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Cardiac Anesthesia Curriculum
Level 2
Stanton Shernan, MD; John Fox, MD; Rosemarie Maddi, MD;
Igor Plotkin, MD; David Morse, MD

Pre-requisites:
This level of training generally takes place as a 2-6 month elective during the CA-3 year. The resident is expected to have Satisfactorily completed the 2 months of Cardiac Anesthesia, Level 1.

The resident is expected to have mastered the material as outlined in the Cardiac Anesthesia Curriculum, Level 1. In addition, the resident will master the following knowledge base, and become competent in the following areas:

Basic Skills and Knowledge

Anatomy & Physiology
1. Embryonic development of the heart
Preoperative Evaluation
1. Risk stratification studies in cardiac surgery
  1. Study design
  2. Study results
  3. Conclusions and drawbacks of the study
Transesophageal Echocardiography
During the Level 2 rotation, the resident will be assigned a 5 day period where there are no clinical duties except to perform supervised TEE exams. During this time, the resident will learn how to obtain the basic views used in intraoperative ultrasound and will receive an introduction to modalities of ultrasound. It is expected that the resident will perform 15 TEE exams during this week. Additionally, the resident will be expected to read a basic text from the TEE library, view videotapes, and work through a computer program of intraoperative TEE. A CA-4 fellow in cardiac anesthesia will rotate for 6 weeks of sole intraoperative ultrasound duties where an advanced knowledge of TEE will be mastered. During this 6 week period, the fellow may perform 90 or more supervised TEE exams.
1. CA3 TEE Knowledge
  1. Basic Exam (See attachment)
    1. Transverse views of cardiac structures
    2. Longitudinal views of cardiac structures
    3. With a multiplane TEE probe, what is the importance of the views at 30-40 degrees and 120-140 degrees
  2. Ultrasound Modalities
    1. M Mode
    2. B Mode
    3. Pulse wave Doppler
    4. Continuous Doppler
    5. Color Flow Doppler
  3. Physics
    1. Define the Doppler Principle
    2. Describe how ultrasound is produced by the transducer.
2. CA4 TEE Knowledge
  1. Physics
    1. Derive the Bernoulli equation (P1-P2=4MV2)
    2. Define and derive the Continuity Equation (V1P1=V2P2).
    3. Define "Aliasing"
    4. Define "Phased Array" Transducer
    5. Where would you use a 3mHz, 5mHz, and 7mHz Transducers
  2. Valvular exams
    1. Define adequacy of mitral repair
    2. Define perivalvular leaks
    3. What is SAM?
    4. Describe the ultrasound signature of tissue and prosthetic valves
  3. Discuss importance of QA in a TEE service.
  4. Discuss infection control in a TEE service.
  5. Discuss approach for ASD and VSD patients
  6. Discuss exam for intracardiac masses
  7. Discuss exam for pericardial tamponade
  8. Discuss exam for LV aneurysms
  9. Discuss exam for aortic aneurysms
    1. Ascending
    2. Descending
  10. Discuss the data for epiaortic scanning
Management of Cardiopulmonary Bypass
1. Anticoagulation and reversal of anticoagulation at termination of bypass
2. Renal protection on cardiopulmonary bypass
  1. Mannitol
  2. Lasix
  3. "Renal Dopamine"
3. Define components of the pump.
  1. Pump
    1. Roller head
    2. Centrifugal pump
  2. Oxygenators
  3. Biological tubing (heparin-coated)
4. Define the inflammatory response to bypasss
5. Define "Cardiotomy Suction"
6. Define Cardioplegia—Antegrade/Retrograde
7. Define how to wean from bypass
Specific Cardiac Operations
1. Coronary Artery Surgery
2. Aortic Valvular Surgery
3. Mitral Valvular Surgery
4. Tricuspid Valve Surgery
5. Great Vessels
  1. Circulatory arrest
    1. Brain protection
      1. Cold
      2. Medications (Barbiturates/Ca blockers/ Ketamine)
      3. pH (alpha stat/ph stat)
6. Descending Thoracic Aorta
7. Cardiac Transplantation
8. Assist Devices: Left and Right
9. Asymmetric Septal Hypertrophy or IHSS
10. Transmyocardial Laser Revascularization
11. Congenital Cardiac Surgery and Anesthesia in the Adult
  1. ASD
    1. Primum
    2. Secundum
    3. Sinus venousus
  2. VSD
    1. Congenital
    2. S/P Myocardial Infarction
  3. Complex Congenital Lesions
    1. Tetralogy of Fallot
    2. Eisenmenger’s
12. Pericardial Disease
  1. Pericardial Tamponade
    1. Physiology of Tamponade
    2. TEE findings
    3. Causes
  2. Pericardial Stripping
    1. Discuss Restrictive Physiology
    2. Discuss Constrictive Physiology
    3. Causes of Both
13. Intracardiac Masses
  1. Myxomas
  2. Tumors
Miscellaneous
1. Discuss complications of cardiac anesthesia and surgery
  1. Post op myocardial infarction
  2. Post op pulmonary failure
  3. Intraoperative recall
  4. Postop renal failure
2. "Fast Track" Policies or Early Extubation

Coagulation

Heparin
1. What is the chemical structure of heparin and how does low molecular weight (LMW) heparin differ in structure, pharmacodynamics and pharmacokinetics? How is LMW Heparin monitored?
2. What is the etiology of heparin resistance?
3. What is the etiology of heparin-induced thrombocytopenia (HIT)? How does one evaluate the condition clinically and what approaches are available for management of cardiopulmonary bypass (CPB) in patients with HIT?
Protamine
1. What is the chemical structure of protamine?
2. What is the classification of protamine reactions and how do the etiologies of these classes differ?
3. What patients are at increased risk for a protamine reaction?
4. How does one evaluate a patient at risk for a protamine reaction and what approaches are available for the management of CPB in a patient with a known protamine reaction?
5. How does one treat a protamine reaction?
CPB Induced Coagulopathy and Antifibrinolytics Protamine
1. How does hyperfibrinolysis result in platelet dysfunction after CPB? How does one clinically measure fibrinolysis?
2. How does complement activation during CPB affect coagulation?
3. How does deep hypothermic circulatory arrest (DHCA) affect coagulation?
4. Antifibrinolytics
  1. What is the structure of aprotinin?
  2. What activities does aprotinin possess outside of its antifibrinolytic activity?
  3. What theoretical concerns exist with regard to aprotinin and graft thrombosis?
  4. What theoretical concerns exist with regard to aprotinin and deep hypothermic circulatory arrest?
Transfusion
1. Blood Bank Issues
  1. What is the rationale for a type and screen? What is the rationale for a type and cross?
  2. What is the risk of transfusing erythrocytes if these tests are not available?
  3. What are the indications and rationale for erythrocyte transfusion? What is an appropriate ‘transfusion trigger’? How are erythrocytes collected, stored and transfused?
  4. What are the types of hemolytic transfusion reaction? How are hemolytic transfusion reactions identified and treated?
  5. How does one perform a type and screen? How does one perform a type and cross? How long does it take to perform these tests? What blood should be transfused if no type is available? When is it appropriate then to switch back to the appropriate type?
  6. In what patients is it acceptable to transfuse Rh incompatible blood?
  7. What are the types of non-hemolytic transfusion reaction? What is a direct and indirect Coombs test? How is it performed?
2. Blood Conservation –
  1. What techniques of erythrocyte conservation are available to patients undergoing CPB?
  2. What are the advantages and disadvantages of preoperative donation, intraoperative hemodilution, cell saver and chest tube reinfusion?

Monitors: CA-3 Year

Physical Skills: In addition to the knowledge obtained during the first and second months, the CA-3 will

Learn to perform a basic bi-plane and multiplane TEE exam.
Learn to insert a TEE probe safely and atraumatically.

Conceptual Skills: In addition to the knowledge obtained during the first and second months, the CA-3 will

Be able to develop a comprehensive monitoring plan for a patient undergoing a CABG, a valve procedure, an aortic level surgery, a congenital heart surgery, a minimally invasive surgery, a ventricular assist device insertion, or a cardiac transplant.
Be able to prioritize ECG, CVP, PA, and TEE for assessment of ischemia, valvular function, left and right ventricular function, intracardiac and intravascular volume.
Be able to use TEE with its various modalities (2-D, M-mode, Doppler) for basic assessment of ventricular function, volume, valvular pathology, aortic disease.
Be able to understand limitations and artifacts of a TEE image.
Learn indications for and contraindication to TEE placement.
Be able to describe abnormal waves on a PA trace and discuss the underlying pathophysiology.
Be able to describe the potential errors introduced in cardiac output measurements.
Learn how to use PAC to calculate intracardiac shunts.
Be able to describe different types of PACs and their indications.
Be able to list complications of a PAC insertion and interpretation and describe alternatives to using a PAC.

Monitors: CA-4 year

Physical Skills: In addition to the knowledge obtained during the first two months and in the CA-3 year, the CA-4 cardiac fellow will

Learn to guide residents in difficult line placements.
Learn to assist residents with difficult line placements while perfecting your own skills.

Conceptual Skills: In addition to the knowledge obtained during the first two months and in the CA-3 year, the CA-4 cardiac fellow will

Be able to discuss cardiac physiology and pathophysiology using the data obtained by the invasive monitoring.
Be able to correlate anatomic and physiologic data from TEE with the hemodynamic and electrocardiographic data.
Learn to perform an advanced TEE exam as described in the attachment.
Learn congenital cardiac lesions and be able to describe the anatomy and the pathophysiology of simple and complex cardiac lesions.
Describe the differences in monitoring approaches between adult and pediatric cardiac patients.