in larger programs and included the first foray into transplantation in a select few. In most hospitals cardiac anesthesia was handled by a majority of the members of a department just as pediatric or obstetrical anesthesia was also. This changed. The primary impetus behind the development of CVA was the explosion in the number of cardiac cases that began in the early 70s because of use of coronary artery bypass as therapy for ischemic heart disease, while the numbers of valve and congenital cases remained relatively level. In larger programs especially, this led to either defacto or de jurie restriction of “hearts” to certain members of a department as the numbers of cases climbed. Often, these individuals were younger departmental members who showed an interest in the many clinical problems encountered and aggressively pursued solutions. These physicians were uncommonly fellowship trained at first. This obviously segregated those departmental members, and the individuals began to think of themselves as cardiac anesthesiologists.

Anesthetic techniques shifted. There has always been a constant, though often slow, evolution in anesthetic technique in response to many clinical issues. One of these, maintenance of clinical stability particularly prior to bypass, was a common problem in CVA in the 1960s and 1970s and directly led many programs to a primarily narcotic-based anesthesia as a “new” technique, especially after Lowenstein’s famous paper¹. At first accomplished with high dose morphine and later with, the then new drug, fentanyl and little to no volatile anesthestic. This technique became standard management for many and, to at least some degree, has remained viable to this day. There was a further progression from high dose fentanyl to higher doses to very high doses (to reduce the “stress response” of course). Interestingly, this approach rapidly changed again in the 1990s as managed care and “fast tracking” patients to reduce costs became popular and the prolonged intubation times which were previously desired for cardiac cases became a problem when early extubation was a newly desired goal. (Of note, we had never adopted the prolonged ventilation approach at THI, with all routine cases being “fast tracked” but without the name since the 1970s. I use the same dose of fentanyl in 2017 for most pump cases as I used in 1978.)

Evolution of drug availability and therapy has also been a constant factor in CVA, with, for instance, use of intravenous propranolol being viewed with suspicion in the 1970s to the everyday use of beta blockade today. Introduction of new drug therapy has been steady. For instance, intravenous nitroglycerin, dopamine, dobutamine, vasopressin, milrinone, nicardipine, PGI 2 (Flolan), nitric oxide, desmopressin, Factor VIIa, and prothrombin complex concentrates have been introduced since 1978. Today, my trainees are shocked when I mention that most of these were not around in the 1980s. Likewise, a high dose morphine and fentanyl, metaraminol, pancuronium, ganglionic blockers, everyday use of nitroprusside, amrinone and aprotinin, among others, all common in the 1970’s, 80s, or 90’s have come and gone.

Clinical advances in anesthesia in general, many still in use, were a direct result of initial work in CVA during those early years. Examples would include routine use of the V5 electrocardiogram lead for enhanced ischemia monitoring beginning in the late 1970s and transesophageal echocardiography in the late 1980s. Echocardiography itself began with uniplane probes. Biplane, then multiplane and, most recently, three-dimensional modes have been added. Pulmonary artery catheterization, introduced at the beginning of expansion of cardiac anesthesia for enhanced monitoring, but without prior outcome studies, was almost universally accepted (not at THI) for most cardiac cases in the 1980s. It was called into question in the 1990s for lack of outcome improvement and is used more selectively at present.

Another large step in the defining of CVA was in education and research. The year 1979 saw the founding of the Society of Cardiovascular Anesthesiologists (SCA) by 3 members of the Anesthesia Department of the Ochsner Clinic². The only prior cardiac anesthesia organization was a small one with a restricted membership, so the SCA found a large number of members immediately and rapidly expanded from the first meeting in New Orleans, where most of the attendees fit into one small meeting room (I was there), to the very large, multinational organization of today. Additionally, at about the same time, the publication of a popular textbook of cardiac anesthesia by Joel Kaplan further defined CVA³. CVA research markedly expanded throughout the world. At THI, research into myocardial ischemia was a large part of the departmental efforts in the 80s. Well-constructed research with large case numbers done by Slogoff and Keats showed a direct relationship between the presence of pre-pump myocardial ischemia and outcome for the first time, a revolutionary concept then and part of the bedrock of cardiac anesthesia today⁴.

There has been a progression of new and innovative surgical procedures that have changed the landscape of cardiovascular surgery. These, in some instances, represent entirely new approaches and in others the progression of conventional ones that were refined through trial, error and experimental therapy. Examples abound including renewal of cardiac transplantation after the initial failure of the technique due to introduction of a new immunosuppressive therapy, cyclosporine; progression of the left ventricular assist device, first used as a heroic, last ditch measure to the more or less routine procedure of today; refinement of technique for thoracic aneurysms with antegrade or retrograde cerebral perfusion; limited access cardiac surgery including robotic approaches and endovascular therapy for valve replacement or repair; and endovascular therapy for thoracic or thoracoabdominal aneurysms. In each case, cardiovascular anesthesiologists approached, reacted and refined needed anesthetic techniques for management.

The above are a few observations that come to mind as I think back. Many are the same as Arthur Keats made in his Rovenstein lecture in the early 1980s⁵. As he said to me when he retired, “It has been a good ride, John.” I agree wholeheartedly and will always treasure my association with him, THI and CVA.

References:

1. Lowenstein E, Hallowell P, Levine F, et al: CardiovascularCardiovascular responses to large doses of intravenous morphine in man. N Engl J Med 1969, 281: 1389 – 93.
2. Reeves, J: An Essay on 35 Years of the Society of Cardiovascular Anesthesiologists. Anesth Analg , 2014, 119:225 – 65.
3. Kaplan, JA, Ed.: Cardiovascular Anesthesiology. New York: Grune and Stratton. 1979
4. Slogoff S: Keats AS Does Perioperative Myocardial Ischemia Lead to Postoperative Myocardial Infarction? Anesthesiology, 1985, 62:107 – 114.
5. Keats AS: The Rovenstein Lecture, 1983: Cardiovascular Anesthesia: Perceptions and Perspectives. Anesthesiology 1983, 60: 467 -474.