Objectives of The Fellowship Program

Our Fellowship program is an internationally acclaimed program with applicants from around the world. Each year from 5-8 candidates are accepted into the Cardiac Anesthesiology Fellowship Program at TGH. The fellow may chose one of two options for their first year of Fellowship.

1)	Clinical Fellowship: This involves 100% clinical rotation with five (5) days a week clinical service. At least two (2) days a week will be administering anesthetics for cardiac surgery. Fellows will also be exposed to pacemaker and defibrillator insertions, heart catheterization procedures and percutaneous closure of atrial septal defects. Call will be taken as 24 hour calls in the cardiovascular intensive care unit (CVICU). Additional weekend cardiac OR call may be required. Fellows will be supervised by staff anesthesiologists with reducing supervision as their clinical year progresses. The fellows at all times will be responsible for their own cases.
2)	Clinical and Research Fellowship: This involves 1 day (20%) as research time with the remainder as clinical responsibilities. Our research fellows have an academic focus with a research mentor and are required to participate in research projects. Faculty from within the Department, as well as collaborators from the Departments of Medicine, Surgery, Pharmacology, serve as mentors and offer expertise in a wide range of research topics. The Research Coordinator is Ms. Jo Carroll. Our fellows are encouraged to present their work at national and international meetings with Departmental sponsorship. There is also university and hospital based research rounds and didactic lectures on study design and statistical analysis, grant and manuscript preparation. Fellows can expect an average of 1-2 days per week of cardiac procedures and other procedures as outlined above. Call will be taken as 24 hour calls in the cardiovascular intensive care units (CVICU). Research content is detailed below.
3)	Perioperative TEE: Fellows will rotate for the one month of TEE per year and will be supervised by staff anesthesiologists.

The second year of the program continues to focus primarily on the clinical excellence with more complex cardiac cases. Fellows may opt to complete a research project during their second year and develop TEE experience towards certification. Clinical responsibilities are similar to the first year.

Clinical Responsibilities

During the first year, the fellow gains further proficiency in and exposure to the perioperative evaluation and intraoperative management of elective and emergency cardiac patients undergoing primary and repeat revascularizations, valvular replacements and repairs, and combination procedures. The first month of clinical work involves giving general anesthetics in the regular operating rooms for a variety of procedures. This allows time for the fellow to become familiar with local practice and be assessed for suitability of clinical skills. During the fellow's first month he/she will be closely supervised in a one to one capacity by staff anesthesiologists during cardiac operations. Following successful completion of their first month fellows will be covered two (2) fellows to one staff anesthesiologist when in the cardiac surgical operating rooms. The fellows will be expected to function independently without direct staff supervision in non-cardiac anesthesia settings however staff coverage is always available.

The training program also includes 24-hour call in the 22 bed Cardiovascular Intensive Care Unit (CVICU) which complements intraoperative care. Experience is gained in all aspects of immediate postoperative care including the management of perioperative dysrhythmias, acute and chronic heart failure, fluid and electrolyte balance, uses of cardiac assist devices and other ICU topics. (Other ICU experience will include day shifts in the CVICU. There are staff anesthesiologists available from 7:00-23:00 physically present in CVICU. Overnight staff coverage from home is available).

Transesophageal Echocardiography

1)	The fellow will be expected to have a basic understanding of the indications, contraindications and risks of peri-operative TEE.
2)	The fellow should gain a basic understanding of the principles of 2D and Doppler echocardiography and also gain an understanding of the physical principles of the Echo machine.
3)	The fellow will be able to recognize normal cardiac structures and common pathological echocardiographic findings. ie. LV function, Regional Wall Motion Abnormalities, Degree of Mitral Regurgitation, Aortic Stenosis etc. This includes the measurements of regurgitant flow, gradients and valve area calculations.
4)	The fellow should be able to perform a routine monitoring TEE, including insertion of the TEE probe and gaining standard echo views i.e. Mid-esophageal 3-chamber, mid-esophageal 4-chamber, trans gastric short axis, etc.
5)	Gain basic knowledge to provide a basis for further training in TEE and perioperative cardiac anesthesia management.
6)	Basic care for and maintenance of the TEE probe and machine (cleaning and storage).
7)	At the completion of the Echo Program either a case report or "study" for publication is expected to be completed by the fellow.

Perioperative 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 case discussions throughout the year that will be mandatory to attend. The fellow will be expected to present an interesting case at the end of their echo rotation, with the mentoring of the staff echo-anesthesiologist. If available, the fellow is encouraged to attend all Operating Room cases where TEE is involved, except when other clinical duties interfere or by discussion with the staff echo anesthetist involved. Fellows are expected to familiarize themselves with the location of equipment and the proper maintenance and cleaning of the equipment.

Program Parameters

1)	The period spent in the Fellowship will be no less than 12 months, with no more than one interrupted period due to reasonable circumstances. A second 12-month period for the continuation or pursuit of research or clinical interests will be optional.*Paid vacation of 20 working days per year and 5 days of paid sick leave included.
2)	There will be an average of 5-8 Cardiac fellows per year at TGH. Fellows usually to start in January or July of a given year.
3)	All candidates for the Fellowship must have satisfactorily completed an accredited residency program in Anesthesiology (in their own country).
4)	All successful candidates must be eligible for an educational license through the Ontario College of Physicians and Surgeons. Candidates are required to be fluent in the English language.
5)	Selection of fellows will be by application and interview with the Cardiac Program Director. Final selections of fellows will be at the discretion of the Cardiac Program Director.
6)	Salary is monthly based on an annual stipend.

Education Program - Accreditation

1)	Cardiac Fellowship programs are not officially recognized by any governing body but their guidelines are set forth by the Program Requirements for Residency Education in Anesthesiology (ACGME).
2)	This training is not recognized towards residency training in Canada. However, the Fellowship may lead to Perioperative Transesophageal Echocardiography Certification.
3)	Although not subject to Board Certification, Cardiac Anesthesia subspecialty is recognized by the American Society of Anesthesiologists and the Canadian Society of Cardiovascular Anesthesiologists.
4)	Certificates are given to the fellows who successfully complete the program.

Curriculum - Clinical Goals

1)	Staff level preoperative assessment of the patient with cardiopulmonary disease.
2)	Evaluation of anesthetic risks and necessary interventions to minimize risk.
	•	Determination of cardiovascular and pulmonary monitoring requirements and acquire expertise in invasive monitoring techniques including TEE.
	•	Design and administration of anesthetic medications and/or regional anesthetics for optimal surgical conditions, with consideration of patient disease processes.
3)	Effective perioperative management of the cardiac surgical patient with complex cardiovascular pathophysiology based upon knowledge and consideration of cardiac, respiratory, neurologic, renal, hepatic, neuromuscular, hematologic and coagulation systems.
	•	Preoperative, intraoperative, and postoperative management of patients with coronary artery disease, valvular disease, congenital heart disease, cardiomyopathies, transplants, dysrhythmias, thoracic and aortic disease.
	•	Management of the patient that is difficult to wean from cardiopulmonary bypass.
	•	Coagulation management during and after cardiopulmonary bypass.
4)	Management of the patient in the Cardiac Catheterization Lab, from the routine invasive procedure to the emergent complication.
5)	Understanding the principles of extracorporeal circulation, cardiopulmonary bypass and circulatory assist devices.
6)	Understanding the principles of myocardial preservation.
7)	Effective management of routine and ill patients in the postoperative cardiac intensive care setting.
8)	Critical review of the cardiovascular literature.
	•	Participation in didactic sessions (e.g., Anesthesiology Grand Rounds), clinical teaching, and organization of and presentation at Cardiovascular Journal Club.
9)	Ability to formulate clinically relevant hypotheses in cardiac and thoracic anesthesiology and design studies to effectively test such hypotheses according to the scientific method.
	•	Introduction to statistical analysis techniques.
	•	Execution of research projects, interpretation of results, and preparation of abstracts and manuscripts.
10)	Research presentation at scientific meetings.

Formal Curriculum Didactics

The Department of Anesthesia conducts weekly seminars, journal clubs and conferences related directly to cardiac anesthesiology and intensive care. Alternate weeks are devoted to specific didactic teaching and review of TEE related topics. These meetings are under the direction of cardiac anesthesiology staff, but the fellows participate in the organization and presentation of the programs. It is expected that each fellow will be responsible for at least one major seminar during the year. Attendance at all didactic sessions is mandatory for fellows.

•	Cardiovascular Physiology and Pharmacology
•	Fast Track Cardiac Anesthesia
•	Weaning From Cardiopulmonary Bypass
•	Cardiopulmonary Bypass Equipment
•	Pathophysiology of Cardiopulmonary Bypass
•	Intraaortic Balloon Pump
•	Management of Perioperative Dysrhythmias
•	Myocardial Protection
•	Congenital Heart Disease
•	Thoracic Aneurysms
•	Cardiac Assist Devices
•	Alternative Cardiac Surgery Techniques (e.g., MIDCABS)
•	Blood Conservation
•	Heart Transplantation
•	Cerebral Protection and Outcomes
•	"Common Problems" In Cardiovascular ICU

Methods of Evaluation

1)	Direct feedback throughout the subspecialty training from faculty.
2)	Assessment of presentations of a cardiac topic
3)	Assessment of Research Project.
4)	Written evaluation of each fellow on a three months basis. These evaluations include attitude, interpersonal relationships, fund of knowledge, manual skills, patient management, decision-making skills, and situational analysis. The Fellowship Director will meet each fellow individually to discuss their evaluations and allow the fellow to voice concerns or questions.
5)	The fellow will be allowed to evaluate each staff member at the end of the Fellowship year.

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