World Leader in Cardiac Critical Care Joins University Hospitals Harrington Heart & Vascular Institute

Rakesh Arora, MD, PhD, to lead cardiac intensive care units and cardiac surgery research

Innovations in Cardiovascular Medicine & Surgery | Fall 2022

Cardiac critical care has emerged as an essential subspecialty over the past 20 years, necessitated in part by the growing clinical needs and comorbidities of the aging Baby Boom generation. All the evidence suggests that older, sicker patients recovering from cardiac surgery or being treated for heart failure in the CICU and CTICU require their own specialized approach. The major cardiac surgery journals in North America, in fact – the Annals of Thoracic Surgery and the Journal of Thoracic and Cardiovascular Surgery – now have dedicated sections for cardiac critical care.

Rakesh C. Arora, MD, PhD

Rakesh C. Arora, MD, PhD, is one of the world’s leading experts in this crucial field and is now lending his expertise to University Hospitals Harrington Heart & Vascular Institute as its newest clinical leader. As Director of Perioperative and Cardiac Critical Care and as Research Director in the Division of Cardiac Surgery, Dr. Arora is charged with innovating and developing evidence-based approaches to improve outcomes for the most challenging critically ill cardiac patients.

“A physician of Dr. Arora’s prominence can choose to work anywhere in the world. With our exceptional team at University Hospitals (UH) Harrington Heart & Vascular Institute, we can make groundbreaking changes in the field of cardiovascular medicine,” said Mehdi Shishehbor, DO, MPH, PhD, President of UH Harrington Heart & Vascular Institute, and Angela and James Hambrick Chair in Innovation. “University Hospitals’ mission is To Heal. To Teach. and To Discover. Dr. Arora will use his decades of expertise to teach us how to better heal our patients and provide them with optimal outcomes after surgery. His research will help UH discover the future of perioperative care which will make surgery and recovery a better experience for countless patients.”

Career in Canada

Dr. Arora comes to UH from Winnipeg Regional Health Authority Cardiac Sciences Program, where he spent seven years as Medical Director of Intensive Care Cardiac Sciences and five years as Section Head and Regional Lead for Cardiac Surgery. During his long career in Canada, he served as one of the founders of the Canadian Cardiovascular Critical Care Society (CANCARE) in 2009. The group aims to improve the care of critically ill cardiovascular patients using interdisciplinary expertise in a cooperative model. It has contributed several guidelines to the Canadian Cardiovascular Society and is currently at work on a guideline on perioperative care. In addition, Dr. Arora currently serves as the Chair of the Society of Thoracic Surgeons Workforce on Critical Care.

Combating Frailty in Older Adults Undergoing Cardiac Surgery

Much of Dr. Arora’s research focus to date has been on strategies to mitigate against delirium and frailty in cardiology and cardiac surgery patients – both before and after surgery or interventional procedures. He was lead investigator on the PROTECT-CS Study (PROTein to Enhance outComes of (pre)frail paTients undergoing Cardiac Surgery). More recently, he’s expanded this work to Enhanced Recovery After Cardiac Surgery (ERACS) protocols.

“That's been relatively new for the cardiac surgery patient,” he says. “We put our first guidelines out 2019, but many of us have been doing enhanced recovery in small pieces, or maybe larger pieces, for quite some time. The newer guidelines provide a 23-point plan for teams to implement to provide the maximum amount of benefit to optimize the patient's recovery to get them back to doing what they want to do as quickly as possible -- not only leaving the hospital, but leaving the hospital to their own home.”

Among the 23 steps, the most important, Dr. Arora says, patients comment that nutrition support before and after surgery, early movement after surgery, guideline-based pain control to avoid delirium and a thorough discharge planning process have been identified as priorities. However, he says that patients, too, are good judges of what will give them the fortitude to successfully emerge from cardiac surgery.

“I think we, as providers, think, ‘These are the most important things,’” he says. “We sometimes get it wrong. So we asked patients what's most important to them through the implementation of formal patient engagement panels. In this forum, patient and caregivers provide valuable insights. Health care and research teams design patient-centered clinical pathways and research studies from the ground up.”

“Pre-habilitation” Showing Results for Cardiac Surgery Patients

Another useful concept for understanding Dr. Arora’s research is the idea of “pre-habilitation” – programming all the typical lifestyle modifications of cardiac rehab before rather than just after surgery.

Early results of this approach are promising, he says.

“Patients who actually complete a prehab program have higher levels of functional capacity, so they will walk farther before their operation, as an example. Probably equally importantly, they patients involved in a “prehab” program experience an attitudinal change towards exercise and diet. After the operation, for as long as a year after surgery, people will have improved attendance to post-op cardiac rehab and better mood and cognitive issues and function.”

Getting older, sicker cardiac surgery patients accustomed to exercise in the prehab process seems to help them build the habit into their lives, Dr. Arora says.

“If you take a typical 70- or 80-year-old who's never really done exercise in their lives and ask them to do it, it causes certain challenges,” he says. “But if they actually do it, it turns out that people seem to enjoy it, and they seem to keep doing it after surgery. They develop a healthier lifestyle after surgery, which seems to have a long durable effect.”

Dr. Arora will be employing these and other strategies in his new position at UH, which has an award-winning Enhanced Recovery After Surgery (ERAS) program. He says he’s excited for his new “adventure” in Cleveland and the opportunity to continue making a difference in cardiac perioperative and critical care.

“It was a big decision, but I knew it was the right one when I met the team at University Hospitals Harrington Heart & Vascular Institute,” he says. “Patients who are older and living with disease deserve to have successful surgery and recovery and go on to live healthy lives. Here at UH, we have the opportunity to implement revolutionary changes for our cardiac patients who are older and sicker than ever before. The opportunity to work with leaders in the field here at UH will serve to ensure our teams provide the best possible care for cardiac patients and aligns perfectly with how we need to move this field forward.”