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Graduate Medical Education - Adult Cardiothoracic Anesthesiology cedars-sinai.edu | Cardiothoracic Anesthesiology Resident CA-1 Questions metrohealthanesthesia.com | Graduate Medical Education - Adult Cardiothoracic Anesthesiology csmc.edu | Cardiothoracic Anesthesiology newdoctor.com |
Cardiothoracic anesthesiology is a subspeciality of the medical practice of anesthesiology devoted to the preoperative, intraoperative, and postoperative care of adult patients undergoing cardiothoracic surgery and related invasive procedures. It is one of the most interesting and challenging careers in anesthesiology.[citation needed] It deals with the anesthesia aspects of care related to surgical cases such as, but not limited to, open heart surgery, lung surgery, and other operations of the human chest.[1][2] Most cardiac surgeries require a machine that take over the functions of the heart and lungs while the heart is repaired . The responsibility of cardiovascular and thoracic (CVT) anesthesiologist is to supervise "bypass" (or heart-lung) machine and to keep the patient "asleep", to monitor and to control the patient's vital signs during the operation. 
[edit] CVT fellowship After satisfactory completion of Accreditation Council for Graduate Medical Education (ACGME) accredited residency program in anesthesiology formal advanced training in cardiac, vascular, and thoracic anesthesia is available via a one-year fellowship.[1][2].The Adult Cardiothoracic Anesthesiology fellowship program has been Governed by Society of Cardiovascular Anesthesioloist[3] which is an international organization of over 6000 cardiac, vascular and thorcic anesthesiologists. Adult Cardiothoracic Anesthesiology became an ACGME approved fellowship in 2006 and there are 44 ACGME accrediated programs for current academic year(2008-2009). This fellowship consists of at least 8 months of adult cardiothoracic anesthesiology, one month dedicated to transesophageal echocardiography, one month in surgical intensive care unit and two months of elective rotation which includes inpatient or outpatient cardiology or pulmonary medicine, invasive cardiology, medical or surgical citical care and extracorporeal perfusion technology. Fellows are trained to provide anesthesia for Coronary Artery bypass surgery (CABG) on CPB and on beating heart, valvular heart surgery, aortic surgeries, heart transplant, lung transplant, heart and lung transplant. Adequate exposure and experience provided in the management of adult patients for cardiac pacemaker and automatic implantable cardiac defibrillator placement, surgical treatment of cardiac arrhythmias. The fellow will gain sufficient experience to independently manage intra-aortic balloon counterpulsation and patients with ventricular assist devices. The Cardiac Catheterization Laboratory will enable the fellow to gain expertise in the care of patients undergoing invasive cardiologic and electrophysiologic therapies.[3] Additional clinical experience within the full one-year fellowship will include anesthetic management of adult patients undergoing thoracic and vascular surgery. Fellows are trained to manage all type of thoracic surgeries which include video assisted thoracoscopy (VAT[4] ),Thoracotomy and aortic surgery. Fellows will achieve expertise in different techniques of lung isolation like Double-lumen endotracheal tube, bronchial blocker, Univent Tube under guidance of fiber optic broncoscophy[5] Fellows are trained to achieve expertise in the advanced monitoring techniques including but not limited to invasive blood pressure, arterial blood gas analysis, pulmonary artery catheterisation, cardiac output monitoring, cerebral oximetry, jugular venous oxygen saturation, cerebral oximetry, Bispectral Index (BIS)[6], Transcranial dopper(TCD)[7],Near Infra Red Spectroscopy(NIRS)[8]. Additional clinical experience during this fellowship include successful completion of advanced perioperative echocardiography education according to training guidelines from American society of Echocardiography and Society of cardiovascular Anesthesisologists. Fellow conferences are held once a week to discuss interesting cases and review selected topics relevant to cardiothoracic anesthesia & intraoperative TEE. Fellows are trained to manage cardiothoracic cases in the postoperative care unit. [edit] ResearchThe recent developments in cardiac surgery expanded the scope of research including neuroprotection[9], myocardial protection[10], blood conservation strategies[11], port access surgery in this young subspeciality. Fellows are offered the opportunity to participate in clinical research and encouraged to present at national or international conference after completion of a research project. [edit] Ultrasound - TEE     Echocardiogram is basically a sonogarphy which produces a real time image of heart by using standard ultrasound technique. There are two way of performing echocardiography depending on placement of echocardiography probe. One is Transthoracic echocardiography(TTE) in which probe is placed over patient chest wall , also called standard Echocardiography and other is transesophageal echocardiography or TEE ( called as TOE in the UK) in which probe is placed into the patient esophagus. The probe contains a transducer when transmitting it convert electrical energy to acoustic energy and when receiving it convert acoustic energy to electrical energy which is processed by the machine in forming image. The direction of flow and velocity of blood can be assess by using Doppler ultrasound.[12][13] Transoesophageal echocardiography (TEE) has rapidly become the most powerful monitoring technique and diagnostic tool for the management of cardiac surgical patients. It provides the detailed information about the structure and function of heart and great vessels. Because of proximity of esophagus to heart TEE provide better image of heart as compare to standard echocardiography(TTE). TEE provide timely information about filling status, systolic and diastolic function, valvular function, presence of fluid in pericardial cavity and state of great vessels. TEE has significant influence on surgical and medical decision making which may lead to changes in therapy. After successful completion of the fellowship with subspecialty training in TEE, the fellows are encouraged to appear for perioperative Transesophageal Echocardiography Examination ( PTEeXAM ) [4]offered by the National Board of Echocardiography (NBE). [5]. Fellow needs to perform and interpret atlest 150 comprehensive intraoperative TEE examination in order to apply for Advanced PTEexam Board certification. [edit] Cardio-pulmonary bypass (CPB)   Cardiopulmonary bypass (CPB) is a technique in which heart-lung machine temporarily takes over the function of the heart and lungs during surgery. This machine drains deoxygenated blood from the patient, oxygenates and pumps it back into the arterial system thereby bypassing the heart and lungs and maintaining the perfusion of the vital organs. CPB is team effort including the cardiac surgeon, perfusionist, and anesthesiologist. The surgeon places a cannula in right atrium, vena cava, or femoral vein to withdraw blood from the body. Venous blood that is removed from the body by the cannula is filtered, oxygenated, cooled or warmed, and then returned to the body. The cannula used to return oxygenated blood is usually inserted in the ascending aorta, but it may be inserted in the femoral artery. The management of the patient undergoing cardiopulmonay bypass (CPB) is one of the defining characteristics of cardiac anesthesia. This demands that the cardiac anesthesiologist have a thorough knowledge of the basic physiology, principles, practical application and management of CPB. For cardiac anesthesiologist it is convenient to think of cardiac operations requiring CPB as occurring in six sequential phases: 1) pre bypass period; 2) initiation of bypass; 3)maintenance of bypass; 4) preparation for separation: 5) separation from bypass; and 6) postbypass period. The main objective of per bypass period is to prepare patient for CPB which include anticoagulation and vascular cannulation. A prebypass TEE evaluation of the heart give anesthesiologist valuable information regarding the management of patient in the post bypass period. Once all preparatory steps have been taken, CPB initiated and anesthesiologist has to monitor this transition and assess whether CPB is adequate and when it is, has to discontinue ventilation of the patient’s lungs. When CPB machine takes over the function of heart and lung, the primary objective is to maintain adequate perfusion to the vital organs. During this period anesthesiologist should ascertain that patient is adequately anesthetised as chances of awareness are quite high during bypass. Emergence from bypass is the most crucial period when clear communication between surgeon, perfusionist and anesthesiologist is required. Prior to discontinuation of CPB , temperature, acid base status , hematocrite etc. must be restored for optimal cardiac and pulmonary function. At this stage anesthesiologist makes functional assessment of the heart and peripheral vasculature based on visual inspection, hemodynamic indices, and metabolic parameters. Based on this assessment, inotropes, vasodilators, and vasopressers should be prepared. [edit] Role of cardiac anesthesiologists in non-cardiac surgery Cardiac anesthesiologists not only provide anesthesia care for cardiac surgery, they also have specific role in providing anesthesia care for patients having complex cardiac disease like valvular heart disease, adult congenital heart disease, congestive heart failure etc.undergoing non-cardiac surgery. Patient with cardiac disease presenting for non-cardiac surgery are at increase risk for serious perioperative complication including myocardial infarction , arrythmia , pulmonary edema. The cardiac anesthesiologist is able to give expert opinion during intraoperative hemodynamic instability/cardiac arrest by evaluating heart function with the help of TEE and advanced hemodynamic monitering. [edit] References
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