Adult Congenital Heart Disease
The Toronto Adult Congenital Heart Disease (ACHD) program of the Peter Munk Cardiac Center (PMCC) is one of the largest ACHD programs in the world. The program is well known for its collaborative approach to patient care. This multi-disciplinary program provides care to more than 10000 ACHD patients.
We are extensively involved in perioperative, intraoperative, and postoperative/ICU care of this growing population. Additional to surgical cases, there is increasing number of ACHD patients requiring procedures in Cath lab including valvular interventions and electrophysiology procedure.
Over the past year, with regular and additional operating times given to our group, we were able to shorten our waiting list significantly. This is remarkable considering the limitations that we have seen in staffing in various levels and operating times.
Cardiovascular Intensive Care Unit
The cardiovascular intensive care unit (CVICU) recovered from the off service burden of COVID coincident with a successful immunization campaign in the spring and summer of 2021. We started the academic year with 25% off service which diminished over the summer to less than 5% of CVICU activity and remained stable through the academic year. Human resources became a new challenge with the onset of the Omicron wave and we operated at ~80% of pre-pandemic volumes. Successful recruitment and training of CVICU nursing staff occurred throughout the year and ended the academic year with nearly full complement of staff.
Cancellations on the same day of surgery were driven by access to operating room services and lack of ward capacity and ranged from 3 to 23% month to month. LOS was increased due to lack of ward capacity with a proportion of patients staying an extra day due to the inability to transfer to the ward. Mortality in CVICU was 44/1280 (3.4%) in hospital overall including emergent cases and advanced therapies. Fast Track (FT) continued throughout the pandemic omicron wave but with the necessity to pivot on location and flow through the academic year. Our FT results were presented at the AATS meeting in Boston 2022.
Transesophagel Echocardiography
The Toronto General Hospital Perioperative Echocardiography Group (PEG) comprises 21 core anesthesiologists that are advance trained in transesophageal echocardiography (TEE). Current PEG members include Drs. Ansari, Duncan, Fiorellino, Foley, Heggie, Hudson, Ibarra, Jariani, Mashari, Minkovich, Moreno, Neethling, Parotto, Salvatori, Snyman, Srinivas, Tylee, Van Rensburg, Vegas, Wasowicz and White. All PEG members have achieved and maintained certification status in Perioperative TEE by the National Board of Echocardiography (NBE).
Over the past year, PEG performed approximately 1000 intraoperative and postoperative TEE studies, reflecting a drop in case load related to COVID. These studies covered a broad range of pathologies and involved 75% of elective cardiac cases, all elective pulmonary thromboembolectomy cases and a selection of lung transplant cases. The PEG service also offers perioperative TEE coverage 7 days a week for both elective as well as emergency cases for all ORs, PACU and CVICU. The cardiology service images structural heart procedures in the heart catheterization laboratory and operating room.
All ultrasound machines have real-time 3D TEE capabilities. All TEE studies are digitally archived using the Siemens Syngo Dynamics PACS reporting system. This permits digital reporting with integration into the patient’s electronic patient record (EPR). PEG has dedicated server storage with full administrative rights on the system including modifying reporting templates and field search. Dr. Mashari is the database manager.
Our commitment to train cardiac anesthesia fellows in TEE remains a large part of PEG activity and includes dedicated hands-on teaching in the OR daily, formal lectures and weekly reading sessions moderated by PEG staff. The TGH fellows pass rate for the advanced perioperative TEE Exam at the National Board of Echocardiography in the USA has been 100% for the past five years.
There is integration of Focused Transthoracic Echocardiography (TTE) into the perioperative setting and in CVICU. Anesthesia residents can select an elective 4-week rotation to learn point of care ultrasound, which includes TTE, lung and abdominal ultrasound. This rotation involves the trainee imaging patients under supervision in the preoperative care unit (POCU), postoperative care unit (PACU) and CVICU. A high-fidelity echocardiography simulator (Vimedix, CAE Healthcare) is available to all TGH fellows and residents for learning TEE and TTE.
PEG staff are popular speakers at many international meetings including the 2021 SCA ECHOWEEK and the EACTIC Echo Course. Staff and fellows published review articles and book chapters. As reported separately the department supports the annual Toronto Perioperative Echocardiography Symposium, held virtually in November 2021.
The department continues to benefit from the expertise of consultant cardiologist, Dr. Ahmed Omran, who provides quality assurance and echo education to PEG. To date he has reviewed and given written feedback on over 300 studies performed by individual staff members. In addition, he contributes to fellow’s education by providing a basic TEE lecture series, didactic talks, moderating reading sessions and important hands-on intraoperative mentoring. Weekly reading rounds and written reviews provide Quality Assurance for the PEG service.