An Evolving Role of Anesthesiologists in the Management of Thoracic Aortic Diseases

Abstract

Thoracic aortic diseases are a spectrum of medical conditions for which surgery is the definitive treatment. For that reason, anesthesiologists are likely to encounter patients with thoracic aortic diseases and have an important role in their care. The importance of the anesthesiologist was recognized in the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease appearing in this issue of the journal and originally published in Circulation. In this first iteration, The Society of Cardiovascular Anesthesiologists (SCA) and 9 other medical societies worked together to create a multidisciplinary set of guidelines for screening, diagnosis, and treatment of patients with thoracic aortic diseases. Together, we believe that guidelines are most valuable to clinicians when they are disease focused rather than specialty focused or intervention focused. By providing detailed, accessible guidelines for the detection, diagnosis, and management of thoracic aortic diseases, the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) also addressed the publicity generated by the death of John Ritter, a well known actor who died on September 11, 2003 of an acute aortic dissection. After his death, John Ritter’s widow, also an actress, filed a wrongful death lawsuit against the physicians who had failed to diagnose and immediately treat her husband’s condition. Although she did not win the lawsuit, she stated that the case was important because it brought together experts and raised public awareness about aortic disease. “I don’t know what you call it in medicine, but in acting or art, it would be called a master class. The most brilliant minds in the aorta business were there.”* In the same year, beginning in January 2003, The Wall Street Journal published a series of articles to bring attention to the incidence of aortic disease and the absence of any organized effort on a national level to identify and treat patients with these conditions.† These articles, by Kevin Helliker and Thomas Burton, had provocative titles such as, “A Death Sentence You Can Avoid,” “Ordering an Autopsy Could Save Your Life,” and “Knowledge Gap. Medical Ignorance Contributes to the Toll from Aortic Illness. Many Doctors Don’t Realize Aneurysms Are Treatable; a Paucity of Experts.” From a physician’s perspective, the articles were especially haunting. Kevin Helliker, an avid triathlete, described vividly in first hand what it was like to be diagnosed with a thoracic aortic aneurysm at the age of 43 years and the inevitable lifestyle changes and decisions that he will have to face. In 2004, the Pulitzer Prize for Explanatory Reporting was awarded to Kevin Helliker and Thomas Burton “for their groundbreaking examination of aneurysms, an often overlooked medical condition that kills thousands of Americans each year.” One such American, Michael DeBakey, the cardiac surgeon who pioneered the use of the Dacron vascular graft for aortic repair and whose name is used in the nomenclature for classifying aortic dissections, almost died from an aortic dissection in 2005. This publicity, together with the publication of the guidelines from the ACCF and AHA, will increase the public’s expectations and the responsibilities of health care providers for diagnosing and managing patients with thoracic aortic diseases. Improved screening and early diagnosis of thoracic aortic diseases would provide little benefit if the prospects for surgical repair were only marginally better than the consequences of the disease itself. Undertaking operations on the thoracic aorta, the conduit for blood to the entire body, is a serious commitment with inherent risks. Strategies to protect the heart, brain, spinal cord, and mesenteric organs from ischemic injury are necessary to ensure successful operations. Fortunately, cardiothoracic surgeons together with anesthesiologists have accomplished much to improve the safety and outcome of these operations. Some examples of specialized organ-protection strategies advocated by the guidelines include: (a) deep hypothermic circulatory arrest, antegrade cerebral perfusion, and retrograde cerebral perfusion alone or in combination to minimize brain injury (section 14.5.1); (b) cerebrospinal fluid drainage and spinal cord perfusion pressure optimization From the Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania.