- Email: [email protected]
“And the beats go on…”
ARTICLE IN PRESS Current Anaesthesia & Critical Care (2005) 16, 319–320
www.elsevier.com/locate/cacc
FOREWORD
‘‘And the beats go ony’’ Cardiac surgery is a relatively new speciality which has burgeoned from its nascent state in the 1960s to a mammoth industry, such that over 1,000,000 cardiac procedures are conducted in the US on an annual basis.1 The development of safe cardiopulmonary bypass and the surgical techniques which it facilitated saw a huge rise in coronary and valve surgery over the subsequent 30 years. However, the ‘‘bread and butter’’ of cardiac surgery remained relatively unchanged despite the advent of offpump bypass and use of arterial grafts until the last 10–15 years. Interventional cardiology, changing social views on what constitutes ‘‘too old’’ or ‘‘too sick’’, improved intensive care and an increased use of mechanical assist devices such as intra-aortic balloon pump devices has changed the face of cardiac surgery. The increased uptake of percutaneous coronary interventions (PCI) since the advent of devices such as drug-eluting stents has all but removed the simple single vessel coronary graft for the cardiac operating list. As PCI devices improve, more and more studies comparing CABGs to PCI with stents are being reported, showing similar results in terms of death, MI and stroke, and whilst stents are associated in these studies with an increased need for re-vascularization, this gap is narrowing.2 The cardiac surgeon and cardiac anaesthetist are therefore being presented with octogenarians with poor left ventricular function and the associated organ dysfunction commonly seen in this age group. Paediatric patients, many of whom would not have previously survived birth, are now being presented for consideration of surgery in the first weeks post birth. Children and adults are supported on ventricular assist devices for many months or years, either as bridging or destination therapy. These patient groups are the sickest, frequently with the most to gain from a successful outcome, but occupy
more ICU bed days, and many more health care pounds and dollars. The care pathway of the un-complicated post cardiac surgery patient is clear and generally straight, with a supervisory eye being the main function of the intensivist in the post operative period. However, as the patients become sicker and older (or younger in the paediatric population), and pre-operative organ dysfunction becomes the rule rather than the exception, the close collaboration of surgeon, intensivist, anaesthetist and perfusionist becomes key in the final discharge of these patients from hospital. A clear understanding of pre-operative risks, intraoperative procedures and post operative organ support are essential for the optimal result for the patient. This issue has chosen a number of fields associated with ‘‘high-end’’ cardiac surgery. It is by no means exhaustive, but reflects the major changes as they have impacted the critical care environment over the past decade. We have included a review on ventricular assist devices as recent data confirms their efficacy and improvement in survival in patients with severe heart failure, a condition whose incidence increases with each passing year. Some of the articles are reviews of a specific field, and some ‘‘tricks’’ or ‘‘pearls’’ that we wished we had learned many years ago. The articles are the combined work of intensivists, anaesthetists and cardiac surgeons, and the issue aims to be a practical guide augmented with recent data and evidence, rather than an isolated academic pre´cis.
References 1. Serruys PW, Ong AT, van Herwerden LA, Sousa JE, Jatene A, Bonnier JJ, et al. Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel
0953-7112/$ - see front matter Crown Copyright & 2006 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.cacc.2006.03.001
ARTICLE IN PRESS 320 disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial. J Am Coll Cardiol 2005;46(4):575–81. 2. Fuster V, Vorchheimer DA. Prevention of atherosclerosis in coronary-artery bypass grafts. N Engl J Med 1997;336(3): 212–3.
FOREWORD J.F. Fraser, C.L. Foot Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, 4032, Queensland, Australia E-mail address: [email protected] (J.F. Fraser)
www.elsevier.com/locate/cacc
FOREWORD
‘‘And the beats go ony’’ Cardiac surgery is a relatively new speciality which has burgeoned from its nascent state in the 1960s to a mammoth industry, such that over 1,000,000 cardiac procedures are conducted in the US on an annual basis.1 The development of safe cardiopulmonary bypass and the surgical techniques which it facilitated saw a huge rise in coronary and valve surgery over the subsequent 30 years. However, the ‘‘bread and butter’’ of cardiac surgery remained relatively unchanged despite the advent of offpump bypass and use of arterial grafts until the last 10–15 years. Interventional cardiology, changing social views on what constitutes ‘‘too old’’ or ‘‘too sick’’, improved intensive care and an increased use of mechanical assist devices such as intra-aortic balloon pump devices has changed the face of cardiac surgery. The increased uptake of percutaneous coronary interventions (PCI) since the advent of devices such as drug-eluting stents has all but removed the simple single vessel coronary graft for the cardiac operating list. As PCI devices improve, more and more studies comparing CABGs to PCI with stents are being reported, showing similar results in terms of death, MI and stroke, and whilst stents are associated in these studies with an increased need for re-vascularization, this gap is narrowing.2 The cardiac surgeon and cardiac anaesthetist are therefore being presented with octogenarians with poor left ventricular function and the associated organ dysfunction commonly seen in this age group. Paediatric patients, many of whom would not have previously survived birth, are now being presented for consideration of surgery in the first weeks post birth. Children and adults are supported on ventricular assist devices for many months or years, either as bridging or destination therapy. These patient groups are the sickest, frequently with the most to gain from a successful outcome, but occupy
more ICU bed days, and many more health care pounds and dollars. The care pathway of the un-complicated post cardiac surgery patient is clear and generally straight, with a supervisory eye being the main function of the intensivist in the post operative period. However, as the patients become sicker and older (or younger in the paediatric population), and pre-operative organ dysfunction becomes the rule rather than the exception, the close collaboration of surgeon, intensivist, anaesthetist and perfusionist becomes key in the final discharge of these patients from hospital. A clear understanding of pre-operative risks, intraoperative procedures and post operative organ support are essential for the optimal result for the patient. This issue has chosen a number of fields associated with ‘‘high-end’’ cardiac surgery. It is by no means exhaustive, but reflects the major changes as they have impacted the critical care environment over the past decade. We have included a review on ventricular assist devices as recent data confirms their efficacy and improvement in survival in patients with severe heart failure, a condition whose incidence increases with each passing year. Some of the articles are reviews of a specific field, and some ‘‘tricks’’ or ‘‘pearls’’ that we wished we had learned many years ago. The articles are the combined work of intensivists, anaesthetists and cardiac surgeons, and the issue aims to be a practical guide augmented with recent data and evidence, rather than an isolated academic pre´cis.
References 1. Serruys PW, Ong AT, van Herwerden LA, Sousa JE, Jatene A, Bonnier JJ, et al. Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel
0953-7112/$ - see front matter Crown Copyright & 2006 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.cacc.2006.03.001
ARTICLE IN PRESS 320 disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial. J Am Coll Cardiol 2005;46(4):575–81. 2. Fuster V, Vorchheimer DA. Prevention of atherosclerosis in coronary-artery bypass grafts. N Engl J Med 1997;336(3): 212–3.
FOREWORD J.F. Fraser, C.L. Foot Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, 4032, Queensland, Australia E-mail address: [email protected] (J.F. Fraser)