Clinical Curriculum-Cardiac
Anesthesia Fellowship

The core 8-9 month rotation will be spent in cardiovascular assignments that will include surgical procedures that require CPB. It is the expectation that they are able to complete a minimum of 120 cases per year of which 50% must be valve or revision of congenital repair. TGH is a referral centre for surgery of the ascending aorta and arch. The fellow will have an opportunity to participate in the operative care of a minimum 10 cases involving deep hypothermia and circulatory arrest.

Fellows will participate in a one-week rotation every 7 – 8 weeks of home call for heart transplant, aortic dissection and LVAD insertion. It is recognized that the majority of these cases occur outside the elective day schedule but also represent a vital component of the fellow’s educational experience. The fellow would do these cases under the direct supervision of the CV anaesthesia attending, and also have an opportunity to participate in the peri-operative TEE examination. Should these cases occur late at night the fellow would be relieved of clinical duties the following day.

Pre-admission cardiac consult clinic is now a component of the cardiac fellowship program. Fellows on their week of LVAD/Heart TX/Dissection call will attend three pre-admission cardiac clinics to assess and manage pre-operative cardiac surgery patients, patients for cardioversions, interventional cardiology procedures and EP studies and ablations.

Procedure

During the core 8 to 9 month rotation the fellow will participate in the care of postoperative cardiac surgical patients. The fellow will rotate one week every 7 – 8 weeks. Rather than a continuous two months of CVICU, the fellow will benefit with the regular exposure over the course of the year. Their skill level and confidence will increase during the year. The CVICU is a 20-bed unit that is managed by the department of cardiovascular anaesthesia in conjunction with the department of cardiovascular surgery. Two attending CV anaesthesiologists are assigned each week to the CVICU. One manages the day while the other supervises the evening and is available throughout the night. A CV anaesthesia fellow and a CV surgical fellow are assigned to the unit each weekday. The anaesthesia fellows alternate with the surgical fellows for the night coverage and each weekend day. During their time in the CVICU, which cumulatively will account for two months of their one-year fellowship, the fellow will become proficient in the management of post op cardiac surgical patients.

Fellowship will include successful completion of advanced perioperative echocardiography education according to the training objectives from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists’ “Guidelines for Training in Perioperative Echocardiography”. This will include the study of 300 complete perioperative echocardiographic examinations, of which a minimum of 150 are performed, interpreted, and reported by the fellow. The remaining studies will be reviewed in a formal TEE reading session each week and is moderated by the Peri-operative TEE Group. This time on the TEE service is protected from call. The fellow will have no other responsibilities during this rotation.

History

TGH inserts 400 permanent pacemakers per year, 350 defibrillator implants per year. There are another 80-100 cases, which involve maintenance and revision of previously implanted devices. Currently, 50 biventricular defibrillators are implanted each year with view to expansion in the near future. Cardiovascular surgeons implant the majority of devices during an elective list four days each week in the main OR. Electrophysiology cardiologists implant biventricular defibrillators in the Cath lab one day each week. An anaesthesia fellow, supervised by the attending staff, is present for each of these lists. Arrhythmia ablation is done two days each week in the cath lab by the EPS service for which anaesthesia services are available. An elective cardioversion list is scheduled weekly. The fellow can expect to be assigned to one of diagnostic, therapeutic or device insertion lists each week.

Interventional cardiology is an expanding commitment. In addition to the insertion of aortic stents
(coarctation), device closure of ASD, VSD, and perivavular leak, percutaneous valve repair and replacement have become an obligation of the department of cardiovascular anaesthesia. Fellow participation for these cases is a priority.

TGH is a large referral center for adults with congenital heart disease. A dedicated multi-disciplinary team exists to manage these patients and the team meets on a weekly basis to present cases for management discussion. Fellow attendance and participation is encouraged. Approximately 80 to 100 cardiac cases are performed each year many of which are revision of a previous repair. The number of congenital cardiac cases will increase significantly over the next decade. In addition to the cardiac surgical cases the patients are referred to TGH for non-cardiac surgery and the anaesthetic considerations can be equally if not more challenging and a valuable learning experience for the fellow.

Heart transplant and ventricular assist devices are managed under the heart failure program. The center performs an average of 30-35 heart transplants per year and is funded for 15 ventricular assist devices. The fellow will participate in either the intra-operative management or the post op care in the CVICU.

TGH is a regional tertiary care vascular center. Major vascular as well as endovascular cases of the descending thoracic aorta and abdominal aorta will comprise some of the non-cardiac assignments for the fellow.

Research

Research is integrated into the fellowship with and average of one academic day per week throughout the year. Academic days can be clustered to accommodate research projects and presentation preparation. The fellow’s abilities will be assessed and they will meet with the director of cardiac anesthesia research to review their academic goals. There are ongoing trials in which they may participate or they may embark on their own individual research projects. Participation and presentation in academic conferences is encouraged and funded by the department.