The fellow gains significant clinical experience that provides direct clinical care of patients and supervisory experience. At a minimum, 25 percent of the required case numbers are obtained with the fellow as the primary anesthesia provider under the supervision of a faculty anesthesiologist. Supervision of residents and other anesthesia providers by the fellow is under the direct supervision of a faculty anesthesiologist. The goal of having fellows teach and supervise core residents and other anesthesia providers is to prepare fellows to become faculty supervisors and teachers.
Fellows must participate actively in scholarly activities related to cardiothoracic anesthesiology. Each fellow must complete a minimum of one academic assignment.
Educational Goals and Objectives
Instructional objectives: The fellowship provides the fellow with the clinical experience necessary to develop new knowledge and skills to evaluate and manage patients with cardiothoracic disease and the inherent hemodynamic changes and consequences during cardiothoracic surgery.
- A faculty member is assigned to each fellow for each case. Fellows are taught and supervised by faculty. The fellow will learn to effectively manage both elective and emergency patients for their surgeries.
- The fellow is expected to become thoroughly familiar with the principles of hemodynamic monitoring and the inherent implications associated with alterations in the patients' monitored parameters. The fellow will be able to recognize normal versus abnormal or altered hemodynamic profiles and be able to establish a differential diagnosis within a reasonable amount of time. With these tools, the fellow will be able to establish a method to rule out the least likely versus most likely diagnosis and ultimately treat the patient effectively.
- The fellow will also be familiar with the basic anatomy of the heart and abnormal pathology of the heart that would affect patient outcome (morbidity and mortality) and pre-op and post-op clinical status. The fellow will be able to reasonably evaluate the patient's labs, EKG, echocardiogram, etc. , prior to surgery and post-op and understand how the patient's pathology may have led to the patient's clinical situation.
- The fellow will have a working knowledge of the equipment used in cardiothoracic surgery and how and why it is important to this subspecialty.
Technical objectives: This fellowship allows the fellow to attain technical skills in invasive catheter placement and interpretation (i. e. , arterial catheters, central venous catheters, and pulmonary artery catheter) and transesophageal echocardiography (TEE). Upon completion of this fellowship, the fellow will have experience in myocardial revascularization surgery, valve repair (including percutaneous valve repair and replacement), heart and lung transplantation, thoracic surgery, insertion surgery for pacemakers and automatic implantable cardiac defibrillators, invasive cardiac catheterization procedures, carotid endarterectomies and vascular surgery, as well as critical care management of adult cardiothoracic surgical patients. The fellow will be familiar with double lumen endotracheal insertions, TEE, pacemakers, automatic implantable cardiac defibrillators (AICD), intra-aortic balloon pump counter pulsation (IABP), Impella pump, extracorporeal membrane oxygenation (ECMO), left-ventricular assist device (LVAD), right-ventricular assist device (RVAD), bi-ventricular assist device (BIVAD) and total artificial heart, along with respective indications and complications.
The fellow gains significant clinical experience that provides direct clinical care of patients, and supervisory experience. At a minimum, half of the required case numbers are obtained with the fellow as the primary anesthesia provider under the supervision of a faculty anesthesiologist. Supervision of residents and other anesthesia providers by the fellow is under the direct supervision of a faculty anesthesiologist. The goal of having fellows teach and supervise core residents and other anesthesia providers is to prepare fellows to become faculty supervisors and teachers.
A. A minimum of six months of operating room and adult cardiothoracic clinical activity.
The minimum clinical experience for each fellow must include six months of clinical anesthesia activity, with a minimum of 70 surgical procedures involving adult patients and requiring comparative pathobiology, to include a minimum of 40 anesthetics involving valve repair or replacement, and a minimum of 40 myocardial revascularization procedures with or without comparative pathobiology.
- Each fellow should provide anesthetic management for patients undergoing minimally invasive cardiac surgery and for congenital cardiac procedures performed on adult patients.
- Each fellow must gain sufficient experience to independently manage intra-aortic balloon counterpulsation and should be actively involved in the management of patients with left ventricular assist devices.
B. Additional required clinical experience within the full one-year fellowship should include:
- At least one month or its equivalent of anesthetic management of patients undergoing noncardiac thoracic surgery, and the anesthetic management of 10 adult patients undergoing surgery on the ascending or descending thoracic aorta requiring full comparative pathobiology, left heart bypass and/or deep hypothermic circulatory arrest. Thoracic aortic stent placements performed under anesthesia may be counted among these cases. The scope of thoracic experience provided, however, should not be limited to stent placement.
- Each fellow is required to have experience in the anesthetic management of adult patients for cardiac pacemaker and automatic implantable cardiac defibrillator placement, surgical treatment of cardiac arrhythmias, cardiac catheterization and cardiac electrophysiologic diagnostic/therapeutic procedures. The majority of the experience should be obtained in nonoperating-room environments to encourage multidisciplinary interaction.
C. Additional clinical experience within the full one-year fellowship 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 300 complete perioperative echocardiographic examinations, of which at least 150 are comprehensive intraoperative TEE examinations personally performed, interpreted, and reported by each fellow
- Each fellow is required to have a one-month rotation managing adult cardiothoracic surgical patients in a critical care (ICU) setting. This rotation may include the management of nonsurgical cardiothoracic patients.
- Each fellow must have two months of elective rotations (not fewer than two weeks in duration) from the following categories: inpatient or outpatient cardiology or pulmonary medicine; invasive cardiology; medical or surgical critical care; and extracorporeal perfusion technology. Experience with pediatric cardiothoracic anesthesia is encouraged. One to two months devoted to a research project in cardiothoracic anesthesiology may be substituted for the two months of clinical elective rotations
D. Research or other well-defined scholarly activity
The program offers fellows significant opportunities to participate in scholarly activities. Each fellow is required to participate in a yearlong research project related to adult cardiothoracic anesthesia, with the goal to complete at least one project initiated during fellowship training. Research skills are taught in the curriculum during regular seminars to discuss specific research topics, including study design, institutional review board proposals, statistical modeling, data analysis and abstract/paper writing.
Fellows are scheduled for protected research time throughout the duration of the program for one month. The scheduled time supplements research activities done throughout the year and provides a set time for the fellow to meet with their research mentor to help with analysis and review of the work being done by the fellow. Together, the fellow and his or her mentor will develop a calendar with milestones to manage the project so that the fellow will have the opportunity to present the results at national meetings. The project will lead to either an abstract presentation at a major meeting or a publication in a journal for adult cardiothoracic anesthesiology, anesthesiology or anesthesia analgesia. The program's scoring system will provide a simple and objective evaluation of the fellow's scholarly activity.
All cardiothoracic anesthesia fellows will gain clinical experience in the following areas:
- Preoperative assessment of the cardiothoracic surgery patient
- Interpretation of noninvasive cardiac diagnostic tests
- Interpretation of cardiac catheterization data
- Interpretation of arterial and venous blood gases
- Interpretation of pulmonary function tests
- Insertion of intravascular monitoring catheters and interpretation of hemodynamic data
- TEE probe placement, examination, and interpretation of 2D and Doppler study
- Anesthesia consultation for preoperative cardiothoracic patients
- Ischemic heart disease and myocardial revascularization
- Repair or replacement of heart valves
- Percutaneous valve repair and replacement
- Cardiomyopathy: dilated, hypertrophic, restrictive, hypertrophic obstructive
- Pericardial tamponade
- Heart transplantation
- Lung transplantation
- Intracardiac masses and tumors
- Minimally invasive cardiothoracic procedures, including limited incision and robotic approaches
- Cardiac pacemakers (permanent and temporary), and AICD
- Cardiac electrophysiologic diagnostic and/or therapeutic procedures
- Palliation or correction of congenital heart lesions
- Deep hypothermic circulatory arrest
- Cardiopulmonary bypass (CPB); perfusion strategies; temperature management; and fluid management
- Pharmacologic support of the heart and circulation during all phases of cardiac surgery
- Coagulation/anticoagulation management before, during and after CPB
- Assessment of vital organ dysfunction during and after CPB
- IABP, Impella pump
- Ventricular assist devices (LVAD, RVAD, BIVAD)
- Total artificial heart
- Thoracic aortic surgery
- Pulmonary wedge resection, lobectomy or pneumonectomy for neoplasm, vascular malformation, or infectious processes
- Lung volume reduction surgery
- Lung isolation/one-lung ventilation techniques
- Thoracic cage surgery
- Fiberoptic bronchoscopy
- Pleura bronchoscopy surgery
- Mediastinoscopy and mediastinal surgery
- Tracheal surgery (stent placement, dilation, resection)
- Esophageal surgery and anti-reflux procedures
- Ventilator management during cardiac and thoracic surgery
- Regional anesthesia for patients undergoing cardiothoracic procedures
- Pain management for patients undergoing cardiothoracic procedures
- Care of critically ill patients post cardiothoracic surgery (ICU)
Fellows must participate actively in scholarly activities related to cardiothoracic anesthesiology. Each fellow must complete a minimum of one academic assignment. Academic projects may include:
- Grand rounds presentations
- Case reports
- Preparation and publication of review articles
- Book chapters
- Manuals for teaching or clinical practice
- Clinical Track Research (CTR) investigation
- Basic Science Research (BSR) Investigation
Developmental Objectives — The Year in Passing
A. During the first three months, adult cardiothoracic anesthesiology fellows are expected to
- Become familiar with the policies and procedures of the fellowship program, the geography of the Cedars-Sinai Heart Center, and the equipment available in the operating rooms and Cardiac Surgery Intensive Care Unit, cardiac catheterization laboratory and patient care floors.
- Attend and prepare for scheduled didactic sessions.
- Learn to perform an appropriate preoperative evaluation of the cardiac surgical patient and articulate an anesthetic plan based on the patient's pathophysiology and coexisting medical conditions.
- Learn how to manage routine postoperative complications and assess a patient's readiness for extubation in the early postoperative period.
Evaluations are based on the following activities:
- Develop skill in the placement of invasive monitors (arterial lines, central lines and pulmonary artery catheters), interpretation of data and recognition of complications.
- Develop the ability to articulate an anesthetic plan based on the patient's cardiac pathophysiology and other coexisting medical conditions.
- Undergo Clinical Competence Evaluation during the first quarter, in which fellows are observed managing a routine cardiac surgical case and evaluated for specific core competencies.
- Master a basic TEE examination, as outlined in the Echocardiography section. Once the requisite knowledge and skills have been demonstrated, fellows progress to advanced training in echocardiography.
B. The second three months are devoted to developing expertise in areas unique to cardiothoracic anesthesia and to functioning more independently. Goals include:
- Displaying a scholarly spirit and inquiry in didactic sessions and utilizing opportunities to discuss issues specific to cardiothoracic surgery and anesthesia at case conferences, pro/con debates, journal clubs and problem-based learning discussions.
- Being able to describe the basic elements of cardiopulmonary bypass, mechanical circulatory support, thoracic anesthesia, pediatric cardiac anesthesia, cardiovascular critical car, and more uncommon cardiac surgical procedures.
- Demonstrating mastery of cardiac physiology, pathophysiology and pharmacology to the point where one is able to instruct second-year residents on their cardiothoracic rotation.
- Developing the cognitive and technical skills required for advanced training in echocardiograph, and being able to narrate a comprehensive TEE examination during TEE case conferences.
C. The last six months are devoted to maturing into a true consultant in cardiothoracic anesthesia.
- Fellows are required to engage in scholarly activities, such as participation in a research project, case report or subject review suitable for presentation and publication in a medical journal.
- Fellows will develop the skills necessary (both clinical and interpersonal) to manage anesthetic induction, maintenance, weaning from cardiopulmonary bypass and post-operative care in complicated cardiac surgical patients, with a minimum of staff intervention.
- With proper insight and self-reflection, fellows will recognize their strengths and weaknesses in various areas. They should be able to direct learning objectives towards those specific types of cases or procedures where experience is lacking, or improvement is needed. The cardiothoracic anesthesia faculty will provide assistance, and every effort will be made to increase exposure to these areas. By the end of the fellowship year, fellows should be able to manage all types of complex cardiothoracic cases independently and confidently.
- Fellows will be given the responsibility of supervising and teaching second-year anesthesia residents during their cardiothoracic rotations.
- The intraoperative experience and didactic training sessions will provide the knowledge base necessary to pass the National Board of Echocardiography Perioperative TEE Certification Examination. This will ultimately lead to board certification in advanced perioperative transesophageal echocardiography.
- Fellows will appreciate that cardiothoracic anesthesia, like all specialties in medicine, entails a dynamic and lifelong commitment to education and training. The skills and knowledge acquired during the fellowship year will allow trainees to function effectively as academic anesthesiologists or private practitioners.