Cardiac anaesthesia: the last 10 years

摘要

In considering the progress and development of cardiac anaesthesia over the last 10 years, it is interesting to note both those things that have changed and also those which perhaps surprisingly have not. Any reflection over a 10-year period will inevitably be personal, and there is certainly enough practice variation in cardiac anaesthesia across the UK to render my observations inaccurate in the eyes of some. I have tried to be objective, but I expect that on occasion my interests and prejudices will have gained the upper hand and forced themselves through. The last 10 years have seen numerous structural changes within the NHS. Despite these changes, the provision of cardiac surgery has shown a modest increase, particularly during the early 1990s. Data from the United Kingdom Cardiac Surgery Register show that up to 2000, cardiac surgical activity increased progressively, this increase being largely accounted for by an increase in coronary revascularisation [1]. There is evidence that the rate of isolated CABG surgery may now have peaked, and recently waiting times for CABG surgery appear to be going down, although there will be some regional variation. In adult cardiac surgery, there is a trend to operate on older and sicker patients [2]. This has become particularly evident in those centres with good access to interventional cardiology. Coronary angioplasty, accompanied by intraluminal coronary stenting, has made an enormous impact on the treatment of ischaemic heart disease, and the introduction of drug eluting stents to inhibit coronary restenosis [3] will result in a much smaller percentage of patients undergoing coronary artery bypass graft surgery as their first intervention for IHD. There is also a trend to an increasing proportion of valve replacement procedures, particularly in elderly patients [4]. Of those patients who do undergo surgical coronary revascularisation, the last 10 years have seen an increase in the number of patients being revascularised without cardiopulmonary bypass support. Initially, MIDCAB (Minimally Invasive Coronary Artery Bypass – usually a single vessel procedure performed through an anterior mediastinotomy) and, more recently, OPCAB (Off Pump Coronary Artery Bypass – a procedure with multivessel access usually performed through a median sternotomy) have been performed. The uptake of these procedures has been variable; infrequent in some centres, commonplace or routine in others. The anaesthetic challenges are not complex but they may be demanding; to maintain good haemodynamic control throughout a procedure in which cardiac displacement may be severe, but mitigated in part by some of the new tissue stabilisation devices [5,6]. Cardiac surgery requires close teamwork between surgeons and anaesthetists, and OPCAB surgery is a perfect example of this. The technique is still controversial [7,8] but recent results have been more consistent [9–11]. OPCAB surgery will not replace PTCA and stent procedures, but I believe it will have a large impact on CABG surgery on-bypass, particularly in elderly or other high risk patients who are an increasing proportion of our workload. The development of newer procedures, such as heart port surgery and robotics, may have a significant future but my perception is that it is still too early to be sure. Heart and heart–lung transplantation has not increased over the 10-year period, and as ever the problem is access to donor organs [12,13]. The rate of paediatric cardiac surgery procedures has changed little overall [1], and with good public health and antenatal screening it is unlikely to change much in the future. The demands for paediatric cardiac surgery have been to deliver high quality outcomes against a background of increasing public expectation. Cardiac anaesthesia during the decade between 1984 and 1994 was transformed by the widespread use of beta blockers for patients undergoing CABG surgery. Recent data have confirmed their value [14]. Anaesthetists