Basic training in cardiovascular anesthesia: wouldn’t it be the time for a unified program in Brazil?

Dear Editor,

In the past years, significant advances have been attained in the treatment of patients with severe cardiovascular diseases in different areas of cardiology, such as cardiovascular surgery and interventionist procedures in the cath-lab.

The current medical residency programs in anesthesiology in Brazil (Ministry of Education and Culture – MEC and/or Brazilian Society of Anesthesiology – SBA) are founded on general training of residents for a period of three years in different medical specialties in which anesthetists work. The current model does not provide enough time, and often does not allow in-depth teaching and practice in certain increasingly more specific and complex areas, which are essential to perioperative decision-making, such as cardiovascular anesthesia. Thus, many recently trained anesthesiologists eventually are additionally trained by more experienced anesthetists who have already been working with heart surgery for years, or they seek improvement in one of few hospitals to be able to practice more safely.

It is currently very common to observe anesthetists who work almost exclusively with cardiovascular surgery, explaining the increasing demand for pursuing improvement to fit job market requirements.

The American Society of Cardiovascular Anesthesiologists (SCA) has implemented for many years a fellowship program for anesthetists to complement learning and expand the number of professionals with skills to work in the cardiovascular area. The members believe that excellence in clinical care, education, and research in Cardiothoracic Anesthesia is better attained through “standard training” in the subspecialty. Adult Cardiothoracic Anesthesia (ACTA) has been a medical subspecialty since 2006 in the United States, and training program requirements are mostly controlled by the Accreditation Council for Graduate Medical Education (ACGME).¹

The European Association of Cardiovascular and Thoracic Anesthesiology (EACTA) has been concerned for some time with the quality of training of its trainees. EACTA recently published a new model of a basic curriculum for cardiovascular and thoracic anesthesia, aimed at more uniform teaching and skill development of professionals.²

Moreover, advances in intraoperative monitoring, such as Transesophageal Echocardiography (TEE) has led many anesthetists to pursue learning on how to use TEE appropriately. The objective of a recent publication was to standardize the management of intraoperative echocardiography for anesthesiologists according to the SBA and the Department of Cardiovascular Imaging (DIC) of the Brazilian Society of Cardiology.³

There are currently few specific programs offering training in cardiovascular anesthesia in Brazil. Among them, the program of the Centro de Estudos da Clínica de Anestesia São Paulo has been a forerunner training course in cardiovascular anesthesia in which recently graduated anesthetists accompany professionals with long time experience in cardiovascular anesthesia procedures. The program has undergone several reformulations throughout the years, and in 2018, after a judicious assessment by EACTA, it was certified as the first and only center for basic training in cardiovascular and thoracic anesthesia outside the European continent, and whose Hospital Base is the Instituto Dante Pazzanese de Cardiologia. This brought key results to the program, such as exchange with other centers of excellence abroad, in addition to participation in major multicenter studies. We can also include the complementation program specialized in Surgical Intensive Care and Anesthesiology of Universidade de São Paulo (USP) – São Paulo and, recently, the specialization course in Cardiovascular Anesthesia of the Instituto Nacional de Cardiologia (INC) – Rio de Janeiro. However, the programs offered are frequently not uniform and do not drive toward the same basic training of anesthetists who seek improvement.

In 2007, the estimated number of cardiac surgeries performed in Brazil in the unified health system (SUS) alone was approximately 350 heart surgeries/1,000,000 inhabitants/year (including defibrillator and pacemaker implants).⁴ A growing number of these procedures may lead to an estimated 350,000 in 2021, beside the increase in the number of complex procedures, such as percutaneous aortic valve implants. To date, over 2,500 patients are estimated to have been submitted to this kind of procedure in our country and this number may reach up to 12,000 a year.⁵ It is important to underscore that not only major centers but also several inner cities have the potential to perform such surgeries; therefore, the need to build skills in anesthetists in the area is increasingly more evident and growing.

Another point is the growing interest in learning and using perioperative transesophageal echocardiography as an additional monitoring method by anesthetists. It is very important we contemplate this topic for teaching on how to use TEE by the anesthetist also be uniform, and in compliance with the Brazilian Society of Cardiology. EACTA, for example, requires that fellows trained at their credentialed training centers include a course with theory and practice in TEE in the basic program, that allows trainees to acquire the required knowledge to pass certification tests.²

Based on this scenario, we believe that more comprehensive and longer skill-building of anesthetists that will work in cardiovascular surgery is increasingly more necessary. The basic program in cardiovascular anesthesia with standardized teaching, already employed in other countries, is an alternative that can be appropriate for Brazil according to our needs.

Acknowledgments

The authors thank all the other individuals who helped and provided contributions to the study.

• Financial support
  This study was supported entirely by department funds.

References

• ¹
  Capdeville M, Hargrave J, Patel PA, et al. Contemporary challenges for fellowship training in adult cardiothoracic anesthesiology: perspectives from program directors around the United States. J Cardiothorac Vasc Anesth. 2020;34:2047-59.
• ²
  Erdoes G, Vuylsteke A, Schreiber JU, et al. European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia Fellowship Curriculum: First Edition. J Cardiothorac Vasc Anesth. 2020;34:1132-41.
• ³
  Salgado-Filho MF, Morhy SS, Vasconcelos HD, et al. Consenso sobre Ecocardiografia Transesofágica Perioperatória da Sociedade Brasileira de Anestesiologia e do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia. Rev Bras Anestesiol. 2018;68:1-32.
• ⁴
  Gomes WJ, J Mendonça JT, Domingo, Braile D. Resultados em cirurgia cardiovascular oportunidade para rediscutir o atendimento médico e cardiológico no sistema público de saúde do país. Rev Bras Cir Cardiovasc. 2007;22:III-VI.
• ⁵
  Lopes MAC, Nascimento BR, Oliveira GMM. Tratamento da Estenose Aórtica do Idoso no Brasil: Até quando podemos esperar? Arq Bras Cardiol. 2020;114:313-8.

Publication Dates

• Publication in this collection
  24 May 2021
• Date of issue
  Mar-Apr 2021

History

• Received
  12 Oct 2020
• Accepted
  14 Nov 2020