UCSF Guidelines for the Perioperative Management of Procedures that May Require Adult Cardiothoracic Anesthesia

Last updated July 27, 2023

The Division of Cardiothoracic Anesthesia has developed these guidelines to optimize the care of patients who have complex cardiothoracic diseases and may require special anesthesia staffing considerations. The goal is to balance the complex needs of such patients, the substantial demand on cardiothoracic anesthesia service, and compassionate, expeditious care. The Division of Cardiothoracic Anesthesia shall make the final decision on staffing after input from members of the multidisciplinary team.

  1. Requests for cardiothoracic anesthesia for non-cardiac surgery/procedure may be made by any provider (proceduralist, cardiologist, anesthesiologist, etc.), but such requests do not automatically guarantee such service. The cardiothoracic anesthesia team must assess the needs of the patient and staffing resources at hand.
  2. Non-cardiac cases requesting cardiothoracic anesthesia, approved or pending approval, are subject to delay based on staff availability and other emergency cases with higher urgency.
  3. The cardiac anesthesia on-call attending (EH1/DH1 whose pager can be given by OR front desk 353-1545) will be available to consult for operative and diagnostic procedures. They should be directly contacted by an attending proceduralist, cardiologist, or anesthesiologist for a discussion on the need for cardiac anesthesia services.  
  4. The cardiothoracic anesthesia team may choose to staff a case directly, support the case as an assisting (second) attending on-site, or support the general anesthesiologist with preoperative recommendation and intraoperative consultation as needed. If a case is released to the general anesthesiologist, a written consultation will be provided, including the reason for the appropriateness of staffing level and recommendations for perioperative management. 
  5. An appeal of the staffing appropriateness may be made to Cardiothoracic Anesthesia Division Chief: Lundy Campbell, or Clinical Chief: Helge Eilers.
  6. The attached table delineates indications for UCSF cardiothoracic anesthesia staffing, as supported by national organizations, national guidelines, and best evidence. This table will largely guide staffing of cases.
POTENTIAL Indications For Staffing by Cardiac Anesthesia/Intensivist Discussion with Cardiac Anesthesia

I. Mechanical Circulatory Support (MCS)
  • Cardiopulmonary bypass (CPB) standby
  • ECLS or ECMO
  • Temporary ventricular assist device (VAD)
  • Implanted VAD 
  • IABP

II. Transesophageal Echocardiography
  • Cardiac intervention requiring TEE-guidance by ANESTHESIA (ref 1) 

 

III. Pulmonary Hypertension (ref 2)
  • Currently on/Planned MCS (see I.)
  • PASP > ⅔ Systemic SBP
  • RV dysfunction: >= Moderate 
  • Home vasodilators >= 2 agents
  • Prostacycline infusion
  • iNO
  • PASP: >= ½ Systemic SBP

IV. Adult with Congenital Heart Disease (CHD) (ref 3)
  • Complex CHD NOT including simple or repaired ASD or VSD
  • Symptomatic CHD
  • Simple or repaired ASD or VSD AND high risk surgery

V. Heart Failure (ref 4)
  • Currently on/Planned MCS (see I.)
  • Severe PH (see III.)
  • RV dysfunction: >= moderate
  • Listed for VAD or transplant
  • Moderate PH
  • Hypertrophic cardiomyopathy AND high risk surgery (ref 5)

VI. Valvular Heart Disease (VHD) (ref 6)
  • Currently on/Planned MCS (see I.)
  • Severe PH (see III.)
  • Severe VHD AND high risk surgery
  • Moderate PH

VII. Coronary artery disease (CAD) (ref 7)
  • Currently on/Planned MCS (see I.)
  • Severe CAD AND high risk PCI 

References

1. Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST, Shanewise JS, Siu SC, Stewart W, Picard MH. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013 Sep;26(9):921-64. PMID: 23998692.

  • Table 4 General Indications for TEE, & Table 5 Appropriate and inappropriate uses of TEE 

2. Rajagopal S, Ruetzler K, Ghadimi K, Horn EM, Kelava M, Kudelko KT, Moreno-Duarte I, Preston I, Rose Bovino LL, Smilowitz NR, Vaidya A; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, and the Council on Cardiovascular and Stroke Nursing. Evaluation and Management of Pulmonary Hypertension in Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation. 2023 Apr 25;147(17):1317-1343. PMID: 36924225.

  • Section on Preoperative Risk Assessment in PH & Figure 3

3. Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Valente AM, Van Hare GF. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019 Apr 2;73(12):e81-e192. PMID: 30121239.

  • Section 3.12. Noncardiac surgery

4. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-e1032. PMID: 35363499.

5. Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P, Evanovich LL, Hung J, Joglar JA, Kantor P, Kimmelstiel C, Kittleson M, Link MS, Maron MS, Martinez MW, Miyake CY, Schaff HV, Semsarian C, Sorajja P; ACC/AHA Joint Committee Members; O'Gara PT, Beckman JA, Levine GN, Al-Khatib SM, Armbruster A, Birtcher KK, Ciggaroa J, Dixon DL, de Las Fuentes L, Deswal A, Fleisher LA, Gentile F, Goldberger ZD, Gorenek B, Haynes N, Hernandez AF, Hlatky MA, Joglar JA, Jones WS, Marine JE, Mark D, Palaniappan L, Piano MR, Tamis-Holland J, Wijeysundera DN, Woo YJ. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg. 2021 Jul;162(1):e23-e106. PMID: 33926766.

6. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2;143(5):e72-e227. PMID: 33332150.

  • Section 15. Noncardiac Surgery in Patients with VHD

7. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS Jr, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022 Jan 18;79(2):e21-e129. PMID: 34895950.

 

Tags: 
cardiac
Anesthesia
Guideline
heart
adult
cardiothoracic
Clinical Area: 
Cardiothoracic
Type: 
Guidelines

 

This information is meant to serve as an educational resource. Clinicians should use their own professional judgment in the care of any individual patient as the guidance contained in this document may not be appropriate for all patients or all situations.