|Glenn P. Gravlee, MD
TEE and So Much More!
A prominent academic anesthesiologist asserts that the only thing different about cardiac anesthesiology is transesophageal echocardiography (TEE). A CA3 resident spends four months in cardiac anesthesia during residency and one month in TEE over three years, passes the TEE Exam, and markets himself (often successfully) as a cardiac anesthesiologist. An SCA member suggests that we should just convert the annual meeting to a TEE meeting. Excuse me, but I think that we may be selling ourselves short.
I do not wish to understate the importance of TEE. What a wonderful tool, and what an incredible difference it has made to the clinical practice of cardiac anesthesiology and surgery! I shudder to think how many patients were compromised by TEE's absence during my earlier days in cardiac anesthesia. I marvel at the possibilities presented by three-dimensional TEE and other nascent echocardiographic innovations. Nevertheless, I contend that TEE constitutes just a small piece of the cardiac anesthesia pie. I fear that we are too easily distracted from our cardiac anesthesia "roots" by the imposing educational commitment required to master perioperative TEE.
Many aspects of cardiac (or more broadly, cardiothoracic) anesthesia expertise simply constitute extensions of the skills required of any anesthesiologist. Placing arterial and central lines, using vasoactive drugs, interpreting physiologic data from a PA catheter, and anesthetizing and reawakening patients with sick hearts serve as examples. As with any skill, greater expertise comes with greater experience, so I like to think that an anesthesiologist who dedicates much of his clinical time (don't ask me to define "much," as I'll squirm and evade the question) to cardiothoracic anesthesiology takes these skills to a higher level than his noncardiac-oriented peers. It doesn't make him a better doctor, but wouldn't you want a cardiac anesthesiologist to do your IJ stick?
Other aspects of cardiac anesthesia seem truly unique to our subspecialty. Where else does the highly intricate physiology of cardiopulmonary bypass (CPB) come into play? Some have argued that the increase in off-pump coronary artery bypasses (OPCABs) renders that expertise less important. Obviously those pundits have not fully experienced the rigors of the OPCAB experience, which generally constitutes a more challenging anesthetic exercise than a CABG with CPB. Similarly, perhaps those individuals have not yet experienced the pleasure of a minimally invasive mitral valve replacement performed via a right mini-thoracotomy using a double-lumen tube and a Heartport CPB circuit. Maybe they haven't struggled intellectually with the appropriateness or inappropriateness of epidural or intrathecal analgesia as a component of OPCAB or of a traditional CPB CABG. I assume that no one seriously questions the legitimacy of pediatric cardiac anesthesia as a subspecialized discipline, whether or not one considers this to be a part of cardiac anesthesia, pediatric anesthesia, or both. Quite a number of us also provide postoperative critical care to cardiothoracic surgical patients, which requires an in-depth understanding of many concepts deriving from cardiology, anesthesiology, cardiac surgery, and critical care medicine.
We cannot and should not deny that TEE is a major part of what we do, and we should take pride in that. We should resist the temptation, however, to drift into educational complacency about the numerous other areas of expertise required to remain a state-of-the-art practitioner of our wholly legitimate subspecialty. The busy cardiac anesthesia practitioner who trained before TEE undoubtedly needs (or hopefully needed) to skew his or her continuing educational content toward TEE at least temporarily, and SCA caters understandingly to that critical need with its annual comprehensive TEE course and with a significant proportion of the Annual Meeting content. However, it would be foolhardy for SCA's Annual Meeting or CPB meeting to convert to predominantly TEE-related educational content, because cardiac anesthesiology is so much more than TEE can ever be.
Glenn P. Gravlee, MD