Cardiac Anesthesiologists: Master Facilitators and Providers of Critical Care

November 28, 2016

From the operating room and catheterization lab to the intensive care unit, cardiac anesthesiologists are central to patient care. Often, it is their role to shepherd the sickest and most complex patients through recovery.

Stéphane Lambert, MD, is the recently appointed Division Head for Cardiac Anesthesiology at the Ottawa Heart Institute. Trained in Montreal, Toronto and San Francisco, he came to the Heart Institute in 2005 following seven years at St. Michael’s Hospital in Toronto.

At a time of growth and transition at the Heart Institute, The Beat spoke with Dr. Lambert about what this and broader changes in the landscape of cardiovascular care mean for his division and his field.

Stéphane Lambert, MD, Division Head, Cardiac Anesthesiology

The Beat: What do you see as the major factors that will impact Cardiac Anesthesiology in the coming years?

Dr. Lambert: Cardiac Anesthesiology has a long history of being an integral part of the successes of the Heart Institute. It’s a great honour to lead this division at an important time in that history, with the new building and the growth. It’s exciting to be part of all that.

At the same time, cardiac medicine is changing and so is the health care system.

When I was born there was no definitive treatment for coronary artery disease, there was no reliable artificial heart valve and heart transplant was just beginning. Today, those are all things that we do every day in our practice. We’ve made giant leaps in technology and techniques, and things are continuing to evolve.

Yet we are facing a tricky set of circumstances. With the increasing needs of a growing population, wait lists are a concern. At the same time, our patients are aging and the health care system is under pressure because it is publicly funded and there is a finite amount of resources. We are very mindful that we have to use those resources responsibly.

The Beat: What about the growth of minimally invasive and catheter-based procedures such as TAVI and MitraClip?

Dr. Lambert: Cardiac anesthesiology is closely linked to cardiac surgery and interventional cardiology. Essentially, it’s a symbiotic relationship. So, not only are we influenced by changes in our own specialty, we are also very much influenced by changes in these other specialties, including minimally invasive surgery, catheter-based procedures, hybrid surgery and robotic surgery, which is on the horizon.

These advances are great for patients because they are less invasive and recovery tends to be faster. At the same time, it’s important to realize that minimally invasive surgery often means maximally involved anesthesia care and intra-operative care.

That is because we often become the surgeon’s eyes. When the surgeon is operating through a tiny incision, they often need echocardiography to guide them. We perform the intra-operative echo. Also, we may have to use special techniques such as one-lung anesthesia, where we must deflate one lung to give the surgeon better access to the heart.

The hybrid operating room will facilitate the advancement of minimally invasive and multidisciplinary techniques because the hybrid room is basically a cross between an operating room and a cath lab.

The Beat: So, is this all changing the role of anesthesiology?

Dr. Lambert: When you think about who we are, what our brand is, we’re master facilitators. We don’t do surgery, but we make surgery safer and more comfortable. We are direct care providers, but at the same time, we make other types of care possible.

The intensive care unit is the exception, where we run the Cardiac Surgery ICU in close collaboration with a multidisciplinary team obviously, but we are the primary drivers in the ICU.

By training, anesthesiologists are natural resuscitators. So the CSICU is a logical extension of what we do in the operating room. I think of us as comprehensive perioperative cardiac physicians. We are involved in the pre-op process—the selection and preparation of the patient—through the safe intra-operative anesthesia care, assistance of the surgeons, transesophageal echo, etc., through the post-operative ICU care. And then we deliver the patient back to the floor after the acute perioperative period. This has been our model of anesthesia care at the Heart Institute for many years.

The Beat: Beyond the hybrid operating room, what will our expansion bring to the table?

Dr. Lambert: The greatest strength of the Heart Institute is its people, and its people could function in any environment and still be great people. But if you provide them with state-of-the-art infrastructure within which to perform, they will obviously perform at their highest potential.

The new building provides a much needed infrastructure renewal. At the same time, the Heart Institute will not just be better, it will be bigger. What it means for us is that we have to grow the division because the needs of the Institute are rapidly growing. But we have to do this without betraying our high quality standards, not only of clinical excellence but also in our academic mission as educators and researchers.

The Beat: What are your priorities in research and training?

Dr. Lambert: On the research side, we are undergoing a great renewal. Our members are helping to implement a peri-operative atrial fibrillation protocol at the Institute. We are involved in studying long-term outcomes in critically ill patients, which will likely influence future resource utilization at the Institute. We also participate in research initiatives in heart failure, women’s heart health and tele-mentoring, among others.

Many of these efforts are being conducted in collaboration with other divisions, which highlights the importance of multidisciplinary teams at the Heart Institute.

In education, peri-operative point of care ultrasound is an important focus. Portable ultrasound is becoming the new stethoscope, and there are many applications for it at the bedside. For example, in an emergency situation, when a patient is crashing in the ICU and you need to make a diagnosis, you can use point-of-care ultrasound to look not only at the heart, but also the lungs and the abdomen.

There is a great demand for training in this area, not only locally but around the country, and we have expertise here already. So we are in an excellent position to disseminate information.

More broadly, we have one of the most popular cardiac anesthesiology fellowships in the country. We also take part in the training of critical care fellows, cardiology fellows, anesthesia residents and cardiac surgery residents, both in the OR and in the ICU. So obviously, teaching is an integral part of what we do every day.

I think the Division of Cardiac Anesthesiology is key to the short and the long-term successes of the Heart Institute, and I feel extremely privileged to be leading such an outstanding group of anesthesiologists. I have no doubt that their expertise and dedication will continue to contribute to high-quality patient care at the Institute for years to come.