VA Hearts

One of more popular rotations among anesthesia residents is VA hearts. Most of us do our required two months of cardiac anesthesia at the beginning of our second year of anesthesia. This rotation allows us to return to cardiovascular anesthesia as senior residents with a little more experience. The procedures at the VA are standard bread-and-butter heart surgeries: bypass surgeries and aortic valve replacements. The surgeons are phenomenal and bypass times are short, reflecting private practice circumstances. The patients are well-screened and optimized. Unlike Stanford, we rarely see exceptionally complex cases like Marfan's syndrome or pulmonary hypertension. Because most cases are standard, the anesthetic is somewhat standard and protocolized, and residents can get a lot more independence and confidence in cardiac anesthesia.

On a typical day, I arrive at 6AM to set up the room. The anesthesia technicians at the VA are incredibly helpful so most things are prepared in advance; I only have to mix up the drips and draw up medications. I meet the patient early, place an IV and an arterial line, and then roll back the OR, usually before all the regular non-cardiac cases. After a gentle induction, we intubate the patient. When I did my initial cardiac rotation, I focused heavily on the intubation because that's where I was in my training. Now, though, the intubation is easy, and I focus on learning how to induce anesthesia in someone with critical aortic stenosis or three vessel coronary artery disease. Although we induce general anesthesia regularly without much planning, a wrong decision in someone with life-threatening heart disease can mean death. After intubation, we place a large introducer with a pulmonary artery catheter. At the VA, cardiac surgeries are protocolized to all use a Swan-Ganz catheter, something we place rarely these days, so this was a great opportunity to familiarize myself with the procedure. We then place a transesophageal echocardiogram probe and get initial views. This had the steepest learning curve for me, but after a few weeks, I could quickly find all the valves and assess the squeeze of the heart.

The surgery itself was fairly predictable in nature. As the surgeons enter the chest, we drop the lungs to avoid laceration. They dissect out vein grafts at the same time as chest opening. After exposure, we heparinize, and the surgeons place cannula in the aorta, inferior vena cava, and those to deliver cardioplegia. We then go onto bypass, sending blood returning to the heart instead to the machine and pumping blood from the machine into the aorta. After aortic cross-clamp, the surgeons get to work and the perfusionist cools the body. Our bypass times were usually around an hour and a half, and as we come off bypass, we warm the body, get the heart beating again, and start vasoactive drips as needed. After reversing the heparin, we assess whether the patient may need product, and given our short pump runs, this was pretty uncommon. We keep the patient intubated to the ICU, and at the VA, they stay deeply sedated overnight. The cases are immensely satisfying, especially as we get the routine of things. There are usually one to two cases several days each week.