Central Line

Episode Number: 152

Episode Title: The Society of Cardiovascular Anesthesiologists

Recorded: January 2025

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VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Hello and welcome to Central Line. I'm your host and editor, Dr. Adam Striker. Today, I'm excited to welcome Dr. Gage Parr and Dr. Jean Santana from the Society of Cardiovascular Anesthesiologists. We're going to touch on a few topics that are salient for anesthesiology. So let's get started. First. Welcome both to the show. Thank you for having us.

DR. JEANS SANTANA:

Thank you for having us.

DR. GAGE PARR:

Yeah, I'm excited to be here.

DR. STRIKER:

Well, I'm excited to have you both. And before we dig in, let's give our listeners a little bit of chance to get to know you both. Do you both mind sharing a little bit why you chose cardiovascular anesthesiology, and also talk a little bit about how you got involved in the SCA? And Dr. Parr, let's start with you.

DR. PARR:

So I got involved with cardiovascular anesthesiology, basically I was introduced to it through my father, who is a retired cardiac surgeon. And in the summers in both high school and the first summer between my freshman and sophomore year in college, actually worked as an anesthesia tech in the ORs in the hospitals where he was working. And in the downtime, wound up hanging out a lot in his room. And as often happens, you wind up standing at the head of the bed. And at those times, I spent a lot of time talking to the cardiac anesthesiologist and what they do and watching cardiac surgery, and really enjoyed both of those experiences. So that is how I got into it. And my experience in residency only reinforced my love for cardiac anesthesia.

DR .STRIKER:

And then how about the society?

DR. PARR:

So I think my introduction was through echo really um, learning how to do transesophageal echocardiography was my intro to it. And from there I got involved with a committee at the SCA. And that has furthered my interest in the SCA and my participation in the society.

DR .STRIKER:

Great. Dr Santana?

DR. SANTANA:

Absolutely. My pleasure. So I chose cardiac anesthesia for essentially its demands and intensity. Uh, there's always something to do in the cardiac OR. And even outside of the cardiac OR in the non operating room and anesthesia areas. And so when I say there's a lot to do, I mean everything from arterial and central venous access to transesophageal echocardiography and ABG Analyzes. This daily workflow of going through these things on a daily basis, uh, really equips me to show up, uh, with my A game. There aren't any easy buckets, if you will. Uh, when you show up to the cardiac or OR the non operating room cardiac setting. And in addition to showing up with this A game or with this high intensity, uh, expectation, you're also part of a subspecialized group of providers. Um, there is community in that hospital or in that care setting. Um, there's community in taking care of the most complicated patients oftentimes. Um, so we're always on and I go back to residency when initially I rotated through cardiac and then I really enjoyed it. I enjoyed it so much that when I rotated off of it, uh, I felt that I really missed dealing with the cardiac patient, dealing with the multitude of things that I had to do to provide the best possible care for these complicated and frail, fragile patients. And so I knew that I needed to figure out a way to dedicate my life's work to that specialty. But then the only way to end up as a cardiac anesthesiologist was to do a cardiac fellowship. So I went ahead and did that. And now I'm very, very happy to be part of this community and taking care of these patients on a daily basis.

Now, in regards to how I got involved with SCA, I think it is important for me to highlight that mentorship is important, especially for me, because I do not come from a family of doctors or health or health care providers. So in fellowship, my division chair encouraged me to get involved with SCA to not only present a poster or quality improvement project, whatever, but to also apply for a committee. So I applied for a committee and sure enough, I was elected to be part of the Quality, Safety and Value Committee in spring of 2022. And I've been fortunate enough to remain on this committee and recently reappointed through 2026.

DR .STRIKER:

Well that's wonderful. Speaking of the subspecialty society, in this case the SCA, what is one positive thing that you have found that you weren't expecting by getting involved with the society?

DR. SANTANA:

I'll say that I wasn't expecting that getting involved was going to open doors in a short amount of time that I've been involved with the society. It has connected me to people outside of my my immediate health network where I work every day. It has been an avenue to really elevate my game outside of what I do on a day to day basis. Um, I consider myself very fortunate and very happy, and I'm happy to continue going and seeing where else I can be of service and and have impact.

DR .STRIKER:

Well, I want to ask you about the specific role of cardiac anesthesiologists during cardiac surgery specifically. You already talked a little bit about what they do. When you were discussing, you know, what got you interested into that specific subspecialty. But what should listeners know about the role you play as a cardiovascular anesthesiologist when it comes to cardiac surgery?

DR. SANTANA:

It is loaded with responsibilities, and I don't think that we shed enough light on how much we have to one know about the patient. Uh, two know about the pathology. Three know about everything else that they have going on: diabetes, smoking, respiratory history, peripheral vascular disease. And then, by the way, knowing the conduct of the surgery and knowing how to get a patient through it safely. Um, so we have a tremendous responsibility to the patient and the team and families that we work for. Um, we have to be technically great with access for arterial access, central venous access. And there are no shortcuts. But you have to be masterful with airway, your anesthetics and how they're going to affect the patient who has multiple, uh, prescription drugs. You have to be excellent or somewhat competent in transesophageal echocardiography, and you have to know your medications and how to support the heart, how to support the lungs. All in a very acute setting. This is not medication or anesthetics that you administer and you see the effect the day after or a week after and you reassess. These are at the moment, in the heat of it, you have to deliver to an effect. Um, and that is getting someone safely through major, major surgery and seeing good outcomes after. It's not just getting them through it, but seeing them extubated, speaking to them the next day, uh, seeing their progress outside of the ICU or in the ICU and off to the step down, um, and then more rehab and then in follow up, um, by way of communication through the cardiac surgeons and quality improvement measures and things like that. It sounds like a lot and it is a lot, but it is very rewarding when when you see folks, uh, who are basically fighting for their lives and they, they turn out fine and not. Of course not everyone, not every case is an excellent case or a positive case, because there are emergencies in cardiac anesthesia that are not so much fun. But for the most part, when we elect to do these cardiac procedures, it's very rewarding work that that is heavily involved with what we have to do for the patient and in getting them through as safely as possible.

DR .STRIKER:

Talk a little bit about the role of the cardiac anesthesiologist beyond cardiac surgery, beyond the cardiac OR. I think a lot of people not in anesthesia probably don't realize that your role is actually quite expansive when it comes to outside of operating suites, correct?

DR. SANTANA:

Yes. So we're involved in cases where we're placing or an Interventionalist is placing percutaneous aortic valves. We are also in the electrophysiology suite and in the catheterization lab where patients are being managed for atrial fibrillation atrial flutter. And these are not open surgical procedures. But these settings do present certain challenges. Patients typically have similar comorbidities as patients who are coming for open heart procedures. And the non operating room suites are non operating room suites. But there are limitations to providing anesthesia in these settings. And um sometimes you're not near an operating room. So when things happen, when events happen, um, things can become a little bit challenging to manage. More challenging than if you were in an operating room setting. So we are involved in the catheterization lab and the electrophysiology suites, and even in the endoscopy suites, whenever we have a complex cardiac patient coming for upper endoscopy or colonoscopy. We are involved in these scenarios that are non operating room settings where we have to be careful and diligent in in the services that we provide to get patients through safely.

DR .STRIKER:

Well let's talk a little bit about that. When it comes to cardiac anesthesiologists outside of the cardiac OR, how do you determine when you need a cardiac anesthesiologist and when you don't? Dr. Parr?

DR. PARR:

Uh. It's tricky. Uh, this is a tricky question, and I don't think there's ever going to be a cut and dry answer. I mean, in some cases it's easier to figure out, you know, maybe the patient has very severe aortic stenosis, and you want someone who is used to dealing with patients with this problem. Um, another sort of more cut and dry answer might be patients with ventricular assist devices having non cardiac procedures. But then there's a fair amount of people who are like no no I can handle that. And I'm not a cardiac anesthesiologist. I've worked with surgeons who were like, I operated on this patient and now I feel that they always need a cardiac anesthesiologist. I don't feel that's the answer. Um, but, uh, it is a complicated question. There is a fair amount of institutional variability of who gets cases. And sometimes it comes down to, you know, how you're what your staffing levels are and who's available to take care of these patients. And in general, the cardiac anesthesiologists tend to get the sicker, more unstable patients, especially from a cardiac standpoint. If you've got someone with a low F or severe valvular disease, um, congenital heart issues that have been fixed or maybe not fixed, really just decompensating patients. But then again, a lot of our colleagues, especially those who do thoracic and or liver transplants, um, wind up taking care of a lot of really sick patients, too. So it is a tricky question, and it's often something that, you know, needs to be decided on a case by case basis.

DR .STRIKER:

Yeah, certainly. Now I do pediatric cardiac anesthesiology. And one thing that is very different from what you do is that we do not routinely perform TEE during cardiac surgery. That's usually the cardiologist. And so I wanted to ask you both about this subject. And Dr. Santana, I want to ask you this first, um, before we discuss this specific topic, one question is, is a fellowship necessary for TEE.

DR. SANTANA:

I believe it is. And I think if you want to or if one wants to be considered an expert or work their way to becoming an expert in transesophageal echocardiography, I believe that the sure way to do it is going through a formal fellowship. To be able to sit for the National Board of Echocardiography Transverse Transesophageal echocardiography exam, you need to be affiliated or have gone through an an accredited program where you can show that you've performed X amount of transesophageal echocardiogram exams. And so for that reason, I find that you need to to be able to sit for that exam, to be board certified by that National Board of Echocardiography. Um, and to continue on your path, to continue to grow your experience in, in TEE. And not too long ago when I was interviewing for jobs, it was almost an expectation that if I wanted to perform cardiac cases for that hospital, I had to show proof of having attended a fellowship. So I am aware that there are places that will hire you based on sheer volume of cardiac cases and transesophageal echo cases that you've done in residency, but I find that most places will expect you to have done a formal fellowship and produce a certification in transesophageal echocardiography.

DR .STRIKER:

Now, Dr. Parr, let's talk a little bit about how it is used. Obviously, it's used for many of the surgeries you perform, whether it's coronary artery bypass surgery or valve replacement, etc., but it's also used as a rescue tool. Do you mind discussing a little bit about when you should use it, when you shouldn't, when it's not a good fit, when it is.

DR. PARR:

So I think most cardiac surgeries, the standard of care now is transesophageal echocardiography or TEE. When I started my fellowship and did my residency in the late 90s, not every case got a TEE because we didn't have the equipment available for every case to get a TEE, or we wound up sharing machines and we had enough probes for each patient. And a lot of lot of times the straightforward cabbages or coronary artery bypass grafts, you wouldn't put a TEE in those patients. Now all those patients get TEEs because not only, um, are you looking at TEEs for valve cases, but in the cabbages you can see regional wall motion abnormalities. You can pick up valvular issues that you missed. Sometimes the surgeons rely on the TEE to help place, um, certain cannulas or certain vents. And then also with the advent of minimally invasive cardiac surgery, being able to look at those placements of different lines and vents and cannulas, TEE is essential in that. So just at baseline, most cardiac cases get a TEE. And then of course, when you start talking about valve surgeries, uh, doing a TEE really helps the surgeon determined what is wrong with the valve, and especially in the case of mitral valves and even in in aortic valves and tricuspid. Are these repairable lesions or do you need to replace the entire valve. And until you get a really detailed TEE exam at the time of surgery, you're not going to know. And sometimes a repair is attempted and it just doesn't work. And you rely on that TEE to let you know whether it's been successful or not. And whether you can separate successfully from bypass or more work has to be done. So those are all essential reasons why we use TEE for more than 90% of cardiac surgeries.

DR .STRIKER:

What is the current thinking in the adult world as to the use of swans?

DR. PARR:

So the use of swans, If you look at the literature, the use of swans is falling out of favor. When you look in practice, there is a lot of surgeons who still want swans, um, for whatever reason. And so I think, you know, in the operating room, swans can be, or a TEE can be very helpful and give you an idea of what's going on with the hemodynamics of the patients and how their valves are functioning and that kind of thing. But that is not an easy thing to take with the patient to the ICU. And you don't have someone there 24 seven standing at the bedside able to do those studies. So in that case, I think they still rely a lot on pulmonary artery catheter data to give them that information that you might otherwise get from a TEE. So the easiest time to put those PA or swan catheters in is in the operating room. So we we do it for them and are less reliant on it in the operating room. I mean, obviously we're paying attention to it as part of what we're looking at for the patients and as a human dynamic whole. But I think they're still really relying on it in the certain ICUs with certain cases. Um, and then it's just hopeful for us to put it in for them at the time of the surgery.

DR .STRIKER:

Sure. Um, well, Dr. Santana, what can you see on TEE better than you can on Transthoracic echo? Why is TEE better?

DR. SANTANA:

Excellent question. And I think Dr. Parr has begun to talk about it. Um, and I would, as a general rule of thumb, it's excellent for posterior structures. So the esophagus is lined up right behind the heart, and that's where the TEE is placed. So it is excellent at, uh, visualizing the mitral valve. Visualizing the left atrium, though you can't see it entirely, but you can see structures like the mitral valve and note its pathology and what's causing, if not the stenosis, then the regurgitation of that valve. You can look more closely at the left atrial appendage, which becomes of particular interest in patients with atrial fibrillation, patients who are undergoing watchman procedures. So the left atrium, the left atrial appendage, the mitral valve. And seeing these structures in 3D is is is is much better appreciated uh, through uh, transesophageal echocardiography. You can also use transesophageal echocardiography to visualize and into atrial septum a little bit better, get more information for a patient who has unexplained strokes. Maybe there is a patent foramen ovale or there is an atrial septal defect. So TEE is excellent in those scenarios as well. And for further workup of of anomalies of the heart as well. Uh, the TEE is, in my opinion, superior than the TTE. Um, you can also at times, not all the time, can get excellent views of the pulmonic valve and assess, uh, other things, um, like the aortic valve as Dr. Parr mentioned.

DR .STRIKER:

And just to put a bow on the TEE conversation, what are the contraindications to using TEE that our listeners should know about?

DR. PARR:

Well, I think the big one is esophageal varices. If you have a patient who has large esophageal varices, um, that are prone to bleeding, in general, the consensus is that's a contraindication to TEE. Um, there's some people who say you shouldn't perhaps put them in in patients who have had any sort of, um, gastric reduction surgery for weight loss, though the general consensus now is maybe you're fine putting the probe in the esophagus, but being really careful, advancing it into the stomach. Then also, there may be some issues with patients who have had esophageal surgery in the past, either um, an esophageal resection for esophageal cancer or have an interposition of colon or something in there. You want to be really careful with those patients. James, can you think of any other?

DR. SANTANA:

Uh, well, patients who've had, uh, rarely see this, it rarely comes up, but patients who have, um, perforated viscus or have an active GI bleed, as Dr. Parr suggested. Um, these are patients who I would not, uh, place a transesophageal echo probe in. Um, uh, it's questionable also for patients who have Zenker's diverticulum or, uh, significant hiatal hernias, um, where you run the risk or there's a potential risk. So it's a relative contraindication, um, to, to placing a device that could potentially perforate that diverticula or cause more harm than good. Esophageal injuries are not fun. So we have to be very careful and diligent and in asking our questions, um, when we assess our patients.

DR. PARR:

And I would also just, another one is patients who have had, uh, laryngeal cancer and may have had radiation to the, uh, area and the posterior pharynx. Those patients may have very friable tissues or prone to bleeding. And sometimes you just can't, yhings are stenosis enough, that you can't get the probe down. Also, people with achalasia, sometimes you can get in proximally approximately, but you cannot get the probe to go down past a certain level because their esophagus is so stainless.

DR .STRIKER:

Right. And of course. Well, let's touch on the, um, the new AHA guidelines and how they impact the management of cardiac patients specifically. Do you mind both talking a little bit about that?

DR. SANTANA:

Yeah, I can take a quick stab at it. It's an extensive report. I think it's over 100 pages. And the general rule of thumb that that we've talked at ASA and continue to talk as, as a division and department is that sometimes less is more. Um, and by that I mean we in the last, I guess, since the guidelines were last updated, um, we've worked patients up beyond belief. And I think the new guidelines are suggesting less workup, more symptoms. We don't need to nuclear stress everyone. We don't need to do serial, uh transthoracic echoes. More lab studies like, uh, pro bnp and troponin studies. If you suspect that a patient is at increased risk of a perioperative cardiac event. Um, and then obviously, uh, pocus, um, doing point of care, uh, ultrasound at the bedside if you have the means to do it. Um, but less is more is my general rule of thumb that I get from the new updated guidelines.

DR. PARR:

Yeah, I would agree. I mean, I think, you know, you can work patients up, um, and sometimes very well should work patients up. But just getting a good history of exercise tolerance will often tell you more than, you know, a stress echo or whatever. Because who knows if they're going to hit the right number of Mets on the treadmill. But if a patient can tell you, hey, and I had a patient the other day who was supposed to have a horrible cardiac function, but he's like, look, I swim 20 minutes a day. That tells me more than an echo for most patients.

DR .STRIKER:

Well, I want to thank both of you for, um, for this great discussion. But before I let you go, um, why don't you think of something that you would like our listeners to know about cardiothoracic anesthesiologists that they might not know, or something about Society of Cardiovascular Anesthesiologists that they might not know? We already talked a little bit about the society, but if there's things that you'd like to leave our listeners with, what would they be? Let's start with Dr. Santana.

DR. SANTANA:

Uh, I would add that it's a great way to stay relevant. Um, it's a great way for those of you who are in fellowship or just about to finish fellowship or just out of fellowship, it's a great way to stay relevant and continue your involvement. Continue to expand what you know, um, through community, through association, through attendance at the annual meetings. Um, it is a way to extend beyond your daily practice and, and really introduce a fun aspect of your work to your work. Um, because attending meetings and meeting new people and understanding or, uh, getting some impression of how folks do things differently, uh, is eye opening and in my personal experience, has been refreshing to hear how things are done differently. And I do come back and tweak my practice a little bit. So I think it's an excellent way to to stay connected, continue your medical education, expand your echo skills and, most importantly, network and mentorship, both ways. Mentee. Mentor. You can find a place, uh, at SCA.

DR. STRIKER:

And Dr. Parr?

DR. PARR:

So I echo everything Dr. Santana just said. Um, I would also say I've been a member of the SCA as both an academic physician and a private practice physician doing cardiac in both situations. And there's something there for everyone. Um, you know, things in cardiac surgery are always changing. Things in interventional cardiology, structural heart are always changing. And those changes may start in the academic world, but quickly get rolled out to the private practice world. And the SCA is a really good place for people who need to learn. What do they need to do, what do they need to know for these new procedures. It's a great resource to go to and say, hey, you know, we're starting to do this at our institution. What do I need as a cardiac anesthesiologist to be able to do for this case? Because if you talk to the surgeons, they may tell you one thing, but they're looking at it from a surgery standpoint. If you talk to the structural heart people, they'll tell you something else. But they're looking at it from a cardiology standpoint. The reps are going to tell you whatever the reps are going to tell you based on what they've been taught by their companies. But if you really want experienced people who have done this and can give you great advice, the SCA is a great place to go.

DR .STRIKER:

Okay, I said that was going to be the last question, but I do actually have one quick other last question, which is, um, either one of you or both of you can answer this, but for residents looking to go into cardiac anesthesia, you guys, you're probably as you rotated through it, you probably thought, this is for me and Dr. Santana, I know you specifically had, you know, mentioned that as part of your experience with your rotation. Um, but if there's residents that are on the fence and they're thinking about it, but not sure because of how how it looks to them or the acuity, maybe some of the cases being a little more involved. What do you have any advice to them?

DR. PARR:

You know, the first the first thing you got to ask yourself is do you like big cases? Do you like big, complicated cases with complicated physiology? And if you do, I think cardiac anesthesia is a great place for you. It's not the only place for you, but it is a fantastic place for you. And if that's the case, I think if you can get, you know, sort of your mandatory months of cardiac anesthesia early -- late in your CA one year or early in your CA two year. So you're exposed to it early because you've got to make a decision on the match, you know, earlier than your CA three year. And a lot of people used to say, hey, I'm going to do another couple of months my CA three year and decide. But the way things are set up now, that's a little late. So if you can get yourself exposed early and make that decision, I think that's a great way to go.

DR. SANTANA:

Yeah, I like that too. Um, I would add, and this is a very layered, uh, question. Um, but I can say that if you like to take care of grandpas and grandmas, and I don't mean that in a bad way, but if you enjoy dealing with that population of folks, I think adult cardiac anesthesia is what you want to do. Um, these are the folks, unfortunately, who are very comorbid and very frail. And if you'd like to, or if you enjoy administering anesthesia safely and and having conversations with these patients, and it could be about anesthesia or their life experiences, it's it's a special cohort of folks that that you're managing and that you're walking through a perioperative and very vulnerable point in their lives. And I would also add that if you want to become very good at access, uh, arterial line access, central venous access, and interpreting a lot of things for one patient at one time, cardiac anesthesia is an excellent place for you. And last but not least, I would say if you want to be part of a subspecialized group which comes with its, uh, bells and whistles, but also, um, can can can burn you out sometimes. But if you want to be part of of a subspecialized community or cohort of folks within your hospital, um, I think it's it's an excellent, uh, avenue to achieve that. Um, I am, for example, one of four cardiac guys in my hospital. There are other centers that are obviously bigger, but you are still the cardiac person. You are one of the cardiac folks who can do TEE, who can do arterial line, who can intubate anyone and also get central access and interpret an ABG. Um, you're you're equipped with a lot of good skills. Um, so I would say consider that before you consider chasing the bag of money that's out there for for generalists and other anesthesiologists.

DR. PARR:

I would add, like, if you like to be the person that people call when they're in trouble, then cardiac anesthesia is a great field for you. Um, because who do people call when they get in trouble? They're like, we need a TEE, we need central line. We need an A line. We need someone who can manage fluids, acid base status, deal with someone with a failing heart or lungs. They're going to call you. So if you like being that person, then cardiac anesthesia is for you. If you don't like being that person, you're probably not the way you want to go.

DR .STRIKER:

Well, thank you both. This has been a great conversation. And, uh, thanks for sharing your expertise and for joining us. Um, it's great to have some of these subspecialty episodes just to get some varying insight from, from all of our subspecialties. So, so thank you for for joining us today.

DR. PARR:

Well, thank you for having us. It's been a great discussion.

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DR. STRIKER:

For listeners who want to learn more about the SCA, you can review their site at scahq.org. And for regular listeners, please tune in again next time for more Central Line. For those of you who may be listening to us for the first time. Tune in again and we've got plenty of episodes to choose from. If you want to go back to our catalog of of conversations and find something that might, might interest you and certainly share your, your thoughts with, with your colleagues. So thanks everybody. Take care.

VOICE OVER:

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