With emerging advances in the management of heart failure patients, the skills of cardiac anesthesiologists are used in many aspects of patient care. Whilst the perioperative anaesthetic care of the surgical patient is the core of speciality work, cardiac anaesthesiologists have a much wider scope of practice which may include:

• Transport of patients with end-stage heart disease for definitive care
• Preoperative optimization of heart failure patients
• Planning for definitive intervention of heart failure patients
• Anesthetic management of patients for heart transplant or LVAD
• Anesthetic management of heart failure patients outside cardiac operation theatre
• Post-operative care of heart failure patients
• The resuscitation and stabilisation of patients in the Emergency Department

Transport of patients with end-stage heart disease for definitive care
The long term survival of patients with end stage heart disease is improving with the advent of transplants and ventricular assist devices.  With very few centers opting for these advanced interventions, there is a need to transport these patients for such definitive interventions.  Patients with end stage heart disease usually have multi-organ dysfunction secondary to poor ejection fraction and are more prone to develop arrhythmias because of the innate nature of their heart disease.  The job of cardiac anesthesiologists in transporting these patients is very challenging as they should be prepared to tackle any airway as well as cardiac emergencies during the transport.  If the transport is by road, cardiac anesthesiologist is well prepared to tackle emergencies as the  ambulance is equipped with all resuscitative drugs, equipments and personnel but is still more challenging if they have to airlift the patients.  Cardiac anesthesiologists who are airlifting patients with apparently compensated heart disease should carry the basic resuscitative drugs and equipments with them and intimate the airline authorities for emergency landing in case any emergency arises.  Patients with decompensated heart failure who are on ventilatory support with or without circulatory assist devices should be airlifted in chartered flights.

Preoperative optimization of heart failure patients
     Cardiac anesthesiologists play a prime role in the preoperative optimization of heart failure patients.  Not only do they evaluate the patients clinically but also optimize the medications, start them on inotrope or inodilator if required, perform a comprehensive TTE to evaluate the cardiac function.  Each day the patient is assessed by their vitals, body weight, fluid balance, medications, laboratory parameters, TTE.  After decision making & once the patient is stable, patients are discharged with or without ambulatory Milrinone infusion and reviewed once every 3 days on OPD basis by the cardiac anesthesiologists.  During each review, clinical assessement, TTE and laboratory tests are conducted to check optimization of the patient status.  If a patient becomes unstable during the preoperative period, insertion of IABP or initiation of ECMO with or without mechanical ventilatory support may be required.  The role of cardiac anesthesiologists in performing these procedures is very pivotal.

Planning for definitive intervention of heart failure patients
     Once patients are optimized, cardiac anesthesiologists perform a hemodynamic study (cath study) in the intensive care unit by floating a PA catheter through the right IJV.  The inferences from this study i.e cardiac output, SVR, PVR, RVSWI will help decide the definitive intervention for the patient (heart transplant/ LVAD/ medical management).

Anesthetic management of patients for heart transplant or LVAD
     During heart transplant, cardiac anesthesiologists play a vital role in donor assessment and management.  Donor assessment is done by eliciting proper history, TTE to assess the heart and ionotrope to maintain the hemodynamics.  TEE of the donor heart and PA catheter insertion by cardiac anesthesiologists provide useful information regarding the hemodynamic variables and titrating ionotropes accordingly.  Management of recipients of heart transplant is the core of the speciality work of a cardiac anesthesiologist.  They play a crucial role during pre CPB, CPB and weaning off CPB.  Induction of anesthesia requires a thorough knowledge about optimizing the cardiac grid in these patients.  Monitoring of CCO using PA catheter pre-induction gives idea about the SVR, PVR, cardiac output and helps in uneventful induction.  In consultation with the cardiac surgeon, anesthesiologist helps in choosing the induction therapy of immunosupression during heart transplant.  TEE and hemodynamic data inferred from CCO PA catheters help cardiac anesthesiologists titrate ionotropes/ vasopressors during the intraoperative and postoperative period.  Maintenance of immunosuppression in the postoperative period is also managed by the cardiac critical care team. 
The role of the cardiac anesthesiologists during LVAD insertion is very important.  With the help of TEE, they help surgeons in ruling out intracardiac shunts, aortic regurgitation, mitral stenosis which would otherwise have a detrimental effect on LVAD performance.  In the post-operative period, cardiac anesthesiologists play a crucial role in educating the patient about troubleshooting in VAD, home INR therapy and Doppler measurement of the blood pressure.    

Anesthetic management of heart failure patients outside cardiac operation theatre
     Management of heart failure patients outside the operation theatre is technically a challenging job.  The cardiac anesthesiologist understands the physiology of heart failure and maintains the cardiac grid during any cardiac procedures.  Procedures outside the operation theatre including AICD insertion, endomyocardial biopsy for post heart transplant recipients, non cardiac surgery for post transplant or LVAD patients is managed by cardiac anesthesiologists.

Post-operative care of heart failure patients
     Management of heart transplant recipient is a team approach.  The dose of immune-suppression has to be titrated against the risk of infection in the post-operative period.  Cardiac anesthesiologists with the cardiac surgeon and cardiologist manage the immunosuppression by monitoring the CD4, CD8, CD25 and the blood levels of immunosuppressants.  Endomyocardial biopsies are also performed in serial intervals to rule out rejection.  Patients with LVAD are put on life-long anticoagulation titrated according to INR.  During each review in the post operative period, transplant or LVAD recipients are assessed with clinical history, TTE, lab results by the heart failure team.   


Acknowledgements – I thank Dr. Rama Subramanian in helping me in preparing this manuscript.