Views from Cardiac Anesthesia

I had the privilege to work with Prof. Mohr from 1998 to 2002 as a codirector and since 2005 as the Director of the Department of Anesthesiology and Intensive Care Medicine at the Heart Center in Leipzig. From the beginning, it was a collaboration which was based on trust and respect for each other. Scientifically it led to 27 publications which are also a strong sign of close collaboration between the two departments.

I just want to mention two fields where the good cooperation can be very well demonstrated and had a real impact on our daily practice: modern cardiac anesthetic management of our patients using the Leipzig fast track protocol, and improved cardiac imaging using perioperative transesophageal echocardiographic techniques (TEE).

The concept of fast track anesthetic management in cardiac surgical patients was initiated in summer 2005. It included strategic discussions on related topics and the idea of implementation of a fast track protocol to completely bypass the intensive care unit (ICU) and of opening of a postanesthetic care unit (PACU) to treat the cardiac surgical patients directly after the operation. Prof. Mohr immediately showed interest and was open minded about this new concept. With his help and support, I could convince our CEO to undertake the necessary investments and to build an initial three-bed PACU. This was established in a room where beforehand Prof. Mohr used to have the cardiac surgical department's morning conferences. In November 2005 we started the Leipzig fast track protocol with a PACU consisting of three beds all equipped like regular ICU beds and with opening hours from 10:00 am to 6:30 pm This unit was run by one anesthesiologist and one anesthetic nurse. The patients were extubated within 90 minutes after the end of the operation and transferred to a stepdown unit for further treatment after further stabilization. After 6 months we did a propensity score matched retrospective comparison of postoperative courses. We compared the conventional treatment of cardiac surgical patients in the ICU with those treated in the PACU. In this analysis, we were able to show that fast track treatment in the PACU was at least as safe as the conventional treatment[1] and in addition, it was very cost effective.[2] Based on this experience a second and larger PACU with eight beds was built, and nowadays we are treating more than 40% of our cardiac surgery patients postoperatively without ICU admission.

Another field of excellent cooperation was perioperative imaging using TEE. We established TEE analysis for all patients receiving cardiac operations and further along focused on the use of TEE during mitral valve surgery. Precise preoperative TEE imaging allowing the surgeon to plan the mitral repair strategy, together with postoperative valve assessment were established. We gave recommendations on annular diameters etc. Also TEE served for immediate quality control. For example, we could demonstrate that it is possible to visualize circumflex coronary artery flow routinely during mitral valve procedures and also to detect potential ligations or distortions of the circumflex artery with TEE immediately in the operating room.[3] [4] I remember one situation during a live case in a patient scheduled for minimally invasive mitral valve repair where the repair was excellent as usual, and there was completely uneventful weaning from bypass. But at the very end, there was a suspicion of circumflex artery distortion by TEE. Prof. Mohr did not hesitate, and we sent the patient to the catheterization laboratory for verification. It was confirmed, and the patient underwent PCI. Due to the immediate treatment, the further course was uneventful. Prof. Mohr was so sovereign to show that complication and talk about it after the live case in front of the audience.

These were just to two examples out of many in the past 12 years where the excellent relationship of cardiac surgeons and cardiac anesthesiologists for the sake of the patients could be demonstrated. Together with my whole team I just want to thank Prof. Mohr and tell him that we will miss his expertise as cardiac surgeon and colleague.

• References

• 1 Ender J, Borger MA, Scholz M , et al. Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept. Anesthesiology 2008; 109 (1) 61-66
• 2 Häntschel D, Fassl J, Scholz M , et al. Leipzig fast-track protocol for cardio-anesthesia. Effective, safe and economical [in German]. Anaesthesist 2009; 58 (4) 379-386
• 3 Ender J, Gummert J, Fassl J, Krohmer E, Bossert T, Mohr FW. Ligation or distortion of the right circumflex artery during minimal invasive mitral valve repair detected by transesophageal echocardiography. J Am Soc Echocardiogr 2008; 21 (4) 408.e4-408.e5
• 4 Ender J, Selbach M, Borger MA , et al. Echocardiographic identification of iatrogenic injury of the circumflex artery during minimally invasive mitral valve repair. Ann Thorac Surg 2010; 89 (6) 1866-1872