Cardiac Anesthesia: Today and Tomorrow

Cardiac Anesthesia: Today and Tomorrow Cheng DCH, guest editor. Anesthesiology Clinics, Volume 26, Number 3. Philadelphia: Saunders, 2008. ISSN 1932-2275; ISBN-13: 978-1-4160-6272-1; ISBN-10: 1-4160-6272-6. pages 399–611, $105.00. This collection of articles on cardiac anesthesia was edited by the distinguished cardiac anesthesiologist, Davy Cheng, Chair of the Department of Anesthesia at London Health Center, University of Western Ontario. The purpose of this issue was to “summarize the current state of the evidence and the future direction” of a number of “cutting-edge” practices in cardiac surgery and anesthesia as they affect anesthesiologists. The consulting editor for this issue, Lee Fleisher, suggested that this information is applicable to all high-risk patients with cardiovascular disease undergoing (noncardiac) operations. It includes 11 articles written by respected experts in their fields. As one would expect with a multi-authored text, the quality and value of the articles varies widely. The 11 articles address Genomics (Body et al. from the Brigham & Women's Hospital), Perioperative Echocardiography (Cahalan et al. from the University of Utah), Minimally Invasive and Off-Pump Coronary Artery Surgery (Bainbridge and Cheng from the London Health Center in Western Ontario), Hybrid Coronary Artery Grafting (i.e., robotic minimally invasive direct coronary artery bypass + percutaneous coronary intervention) (Bainbridge and Dobkowski from the London Health Center in Western Ontario), Transcatheter (and Transapical) Aortic Valve Replacement (Cheung and Ree from the University of British Columbia), Endovascular Stenting of Thoracic Aortic Aneurysms (Cheung et al. from the University of Pennsylvania), Transmyocardial Laser Revascularization (Allen et al. of the Mid America Heart Institute in Kansas City), Brain Protection (Hogue et al. of Johns Hopkins Hospital), Assisting the Failing Heart (Vegas of the University of Toronto), Hepatic and Renal Protection (Sladen et al. of Columbia University), and Analgesia After Cardiac Surgery (Myles et al. of the Alfred Hospital and Monash University in Melbourne, Australia). For the most part, these articles are well referenced and provide a very useful introduction to the topic with practical advice for the novice, while placing the role of these new developments in a proper perspective. However, by selecting enthusiastic authors who are in the forefront of these new approaches, a degree of objectivity is lost. This requires critical assessment on the part of the reader and familiarity with the contemporary literature to place the enthusiasm of the authors in proper perspective. This limitation is most notable in the article on transmyocardial laser revascularization, which, in my opinion, does not provide a balanced and objective review of the evidence as reflected in the more reserved assessments by Paterson et al. (JACC 2003;42:1611–6), the Society of Thoracic Surgeons Practice Guidelines (ATS 2004;77:1494–506), the meta-analysis by Liao et al. (Am J Cardiol 2005;95:1243–5), and the recent systematic review from the Cochrane Collaboration (Briones et al. Cochrane Database Syst Rev 2009). Other articles present methods that are highly investigational or in early clinical development (e.g., genomics, hybrid coronary artery bypass graft [CABG], transarterial and transapical aortic valve replacement, endovascular stenting for thoracic aneurysms, and assist devices for the failing heart), so that their relevance to most clinical anesthesiologists may be very limited. The article on genomics was very instructive but suggests that any practical clinical applications are a while away. The article on perioperative echocardiography gives an excellent review of the “state of the art” and makes a number of predictions about its future, raising, but not fully developing, the issues of the practice of echocardiography by noncardiac anesthesiologists and the use of portable transthoracic echocardiography machines (to become the “stethoscopes of the future”). I was disappointed by lack of discussion of tissue Doppler, and I am skeptical of the authors' prediction that transesophageal echocardiography will make use of pulmonary artery catheterization obsolete in critically ill patients. The article on off-pump CABG was extremely informative, practical, and generally well referenced (although a number of statements by the authors could have benefited by supporting references). It is unfortunate that the authors did not provide a reference to their meta-analysis of randomized controlled trials comparing OP-CAB to conventional CABG surgery (Cheng et al. Anesthesiology 2005;102: 188–203), and that they did not discuss another option for coronary artery surgery, namely, beating heart on-pump CABG. Additionally, they did not acknowledge the important advances in the conduct of cardiopulmonary bypass, which has made this technique more safe and effective over the past 20 years. The article on brain protection was very reasoned, conservative, and largely evidenced based and could have served as a model for other articles in this book. My only reservation was the reproduction of their Table 2 from a previous article by the senior author, which I believe could have benefited from an update. The article on assisting the failing heart was an excellent review of this rapidly changing field; however, the inclusion of cardiac transplantation seemed out of place and confusing. This was most obvious by the inclusion of both topics in their Box 1. The article on hepatic and renal protection provided a strong review of pathophysiology but was excessively lengthy and led me to the unfortunate conclusion that there is little known about what we can do as clinicians to prevent these injuries. The final article on analgesia practice after cardiac surgery provided very little practical information for the clinician, largely because of the limited number of high-quality studies in this subspecialty. The authors take a cautious approach to use of central neuraxial blockade and failed to mention opioid-related hyperalgesia. In my opinion, this collection of articles could have been improved by including an article addressing the ethical and practical issues raised by the introduction of these cutting-edge techniques into clinical medicine. Also missing from this book were articles discussing innovations in perfusion technology (e.g., low prime, management of shed blood, temperature, hematocrit, and arterial blood pressure) and monitoring during cardiopulmonary bypass (e.g., oxygen delivery, echocardiography, and neurologic). In summary, this book is a worthy addition to the Anesthesiology Clinics series and can serve as a useful starting resource (and reference source) for those who wish to learn more about newer techniques and future advances in cardiac surgery and anesthesia. Eugene A. Hessel II, MD Department of Anesthesiology University of Kentucky College of Medicine Lexington, Kentucky [email protected]

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