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Current Status of Cardiovascular Anesthesia in China

Lu, Jiakai MD*; Wang, Weipeng MD; Cheng, Weiping MD*; Chen, Lei MD; Huang, Jeffrey MD; Ethridge, Chris A. MD§; Huang, Jiapeng MD, PhD

doi: 10.1213/ANE.0000000000002051
Cardiovascular Anesthesiology
Free

High quality and safe cardiac anesthesia is a prerequisite for success in cardiac care. Cardiac surgery has developed rapidly over recent years in China. Because of language barriers, the current status of cardiac anesthesia in China is not well known to Western countries. To assess practice patterns, volume, workforce, and training requirements of Chinese cardiovascular anesthesiologists, we surveyed 92 major cardiovascular centers in China regarding their anesthesia practice, monitoring techniques, resources, staffing, and work hours. We aim to provide a review of the history, new developments, and a current cross section of cardiac anesthesia practice patterns in China. The goal is to allow Western readers to understand the unique achievements and challenges in Chinese cardiovascular anesthesiology, thus promoting further communications with Chinese cardiovascular anesthesiologists.

Published ahead of print May 4, 2017.

From the *Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, People’s Republic China

Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Science, Beijing, People’s Republic of China

Anesthesiologists of Greater Orlando, Orlando, Florida

§Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky

KYOne Health and Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky.

Published ahead of print May 4, 2017.

Accepted for publication January 30, 2017.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Jiapeng Huang, MD, PhD; and Jiakai Lu, MD, Department of Anesthesiology & Perioperative Medicine, University of Louisville, Jewish Hospital, 200 Abraham Flexner Way, Louisville, KY 40202; and Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases and Anzhen Hospital, 2 Anzhen Road, Chaoyang District, Beijing, People’s Republic of China. Address e-mail to jiapenghuang@yahoo.com; and lujiakai620@163.com.

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HISTORY AND PIONEERS OF CARDIAC ANESTHESIA IN CHINA

With very limited resources, pioneer cardiac surgeons and anesthesiologists overcame many obstacles to start cardiac surgery programs in China in the mid-20th century. Internationally renowned cardiothoracic surgeon Dr Yingkai Wu completed the first case of patent ductus arteriosus ligation and pericardiectomy for restrictive pericarditis in 1944 and 1947 separately.1 Dr Wu then started an open-heart surgery program early in 1960 at Fuwai Hospital with the use of hypothermia and extracorporeal circulation.2,3 This was widely considered the beginning of cardiac surgery in China.

In the field of congenital heart surgery, Dr Mei-Hsin Shih performed the first Blalock-Taussig shunt in Shanghai in 1953.1 Pulmonary valvotomy and atrial septal defect repair were also carried out successfully without cardiopulmonary bypass (CPB) in the 1950s. The first CPB procedure, a ventricular septal defect closure under CPB, was successfully completed by Dr Hong-Xi Su in Shanghai. Dr Kai-Shi Gu designed the first clinically used and entirely Chinese-made heart-lung machine in 1958.1 At the same time in Beijing, Fuwai hospital grew to be the biggest cardiovascular center in China. Intracardiac operations under hypothermia without CPB had been conducted since early 1958 at Fuwai.1The Table lists all early cardiac operations in China by time.1,4–8

Table.

Table.

The advancement of cardiac anesthesia in China kept close pace with cardiac surgery. Several pioneer anesthesiologists established respected cardiac anesthesia practices to support cardiac surgery in different regions of China. Dr Deyan Shang is widely considered to be the founder of Chinese cardiac anesthesiology. Dr Shang (1918–1985) was selected to visit the United States to study anesthesiology in 1947 and returned to China in 1949, after which he established and chaired many Departments of Anesthesiology, to include the department at Fuwai Hospital. His research focused on hypothermic protection in cardiac surgery and controlled hypotension.9,10 Dr Shang’s contribution also included the development of the first heart-lung machine made in China. In 1979, he was elected as the inaugural President of Chinese Society of Anesthesiology.

Dr Xingfang Li (1916–2011) underwent training in anesthesiology in the United States between 1944 and 1947, and went on to chair the Departments of Anesthesiology of both Shanghai Renji Hospital and Reijin Hospital. She led the nation in closed-loop general anesthesia and provided anesthesia for the first closed mitral commissurotomy in 1954. In 1957, Dr Li initiated anesthesia for traumatic abdominal homograft implantation under hypothermia and anesthetized the first open pulmonary valvotomy patient. She subsequently provided anesthesia for cardiac surgeries under CPB and the first heart transplant in China.11 Dr Yuanchang Wang (1922–1998) invented extrathoracic cardiac compression technique in 1957 and a hypothermic low-flow partial perfusion technique to overcome limited oxygenation provided by these initial heart-lung machines.12

In the field of cardiac monitoring, Drs Dajin Sun (1929–) and Yannan Hang (1936–) were pioneers in central venous pressure monitoring, radial artery blood pressure monitoring, and Swan Ganz catheter monitoring in China. Dr Jin Liu (1956–) started intraoperative ultrasound training to include transesophageal echocardiography (TEE) in cardiac surgery, fast ultrasound scanning in emergent surgery, and ultrasound-guided nerve blocks/vascular access at Huaxi Hospital, Sichuan Province beginning in 1999. Cardiac anesthesiologists in Huaxi Hospital have performed all intraoperative TEEs for cardiac surgery since 2008 (personal communications).

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CARDIOVASCULAR HOSPITALS IN CHINA

There are about 2 million patients with rheumatic heart disease, nearly 2 million patients with congenital heart defects, and 1.6 million patients with idiopathic cardiomyopathy in China. China has nearly 10 million patients with potential need for cardiac surgery by estimation. According to Chinese Society of Extra-Corporeal Circulation statistics, 734 hospitals reported 207,781 cases of cardiac surgery in 2013 and 209,765 cases in 2014.13,14 (Figure 1 shows the surgical type distribution.) Surgical mortality rate in major Chinese cardiac centers is around 1% to 3%.13

Figure 1.

Figure 1.

To familiarize readers with the geographic, economic, or demographic distributions in China, we provided a map of all major cardiovascular centers (defined as >1000 cardiac or major vascular cases/year) in Figure 2. The distribution of major cardiovascular centers correlates well with the economic status of corresponding provinces except for Inner Mongolia and northeast China. Shanghai has the highest number of major cardiovascular hospitals (6) and many west, north, or midwest provinces do not even have 1 major cardiovascular hospital. The hospitals with highest surgical volumes are concentrated in Beijing, Shanghai, Guangzhou, Wuhan, Changsha, and Zhengzhou. Accumulation of cardiovascular hospitals along eastern and southern China reflects their local governments’ abilities to provide significant monetary support for these high-cost cardiac surgical care services. Many Chinese patients travel long distances to major hospitals for medical care instead of seeking care locally. Patients commonly undergo operations at the major medical centers and then receive postoperative care at their local hospitals. This is largely due to a combination of culture and significantly better surgical outcomes at these major hospitals compared to local hospitals that lack resources.

Figure 2.

Figure 2.

In 2015, Fuwai Hospital, the largest cardiovascular hospital in China, performed 13,755 cardiac operations with a perioperative mortality rate <1%.15 Fuwai’s mortality rate for coronary artery bypass grafting (CABG) was 0.4%, congenital cardiac surgery mortality rate was <0.4%, valvular surgery mortality rate significantly <1%, and aortic surgery mortality rate <2%.15 These data are comparable to leading cardiac centers worldwide. For heart transplant, 1-year survival rate was 94.7 % and 5-year survival rate was 88.2%, which is higher than the International Society of Heart and Lung Transplantation standard.15 For length of stay, CABG patients have an average length of stay of 7.8 days, which is close to Society of Thoracic Surgery data (www.sts.org). Figure 3 showed the impressive blood conservation success in adult and pediatric cardiac surgeries at Fuwai compared with Society of Thoracic Surgery data.

Figure 3.

Figure 3.

In 2015, Anzhen hospital, the No. 1 ranked general hospital with a focus on cardiac care in China, performed a total cardiac surgery volume of 11,490 with a mortality rate of 1.07% (from Anzhen Cardiac Surgery Database). Since 2009, major aortic surgeries increased exponentially at Anzhen Hospital and reached 700 in 2013.16 In addition, Anzhen hospital is a major center for surgical treatment of chronic thromboembolic pulmonary hypertension in China.17

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CARDIAC ANESTHESIA WORKFORCE, EDUCATION, AND RESEARCH IN CHINA

Currently there are about 12,000 members in the Chinese Society of Anesthesiology (CSA), the main society for Chinese anesthesiologists. However, there are still many anesthesiologists who are not members of CSA, and it is unknown how many members are considered cardiovascular anesthesiologists. The Chinese Society of Anesthesiologists has established a cardiothoracic anesthesia–focused seminar at their annual meetings and has invited many national and international experts to speak and lead. On January 26, 2015, the Chinese Society of Cardiothoracic and Vascular Anesthesiology (CSCVA) was founded in Beijing (http://www.csctva.org/CSCTVA/Home). This should greatly promote the progression of cardiac anesthesia in China and serve as an important platform for international anesthesia communities. There are currently about 3000 members in CSCVA. It should be noted that there are many members of CSCVA who are not clinical cardiac anesthesiologists. Exact numbers of practicing cardiovascular anesthesiologists are difficult to calculate from these 2 societies.

We sent 92 surveys to cardiovascular centers in China and received 91 surveys back, for a return rate of 98.9%. The complete survey form is attached in the Appendix. The total self-reported cardiac and major vascular cases among these 91 hospitals was 141, 997. According to the Chinese cardiovascular report, in 2015 there were total of 209,765 cardiac and major vascular cases in Mainland China.14 Our sample comprised 67.6% of the total cardiovascular cases in China. There were a total of 1517 cardiovascular anesthesiologists providing clinical care to these patients in our surveyed hospitals. Assuming similar workload across hospitals, we estimate that there are about 2300 clinical cardiac anesthesiologists in China.

Cardiac surgical volume is increasing dramatically due to an aging patient population and financial improvement. Cardiac anesthesiologists’ work hours and intensities are expected to increase accordingly. In our survey, only 9.6% of cardiac anesthesiologists work less than 40 hours/week; the majority of cardiac anesthesiologists (64.5%) work between 40 and 55 hours/week and 23.6% of anesthesiologists reported working 55 to 77 hours/week. To ensure cardiac anesthesia quality and safety, we must strive to avoid cardiovascular anesthesiologists’ fatigue and burnout by solving anesthesiologist shortages. In addition, cardiovascular cases are usually longer and patients are much sicker, and these factors can significantly increase the intensity of work for cardiovascular anesthesiologists.

There is no professional journal dedicated to cardiovascular anesthesiology in China. Chinese cardiovascular anesthesiologists do have access to multiple guidelines from the Society of Cardiovascular Anesthesiologists, American Society of Echocardiography, and European societies through online resources. These guidelines are frequently discussed at seminars and meetings yet not uniformly adopted in China. However, some guidelines such as Advanced Cardiac Life Support are utilized and promoted widely.

Education in cardiovascular anesthesiology is not standardized and very much hospital dependent in China. Until 2013, the National Health and Family Planning Commission of The People’s Republic of China published guidelines regarding standardized residency training for all physicians including anesthesiologists.18 The proposed and mandated model is a “5+3” plan, which includes 5 years of medical school followed by 3 years of specialty residency training. Anesthesiologists will have to finish 3 years of anesthesiology training after medical school before being considered as a practicing anesthesiologist. Currently there is neither certified specialty cardiovascular anesthesiology training/fellowship nor an accrediting body to certify cardiac anesthesiologists in China. Most Chinese cardiac anesthesiologists have received training from Departments of Anesthesiology at major cardiac hospitals. These training programs commonly follow a traditional apprenticeship model and are starting to become more and more standardized nowadays. Plans are in place to develop a cardiovascular anesthesiology fellowship in the future (personal communications).

Many major hospitals are hosting routine seminars on cardiovascular anesthesia with high-quality speakers and materials. The CSA and CVCSA annual meeting provides an excellent source of education for cardiac anesthesiologists, and there are many training seminars and courses available to teach TEE and cardiac anesthesia across China now. Online education has become very popular over recent years with the New Youth Anesthesia Forum (www.xqnmz.com) providing free courses and live discussions with expert cardiovascular anesthesiologists from China and the United States.

Research in clinical cardiac anesthesia in China has primarily been focused on blood conservation and organ protections due to their limited medical resources. A trend for increasing surgical volume while decreasing use of blood products has been observed at several hospitals.

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CARDIAC ANESTHESIA CURRENT PRACTICE PATTERN IN CHINA

To understand the current clinical practice pattern of cardiac anesthesia in China, we performed a survey of cardiovascular anesthesiologists regarding monitoring techniques, anesthesia techniques, and cardiac medication choices made in cardiovascular surgery.

Cardiac surgery is a high-risk specialty for significant bleeding and definitely requires availability of blood products. Our survey showed that 91.3% of surveyed hospitals have a blood bank on site. Public tertiary hospitals, which are allowed to perform cardiac surgery in China, are required to have blood banks on site. As a critical decision-making tool for blood transfusion, 97.8% of hospitals own bedside blood gas and hemoglobin analysis equipment. In 2000, the Chinese Ministry of Health published their “Clinical Blood Transfusion Guideline” (http://www.nhfpc.gov.cn) and recommended packed red blood cell transfusion for hemoglobin level <6 g/dL or hematocrit <20%; platelets transfusion for platelet count < 50 × 109/L and transfusion of 10 to 15 mL/kg fresh frozen plasma for coagulation factor deficiency.

During anesthesia induction for cardiac surgery, etomidate and propofol are the 2 most popular induction agents for Chinese cardiac anesthesiologists with some use of Ketamine or a combination of drugs (Figure 4). It is unclear why almost 50% of Chinese anesthesiologists use propofol in cardiac induction, although there is a significant price difference between etomidate versus propofol in China.

Figure 4.

Figure 4.

For maintenance of anesthesia, sevoflurane and IV propofol infusion dominated with some use of isoflurane, IV dexmedetomidine infusion, fentanyl, sufentanil, etomidate, and midazalom (Figure 4). In China, inhalational agents are restricted in use at many hospitals due to the lack of dantrolene, the antidote for malignant hyperthermia.19 In addition, many heart lung machines in China do not have a vaporizer for inhalational agents, further limiting its use. These could explain the overwhelming use of intravenous propofol for maintenance of anesthesia in China. Recent literature does suggest that sevoflurane may exhibit a more favorable cardioprotective effect during cardiac surgery than propofol.20 Whether this new information will impact Chinese anesthesiologists’ choice of a maintenance agent remains to be seen.

The use of pulmonary artery catheters (PACs) during cardiac surgery varies considerably depending on local policy, ranging from use in 5% to 10% of the patient population to routine application in Western countries. In our survey, 62% of Chinese cardiovascular anesthesiologists rarely use PACs and 26% never use PACs (Figure 4) during cardiac surgery. In 2007, the Chinese Medical Association Branch of Anesthesiology published “Guideline on Pulmonary Artery Catheter Clinical Use” and provided guidance for choice of monitors in cardiac anesthesia (www.csaol.com). Unfortunately, PAC monitoring is not used routinely for indicated patients due to economic and skill limitations.

In China, 13% of cardiovascular anesthesiologists always use TEE intraoperatively for cardiac surgery; 48% usually use TEE; 37% rarely use TEE; and 5% never use TEE (Figure 4). This actually has been a significant improvement over the last several years after a strong promotion of TEE in cardiac surgery by a team of cardiovascular anesthesiologists from the Chinese American Society of Anesthesiology and CSA.

In the United States, cardiac anesthesiologists perform the majority of intraoperative TEEs. In China, many physicians (cardiac anesthesiologists, ultrasound physicians, cardiac surgeons, and cardiologists) are credentialed to perform TEEs. Most intraoperative TEEs involve ultrasound physicians either independently or in a supervisory role. Chinese cardiac anesthesiologists are beginning to catch up with ultrasound physicians and participate in 48.9% of intraoperative TEEs. Ultrasound physician is a very specialized medical discipline in China with the sole focus on ultrasound. In many provinces, ultrasound physicians are the only ones allowed to bill ultrasound services including TEEs (Figure 4). When questioned why TEEs are not used, the most common reason listed is the lack of support on equipment and training.

For cardiac protection techniques, 56.5% use antegrade cardioplegia and 43.4% use combined antegrade and retrograde cardioplegia. None use retrograde cardioplegia alone. These practices are consistent with Western country clinical standards.

In terms of medication choices for inotropes (Figure 4), dopamine was ranked the number one choice for Chinese cardiovascular anesthesiologists (48.9%), which is in sharp contrast with US cardiac anesthesia practice. The use of dopamine has reduced dramatically after the publication of a New England Journal of Medicine article which showed that dopamine was associated with increased adverse events compared to norepinephrine.21 The reasons for such a frequent use of dopamine in China might be related to local practice patterns and economic considerations. Epinephrine is a close number 2 choice at 32.6%. Dobutamine and milrinone are also used by some centers as inotropes. For choice of vasopressors, norepinephrine (57.6%) is the most commonly used medication followed by dopamine again (19.5%) and phenylephrine. Vasopressin is available in China, but it is mainly used in liver transplant cases, not cardiovascular cases.

For postoperative care, 97.8% of surveyed hospitals have an intensive care unit (ICU) and cardiac surgical patients return to ICUs after surgery. Most cardiac surgical patients are extubated within 24 hours after arrival in the ICU (79.3%). The remaining patients (20.6%) are extubated within 24 to 48 hours of arrival. In many countries, anesthesiologists provide cardiac ICU and perioperative care. In China, cardiac anesthesiologists are mainly operating room based and are rarely involved in ICU care. Chinese cardiac ICUs are staffed by generally equal numbers of cardiac surgeons and intensivists (Figure 4).

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FUTURE DIRECTIONS OF CARDIOVASCULAR ANESTHESIA IN CHINA

Many complex congenital heart defects can only be cured during the neonatal and infantile period. The shift for pediatric cardiac anesthesia will be toward more complex cases at a much younger age. Pediatric cardiac anesthesiologists must work hard to improve pediatric cardiac monitoring, anesthesia techniques, and organ protection. With increasing congenital heart surgery cases in China, more palliatively repaired congenital heart patients will reach adulthood and require adult congenital heart surgery and noncardiac surgery. With improved nutrition and sedentary lifestyle being more common, more patients with coronary artery disease will need CABG in the future. These will probably compose the largest case growth for Chinese cardiac anesthesiologists.

Management of end-stage heart failure will be another directive in China due to increasing numbers of patients with heart failure. Mechanical assistance devices are only limited to a few major medical centers in China now, and due to economic, quality, and technical limitations, there are no commercially available and approved ventricular assist devices. With an improved economy and current and future policy change, mechanical support devices including ventricular assist devices and extracorporeal membrane oxygenation will become more readily available. This will require anesthesiologists to optimize these high-risk patients’ management, carefully select and use inotropic medications, choose appropriate monitors, and improve resuscitation of patients with heart failure perioperatively.

With advancements in interventional cardiology, especially endovascular treatment of aortic diseases, percutaneous repair and replacement of aortic and mitral valves will become more prevalent. Development of these minimally invasive techniques will shift Chinese cardiovascular anesthesiologists from the traditional operating rooms to the catherization laboratory with its associated challenges and rewards.

In summary, cardiovascular anesthesia in China has had an extraordinary past, is experiencing a solid present, and will have a bright future through evidence-based medical practice, standardized residency/fellowship training, and productive clinical research using this impressively large patient population.

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APPENDIX

Cardiac Anesthesia Survey

Hospital Name:

In 2015, what is the total number of cardiac and major vascular cases performed in your hospital:

  1. How many cardiac anesthesiologists practice cardiac anesthesia in your department?
  2. Do you use TEE for cardiac surgery?
    • A. Always
    • B. Usually
    • C. Rarely
    • D. None
  3. Who performs TEE in cardiac surgery?
    • A. Cardiac anesthesiologists
    • B. Ultrasound physicians
    • C. Cardiac surgeons
    • D. Cardiologists
  4. What is the reason that you do not use TEE?
    • A. We do not have TEE machines
    • B. Ultrasound physicians do not want us to do TEE
    • C. Lack of training
  5. What kind of cardioplegia do you use?
    • A. Antegrade cardioplegia mostly
    • B. Retrograde cardioplegia mostly
    • C. Combination of antegrade and retrograde cardioplegia
  6. Do your cardiac surgical patients go to ICU after surgery?
    • A. Yes
    • B. No
  7. Who is in charge of the cardiac surgery ICU?
    • A. Cardiac anesthesiologists
    • B. Intensive care physicians
  8. Do you have blood bank in your hospital?
    • A. Yes
    • B. No
  9. Do you have point-of-care devices to measure ABG and hemoglobin level?
    • A. Yes
    • B. No
  10. Which medication do you use for induction of anesthesia in cardiac surgery?
    • A. Etomidate
    • B. Propofol
    • C. Ketamine
    • D. Combination of drugs
  11. Which medication do you use for maintenance of anesthesia in cardiac surgery?
    • A. Isoflurane
    • B. Sevoflurane
    • C. Halothane
    • D. IV propofol infusion
    • E. Others (please specify)
  12. Do you use pulmonary artery catheters in cardiac surgery?
    • A. Always
    • B. Usually >50%
    • C. Rarely <20%
    • D. None
  13. Which inotropic medication do you use most often to support contractility of the heart?
    • A. Dopamine
    • B. Dobutamine
    • C. Epinephrine
    • D. Milrinone
    • E. Others (please specify)
  14. Which vasopressor agent do you use most often to support blood pressure?
    • A. Dopamine
    • B. Norepinephrine
    • C. Epinephrine
    • D. Vasopressin
    • E. Others (please specify)
  15. When do you extubate cardiac surgical patients?
    • A. In the OR
    • B. Within 24 hours in the ICU
    • C. 24–48 hours in the ICU
    • D. Longer than 48 hours
  16. What is your average hours of work per week as a cardiac anesthesiologist (all in-hospital hours included)?
    • A. Less than 40 hours
    • B. 40–55 hours
    • C. 55–70 hours
    • D. More than 70 hours
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DISCLOSURES

Name: Jiakai Lu, MD.

Contribution: This author helped design and conduct the study, and prepare the manuscript.

Name: Weipeng Wang, MD.

Contribution: This author helped design and conduct the study, and prepare the manuscript.

Name: Weiping Cheng, MD.

Contribution: This author helped design and conduct the study, and prepare the manuscript.

Name: Lei Chen, MD.

Contribution: This author helped design and conduct the study, and prepare the manuscript.

Name: Jeffrey Huang, MD.

Contribution: This author helped design and conduct the study, and prepare the manuscript.

Name: Chris A. Ethridge, MD.

Contribution: This author helped prepare the manuscript.

Name: Jiapeng Huang, MD, PhD.

Contribution: This author helped design and conduct the study, and prepare the manuscript.

This manuscript was handled by: W. Scott Beattie, PhD, MD, FRCPC.

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