For the Public

1) What is a Cardiovascular Anesthesiologist? 

A cardiovascular anesthesiologist is a physician who specializes in providing anesthesia care for patients undergoing either cardiac (heart), thoracic (lungs) or vascular (blood vessels) surgery. As a physician, your anesthesiologist spent four years in medical school, and another four years training to provide anesthesia during surgery. Cardiovascular anesthesiologists often spend another 1-2 years learning the particular field of cardiac and/or vascular anesthesia. Hospitals that specialize in cardiac, thoracic or vascular surgery often have teams that specialize in doing just these types of surgery. The specialized teams consist of surgeons, anesthesiologists, operating room nurses, and the intensive care unit staff.

2) How is anesthesia for cardiac, thoracic or vascular surgery different from that used for other surgeries?

Cardiac, thoracic, and vascular surgery require specific techniques and may present particular problems that are not seen in other surgery. For example, the types of devices to monitor your heart during cardiac or vascular surgery can be quite different than that used to monitor a patient having other types of non-cardiac surgery. Your anesthesiologist may insert special tubes (catheters) in arteries, large veins near the heart, or in the artery leading from the heart to the lungs (pulmonary artery catheter). Many patients will be monitored using a echocardiography (ultrasound of the heart) using a special probe that is place in your esophagus (swallowing tube) after you are under general anesthesia. Additionally, the type of stress placed on the heart will be different, and may require specialized drugs. Patients undergoing cardiac surgery often require cardiopulmonary bypass (the heart-lung pump), a device that takes over the work of the heart and lungs during the period of time the surgeon is operating on the heart. 

Most patients undergoing cardiac and vascular surgery will have a general anesthetic – they will be completely anesthetized (asleep), and will have a breathing tube in place during the surgery and possibly for a period of time after surgery. In addition, the anesthesiologist may choose to use a regional anesthesia technique either during surgery or after surgery to provide pain relief (analgesia). “Regional” means that the pain relieving drugs like lidocaine or narcotics are placed right in the area of the nerves that carry the pain message from the surgical incision. This technique can involve giving just one dose of drug before the surgery begins or can involve insertion of a tiny catheter (about the size of high test fishing line) so that drugs can be given continuously or repeatedly. A catheter inserted into the area around the spinal canal is called an epidural. Epidural analgesia is the technique used to provide relief to pregnant women in labor, and has been used safely for nearly a hundred years.

3) What sorts of information should I tell my anesthesiologist?

Your anesthesiologist will review all of the medical information that your other physicians have collected about you, everything about your medical history and the diagnostic tests that you have had. Anesthesiologists in particular will want to know many details about your smoking history, the medications you take on a regular basis and any over-the-counter, herbal, or vitamin supplements you take. Your anesthesiologist will discuss with you which of your medications you should take or did take the morning of surgery. They will also ask about any alcohol use/abuse, and any personal or family history of bad reactions to anesthesia (high fevers or a long time waking up), or nausea or vomiting you may have had in the past after anesthesia. Because the anesthesiologist will most likely be using a breathing tube to help control your breathing during surgery, he or she will want to know about any history of jaw surgery, limitation of mouth-opening, or problems with placing breathing tubes in you in the past (called “difficult intubation”). Your anesthesiologists will want to know if you have any trouble swallowing solid foods, as this may be associated with problems using a certain monitor during surgery.

4) What is the risk of something bad happening to me?

While the great majority of patients have no problems related to surgery and the risks of anesthesia are very low, cardiac, thoracic, or vascular surgery carries more risk to you than many other surgeries. First of all, patients needing these types of surgery either do have heart disease or are at high risk of having heart disease. The risk of having a heart attack during or right after surgery is higher in cardiac, thoracic, and vascular patients than for patients without heart disease undergoing other types of surgery. The risk of a very bad outcome, such as death or stroke, will be different for each patient. Your surgeon and anesthesiologist can advise you of your risk profile for the particular procedure you are scheduled to undergo. While it is important to understand the risks associated with cardiac, thoracic, and vascular surgery, these should be weighed against the risks of alternative therapies. In nearly all cases, you would not be referred for surgery unless your doctors felt that the benefits of surgery outweighed the risks.

5) What can I do before surgery to decrease my risk?

There are a number of things that patients can do before surgery to improve their chances of doing well. Most importantly, do not smoke! The nicotine and other drugs in cigarette and cigar smoke can cause blood vessels in the heart or legs to constrict (get smaller) and can even cause a heart attack. Stopping smoking is the most important thing you can do to improve your health, even if you have smoked for many years. Another very important thing to do is to increase your activity, even if it is just going for a walk every day. In your visit to your surgeon before surgery, you may be given a breathing exercise device (called an inspirometer) – use it often to improve your breathing – you will be doing these breathing exercises after surgery to help clear your lungs and prevent pneumonia. Be sure to follow your doctor’s orders to control other diseases you may have, such as diabetes or high blood pressure.

6) What about blood transfusions?

This risk of blood loss and needing a transfusion is higher in cardiac, thoracic, and vascular surgeries. Patients with various cardiac conditions may be taking a drug that thins the blood, because these drugs decrease the risk of heart attacks or strokes. However, these drugs increase the risk of bleeding during surgery. Blood thinners include aspirin, Plavix, Ticlid, warfarin (Coumadin), dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and others (this is not a complete list). Mega doses of vitamin E can also cause blood thinning. Be sure to ask your doctor about whether you should stop any of these drugs before surgery. 

In conjunction with the surgeon, the cardiovascular anesthesiologist may employ various methods that may potentially reduce your chance of being transfused with another person’s blood (i.e., blood from a blood bank). These include methods of saving your own blood by using the “cell-saver,” (i.e., blood lost during the surgery is washed in the operating room and returned to you), and “acute normovolemic hemodilution,” in which your own blood is collected in the operating room for use later during the surgery. Your anesthesiologist may also use medications that potentially boost the ability of your own blood clotting system.

If you do need a blood transfusion, however, be assured that the blood supply is the safest it has ever been. New tests to discover viruses that might be in the blood have decreased the risk to the lowest historical levels seen in medicine. The risk of getting hepatitis from a blood transfusion is about 1 in 30,000, the same sort of risk of being hit by lightning in your lifetime. The risk of getting HIV or AIDS from a transfusion is around 1 in a million.