The spectrum of cardiac surgical cases performed at Duke University Medical Center is one of the broadest in the country. Procedures ranging from minimally invasive surgery (port-access), “off-pump” surgery, robotic surgery, and transmyocardial laser revascularization to valve repairs, multi-valve replacements, re-operations, thoracoabdominal aortic aneurysm repairs, complex multi-stage aortic surgery including endovascular stent-graft placement, heart and lung transplantation, ventricular assist device placement, and “routine CABG” surgery provide the trainee with an expansive exposure to the field of cardiothoracic anesthesiology. For all of these surgical procedures, transesophageal echocardiography (TEE) is routinely performed by the anesthesiologists who are board certified in echocardiography, leading to the rapid development of the technical and cognitive skills necessary for utilization of this important technology. Separation from cardiopulmonary bypass is also conducted primarily by the anesthesiology care team, providing an incomparable experience in managing the complex physiology and pharmacology of this period. With an average of 1400 adult (plus 300 pediatric) cardiothoracic procedures performed at Duke University Medical Center annually, the extensive training and expertise of our physicians is unsurpassed.
The Division of Cardiothoracic Anesthesiology and Critical Care Medicine also anesthetizes 1300 patients per year undergoing (non-cardiac) thoracic surgery, providing familiarity with complex interventional pulmonology procedures, mediastinoscopy, wedge resection, lobectomy, pneumonectomy, esophageal resection, and all types of 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, including thoracic epidurals and paravertebral blocks, in providing postoperative comfort to these patients. In addition, our faculty provide anesthesia for a large percentage of the 1200 Duke University Medical Center patients undergoing electrophysiology procedures ranging from pacemaker and defibrillator placements to complex atrial and ventricular ablations.
In recent years, the role of the cardiothoracic anesthesiologist has been transformed into that of a physician responsible for the entire perioperative period, 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. Through our leadership in the cardiothoracic surgery intensive care unit, the Division has sustained the excellence of care provided in the OR into the postoperative period.
The Division of Cardiothoracic Anesthesiology and Critical Care Medicine has achieved international prominence from its research activities. Although we have for many years focused on outcomes research by leveraging the strengths of the long-term follow-up data available through the Duke Clinical Research Institute, we continue to engage in a wide spectrum of research activity, yielding an abundance of published abstracts, manuscripts, textbook chapters, full textbooks, and invited presentations. As an example, in 2009, Duke Faculty accounted for 19% of all the abstracts at the annual meeting of the Society of Cardiovascular Anesthesiologists. Also, in 2008, Duke University hosted the Annual Meeting of the Association of University Anesthesiologists, where several of our faculty members were elected as members of this prestigious organization. However, competitive funding from agencies such as the National Institutes of Health and the American Heart Association, publications in high-profile journals such as the New England Journal of Medicine, JAMA and Stroke, and defining cardiothoracic anesthesia practices such as temperature management during cardiopulmonary bypass (CPB) are the ultimate measure of the successes achieved by our research program.
Divisional clinical research is currently focused on mechanisms of and protection from perioperative organ injury, two- and three-dimensional transesophageal echocardiography, 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. New clinical research initiatives include whole genome analyses of perioperative injury and postoperative pain, metabolomic profiling of cardiac and cerebral outcome, the role of stem cells in injury and repair, and the effect of TEE simulation on education.
Laboratory and Translational Research
Systems Modeling of Perioperative Injury Laboratory: Drs. Podgoreanu and Mackensen have joined their efforts to provide laboratory support complementary to our ongoing clinical research aims, for a programmatic translational approach to investigate adverse perioperative outcomes. These efforts capitalize on several unique resources available to their collaborative team, including well-characterized small (rodent) and large (porcine) animal models of CPB, deep hypothermic circulatory arrest (DHCA) and cardioplegic arrest (CA), expertise in high-throughput molecular profiling of organ specific responses to ischemia-reperfusion injury, computational and evolutionary biology capabilities, as well as large biorepositories of well-phenotyped cardiac surgical patients. This systems biology paradigm enables elucidation of the complex mechanisms underlying perioperative organ injury (brain, kidney, and heart in particular), identification of organ dysfunction biomarkers, and prioritization of novel cardio- and neuroprotective compounds.
Variations of the original rodent model have led to investigation of the significance of cerebral air emboli and focal brain ischemia in the context of CPB, the effects of low-flow CPB and DHCA on cerebral outcome, and hyperglycemic exacerbation of myocardial injury following CA. Other investigations utilizing the rodent models of CPB and DHCA have explored specific hematologic, renal, and pulmonary responses to perioperative ischemia-reperfusion injury and inflammatory stress. Metabolomic approaches have been employed to comprehensively characterize the myocardial metabolic deregulation associated with surgical ischemia-reperfusion in normal and dysfunctional ventricles.
Visit the Systems Modeling of Perioperative Injury Laboratory page for more information.
The Division of Cardiothoracic Anesthesiology initiated the DREAM (Developing Research Excellence in Anesthesia Management) Campaign, the first and only philanthropic campaign at Duke dedicated to supporting anesthesiology research. The DREAM Campaign now encompasses the entire Department of Anesthesiology and is dedicated to changing the paradigm of how anesthesiology researchers raise their funding. An early success of the campaign was the establishment of the Jerry Reves, MD Endowed Professorship. The Division is leading the way not only in medical research, but also in mobilizing donors to fund our research and educational programs for future generations.
The Division of Cardiothoracic Anesthesiology and Critical Care Medicine is the best in the land because of its outstanding and accomplished faculty, excellence in clinical care, unparalleled research productivity, and comprehensive and balanced training for learners at all levels.
Joseph P. Mathew, MD, MHSc, FASE [BIO]
Chief, Division of Cardiothoracic Anesthesia and Critical Care Medicine
Faculty [click name for bio]
Sol Aronson, MD
Michael W. Manning, MD
Rebecca Aron, MD
Barbara Phillips-Bute, PhD