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European Cardiovascular Disease 2007 - Issue 2;2007:3(1):10-10

Medical advances and new technologies have allowed us to fight, with growing success, cardiovascular diseases in an increasing elderly population with higher levels of co-morbidities. Accordingly, the number of patients undergoing cardiac surgery and invasive cardiological procedures will further increase in the near future. From a cardiothoracic anaesthesiologist’s point of view, the primary concerns with this development are the continuous increase in high-co-morbidity elderly patients, the unconcealed demand for more cost-effective procedures, the lack of trained staff and the decrease in medical research funding.
Recent advances in the deployment of drug-eluting stents and the new concept of percutaneous transcatheter or transapical aortic valve implantation offer hope to non-surgical candidates. The challenge of designing anaesthesia and intensive care that can cope with the risks from the multiple co-morbidities prevalent in elderly patients is perhaps mostly psychological, as cardiac surgery seems safe in octogenarians with good short-term and medium-term results, especially in early surgical interventions.
Length of stay in the intensive care unit (ICU) is one of the factors limiting operating room utilisation in cardiac surgery and, consequently, is one of the primary cost-effectiveness parameters. Another major determinant of the augmented demand for ‘fast-track’ cardiac surgery is the need for containing the burgeoning costs, saving resources and reducing the amount of time in the ICU. The issue of quality has been less widely debated; this is also true for potential safety issues related to fast-track cardiac surgery. However, there seems to be available evidence that fast-track procedures can be applied to many – but probably not all – patients, and can be accomplished without demonstrable patient harm. At present it seems that factors guiding time in the ICU have reached a stage where the need for patient turnover, practical convenience and local policies are more important than what is actually possible. Research and quality programmes are needed to create goal-orientated programmes with a co-ordinated approach involving anaesthesia, surgery and nursing, with constant re-evaluation as events unfold rather than rigid protocols.
In terms of staff, the primary problem is conceivably not the number of new staff members, but merely the number with sufficient qualifications to fill vital positions in the relatively demanding areas of invasive cardiology, cardiac surgery, cardiothoracic anaesthesia and recovery. The European Association of Cardiothoracic Anaesthesiologists (EACTA) has, during the last few years, focused on various aspects of training. Together with the European Association of Echocardiography (EAE), EACTA has implemented an accreditation programme in trans-oesophageal echocardiography and is currently working on a European accreditation programme for the education of cardiothoracic anaesthesiologists.
As a result of the augmented interest in cost-effectiveness, research seems to have been sacrificed in many institutions. As a consequence, senior doctors are no longer allowed time for research, or have seen their allocated research time seriously reduced. Furthermore, private and free research funding has decreased; this has been remedied by only slightly higher government funding. However, government funding carries a risk of research unification and direction of research into what suits the system better. To combat this, some years ago EACTA instituted research grants and scholarships for young doctors; although this effort seems to be a drop in the ocean, it is of major concern to EACTA to be able to increase this kind of funding in the years to come. Ôûá