UHN - Toronto General Hospital - Cardiac Anesthesia, Cardiovascular Intensive Care and TEE Fellowship Program

Description

The focus of the Cardiac Anesthesiology Fellowship is to provide an environment in which to acquire knowledge and develop the technical skills necessary to provide quality clinical care and research in cardiac anesthesia. The Fellowship is set up as a one to two years specialized and personalized training program designed to allow the individual maximal exposure to the clinical and research opportunities. Though clinical experience represents the foundation of Fellowship training, the program is individualized to meet the goals of the successful applicant. Candidates may chose a second year to complete research projects or pursue a specific clinical interest eg. TEE. Training occurs at The Toronto General Hospital (TGH) which performs 2500 cardiac surgical procedures annually. Sentinel North American studies for the Fast Track Cardiac Surgery Technique was performed at TGH and form the basis of our current practice. Training is directly supervised by our staff anesthesiologists.

At the completion of the Fellowship, successful fellows will have achieved the following goals:

The Toronto General Hospital Cardiac and Cardiac Anesthesia and ICU Program

The University Health Network (UHN) comprises three teaching hospitals: the Toronto General Hospital (TGH), Toronto Western Hospital (TWH) and Princess Margaret Hospital (PMH). The Cardiac Surgery Division is sited at the Toronto General Hospital, a 510-bed tertiary referral hospital, in which more than 2500 cardiac surgical procedures are performed annually on adult patients. TGH is the busiest cardiac surgery center in Canada and one of the largest in North America. Cardiac surgeries at TGH are distributed among coronary revascularization (60%), valve procedures (35%) and adult congenital heart procedures (5%). With Dr. Tirone David as Chief of Cardiovascular Surgery, our clinical caseload includes all adult cardiac surgical procedures: CABG, valve, congenital heart, aortic reconstruction, Ross procedures, Maze procedures, ventricular re-modeling and mapping surgery, left ventricular reduction surgery, minimally invasive coronary bypass operation and heart transplantation. As one would expect from a tertiary academic medical center, these procedures encompass the entire spectrum of available treatment modalities including both standard and experimental therapeutic options. A new mechanical cardiac assist devices program started in 2001 will allow fellows to gain experience with the anesthesia for placement and clinical use of these ventricular support devices. An integrated heart transplantation program supported by the Division of Cardiology exposes fellows to the perioperative management of these patients. The Cardiac Catheterization Laboratory will enable the fellow to gain expertise in the care of patients undergoing invasive cardiologic and electrophysiologic therapies. The fellow will be an integral member of the TGH cardiac anesthesiology team involved in the varied aspects of adult clinical care.

Early in the Fellowship year a fellow administers anesthesia to patients in relatively good physical condition who are undergoing more or less routine cardiac operations. Subsequently the fellow is assigned more complex and challenging cases.

The Cardiac Anesthesia & Intensive Care Program at the Toronto General Hospital has been recognized internationally as a prominent research and teaching centre in cardiac anesthesia.
Leading research in the following areas has allowed our centre to contribute and change the perioperative care of cardiac surgical patients in terms of reducing the postoperative morbidity and optimizing cost containment. In collaboration with multidisciplinary subspecialties, we have:

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safety and morbidity outcome in early extubation anesthesia in cardiac surgery

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established the cost benefit and reduction in resource use by early extubation in the post-cardiovascular intensive care unit and early hospital discharge

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identified the perioperative risk factors in postoperative morbidity and mortality in fast track cardiac surgery

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identified the etiology for preoperative anemia in cardiac surgical patients

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efficacy of antifibrinolytic agents in blood conservation during cardiac surgery

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rational use of postoperative chest x-rays in the post cardiac ICU

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perioperative management of pain in cardiac surgery procedures

Current research includes:

Perioperative Transesophageal Echocardiography Program

The University Health Network, Toronto General Hospital performs approximately 2500 cardiac surgical cases per year. At TGH, TEE is an intraoperative diagnostic tool for assessment of the adequacy of surgical repair for a broad spectrum of procedures. There is a large volume of valve repairs; aortic root replacements with valve sparing, ventricular myectomies for HOCM and congenital heart repairs. The TEE program offers fellows a broad exposure to TEE use both as routine monitor and more importantly as a diagnostic tool. It is expected that all fellows will acquire a basic clinical proficiency in the use and application of perioperative TEE. To complement the "hands-on" operating room exposure didactic TEE teaching sessions are held every two weeks. Moreover, TEE conferences are held twice a month to discuss interesting cases and review selected topics relevant to the use of intraoperative TEE.

Transesophageal Echocardiography - Responsibilities

Although there will be guidance and teaching, the fellow will be responsible for their background learning of TEE. Reading materials and video's will be made available either through handouts or loans to the Echo fellows. The formal echo rotation will be one month in duration and will provide most of the hands on education for the fellow. This will be supervised one-to-one by the Anesthesia echo staff on call for that day. There will also be regular seminars and echo cases throughout the year that will be mandatory to attend. The fellow will be expected to present and interesting case at the end of their echo rotation, with the mentoring of the staff echo-anesthesiologist. Prior to beginning their rotation, the fellow should contact Dr. Heinrich or Dr. Djaiani to discover where equipment is physically kept and further discuss what your responsibilities will be. You are expected to attend all Operating Room cases where echo is involved, except when other clinical duties interfere or by discussion with the staff echo anesthetist involved. The echo fellows will be expected to familiarize themselves with the location of equipment and the proper maintenance and cleaning of the equipment. It is expected that the Fellow will be present for the entirety of the echo study.