The UCLA Division of Cardiothoracic Anesthesiology provides anesthesia for nearly 1300 cardiothoracic surgeries each year at the UCLA affiliated hospitals. As a tertiary and quaternary referral center, we serve a diverse patient population that includes neonates, infants, children, and adults for all types of cardiac surgery including complex congenital heart disease, acquired heart disease, heart and lung transplantation, thoracic aortic surgery, and implantation of ventricular assist devices. Approximately 30 percent of our cases are pediatric (half are less than a year of age), 40 to 50 percent of our patients have had cardiac surgery in the past, and 15 percent are transplants.
Our division is comprised of fellowship-trained physician anesthesiologists who are certified in advanced perioperative echocardiography. Several have advanced training in the management of patients with complex congenital cardiac disease as well as management of cardiac implanted electronic devices. Our patients run the gamut from neonates and infants to geriatric patients undergoing all types of cardiac surgeries, including repair of congenital or acquired heart disease, heart and lung transplantation, aortic surgery, and implantation of ventricular assist devices.
The cardiac anesthesia team plays an integral part in UCLA’s global health initiatives. Our anesthesiologists are intimately involved in the care of children from different parts of the world who are transferred to UCLA for a higher level of medical care. In addition, many of our cardiac anesthesiologists volunteer their expertise in medical missions all over the world to share their knowledge with the local medical communities.
The combination of advanced clinical and echocardiography skills obtained while managing complex cases in the operating room positions our faculty and fellows to be successful perioperative consultants. Our group provides diagnostic echocardiography services in all the operating rooms and surgical suites, intensive care units, and interventional cardiovascular laboratories. All members of our group are board certified by the National Board of Echocardiography. Transesophageal echocardiography (TEE) is the mainstay of perioperative management. We staff a 24-hour echocardiography consult service, with TEE and transthoracic echocardiography (TTE) performance and analysis available throughout the hospital. TTE has proven utility for perioperative patient management, and can be performed by our team at any time during the patient's clinical course. We have a state-of-the-art echocardiography lab where 2D and 3D TTE (including speckle tracking strain imaging) guide clinical decision-making.
Our division is an integral part of the cardiac implanted electronic device (CIED) management service. We provide an electrophysiology consult service for the interrogation and reprogramming of pacemakers and ICDs for patients undergoing all types of surgery, and provide consultation for device management in the perioperative setting. Programmers from three major vendors are dedicated for OR use and are immediately available. Our group functions as part of the electrophysiology team to provide preoperative device assistance, as well as postprocedure inpatient management.
We aid in preoperative risk stratification, intraoperative management, and postoperative care for patients undergoing a wide range of surgical and interventional procedures. Outside the operating room, our group provides anesthesia services in the interventional cardiology and electrophysiology suites at Ronald Reagan UCLA Medical Center, which is home to the largest ventricular arrhythmia center in the Western United States. We perform diagnostic echocardiography throughout the hospital (operating rooms, surgical suites, interventional cardiovascular laboratories, and the cardiothoracic intensive care units) and electrophysiology consultation for all surgical patients.
The pediatric cardiac anesthesia team provides anesthesia for all diagnostic, interventional and surgical procedures for children with cardiac defects, and we are an integral part of the multidisciplinary congenital heart disease team. At a weekly conference, all planned surgeries and percutaneous interventions are discussed. As one of the busiest pediatric transplant centers in the world, our team gains vast experience in dealing with children suffering from heart failure. Anesthetics for children requiring procedures as a bridge to heart transplantation (ECMO/Ventricular assist devices) are routinely performed at UCLA, and palliative hybrid procedures particarly in low birth weight infants are performed in our hybrid lab. The anesthesia team participates in the pediatric arrhythmia management and electrophysiology program at UCLA.
Our echocardiography projects have included investigation into the effectiveness of simulator training in learning basic transthoracic imaging. We have also used more advanced echocardiographic measures of cardiac mechanics to describe the effects of cardiac surgery on heart function, and to predict patient outcomes. Ongoing projects involve the clinical applications of 3D imaging, 3D and conventional strain imaging, and perioperative diastolic function assessment in a variety of perioperative procedural settings.
UCLA is a nationally recognized center for lung transplantation. Many patients presenting for lung transplants have elevated pulmonary artery pressures and impaired right ventricular function. Previous studies have demonstrated variable improvements in function following transplantation. We are studying whether right ventricular function before surgery predicts improvement in heart function and overall outcomes after surgery. The cardiac response to lung transplantation has yet to be fully elucidated, and our goal is for this study to add valuable prognostic information to guide clinical care for this critically ill patient population.
Our division is actively involved in translational research seeking to predict how and why cardiac surgery is often followed by the onset of atrial fibrillation. Postoperative atrial fibrillation is a significant cause of morbidity and mortality. To improve prediction and treatment of this devastating complication, our clinical faculty anesthesiologists are collaborating with basic science researchers in the Division of Molecular Medicine. Their work investigates epigenomic mechanisms of cardiovascular disease with the goal of finding DNA methylation biomarkers to predict postoperative atrial fibrillation. This novel research seeks to minimize adverse patient outcomes by predicting them prior to surgery and enabling clinicians to personalize patient care.
The Human Genome Project was expected to usher in a new renaissance in science and medicine. It has now been 14 years since the completion of this project, and while advances in science have been made, the translation to clinical medicine has been slow. Initial obstacles to this growth included the high cost of sequencing and the painstaking task of integration with clinical data. Now, with advances in technology and the use of electronic medical records, we have the tools to capitalize on the accomplishments of the Human Genome Project. The UCLA Health system recently announced the launch of its Institute of Precision Medicine, tasked with integrating genomic information into the diagnostic and therapeutic management of patient care. Our division will be at the forefront of this initiative.
Our job will be developing one of the core components of the institute: perioperative genomics. As perioperative physicians, we face new challenges to patient care in an era of increasing surgeries, constrained resources, patients with complex and critical illnesses, and an aging population. Genomics has the potential to provide us with the tools necessary to overcome these challenges and continue to provide a high level of care to our patients. If we can understand the contribution of genetics to the outcomes of our patients, we may be able to anticipate how each individual patient will respond to the numerous stresses and pharmacological exposures of the perioperative period. Phenotypes that will be specifically addressed include responses to therapeutic techniques such as spinal cord stimulation. Different phenotypes affect reactions to common drugs used in the perioperative arena such as pain medications, anesthetics, anticoagulants, and drugs used to augment the cardiovascular system. Other areas of interest include assessing the perioperative risk for complications such as stroke, myocardial infarction, acute kidney injury, bleeding, arrhythmias, cognitive decline, and sepsis. We are proud to play a pivotal role in the Institute of Precision Medicine as we acknowledge the tremendous impact of genomics on the future of medicine.
During their months of rotation on cardiothoracic anesthesiology, residents are exposed to all aspects of pediatric and adult cardiac disease, and the issues involved in providing anesthesia for these patients. All UCLA anesthesia residents learn to perform and interpret focused TTE exams. They receive a two-week foundation in TTE during the PACU rotation. This includes training on a transthoracic echocardiography simulator, and supervised patient exams guided by our ultrasonagrapher and physicians. The resident experience includes our active extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD) program, associated with the heart and lung transplantation service.