Embracing the ’NORCA’ Revolution: From Operating Room ‘Marathon’ to Cathlab ‘Sprints’
Year: 2025
Type: article
Abstract: The field of cardiac anesthesiology, traditionally anchored in the operation theatres, is undergoing a fundamental shift. The increasing volume and complexity of percutaneous and transcatheter cardiac interventions, both in adults and children, have expanded our professional arena into catheterization laboratories and hybrid suites. This evolution demands cardiac anesthesiologists swiftly adapt from roles likened to marathon runners—supporting long surgeries with laborious postoperative course—to sprinters, prepared for high-intensity, short-duration interventions with photo-finish outcomes. Echocardiography labs, electrophysiology suites, and cardiac catheterization labs routinely conduct advanced, minimally invasive procedures for the diagnosis and treatment of a wide range of cardiac conditions.[1,2] These non-operating room anesthesia (NORA) cases constitute a growing proportion of anesthesiologists’ clinical responsibilities, with cardiologist-led procedures, in particular, aligning with the specialized skill set of cardiac anesthesiologists. The growing volume of cardiac interventions, such as transcatheter aortic valve implantations (TAVI), MitraClip procedures, and complex electrophysiological cryoablations, has led to the emergence of a distinct and rapidly emerging frontier of cardiac anesthesia that can be best termed non-operating room cardiac anesthesia (NORCA). While the broad term “NORA” is well-established, NORCA can be considered a subdomain with unique challenges and demands, distinct from non-cardiac NORA. The proportion of NORCA in anesthetic practice is growing.[3] Today, a simple audit of workload patterns at any contemporary advanced cardiac center in India would reveal a growing proportion of cardiac anesthesia being administered outside the conventional operating room settings, usually at cardiac catheterization labs [Figure 1]. The rising trends could be attributed to changing practices, where definitive treatments for cardiac conditions can be provided through minimally invasive, advanced procedures in hybrid operating rooms, electrophysiology suites, and cardiac catheterization labs.[4] Furthermore, nearly two-thirds of patients undergoing procedures in cardiac interventional labs who require anesthesia or sedation are classified as having a higher ASA physical status, in contrast to approximately one-third in other NORA settings, such as gastroenterology and radiology suites.[5] Consequently, the incidence of adverse events is also expected to be higher in this population.Figure 1: Year-wise trends in workload recorded by cardiac anesthesiologists at the author’s hospital in Delhi, India. TAVR: Transcatheter aortic valve replacement/implantation; TMVR: Transcatheter mitral valve replacement; TPVI: Transcatheter pulmonary valve implantation; GA: General anesthesiaAdvanced cardiac interventions conducted outside the operating room demand expertise in applications of cardiac physiology and pharmacology, making cardiac anesthesiologists uniquely suited to manage them.[1] The traditional cardiac operating theatre experience involves long surgeries unfolding under controlled conditions, with various surgical and perfusion-related protocols, followed by intensive postoperative care. On the contrary, advanced cardiac interventions performed by cardiologists are capital-intensive procedures that are sometimes time-sensitive and pose unique challenges. The workflow of cardiac anesthesiologists when managing sick patients in a cardiac interventional lab may be unfamiliar to cardiologists. Assistance from other anesthesiologists is not readily available. Cardiac anesthesiologists are exposed to unfamiliar environments, including equipment limitations, variable ergonomics, and constrained access to patients, as well as the constant need to troubleshoot imaging-related anesthetic challenges.[5] The skills required for NORCA are distinct. The expected anesthetic challenges related to airway management outside the operating room, including hemodynamic instability at induction, as well as the implications of multiple comorbidities, continue to exist. NORCA demands rapid induction of sedation in patients with multiple comorbidities, vigilant hemodynamic management during intra-cardiac manipulations, and seamless recovery without the expectation of prolonged ICU optimization. Proficiency in customizing sedation strategies, identifying the need for rapid upgradation of airway support, ensuring safe and reliable airway manipulation, ensuring compatibility with real-time imaging, providing focused TEE guidance during interventions, and demonstrating competence in limited-resource crisis management is paramount. There is a premium on fine motor skills, swift decision-making, and the ability to provide precise anesthetic depth without compromising patient stability or compromising the quality of intervention. Rather than viewing NORCA cases as “external domains,” we should recognize them as a natural evolution of the cardiac anesthesiologist’s perioperative scope, applying the same rigorous standards and principles adopted from the operating room to NORCA settings—without exception or dilution of safety.[2] Adapting to NORCA mandates reorienting training and professional identity. Cardiac anesthesiologists must develop flexible competencies: balancing high-performance perioperative assessment with immediate, procedure-specific interventions. Simulation training, focused short-course interventions, cross-training in interventional cardiology workflows, and reorienting to a “day-case” recovery model will be essential for success. NORCA provides an opportunity for all stakeholders to be educated about the unique, tailor-made care sedation options that can be made available to patients. The professional demands of these new roles mirror the physiological challenges faced by various types of athletes. Marathoners dominate endurance sports and are rich in type-I slow-twitch muscle fibers and white fat reserves, which are suited for prolonged energy expenditure. Sprinters, by contrast, rely on type-II fast-twitch fibers and quick energy sources, including brown adipose tissue, optimized for intense bursts of activity.[6] Similarly, cardiac anesthesiologists must recalibrate their practice—cultivating both the “endurance muscle” for conventional surgery and the “explosive muscle” for NORCA. Training must, therefore, focus on cultivating dual proficiencies: maintaining the depth of conventional practice while acquiring the agility, speed, and precision needed for cardiac interventions. This shift in perspective will enable a smooth transition in daily practice from the sustained endurance required for cardiac surgeries to the rapid execution necessary for advanced cardiology intervention suites. The future of cardiac anesthesia is increasingly hybrid, and the sooner we adapt, the better we will serve our evolving patient requirements. Acknowledgment of the emergence of NORCA would further bolster the professional status and expertise of cardiac anesthesiologists as experts in daycare, in addition to being experts in managing post-cardiotomy shock. The advent of NORCA signals not only a change in the practice environment but also a need for a metamorphosis in our professional physiology.
Source: Annals of Cardiac Anaesthesia
Authors: Devarakonda V. Bhargava, Mukul Kapoor
Language: English
Subfield: Anesthesiology and Pain Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4412112969