UEMS Section of Cardiothoracic Surgery

CARDIAC/CARDIOTHORACIC/CARDIOVASCULAR SURGERY

SYLLABUS

Physiology
Myocardial cellular physiology
Electrophysiology
Physiology of congestive heart failure

Anatomy
Heart, pericardium and great vessels
Coronary anatomy
Valvular anatomy
Anatomy of the peripheral vascular system
Anatomy of cardiac innervation

Pathology
Atheroma, medial necrosis
Myocardial infarction and complications
Intrinisic myocardial disorders
Endocarditis
Pericarditis
Tumors of the heart
Sequelae of chest wall and mediastinal radiation

Pharmacology
Drugs used in the treatment of hypertension, heart failure, and angina
Inotropes, vasodilators and vasoconstrictors
Anticoagulants, antiplatelet drugs

Microbiology
Antibiotic prophylaxis for cardiac surgery

Imaging
Echo
Cardiac cath
CT-SCAN
MRI

General Patient Management

Diagnosis, evaluation and treatment of heart disease
Risk assessment (including when not to operate)
Cardiopulmonary resuscitation (open chest)
Cardiac arrhythmias – diagnosis and management
Cardiac rehabilitation
Management of complications of cardiac surgery
Median sternotomy
Peripheral arterial and venous cannulation technique
Wound infection and sternal disruption
Cardiac tamponade
Interpretation of:
Hemodynamic data
ECG including exercise data
Coronary angiography
Cardiac cath hemodynamics
Echo including 2D, Doppler and transthoracic, stress echo
Nuclear cardiology
Cardiac MRI
CT angiography

CARDIOPULMONARY BYPASS, MYOCARDIAL PROTECTION, AND CIRCULATORY SUPPORT

Metabolic response to CPB

Temperature regulation
Principles of myocardial preservation
Physiology of balloon pump
Anatomy of femoral triangle and thoracic inlet and neck
Principles and practice of CPB
Relevant equipment and technology and its application
Monitoring during CPB
Priming fluids and hemodilution
Acid base balance – pH and alpha stat
Neuropsychological consequences of CPB
Cell salvage and blood conservation
Cardioplegia solutions and delivery modes
Noncardioplegic techniques of preservation
Intra-cardiac balloon pump – indications for use, patient selection and complications
Coordination of perfusionist, anesthesiologist, and surgeon
Patient selection for mechanical circulatory support
Management of balloon pump
Weaning from bypass and decannulation
Recognize and manage acute complications of CPB
Cannulation and institution of CPB
Repeat sternotomy with pericardial dissection, cardiac mobilization
Femoral or axillary cannulation and decannulation

ISCHEMIC HEART DISEASE

Diagnosis, investigation and treatment of ischemic heart disease

Results of surgery: survival, graft patency, recurrence
Guidelines for myocardial revascularization
Arterial revascularization
Role of PCI and nonoperative treatment
Hybrid approaches
Complication of MI and ischemic heart disease: VSD, mitral regurgitation, aneurysm
On and off pump techniques
Preop cardiovascular assessment including general history and exam, conduit
assessment, drug history, comorbidities, and risk assessment
Imaging interpretation
Postop management including complications
Mammary artery/radial artery harvest, venous conduit procurement
Proximal and distal coronary anastomosis
Repeat coronary artery surgery
Minimally invasive conduit procurement
Combined coronary and carotid intervention

HEART VALVE DISEASE

Anatomy of cardiac chambers and valves

Valve physiology and hemodynamics
Calculation of valve area and regurgitant fraction
Pathophysiology of valve incompetence and stenosis
Consequences of valve disease on cardiac function and morphology
Pathophysiology of mixed valve disease and combined valve pathology
Diagnosis, investigation and assessment of valvular heart disease
Determination of need and timing of surgical intervention valve disease
Cardiovascular system and general history and exam including drug history, identification of
comorbidity and risk assessment
Echo interpretation (thoracic and transesophageal)
Combined valvular and ischemic heart disease
Endocarditis and prosthetic valve endocarditis
Indications for operative management including: valve replacement/repair (mechanical,
biologic stented and stentless grafts, homografts and autografts)
Guidelines for valvular heart disease and endocarditis
Valve design: materials, anticoagulation and biomechanics
Results of surgery – survival, long-term functional status, valve thrombosis, endocarditis,
bleeding
Alternative surgical approaches to valve surgery including thoracotomy,
transseptal/transapical approaches, minimal access surgery, and percutaneous approaches
Management of postop heart valve patient including complications
Medical management of endocarditis
Valve selection
Long-term anticoagulation and antibiotic prophylactic guidelines
Aortic valve and root surgery: repair and replacement
Mitral valve surgery: repair and replacement
Tricuspid valve surgery: repair and replacement
Pulmonary valve and right ventricular outflow tract surgery: repair and replacement
Combined valve and graft surgery
Surgical strategies for managing small aortic root

GREAT VESSEL DISEASE

Vascular pathology (including atherosclerosis, inherited and acquired disorders)

Blood supply of the spinal cord
Spinal cord and cerebral preservation
Traumatic aortic transection
Results of surgery – survival, complication rates
Role of endovascular stenting
Medical management of great vessel disease
Knowledge of thromboembolic disease
Interpretation of CT scan, MRI, aortography
Medical management of great vessel disease
Selection of patients for surgery
Management of postop patients including complications
Medical and surgical management of venous obstructive disease
Medical and surgical management of acute and chronic pulmonary embolic disease
Intraoperative monitoring
Spinal cord and cerebral protection
Bypass and non-CPB strategies for major aortic surgery
Surgery for acute dissection of thoracic aorta
Aortic root replacement for acute and chronic aortic root disease
Complex aortic surgery, including aortic arch surgery, descending aortic and thoraco-
abdominal aortic surgery
Endovascular stenting
Pulmonary embolectomy
Great vessel venous reconstruction

PERIPHERAL VASCULAR DISEASE

Vascular exam (including interpretation of ankle: brachial index)

Diagnosis and management of DVT
Diagnosis and management of acute limb ischemia
Diagnosis and management of visceral ischemia
Carotid artery disease and transient ischemic attacks
Aneurysmal disease
Leg ulceration
Atherosclerotic arterial disease
- aortic
- acute and chronic limb ischemia
Embolic and thrombotic arterial disease
Venous insufficiency
Diabetic ulceration
Pseudoaneurysms
Complication of vascular access
Saphenous vein harvest
Vascular anastomosis
Embolectomy
Fasciotomy

CARDIAC CONDUCTION SYSTEM DISORDERS

Anatomy of normal conduction pathways

Anatomy and influence of sympathetic and parasympathetic nervous system on cardiac
conduction
Characteristics of atrial conduction disorders (sinus node dysfunction, atrial flutter, atrial
fibrillation, Wolf-Parkinson-White syndrome, AV Node Reentry)
Characteristics of ventricular conduction disorders [ventricular tachycardia (monomorphic vs.
polymorphic), ventricular fibrillation, left bundle branch block, right bundle branch block]
Risk factors for post-operative atrial fibrillation
Adverse consequences of atrial and ventricular arrhythmias and current medical therapies
Indications for pacemaker placement for atrial and ventricular disorders
Indications and timing for automatic implantable cardiac defibrillators
Indications for epicardial lead placement
Indications for cardiac resynchronization therapy
Complications of intravascular leads (perforation, infection, great vessel stenosis)
Indications for and complications of catheter ablation
Select appropriate patient and lesion set for lone and concomitant surgery for atrial
fibrillation and define the success rates
Manage anti-coagulation and anti-arrhythmic medication after surgery for atrial fibrillation
Manage post-operative atrial fibrillation
Complications of transvenous lead extraction
Determine the need for emergent operation after complications of ablation and lead
extraction
Select appropriate patients for the surgical treatment of cardiac dysrhythmias
Manage temporary cardiac pacing in the peri-operative setting
Implantation of pacemakers and leads
Atrial fibrillation operation

DISEASES OF THE PERICARDIUM AND MYOCARDIUM. CARDIAC TUMORS

Anatomy of the pericardium

Pathology of the pericardium (benign, malignant, inflammatory)
Pathophysiological consequences of pericardial constriction and tamponade
Clinical and imaging techniques used to detect pericardial disease
Pericarditis (primary and post pericardiotomy)
Needle aspiration of pericardial fluid with echo guidance
Pericardial window (subxiphoid, thoracoscopic approach)
Pericardiectomy for relief of constriction
Materials used for pericardial replacement
Complications following pericardial surgery
Indications for pericardial reconstruction
Interpretation of laboratory, physiological and imaging techniques, including echo
Recognition and assessment of pericardial tamponade and constriction
Recognition of pericardial herniation and cardiac strangulation
Postop management of patients following pericardial surgery
Benign and malignant cardiac tumors
Management of cardiac tumors
Diagnosis and management of HOCM

HEART FAILURE AND CARDIAC TRANSPLANTATION

Etiology and natural history of heart failure

Modes of action and interaction of commonly used drugs in heart failure
Evaluation and management of advanced heart failure
Indications for acute and chronic mechanical assistance
Pathophysiology of nonpulsatile flow
Cardiovascular and general history and exam: preoperative assessment for cardiac
transplantation
Indications and assessment for heart transplantation
Acute and chronic cardiac rejection
Results of heart transplantation and non-transplant interventions for heart failure
Management of brain-dead donor
Donor retrieval
Management of postoperative transplant patient including complications
Immunossupressant therapy
Diagnosis and treatment of device failure
Management of acute post-cardiotomy heart failure
Cardiac transplantation technique
Surgical revascularization for ischemic cardiomyopathy
Ventricular remodeling surgery
Mitral valve repair for heart failure
Provision and management of acute mechanical ventricular support
Extracorporeal and intracorporeal ventricular assistance devices

CARDIOTHORACIC TRAUMA

The mechanism and patterns of injury associated with blunt, penetrating, and
deceleration injuries to the chest
Indications and use of appropriate investigations in thoracic trauma management
Indications for thoracotomy in trauma
Care of blunt, penetrating and deceleration injuries to the chest
Diagnosis and management of immediately life threatening situations:
obstructed airway, tension pneumothorax, massive hemothorax, open
chest wound, flail chest, and cardiac tamponade
Diagnosis and assessment of potentially life threatening situations:
lung contusion, bronchial rupture, blunt cardiac injury, intrathoracic bleeding,
esophageal injury, simple pneumothorax and major vascular injury
Pericardiocentesis and subxiphoid window for tamponade
Various approaches to expose thoracic trauma
Repair of cardiac injuries
Repair of aortic transection
Repair of other great vessel injuries

PRINCIPLES OF THORACIC SURGERY

Open versus minimally invasive approaches to thorax

Early and late complications of thoracic incisions
Management of post-thoracic surgical complications
Postoperative management of pain control
Treatment of cardiac arrhythmias
Physiotherapy and rehabilitation
Understanding thoracic-specific ventilatory techniques (e.g., lung isolation)
Introduction to benign and malignant tumors of trachea, bronchus, lung
Principles of lung resections
Etiology, pathology and physiology of COPD
Smoking cessation measures and outcome
Interpretation of pulmonary function tests
Chest drains insertion, management, removal
Introduction to congenital, benign, infectious and malignant (primary and secondary)
conditions of the mediastinum
CONGENITAL HEART DISEASE

Physiology
Hemodynamics; physiology and measurement including shunt calculations, PVR, SVR
determinations
Physiology of Left-to-Right shunts and Right-to-Left shunts
Physiology of pulmonary vasculature and changes with development
Basic conduction disorders
Acid base balance (including Ph stat and alpha stat CPB mgmt)
Physiology of pediatric cardiopulmonary bypass including hypothermia, low-flow, and
circulatory arrest.

Anatomy
Basic embryology of the heart, lungs, great vessels
Coronary anatomy and variants
Location and course of the conduction system in congenital heart disease
Anatomy as it pertains to vascular conduits including aortopulmonary shunts
Basic anatomy of atrial septum and ventricular septum
Basic concepts of cardiac position, situs, atrioventricular and ventriculoarterial connections

Pathophysiolology
Basic concepts of volume and pressure overload
Mechanisms of cyanosis
Manifestations of congestive heart failure in infants and children

Pharmacology

Specific drugs used in the treatment of congenital heart disease (beta blockers, ACE inhibitors,
Digoxin, Diuretics, PGE1, nitric oxide, systemic vasodilators)
Specific dosing and application
General indications and use of inotropes, anti-arrhythmic drugs, hemostatic drugs,
antiplatelet, anticoagulant and thrombolytic drugs, analgesics, antibiotics,
anesthetic agents, and vasodilators (systemic and pulmonary) in the pediatric
population

Congenital Heart Disease

Data Interpretation
Routine hematology and biochemical investigations
Chest radiograph and ECG
Cardiac catheterization data including interpretation of hemodynamic data, shunt and
resistance calculation
Basic congenital heart disease imaging (Echo, MRI, CT) interpretation
Diagnosis, assessment, and treatment of common congenital heart disease
Collaborative and complementary role of interventional cardiology
Risk assessment and stratification
Basic pediatric intensive care to include ventilator management
Perioperative management of adults and children following congenital heart surgery
Mechanical assist (IABP, VAD, ECMO)
Indications for heart or lung transplantation referral
Management of complications of surgery
Cardiopulmonary resuscitation
Diagnosis and treatment of common congenital cardiac arrhythmias
Wound infection and sternal dehiscence
Sternotomy
Thoracotomy
Preparation for and management of cardiopulmonary bypass including partial bypass
Basic ECMO techniques, cannulation, and management.

Anatomy, pathophysiology, natural history, management, and results of the following

conditions or procedures:
Patent ductus arteriosus
Atrial septal defect
Ventricular septal defect
Coarctation
PA banding and shunts
Transposition of the great arteries/arterial switch procedure
Tetralogy of Fallot
Vascular ring
Functional single ventricle leading to single ventricle pathway and principles of
treatment (Fontan procedure)
Congenital aortic stenosis/insufficiency (Konno, Ross procedure)
Rastelli procedure
Hypoplastic left heart and Norwood procedure
Truncus arteriosus
Double outlet right ventricle
VSD, Pulmonary atresia, and MAPCAs
Pulmonary atresia and intact septum
Partial and complete atrioventricular septal defects
Mitral valve disease
Tricuspid valve disease including Ebstein’s anomaly
Interrupted aortic arch
Total anomalous pulmonary venous drainage
Extra Corporeal Membrane Oxygenation
Transplantation – Heart and Lung