Clinical Program

The spectrum of cardiac surgical cases performed at Duke University Medical Center remains one of the widest and strongest in the country. Procedures ranging from minimally invasive surgery (port-access), “off-pump” surgery, robotic surgery, and transmyocardial revascularization to valve repairs, multi-valve replacements, re-operations, thoracoabdominal aortic aneurysm repairs, and “routine CABG” surgery provide the trainee with an expansive exposure to the field of cardiac anesthesiology. The number of patients presenting for management of end-stage heart and lung disease continues to increase, resulting in a rise in the number of ventricular assist device placements as well as heart and lung transplantations. Transesophageal echocardiography (TEE) is routinely performed in these procedures, leading to the rapid development of the technical and cognitive skills necessary for achievement of the advanced training level. In addition, the division anesthetizes over 1,600 patients undergoing thoracic surgery, providing familiarity with mediastinoscopy, wedge resection, lobectomy, pneumonectomy, esophageal resection, and video-assisted thoracoscopic surgery. The recognition by accreditation agencies that pain management is a vital part of patient care has emphasized the importance of regional anesthesia techniques (thoracic epidurals, paravertebral blocks) in providing postoperative comfort, particularly for thoracic surgery patients.

In recent years, the role of the cardiothoracic anesthesiologist has been transformed from one of a caretaker of patients undergoing procedures with cardiopulmonary bypass to a perioperative physician, able to define and modify risk in the patient with complex cardiovascular disease, regardless of the procedure. As the population ages, we are participating in the care of patients who have significant co-morbidities. Since our ability to effectively care for these “sicker” patients in the OR has contributed to the overall safety of cardiac surgery, the involvement of cardiothoracic anesthesiologists, trained simultaneously as intensivists, can only serve to improve the overall outcome of the patient. Under the leadership of Dr. Steve Hill, the co-medical director of the cardiothoracic ICU, and with significant contributions from Drs. Burkhard Mackensen, Madhav Swaminathan, and Ian Welsby, the division has sustained the excellence of care provided in the OR into the postoperative period.

We continue to take pride in noting the substantial accomplishments of our faculty. In 2004, Drs. Hilary Grocott, Joseph Mathew, and Mark Stafford-Smith were voted into the membership of the Association of University Anesthesiologists. Similarly, Dr. Joseph Mathew was designated a Fellow of the American Society of Echocardiography. Finally, we note that Dr. Mark Newman was appointed to the first endowed chair within the Department of Anesthesiology: the Merel H. Harmel Professorship. Dr. Newman continues to be listed as one of the “Best Doctors in America.”

Training Program

With the assistance of Drs. Katherine Grichnik, Madhav Swaminathan, and Burkhard Mackensen, the educational program has been revised and updated. The division now offers a CA-3 rotation designed to provide exposure to TEE as well as advanced training in cardiac anesthesia. Both written and oral examinations are a part of this curriculum. Educational goals for the past year also included the growth and strengthening of the fellowship program and the provision of continuing medical education at the “Annual Cardiothoracic Update” on Hilton Head Island, organized by Dr. Grichnik. The popularity of this event has grown since its inception, with an increasing number of returning attendees serving as a testament to the quality of this meeting.

Research Program

The division has achieved international prominence from its research activities. We continue to engage in a wide spectrum of research and educational activity, yielding an abundance of published manuscripts, textbook chapters, and invited presentations. In 2004, Duke faculty provided a substantial number of the presentations (abstracts, workshops, lectures) at the annual meeting of the Society of Cardiovascular Anesthesiologists (SCA). Three of the four abstracts selected at this national meeting as “most likely to impact the Society” were submitted by Duke authors. Also in 2004, Dr. Burkhard Mackensen returned to Duke to join our faculty, strengthening both our laboratory and neurologic outcomes research program. Competitive funding from the National Institutes of Health and the American Heart Association accompanied by publications in high-profile journals such as the JAMA and Stroke are a measure of the successes achieved in the past year. Our ongoing commitment to excellence of clinical care is the foundation upon which all research activities must and will be built.

Clinical Research

Divisional clinical research is focused on mechanisms of and protection from perioperative organ injury, analgesic techniques, TEE, genetic associations with cardiovascular disease and long-term quality of life and outcomes research. Organized groups within the division form the basis of research efforts, including the Neurologic Outcome Research Group (NORG), the Cardiac Anesthesia Research Endeavors (CARE) group, the Perioperative Organ Protection Research group, and other collaborations directed towards research involving the brain, the kidney, the heart, and the hemostatic system. Notable publications have included collaborative work by Dr. Newman, who established a novel diagnostic test for acute stroke and by Dr. Stafford-Smith, who demonstrated the utility of high-fidelity simulation in training research personnel, Dr. Mathew’s multicenter risk index for atrial fibrillation after cardiac surgery, and Dr. Grocott’s investigations on rewarming techniques.

Research and publications in TEE by the division have served to maintain Duke as the premiere site for training and research in intraoperative TEE. Faculty-mentored fellow projects have also contributed significantly to research within the division, with every fellow successfully preparing and presenting an abstract at the 2004 SCA Meeting.

New clinical research initiatives in the past year included a comprehensive examination of the effect of genetics, proteomics, and metabolomics on perioperative outcome. We have also expanded our patient base for research activities by establishing a collaborative relationship with Durham Regional Hospital. Such relationships are vital to the long-term viability and stability of our research program.

Laboratory and Translational Research

Drs. Debra Schwinn, Grocott, and Mackensen have major lab-based investigative initiatives. Dr. Schwinn has significant funding from the NIH and continues in her role as vice-chairman for research and director of the molecular pharmacology laboratory. She has studied the role of polymorphisms of the alpha-1 adrenergic receptor in hypertension and leads the department’s and division’s initiatives in genomics. Research directed by Dr. Grocott and Dr. Mackensen through the multidisciplinary neuroprotection laboratory has been complementary to our ongoing clinical research aims. Using a rat model of cardiopulmonary bypass (CPB), investigations have been undertaken to examine several neuroprotective compounds, the influence of perioperative temperature, and the potential molecular mechanisms (including CPB-induced differential cerebral gene expression) contributing to the neurologic injury associated with cardiac surgery. Investigations related to the hematologic, myocardial and renal effects of CPB have also been conducted. Variations of the original rat model have led to investigation of the significance of cerebral air emboli and focal ischemia in the context of CPB, while the effects of low-flow CPB and deep hypothermic cardiac arrest (DHCA) on cerebral outcome have been examined in a newly developed rat model of DHCA.

Future research successes will be predicated on partnerships with basic scientists capable of conducting translational research.

The Division of Cardiothoracic Anesthesiology and Critical Care Medicine remains the best in the land because of its outstanding and accomplished faculty, excellence in clinical care, comprehensive training for learners, and unparalleled research productivity.

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Joseph P. Mathew, MD

Chief, Division of Cardiothoracic Anesthesia and Critical Care Medicine
Medical Director, Clinical Anesthesia Research Endeavors (CARE)
Medical Director, Neurologic Outcome Research Group (NORG)
Professor of Anesthesiology

Faculty

Sol Aronson, MD
Katherine P. Grichnik, MD, FASE
Steven E. Hill, MD
G. Burkhard Mackensen, MD, PhD, FASE
Carlo Marcucci, MD
Mark F. Newman, MD
Mihai V. Podgoreanu, MD, FASE
Andrew Shaw, MD, FRCA, FCCM
Mark Stafford Smith, MD, CM, FRCPC, FASE
Madhav Swaminathan, MD, FASE
Ian J. Welsby, MB, BS, BSc, FRCA

Fellows

Richard D'Alonzo, MD
Ryan Lauer, MD
Susan Martinelli, MD
Ajay Satyapriya, MD
Shanna Ten Clay, MD
Christopher Thunberg, MD

Faculty Fellows

Niamh Conlon, MD Bettina Jungwirth, MD
Johannes van der Westhuizen, MD, MBChB

Biostatistics Staff

Barbara Phillips-Bute, PhD
William White, MPH

Support Staff

Renee Farmer
Melinda Macalino
Cheryl Stetson