European School for Cardio-Thoracic Surgery

CURRICULUM - CARDIAC SURGERY COURSE

Index

Unit I - PREOPERATIVE AND POSTOPERATIVE CARE

CONTENTS:

• Hemodynamic monitoring

  • Non-invasive monitoring

  • Invasive monitoring

  • Cardiac output measurements

• Circulatory management

  • A. Inotropic

• Complications

  • Cardiac tamponade

  • Renal failure

  • Dialysis

    • Indications

    • Complications

    • Types

  • Congestive heart failure

  • Cardiac dysrhytmias

  • Management of bleeding and transfusion

  • Sepsis

  • Wound infection

• Mechanical ventilation

  • Indications

  • Complications

  • Weaning

• Pain management

• Nutrition

• Special problems in the elderly

• Central Venous Lines and Arterial Lines

  • A. Central venous lines

  • B. Indications

  • C. Contraindications

  • D. Complications

•  Catheter types, including pulmonary artery catheters

• Arterial lines

  • A. Indications

  • B. Contraindications

  • C. Complications

  • D. Catheter types

• Knows the physiologic characteristics of neonates and small infants;

• Understands the management of infants and children who have undergone operative

• correction of simple and complex congenital cardiac anomalies;

• Understands the postoperative management of patients with systemic-to-pulmonary artery

• shunts

• Understands the management of patients who have had a right heart bypass operation;

• Understands the physiologic preoperative and postoperative management of patients with

• hypoplastic left heart syndrome;

• Understands which infants and children are prone to have a pulmonary hypertensive crisis;

• Knows the prevention, recognition, and treatment of pulmonary hypertensive crises.

Unit II - ETHICS, PRACTICE, OUTCOMES

UNIT OBJECTIVE:
At the end of this unit the resident understands the non-clinical elements of a thoracic surgical practice, understands the application of the scientific method to thoracic surgery, is able to describe problems in research terms and to design a scientific approach to the solution of an unsolved problem in thoracic surgery. The resident becomes facile in the interpretation and critical evaluation of the thoracic surgery literature.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understand the ethical components of surgical practice;

• Understands the scientific method as it applies to basic and clinical research

• Knows how to access the literature including computerized and conventional library searches

• Is able to interpret published material critically and will be able to use clinical database and outcome analysis in surgical practice;

• Knows the medico-legal aspects of surgical practice;

• Understands critical pathways and cost-benefit analysis in clinical decision-making;

• Understand organizational structure and mechanics of solo practice, group specialty practice,multi-specialty practice, and academic practice;

• Knows the structure and differencesof European HealthCare organisations, contractual agreements, physician-hospital organizations, and independent practice agreements;

• Understands the time constraints imposed by the responsibilities of practice and the need for effective time management.

• Understands the role of statistics in validating scientific inferences including the appropriate application of statistical tests commonly used in the thoracic literature, their limitations and deficiencies

• Understands the role of power, significance, and sample size in interpreting data

• Knows how to develop and design a research proposal and complete the process of solving a problem scientifically

CONTENTS:

• Fundamental elements of ethical practice

  • Hippocratic oath

  • Primum non nocere

  • Personal responsibility

  • Honest and open communications

  • Critical self analysis

• Clinical database and outcome analysis

  • Data collection

  • Risk stratification

  • Statistical analysis

  • Regular review of data

  • Comparative analysis

• Cost factors and clinical outcome

  • Analysis of redundancy, waste, inefficiency
  • Entrepreneurial approach to cost and quality

• Practice arrangements

  • Administration of practice (e.g., fees, collections, insurance, billing, overhead, office

  • management)

  • Advantages and disadvantages of different practice arrangements

• External economic forces

• Medico-legal factors

  • Prevention of litigation

  • Record keeping

  • Response to malpractice lawsuit

  • Expert witness testimony

• Time management

  • Family needs

  • Practice needs (e.g., patients, administration, associates)

  • Community responsibilities

  • Personal needs (e.g., continuing education, personal growth, life outside medicine)

Unit III - COAGULATION MANAGEMENT AND BLOOD COMPONENT THERAPY

UNIT OBJECTIVE:
At the end of this unit the resident knows the physiology, methods, and techniques to manage the coagulation and fibrinolytic systems, and uses component therapy to treat specific clinical problems.

LEARNER OBJECTIVES:
At the end of the unit the resident:

• Understands the major blood groups, the clotting cascade, and the pathophysiology of clotting (e.g., abnormal clotting, activation of compliment, Kallikrein, prostanoids);

• Understands the specific hemorrhagic and thrombotic complications of cardiac surgery and their management;

• Understands the methods used in blood component storage and the measures taken to ensure a safe blood supply;

• Understands the use of specific blood components to treat abnormalities of red cell quantity and quality, platelet quantity and quality, and coagulation function;

• Knows the preoperative risk factors for excessive blood loss and blood utilization;

• Understands the operative and postoperative techniques to ensure blood conservation.

CONTENTS:

• Blood characteristics

  • Blood groups and specific antigens

  • Cellular elements

  • Clotting cascade

  • Pathophysiology of clotting

  • Drugs that affect clotting and platelet function

• Hemorrhagic and thrombotic complications of cardiac surgery

  • Diagnosis

  • reoperative, intraoperative, and postoperative management

  • Heparin, Protamine

  • Cardiac and vascular prostheses

• Component therapy

  • Packed red blood cells

  • Fresh frozen plasma

  • Platelets

  • Cryoprecipitate

  • Specific clotting factors

• Blood conservation

  • Indications for transfusion

  • Autotransfusion

  • Cell-plasma salvage

  • Hemoconcentration

  • Pharmacologic manipulation

Unit IV - HISTORY OF CARDIO-THORACIC SURGERY

UNIT OBJECTIVE:
At the end of this unit the resident has knowledge of the historic development of cardio-thoracic surgery.

Unit V - ANESTHESIA

UNIT OBJECTIVE:
At the end of this unit the resident understands the physiology, methods, and techniques of anesthesia in cardio-thoracic surgery.

CONTENTS:

• Preoperative risk assessment

• Preoperative risk management

• Agents used in cardiac anesthesia

• Cardiac effects of general anesthesia

• Central nervous system monitoring

• Prevention ischemic injury

• Fast tracking in cardiac surgery

• Anesthesia for pediatric cardiac surgery

• Hemorrhage, coagulation and transfusion

  • Intraoperative fluid management

  • Intraoperative blood transfusion

  • Intraoperative use of coagulation factors

• Intraoperative monitoring

• Anesthesia and minimal invasive surgery

Unit VI - PULMONARY EMBOLISM

UNIT OBJECTIVE:
At the end of this unit the resident understands the pathofysiological aspects of pulmonary embolism and the surgical and non-surgical management.

CONTENTS:

• Incidence

• Risk factors

• Pathogenesis

  • Deep vein thrombosis

• Clinical manifestations

  • Symptoms

  • Arterial blood gases

  • Electrocardiogram

  • Chest x-ray

  • Diagnosis

  • Pulmonary angiography

  • Transoesophageal echocardiography

  • MRI-scan

  • CT-scan

  • Ventilation-perfusion scanning

• Treatment

  • Anticoagulation

  • Trombolysis

  • Surgery

  • Cava interruption

• Prognosis

• Prevention

Unit VII - EXTRACORPOREAL BYPASS AND COAGULATION-BLOOD PRODUCTS

A. Physiology of Extracorporeal Bypass

UNIT OBJECTIVE:
At the end of this unit the resident understands the physiology and pathologic derangements of pulsatile and non-pulsatile extracorporeal bypass, and has a working knowledge of oxygenators, perfusion systems, and ventricular support devices as they apply to adult patients.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Understands the physiology and mechanics of membrane and bubble oxygenators;

• Understands the mechanics and operation of roller and vortex pumps;

• Understands the physiology of various extracorporeal bypass circuits and the derangements caused by their use;

• Knows the coagulation system and alterations of blood elements;

• Understands the basic design and function of ventricular support devices.

CONTENTS:

• Membrane oxygenators

  • Physiology

  • Design

  • Complications

• Bubble oxygenators

  • Physiology

  • Design

  • Complications

• Roller head pumps

  • Design

  • Safety measures

  • Complications

• Vortex pumps

  • Mechanism and design

  • Safety measures

  • Complications

• Extracorporeal circuits

  • Set-up

  • Types of tubing, filters, hemoconcentrators

  • Safety measures

  • Blood and artificial surface interaction

• Perfusion solutions

  • Prime solutions

  • Hemodilution

  • Oxygenators (types, indications, benefits, disadvantages)

  • Venous reservoir

  • Cardiotomy reservoir

  • Tubing (choice of adequate internal diameter)

  • Osmotic pressure, oncotic pressure (use of mannitol, albumin)

  • Blood gas control

• Manipulation of:

  • Flow

  • Pressure

  • Temperature

B. Techniques of Extracorporeal Bypass

UNIT OBJECTIVE:
At the end of this unit the resident understands the techniques of extracorporeal bypass and their application to solve specific clinical problems.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Understands the standard techniques for extracorporeal bypass;

• Understands the techniques for left heart bypass and right heart bypass for the treatment of specific clinical problems;

• Understands the techniques of cannulation for extracorporeal bypass;

• Oversees the management of patients undergoing extracorporeal bypass.

• Understand the principles of use and the various types of cardioplegia.

CONTENTS:

• Standard cardiopulmonary bypass

  • Routes for cannulation (arterial and venous)

  • Types of extracorporeal circuits

  • Monitoring

  • Complications

• Anticoagulation for cardiopulmonary bypass

  • Heparin and other agents

  • Monitoring

  • Reversal

  • Complications

• Special situations

  • Left and/or right heart bypass

  • Profound hypothermia and circulatory arrest

    • Cerebral protection

• Cardioplegia

  • Cold and warm crystalloid cardioplegia

  • Cold and warm blood cardioplegia

  • Crystallloid versus blood cardioplegia

  • Routes of carioplegia

C. Mechanical Support

UNIT OBJECTIVE:
At the end of this unit, the resident understands the indications for mechanical cardiac support and ECMO, patient selection, device selection, recognition and treatment of the complications of mechanical support, methods for weaning the patient from support, and "bridging" to transplantation.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Understands the indications for cardiac support with mechanical devices or ECMO;

• Understands alternatives to mechanical support (e.g., intra-aortic and intra-pulmonary balloon pumping);

• Knows the techniques for inserting these ventricular support devices;

• Recognizes complications of the devices;

• Understands the principles of weaning patients from these devices;

• Understands the use of mechanical devices as a "bridge" to transplantation;

• Knows the requirements for anticoagulation and monitoring of blood trauma;

• Understands Federal regulations that apply to the use of these devices

CONTENTS:

• Indications for mechanical support

  • Deterioration of an established prospective transplant recipient

  • Patient unable to be weaned from cardiopulmonary bypass but is a candidate for "postcardiotomy" usage or "bridging" to transplantation

  • Acute myocardial infarction with balloon-dependent left heart failure

• Respiratory failure

  • Indications for ECMO

  • Alternatives to ECMO

• Alternatives to mechanical devices

  • Balloon pumping (left and right)

  • Centrifugal devices

  • Impeller devices

  • Pulsatile devices

  • Total artificial heart

• Techniques of insertion

  • Cardiac

  • ECMO

• Complications

  • Blood trauma

  • Thrombosis

  • Bleeding

  • Infection

• Weaning the patient from support devices and the use of mechanical devices to "bridge" to transplantation

  • Hemodynamic parameters used in weaning from cardiac support, criteria for weaning and rate of weaning

  • Concept of "rehabilitation" of the bridging patient and modification of transplantation criteria for the bridging patient

• Anticoagulation

  • Requirements for various mechanical devices

  • Detection of blood trauma

  • Early detection of thrombotic problems

ACQUIRED HEART DISEASE

Unit VIII - VALVULAR HEART DISEASE

UNIT OBJECTIVE:
At the end of this unit, the resident knows the normal and pathologic anatomy of the cardiac valves, understands their natural history, physiology and clinical assessment.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Understands the normal and pathologic anatomy of the atrioventricular and semilunar

• Knows the natural history, pathophysiology, and clinical presentation of each major valvular lesion (mitral stenosis and incompetence, aortic stenosis and incompetence, tricuspid stenosis and incompetence);

• Understands the operative and non-operative therapeutic options for the treatment of each major valvular lesion; knows the relative risks of operative and non-operative treatment for valvular heart disease in planning interventions;

• Knows the theory of techniques for repair and replacement of cardiac valves;

• Knows the theory of the preoperative and postoperative management of patients with valvular heart disease including catheterizations and echocardiograms

GENERAL CONTENTS:

• Assessment of patients with valvular heart disease

  • History and physical examination

  • Echocardiogram

  • Cardiac catheterization data

• Choice of treatment

  • Prosthetic valves

  • Stented xenografts

  • Non-stented human and xenograft valves

  • Autograft valves for aortic valve replacement

  • Valve repair

• Long term complications of replacement devices

  • Thrombosis

  • Embolus

  • Prosthetic dysfunction

VALVE SPECIFIC CONTENTS

• Aortic valve

  • Normal anatomy

  • Normal function

  • Aortic stenosis

    • etiology and pathologic anatomy

    • natural history and complications

    • physiology (ventricular hypertrophy, mitral incompetence)

    • non-operative therapy

    • indications for operative intervention (risk stratification)

    • techniques of valve replacement and repair

    • management of small aortic root

    • homograft and autograft valve replacement

    • perioperative care considerations

    • early and late results

  • Aortic incompetence

    • etiology and pathologic anatomy

    • natural history and complicationq

    • physiology (LV dilatation and LV dysfunction)

    • non-operative treatment

    • indications for operative intervention

  • in absence of clinical symptoms

    • when complicated by endocarditis

    • when complicated by aortic root aneurysm

    • techniques of valve repair and replacement

      • with endocarditis and aortic root abscess

      • with ascending and root aneurysm

    • Perioperative care considerations

    • early and late results

• Tricuspid valve

  • Normal anatomy

  • Normal function

  • Tricuspid incompetence

    • etiology and pathologic anatomy

    • physiology

    • indications for operation

    • functional incompetence

    • endocarditis

    • techniques of repair, indications for replacement

    • ring and suture annuloplasty

  • endocarditis (valve excision vs. repair or replacement)

  • perioperative care

    • management of RV dysfunction

    • interventions to decrease pulmonary vascular resistance

  • early and late results

  • Tricuspid stenosis

    • etiology and pathologic anatomy

    • physiology

    • differentiation from constrictive pericarditis

    • indications for operative repair vs. replacement

  • techniques of repair and replacement

  • early and late results

• Mitral valve

  • Normal anatomy

  • Normal function

  • Mitral stenosis

    • etiology and pathologic anatomy

    • natural history and complications

    • physiology

    • non-operative treatment

    • indications for intervention (risk stratification)

    • merits of balloon valve dilation vs. operative repair or replacement

    • techniques of valve repair and replacement

    • intraoperative and postoperative complications and management

    • early and late results of operative and balloon valvulotomy

  • Mitral incompetence

    • etiology and pathologic anatomy

    • natural history and complications

    • physiology (mechanisms of incompetence)

    • non-operative treatment

    • for nonischemic etiology

    • for ischemic etiology

    • indications for surgical intervention (risk stratification)

    • techniques of valve repair

    • ring and suture annuloplasty

    • leaflet plication, excision

    • chordal/papillary muscle shortening

    • chordal transposition and artificial chordae

    • perioperative care

    • early and late results of repair and replacement

• Endocarditis

  • Etiology

  • natural history and complications

  • non-operative treatment

  • techniques of valve repair and replacement

    • aortic root abscess

  • Outcome

• Combined valve lesions

  • natural history and complications

  • physiology

  • non-operative treatment

  • indications for surgery (risk stratification)

  • techniques of valve repair and replacement

  • intraoperative and postoperative complications and management

  • early and late results of therapy

Unit IX - CORONARY ARTERY DISEASE

UNIT OBJECTIVE:
At the end of this unit, the resident understands the physiology of coronary circulation, thepathophysiologic causes and derangement of ischemic heart disease and the sequelae of coronary events.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Understands the physiology of coronary circulation and the physiologic derangements caused by stenosis and obstruction;

• Understands the development of atherosclerotic plaques and the current theories of plaque origination;

• Knows the normal and variant anatomy of coronary circulation as well as the radiographic anatomy of the coronary arteries and the left and right ventricles;

• Understands the rationale for and techniques of coronary artery bypass operations as well as the use of various conduits;

• Understands the risks and complications of coronary artery bypass operations, coronary angiography, and percutaneous coronary artery balloon angioplasty;

• Understands the preoperative and postoperative care of patients undergoing coronary artery bypass grafting;

• Can describe outcomes of angioplasty and of operative and non-operative treatment of coronary artery disease, using statistical methods.

• The residents knows how to evaluate patients with angina pectoris, unstable angina pectoris, and acute myocardial infarction;

• Can read and interpret invasive and non-invasive tests of patients with ischemic heart disease

• Has knowledge about the critical care management of preoperative and postoperative patients with ischemic heart disease;

• Knows how to evaluate exercise tolerance tests, echocardiograms, and cardiac catheterizations.

• Knows the new techniques in coronary surgery

CONTENTS:

• Cardiac anatomy

  • Left and right main coronary arteries

  • Left anterior descending coronary artery

  • Circumflex coronary artery

  • Right coronary artery

  • Coronary venous system

  • Left and right ventricular anatomy

• Radiographic cardiac and coronary anatomy

  • Right anterior oblique views

  • Left anterior oblique views

  • Cranial view

  • Ventriculography

• Pathologic development of atherosclerotic plaque

  • Endothelial injury

  • Platelet factors

  • Cellular factors

  • Serum factors

• Coronary artery bypass grafting

  • Rationale

  • Conduits

  • Techniques

  • Technical considerations

  • Myocardial protection

• Preoperative evaluation

  • Symptoms of cardiac ischemia

  • Non-invasive testing

  • Invasive testing

  • Decision making

• Postoperative care

  • Intensive care

  • Acute care

• Long term management

  • Late complications

  • Outcome

  • Expected operative mortality

  • Long term results

  • Complications of ischemic heart disease

• Ischemic mitral insufficiency

  • Ruptured papillary muscle (non-operative and operative management)

• Ventricular septal defect (non-operative and operative management)

• Cardiac rupture (non-operative and operative management)

• Left ventricular aneurysm

• Combined Coronary artery and carotid artery disease

• New Techniques in coronary surgery

  • Techniques of off-pump surgery (OPCAB)

  • Pro’s and con ’s of off pump surgery

  • Minimal invasive coronary surgery (MIDCAB)

  • Robotically assisted surger

Unit X - CARDIAC ARRHYTHMIAS

UNIT OBJECTIVE:
At the end of this unit, the resident understands the etiology and physiology of cardiac arrhythmias, and operative and non-operative treatment.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Understands the etiology of cardiac arrhythmias and underlying physiologic disturbances;

• Understands operative and non-operative management;

• Knows the indications for and techniques of electrophysiologic studies and the application of this information to patient management.

CONTENTS:

• Cardiac arrhythmias

  • Atrial

  • Ventricular

• Non-operative management

  • Anti-arrhythmic drugs

  • Electrical cardioversion and pacing

  • Catheter ablation

• Operative management

  • AICD

  • Intraoperative mapping and ablation

  • Permanent pacing systems

Unit XI - ABNORMALITIES OF THE AORTA

UNIT OBJECTIVE:
At the end of this unit, the resident understands the etiology and physiology of diseases of the aorta and the operative and non-operative treatment.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Understands the etiology and the physiology of aortic dissections and all aneurysms involving the ascending, transverse, descending, and abdominal aorta;

• Recognizes the potential morbidity and mortality associated with aortic aneurysms and develops appropriate treatment plans for their management;

• Evaluates and interprets plain radiography, echocardiography, CT scans, MRI, and contrast studies for diseases of the aorta;

• Develops knowledge on operative and non-operative management of thoracic aortic disease, including aneurysms, acute and chronic dissections, and occlusive disease;

• Has knowledge on the use of extracorporeal bypass, hypothermia, and circulatory arrest for aortic diseases;

• Develops knowledge on preoperative and postoperative care of patients with aneurysms, dissections, and occlusive disease of the aorta.

CONTENTS:

• Aortic aneurysms (atherosclerotic, aortic dissections)

  • Ascending

  • Transverse

  • Descending

  • Abdominal

• Operative and non-operative treatment

  • Ascending

  • Transverse

  • Descending

  • Abdominal

• New techniques in treatment of aortic diseas

  • Stent techniques

Unit XII - CARDIAC TUMORS

• Tumors
  • Types, pathology
  • Location
  • Physiology
  • Primary vs. metastatic
  • Malignant pericardial effusion

Unit XIII - MYOCARDITIS, CARDIOMYOPATHY, HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

UNIT OBJECTIVE:
At the end of this unit, the resident understands the pathology and etiology of diseased myocardium, the natural history of the diseases and physiologic alterations, and understands operative and non-operative management.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Understands the types of cardiac tumors (frequency, anatomic location, physiologic and pathologic derangements, diagnostic methods and surgical management);

• Understands myocarditis (causes, physiologic changes, treatment, prognosis, and radiographic, EKG and echocardiographic changes)

• Understands hypertrophic cardiomyopathy (genetic linkage, pathologic and anatomic changes, physiologic derangements, clinical features, diagnostic tests, natural history, medical and surgical treatment)

• Knows the types of cardiomyopathies (causes, natural history, diagnostic methods, operative and nonoperative treatment)

• Evaluates and interprets chest x-rays, CT scans, MRI, echocardiograms, and cardiac catheterizations of patients with cardiac tumors, myocarditis, cardiomyopathy and hypertrophic cardiomyopathy (HCM)

• Understands cardiac transplantation (immunology/rejection and treatment, physiology, indications, operative techniques, diagnostic techniques in follow-up).

• Knows how to perform heart transplants and develops knowledge on preoperative and postoperative care

• Knows how to perform operative excision of cardiac tumors

• Knows how to perform operations for the treatment of HCM

• Has knowledge on echocardiography, cardiac catheterization, endomyocardial biopsy, and donor heart harvesting.

CONTENTS:

• Hypertrophic cardiomyopathy (HCM)

  • Pathologic changes

  • Anatomic changes

  • Pathophysiology

  • Obstructive vs. non-obstructive

  • Arrhythmias

  • Diagnosis

  • History and physical examination

    • echocardiography

    • cardiac catheterization

  • Mitral valve

    • systolic anterior motion

    • mitral regurgitation

  • Treatment

    • mitral valve replacement

    • myectomy and myotomy

    • pacing

  • Outcome

    • complications

    • long-term results

• Cardiomyopathy

  • Dilated

  • Restrictive

  • Causes

  • Pathology

  • Pathophysiology

  • Diagnosis

    • echocardiography

    • endomyocardial biopsy

  • Clinical course

  • Treatment

  • Outcome

• Cardiac transplantation

  • Techniques

  • Indications

  • Immunology

  • Immunosuppressive treatment

  • Physiology

  • Complications and infection

  • Rejection

    • Diagnosis

      • Treatment

  • Coronary artery disease development

  • Organ harvesting, preservation

  • Long term complications and outcome

  • Diagnostic methods

  • Treatment

  • Outcome

• Myocarditis

  • Pathologic changes

  • Etiology

  • Clinical findings

  • Radiographic changes

  • Electrocardiography

  • Echocardiography

  • Treatment

  • Outcome

Unit XIV - MINOR PROCEDURES

A. Permanent Pacemakers

UNIT OBJECTIVE:
At the end of this unit the resident understands the indications, implantation techniques, and complications of permanent pacemaker implantation.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understands the indications and contraindications for permanent cardiac pacing;

• Knows the techniques and complications of epicardial and transvenous cardiac pacemakers

• Understands phrenic nerve pacing

• Understands cardiomyoplasty pacing techniques.

Unit XV - CARDIOVASCULAR TRAUMA

UNIT OBJECTIVE:
At the end of this unit the resident understands the pathophysiology of thoracic trauma resulting in injury to the heart and great vessels, and knows how to diagnose, resuscitate and treat patients with these injuries.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• 1. Evaluates patients who have sustained cardiovascular trauma;

• 2. Understands the physiology of deceleration injuries to the thoracic aorta;

• 3. Understands both invasive and noninvasive methods for the diagnosis of cardiovascular traumatic injuries.

CONTENTS:

• Cardiac contusion

  • Pathophysiology

  • Noninvasive diagnostic techniques

  • Management

  • Follow-up and outcomes

• Penetrating cardiovascular injuries

  • Major vessel laceration

  • Penetrating cardiac trauma

  • Laceration of coronary arteries

  • Pericardial tamponade

  • Diagnostic methods

  • Management

• Operative approaches for specific injuries

  • use of cardiopulmonary bypass or partial mechanical support

  • management of concomitant injuries

• Postoperative management

  • Outcomes

• Traumatic aortic transection

  • Pathophysiology

  • Anatomic locations and operative approaches

  • Operative management

  • Management of associated injuries

  • Outcomes

Unit XVI - CARDIAC TRANSPLANTATION

UNIT OBJECTIVE:
At the end of this unit, the resident knows the principles of organ preservation, immunosuppressive therapy, signs and treatment of rejection, and the indications for and techniques of cardiac transplantation.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• 1. Knows the indications for cardiac transplantation;

• 2. Understands the management of immunosuppressive therapy in cardiac transplantation;

• 3. Knows the techniques of cardiac transplantation;

• 4. Recognizes the signs and symptoms of cardiac rejection and knows the appropriate management;

• 5. Understands the evaluation and management of organ donors;

• 6. Knows the methods of organ harvest and preservation;

• 7. Is familiar with the techniques and complications of endomyocardial biopsy.

CONTENTS:

• Indications for cardiac transplantation

  • Patient evaluation

  • Patient selection

  • Informed consent

• Immunosuppressive therapy in cardiac transplantation

  • Evaluation of therapy

  • Drugs

  • Complications

• Technique of cardiac transplantation

  • Orthotopic

  • Heterotopic

• Donor preparation and organ harvest

  • Brain death, legal and family-related issues

  • Donor evaluation

  • Methods of organ procurement and preservation

• Cardiac rejection

  • Signs and symptoms

  • Endomyocardial biopsy

  • Histologic evaluation

  • Management

• Mechanical support and re-transplantation

• Immunosuppressive therapy

  • Immunosuppressive drugs and their side effects

  • Polyclonal and monoclonal antibody therapy and side effects

  • Complications

Unit XVII - CONGENITAL AND ACQUIRED ABNORMALITIES OF THE PERICARDIUM

UNIT OBJECTIVE:
At the end of this unit the resident understands pericardial diseases and knows how to perform operative and non-operative management.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understands the physiologic consequences of increased pericardial fluid and the techniques for diagnosis and management;

• Understands the operative management of benign and malignant pericardial neoplasms;

• Understands the physiologic consequences of pericardial constriction and the techniques for diagnosis and management.

• Understands abnormal physiologic findings to diagnose pericardial pathology;

• Knows how to evaluates and manage patients with pericardial cysts or tumors;

• Knows how to perform diagnostic tests and therapeutic interventions for the treatment of pericardial tamponade, pericardial effusions, and constrictive pericardial disease.

CONTENTS:

• Pericardial effusions

  • Benign

  • Malignant

  • Diagnostic tests

  • Management (operative and non-operative)

• Constrictive pericarditis

  • Infectious

  • Postoperative

  • Management (operative and non-operative)

• Pericardial cysts and tumors

  • Congenital cysts

  • Benign tumors

• Malignant tumors

  • Management (operative and non-operative)

CONGENITAL HEART DISEASE

Unit XVIII - ANATOMY

UNIT OBJECTIVE:
At the end of the unit the resident understands the embryology of the heart and great vessels as it relates to the development of congenital heart anomalies, the normal anatomy of the heart, and the abnormal anatomy of the principal congenital cardiac anomalies, and applies this knowledge to the interpretation of echocardiograms, angiocardiograms, and other imaging techniques.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• 1. Knows the embryology and anatomy of the normal heart

• 2. Knows the embryology and anatomy of major cardiac anomalies

• 3. Interprets angiocardiograms, echocardiograms, and other images and correlates these with normal and abnormal cardiac anatomy

• Knows the history of congenital cardiac surgery, and the intellectual development of operations used to manage each cardiac anomaly

Unit XIX -  PHYSIOLOGY AND PHYSIOLOGIC EVALUATION

UNIT OBJECTIVE:
At the end of this unit the resident understands the physiology of the developing heart, the physiologic changes of advancing age and transition ex-utero, and the physiologic consequences of congenital heart disease. The resident understands the findings in and limitations of invasive and non-invasive tests to define physiologic abnormalities and uses them in patient management.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• 1. Understands normal fetal circulation

• 2. Understands the transitional nature of circulation as the fetus becomes a neonate

• 3. Understands the physiology of obstructions, of intra- and extracardiac

• 4. shunts, of abnormal connections to the heart, and of combinations of these anomalies in the fetus, neonate, and child.

Unit XX - CARDIOPULMONARY BYPASS FOR OPERATIONS ON CONGENITAL CARDIAC ANOMALIES

UNIT OBJECTIVE:
At the end of this unit the resident has a working knowledge of the principles of cardiopulmonary bypass for congenital heart disease, the techniques of myocardial preservation, and the use of profound hypothermia and total circulatory arrest in the infant and child.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Knows the indications for the various techniques of bypass (anatomy, pathophysiology, and technical requirements of the underlying cardiac defects);

• Knows arterial and venous cannulation techniques for different intracardiac defects;

• Understands the techniques of myocardial protection in the neonate and young infant;

• Understands the use of varying levels of hemodilution and anticoagulation;

• Understands perfusion flow and pressure control;

• Knows the methods of body temperature manipulation, and the indications for and techniques of profound hypothermia with and without total circulatory arrest.

Unit XXI - LEFT-TO-RIGHT SHUNTS

UNIT OBJECTIVE:
At the end of the unit the resident understands the diagnosis and treatment of left-to-right shunts caused by congenital cardiac anomalies, and performs operative and non-operative treatment.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Knows the anatomy, embryology, and physiology of the most common or important anomalies;

• Knows the operative indications of the most common or important anomalies;

• Knows the technical components of the operative repair of the most common or important anomalies;

• Understands the postoperative care of each anomaly.

A. Atrial septal defect

CONTENTS

• Anatomy

  • types of atrial septal defects and key landmarks of the right atrium.

• Clinical features

  • natural history, indications for operation

  • clinical signs and symptoms, physical exam

  • chest x-ray and ECG

  • echocardiogram and cardiac catheterization

• Operative repair and complications

  • extracorporeal bypass and myocardial protection

  • incisions in the heart

  • techniques for defect closure

  • treatment of associated anomalies (e.g., cleft mitral valve)

  • complications of closure (e.g., air embolism, conduction abnormalities, residual defects)

• Outcome

  • expected operative mortality

  • long-term results

  • complications

B. Ventricular septal defect

CONTENTS

• Anatomy

  • types

• Clinical features

  • clinical signs and symptoms, physical exam

  • echocardiogram and cardiac catheterization

  • chest x-ray and ECG

  • natural history

  • indications, contraindications, timing of operation (e.g., total repair vs. pulmonary artery banding)

• Operative repair and complications

  • extracorporeal bypass and myocardial protection

  • incisions for different types of defects

  • closure techniques (direct suture vs. patch)

  • treatment of associated anomalies (e.g., atrial septal defect, right ventricular muscle bands)

  • complications (rhythm disturbances, residual defects, air)

  • techniques of PA banding

• Outcomes

  • expected operative mortality

  • long-term results

  • complications

C. Patent ductus arteriosus

• Anatomy

• Physiology

  • neonate vs. older child

  • effect of prostaglandin and prostaglandin inhibitors

• Diagnosis and clinical features

  • symptoms and physical findings

  • echocardiogram and cardiac catheterization

  • chest x-ray and ECG

  • natural history (neonate vs. older child, endocarditis)

  • indications for operation

  • associated anomalies (e.g., ductus-dependent conditions)

• Operative repair and complications

  • operative techniques for simple ductus

  • management of the difficult ductus

  • complications of operative repair

• Outcome

  • expected operative mortality

  • long-term results

  • complications

D. Atrioventricular septal defect

• Anatomy

  • types (complete, transitional, ostium primum ASD)

  • atrioventricular valve pathologic anatomy

• Physiology

  • shunts and resistance calculation

  • complete vs. incomplete

• Diagnosis and clinical features

  • Symptoms and signs (infant vs. older patient, physical exam)

  • echocardiogram, angiocardiogram, cardiac catheterization

  • chest x-ray and ECG

  • natural history (development of Eisenmenger's syndrome)

  • indications for and timing of operation (size of shunt, endocarditis risk, total repair vs. pulmonary artery banding)

• Operative repair and complications

  • cardiopulmonary bypass and myocardial protection

  • incisions in the heart

  • operative techniques

  • complications (residual defects, residual "mitral valve" insufficiency, heart block)

• Outcome

  • expected operative mortality

  • long-term results

  • complications

E. Double-outlet right ventricle

• Anatomy

  • Types (subaortic, subpulmonic, uncommitted)

  • associated anomalies

• Clinical features

  • natural history

  • indications for and timing of operation

  • signs and symptoms of each of the anatomic types

  • chest x-ray, ECG

  • echocardiogram and cardiac catheterization

• Operative repair and complications

  • palliative operations vs. total repair (application of shunts, pulmonary artery band, total repair)

  • cardiopulmonary bypass and myocardial protection

  • approach to each anatomic subtype and placement of incisions in the heart

  • specific operative techniques (e.g., suturing, placement of patches)

  • complications and their management

  • Outcome

• expected operative mortality

• long-term results

• complications

F. Aorto-pulmonary window

• Anatomy

• Clinical features

• natural history (development of pulmonary vascular obstructive disease)

• symptoms and signs

• echocardiogram, angiocardiogram, cardiac catheterization

• chest x-ray, ECG

• Operative repair

  • Outcome

  • expected operative mortality

  • long-term results

  • complications

Unit XXII - CYANOTIC ANOMALIES

UNIT OBJECTIVE:
At the end of this unit the resident knows the anatomy and physiology of anomalies that result in cyanosis, their diagnosis, their preoperative, operative, and postoperative management, and performs operative and non-operative treatment.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Knows the anatomy and physiology of each anomaly;

• Knows the methods of diagnosis;

• Understands the role of medical management and interventional cardiology as treatment

• Knows the indications for and timing of operation;

• Understands the technical components of operative repair;

• Knows the postoperative care, expected outcome, long-term results, and complications.

CONTENTS

A. Tetralogy of Fallot

• Anatomy and embryology

  • embryology of malaligned ventricular septal defect

  • levels of right ventricular outflow tract obstruction

• Physiology

  • genesis of "tet spells" and infundibular spasm

  • factors which affect degree of right-to-left shunt

  • associated anomalies

• Clinical features

  • symptoms and physical findings

  • cardiac catheterization, echocardiogram, angiocardiogram

  • chest x-ray, ECG

  • natural history

  • indications for and timing of operation

• Operative repair and complications

  • role of systemic-to-pulmonary artery shunt vs. total repair

  • types of aortic-to-pulmonary artery shunts

  • extracorporeal bypass and myocardial protection

  • ventricular septal defect closure by transventricular or transatrial approach

  • techniques for relief of right ventricular outflow tract obstruction and indications for transannular patching

  • indications for conduit repair

• Outcome

  • expected operative mortality

  • long-term results

  • complications

B. Transposition of the great vessels (TGA)

• Anatomy

  • simple TGA

  • complex TGA (ventricular septal defect, pulmonary stenosis)

• Physiology

• Concept of circulations in parallel and mixing

• Clinical features

  • symptoms and physical findings

  • echocardiogram, angiocardiogram, cardiac catheterization

  • chest x-ray, ECG

  • natural history, role of balloon atrial septostomy

  • indications for and timing of operations

• Operative repair and complications

  • technique of Blalock-Hanlon atrial septectomy, open atrial septectomy

  • cardiopulmonary bypass and myocardial protection

  • operative techniques for total repair (Mustard, Senning, arterial switch, Rastelli)

  • palliative operations (PA band, systemic-to-pulmonary artery shunt)

• Outcome

  • expected operative mortality

  • long-term results

  • complications

  • arrhythmias after atrial repairs

  • semilunar insufficiency, PA stenosis, coronary problems after arterial switch

  • conduit obstruction after Rastelli

C. Truncus arteriosus

• Anatomy

  • types of truncus arteriosus

  • associated anomalies (VSD, left ventricular outflow tract obstruction, arch interruption, DiGeorge syndrome)

• Clinical features

  • symptoms and physical findings

  • cardiac catheterization, echocardiogram, angiocardiogram

  • chest x-ray, ECG

  • natural history (development of pulmonary vascular obstructive disease)

  • indications for and timing of operation

• Operative repair and complications

  • extracorporeal bypass and myocardial protection

  • operative techniques

    • conduits (composite and homograft)

    • modifications required for types II and III truncus

  • techniques for repair of associated anomalies

• Outcome

  • expected operative mortality

  • long-term results

  • complications

D. Tricuspid atresia

• Anatomy

  • types I and II, subtypes

• Physiology

  • subtypes with right-to-left shunt

  • subtypes with left-to-right shunt

• Clinical features

  • symptoms and physical findings

  • echocardiogram, angiocardiogram, cardiac catheterization

  • chest x-ray, ECG

  • natural history, role of balloon atrial septostomy

  • indications for and timing of operation

  • role of palliative operations (systemic-pulmonary artery shunts, PA banding, bidirectional Glenn, Fontan, other right heart bypass operations)

• Operative repair and complications

  • palliative operations

  • operations for right heart bypass (bidirectional Glenn, Fontan)

• Outcome

• expected operative mortality

• long-term results

• complications

E. Total anomalous pulmonary venous connection

• Anatomy

  • supracardiac, cardiac, infracardiac, mixed

• Physiology

  • obstructive vs. nonobstructive

• Clinical features

  • symptoms and physical findings

  • cardiac catheterization, echocardiogram, angiocardiogram

  • chest x-ray, ECG

  • natural history

  • indications for and timing of operation

• Operative repair and complications

  • extracorporeal bypass, myocardial protection

  • operative techniques for different subtypes

• Outcome

  • expected operative mortality

  • long-term results

  • complications

F. Ebstein's anomaly

• Anatomy

• Physiology

  • concept of atrialized ventricle

  • right ventricular outflow tract obstruction

• Clinical features

  • symptoms and physical findings

  • cardiac catheterization, echocardiogram, angiocardiogram

  • chest x-ray, ECG

  • natural history

  • associated lesions (e.g., Wolf-Parkinson-White syndrome)

  • indications for and timing of operation

• Operative repair and complications

  • extracorporeal bypass and myocardial protection

  • technique of tricuspid repair, obliteration of atrialized ventricle

  • technique of tricuspid valve replacement

• Outcome

  • expected operative mortality

  • long-term results

  • complications

Unit XXIII - OBSTRUCTIVE ANOMALIES

UNIT OBJECTIVE:
At the end of this unit the resident understands the anatomy and physiology of obstructive anomalies of the left and right sides of the heart and aorta, their diagnosis, management, and postoperative care, and performs the operative and non-operative treatment.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Knows the anatomy and physiology of each anomaly; Knows the methods of diagnosis;

• Understands the role of medical management and interventional cardiology;

• Knows the indications for and timing of operation

• Knows the technical components of operative repair

• Understands the principles of postoperative care;

• Knows the expected outcome, long-term results and complications

CONTENTS:

A. Aortic stenosis

• Anatomy

  • supravalvular, valvular, subvalvular (including subtypes)

• Physiology

• associated anomalies

• Clinical features

  • symptoms and physical findings

  • cardiac catheterization, echocardiogram, angiocardiogram

  • chest x-ray, ECG

  • natural history

  • Indications for and timing of operation

• Operative repair and complications

  • extracorporeal bypass, myocardial protection

  • operative techniques pros and cons of various techniques and patch configurations for supravalvular stenosis

  • techniques of aortic valvotomy

  • operations to enlarge the aortic annulus (e.g., Konno-Rastan procedure, Ross procedure)

  • technique of apical aortic conduit

  • myomectomy and myotomy for subaortic obstruction

• Outcome

  • expected operative mortality

  • long-term results

  • complications

B. Pulmonary stenosis

• Anatomy

  • Valvular and supravalvular

  • associated anomalies (e.g., atrial septal defect, ventricular septal defect, branch stenosis)

• Clinical features

  • symptoms and physical findings

  • echocardiogram, angiocardiogram, cardiac catheterization

  • chest x-ray, ECG

  • natural history; role of balloon valvuloplasty

  • Indications for and timing of operation

• Operative repair and complications

  • extracorporeal bypass, myocardial protection

  • incisions in the heart and great vessels

  • operative considerations (technique of valvulotomy, indications for

  • transannular patching, division of right ventricular muscle bands)

  • complications (residual obstruction)

• Outcome

  • expected operative mortality

  • long-term results

  • complications

C. Coarctation of the aorta

• Anatomy

  • relationship to the ductus arteriosus

  • associated anomalies (e.g., hypoplasia of transverse aorta, patent ductus arteriosus, LVOT obstruction)

• Physiology

  • infant vs. older child

  • preductal vs. paraductal vs. postductal

  • assessment of adequacy of collateral circulation

• Clinical features

  • symptoms and physical findings (neonate with a closing ductus vs. older infant and child)

  • echocardiogram, angiogram, cardiac catheterization

  • chest x-ray, ECG

  • natural history

  • Indications for and timing of operation

  • role of prostaglandins in stabilizing neonates

  • effect of associated anomalies (e.g., patent ductus arteriosus, aortic stenosis, ventricular septal defect)

• Operative repair and complications

  • methods of repair (end-to-end vs. patch vs. subclavian angioplasty)

  • methods of arch reconstruction

  • complications (residual obstruction, paraplegia, chylothorax)

  • extracorporeal bypass, shunts in the absence of adequate collateral circulation

• Outcome

  • expected operative mortality

  • long-term results

  • complications

  • re-coarctation

D. Interrupted aortic arch

• Anatomy

  • types A, B, and C

  • associated anomalies (e.g., DiGeorge syndrome, VSD)

• Physiology

  • role of ductal patency, prostaglandin

• Clinical features

  • symptoms and physical findings

  • echocardiogram, angiocardiogram, cardiac catheterization

  • chest x-ray, ECG

  • natural history

  • indications for and timing of operation

  • the role of prostaglandins in preoperative stabilization

  • DiGeorge syndrome (hypocalcemia, need for irradiated blood)

• Operative repair and complications

  • extracorporeal bypass, hypothermic arrest

  • median sternotomy vs. left thoracotomy

  • techniques (e.g., end-to-end anastomosis, interposition grafting, absorbable vs. nonabsorbable sutures)

  • complications (e.g., residual obstruction, recurrent laryngeal nerve injury, chylothorax)

  • repair of associated anomalies

• Outcome

  • expected operative mortality

  • long-term results

  • complications

  • reoperation

  • management of DiGeorge syndrome

E. Vascular ring

• Anatomy

  • double aortic arch, anomalous subclavian artery, unusual rings, pulmonary artery sling

• Physiology

  • compression of airway and esophagus

• Clinical features

  • signs and symptoms

  • barium esophagogram, CT scan, MRI

• Operative repair and complications

  • techniques for exposure by left thoracotomy, indications for other approaches

• technique for correction of each type

• role of aortopexy

• complications (e.g., recurrent laryngeal nerve paralysis, chylothorax, residual tracheomalacia)

• Outcome

  • expected operative mortality

  • long-term results

  • complications

  • residual tracheomalacia

Unit XXIV - MISCELLANEOUS ANOMALIES

UNIT OBJECTIVE:
At the end of this unit the resident is familiar with the anatomy, physiology, diagnosis, and operative treatment of unusual complex congenital anomalies and performs operative and nonoperative treatment.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Understands the natural history, evaluation, and treatment of coronary anomalies, congenital complete heart block, hypoplastic left heart syndrome, pulmonary atresia (with and without VSD), corrected transposition, single ventricle, cor triatriatum, and cardiac tumors;

• Understands the role of corrective and palliative operations for the above anomalies and of cardiac transplantation for appropriate cardiac pathology.

CONTENTS

• Coronary anomalies

• Hypoplastic left heart syndrome

LUNGS AND PLEURA

Unit XXV - ANATOMY, PHYSIOLOGY, EMBRYOLOGY AND TESTING

UNIT OBJECTIVE:
At the completion of this unit the resident understands the embryology and anatomy of the lungs and their relationship to adjacent structures, the physiology of airway mechanics, gas exchange, and blood flow, and knows how to apply the findings of invasive and non-invasive tests to patient management.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understands the segmental anatomy of the bronchial tree and bronchopulmonary segments

• Understands the arterial, venous and bronchial anatomy of the lungs and their interrelationships

• Understands the lymphatic anatomy of the lungs, the major lymphatic nodal stations, and lymphatic drainage routes of the lung segments;

• Knows the indications for different thoracic incisions, the surgical anatomy encountered, and the physiological impact;

• Knows the indications for and how to read and interpret plain radiography, CT scan, magnetic resonance imaging, and PET scanning for staging of lung cancer;

• Knows the indications, interpretation, and use of nuclear medicine ventilation/perfusion scanning (V/Q scan) to determine the operability of candidates for pulmonary resection;

• Understands the methods of invasive staging (e.g., mediastinoscopy, Chamberlain procedure, scalene node biopsy, thoracoscopy);

• Knows how to interpret pulmonary function tests;

• Knows how to perform pulmonary function tests.

CONTENTS:

• Normal anatomy and histology of the lung

  • Segmental anatomy of the bronchial tree

  • Bronchopulmonary segments (topography)

  • Hilar anatomy

  • Lymphatic anatomy and drainage of the lung

  • Histologic anatomy and cell types of the lung

  • Endoscopic anatomy of the larynx, trachea, and bronchi

• Normal physiology of the lung

  • Chest wall mechanics

  • Large and small airway mechanics

  • Alveolar mechanics and gas exchange

• Imaging of the thorax

  • Chest x-ray

  • CT scan of the chest and abdomen

  • MRI of the chest

  • Contrast angiography of major vessels within the chest

  • Radioactive isotope scanning of organs within the chest

• Surgical anatomy

  • Anterior thoracotomy

  • Posterolateral thoracotomy

  • Posterior thoracotomy

  • Muscle sparing thoracotomy

  • Mediastinotomy

  • Transverse anterior sternotomy

  • Incisions common to video assisted thoracic surgery

  • Incisions common to cervical and anterior mediastinoscopy

Unit XXVI - NON-NEOPLASTIC LUNG DISEASE

UNIT OBJECTIVE:
A t the end of this unit the resident understands infectious, inflammatory, and environmental injuries of the lung and knows how to perform operative and non-operative management.

LEARNER OBJECTIVES:
Upon completion of this unit, the resident:

• Understands diagnostic procedures used to evaluate non-neoplastic lung disease;

• Knows the common pathogens that produce lung infections, including their presentation and pathologic processes, and knows the treatment and indications for operative intervention;

• Understands the natural history, presentation and treatment of chronic obstructive lung disease;

• Knows the indications for bullectomy, lung reduction, and pulmonary transplantation;

• Understands the pathologic results and alterations of pulmonary function due to bronchospasm;

• Understands the principles of surgical resection for non-neoplastic lung disease;

• Understands the mechanisms by which foreign bodies reach the airways, how they cause pulmonary pathology, and the management of patients with airway foreign bodies;

• Understands the causes, physiology, evaluation and management of hemoptysis;

• Knows the complications of lung resection and their management.

CONTENTS:

• Common pulmonary pathogens

  • Bacteria

  • Fungi

  • Tuberculosis mycobacterium

  • Viruses

  • Protozoa

  • Immunocompromised patients

• Chronic obstructive pulmonary disease

  • Natural history

  • Presentation, evaluation

  • Alteration of lung function

  • Complications requiring operative treatment

  • Treatment (operative and non-operative)

• Bronchospasm

  • Natural history

  • Evaluation

  • Complications requiring operative treatment

  • Treatment (operative and non-operative)

• Foreign bodies of the lung and airways

  • Common types

  • Causes, pathology

  • Evaluation

  • Treatment (operative and non-operative)

• Hemoptysis

  • Causes

  • Physiologic derangements

  • Evaluation

  • Treatment (operative and non-operative)

• Pneumothorax

  • Etiology

  • Indications for treatment

  • Types of treatment

Unit XXVII - LUNG TRANSPLANTATION

UNIT OBJECTIVE:
At the end of this unit, the resident knows the principles of organ preservation, immunosuppressive therapy, signs and treatment of rejection, and the indications for and techniques of lung transplantation.

LEARNER OBJECTIVES:
Upon completion of the unit the resident:

• Knows the indications for lung transplantation;

• Understands the management of immunosuppressive therapy in lung transplantation;

• Knows the techniques of lung transplantation;

• Recognizes the signs and symptoms of lung rejection and knows the appropriate management;

• Understands the evaluation and management of organ donors;

• Knows the methods of lung harvest and preservation;

• Is familiar with the techniques and complications of lung biopsy.

CONTENTS:

• Indications for lung transplantation

  • Patient evaluation

  • Patient selection

  • Informed consent

• Immunosuppressive therapy in lung transplantation

  • Evaluation of therapy

  • Drugs

  • Complications

• Technique of lung transplantation

• Donor preparation and organ harvest

  • Brain death, legal and family-related issues

  • Donor evaluation

  • Methods of organ procurement and preservation

• Lung rejection

  • Signs and symptoms

  • Lung biopsy

  • Histologic evaluation

  • Management

  • Ventilatory support and re-transplantation

• Immunosuppressive therapy

  • Immunosuppressive drugs and their side effects

  • Polyclonal and monoclonal antibody therapy and side effects

  • Complications

Unit XXVIII - NEOPLASTIC LUNG DISEASE

UNIT OBJECTIVE:
At the end of this unit the resident understands the natural history, types, evaluation, and management of lung neoplasms, and knows how to perform operative and non-operative treatment.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understands TNM staging of lung carcinoma and its application to the diagnosis, therapeutic planning, and management of patients with lung carcinoma;

• Evaluates and diagnoses neoplasia of the lung, using a knowledge of the histologic appearance of the major types;

• Knows the signs of inoperability;

• Understands the therapeutic options for patients with lung neoplasms;

• Understands the principles of bronchoplastic surgery;

• Understands the complications of pulmonary resection and their management;

• Understands the role of adjuvant therapy for lung neoplasms;

• Understands the indications for resection of benign lung neoplasms;

• Understands the indications for resection of pulmonary metastases.

CONTENTS:

• Benign tumors of the lung and airways

  • Pathology, biologic behavior

  • Evaluation, diagnosis, treatment (operative and non-operative)

• Solitary lung nodule

  • Differential diagnosis, evaluation, diagnostic techniques

  • Treatment (operative and non-operative)

• Malignant tumors of the lung and airways

  • Pathology, biologic behavior

  • Evaluation, diagnosis, treatment (operative and non-operative)

• Metastatic tumors to the lungs

  • Pathology and biologic behavior

  • Evaluation, diagnosis, treatment (operative and non-operative)

Unit XXIX - CONGENITAL LUNG DISEASE

UNIT OBJECTIVE:
At the end of this unit the resident understands the embryology, pathology and principles of management of congenital lung abnormalities and understands how to perform appropriate treatment.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Recognizes various congenital lung abnormalities and understands their anatomy, indications and forms of treatment

CONTENTS:

• Pulmonary sequestration

  • Presentation (intralobar and extralobar)

  • Evaluation and management

  • Prognosis

• Congenital lobar emphysema

  • Presentation and physiology

  • Evaluation and management

• Cystic fibrosis

  • Presentation and physiology

  • Evaluation and management

  • Complications and their management

  • Role of pulmonary transplantation

• Bronchogenic cysts

  • Presentation

  • Evaluation and indications for operation

  • Operative options

• Cystic adenomatoid malformation

  • Presentation and physiology

  • Evaluation and indications for operation

  • Operative options

Unit XXX - DISEASES OF THE PLEURA

UNIT OBJECTIVE:
At the end of this unit the resident understands the benign and malignant abnormalities of the pleura, pleural effusions, and the evaluation and treatment of pleural diseases.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Is familiar with the clinical presentation of benign and malignant diseases of the pleura;

• Understands the types of pleural effusions, their evaluation and treatment;

• Understands the management of empyema with and without bronchopleural fistula;

• Understands the indications, contraindications, and complications of video assisted thoracic surgery and has a working knowledge of the equipment;

• Understands the treatment of benign and malignant diseases of the pleura.

CONTENTS:

• Mesothelioma

  • Pathology, biologic behavior, and natural history

  • Treatment (operative and non-operative)

• Pleural effusions

  • Types

  • Diagnosis

  • Treatment (operative and non-operative)

• Empyema

  • Presentation with and without bronchopleural fistula

  • Diagnosis

  • Treatment (operative and non-operative)

  • Surgical options (e.g., thoracentesis, tube thoracostomy, decortication, rib resection, repair of bronchopleural fistula)

Unit XXXI - TRACHEA AND BRONCHI

A. Anatomy, Physiology and Embryology

UNIT OBJECTIVE:
At the end of this unit the resident understands the anatomy, blood supply, physiology, and embryology of the trachea and bronchi and applies findings of radiography, pulmonary function tests, and endoscopy to patient care.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understands the anatomy and blood supply of the trachea and bronchi;

• Understands the endoscopic anatomy of the nasopharynx, hypopharynx, larynx, trachea, and major bronchi;

• Understands and interprets pulmonary function studies of the trachea and bronchi;

• Understands the radiologic assessment of the trachea and bronchi.

CONTENTS:

• Trachea

  • Blood supply

  • Histologic and gross anatomy

  • Lymphatic anatomy and drainage

  • Contiguous structures

  • Radiographic anatomy and tests

  • Endoscopic anatomy and tests

• Bronchi

  • Blood supply

  • Histologic and gross anatomy

  • Segmental anatomy

  • Lymphatic relationships

  • Radiographic anatomy and tests

  • Endoscopic anatomy and tests

• 3) Physiologic evaluation

  • Pulmonary function tests

  • Flow volume loops

• 4) Radiologic evaluation

  • Plain radiographs

  • Tomography

  • CT scan

  • Fluoroscopy

  • MRI

  • Barium swallow

Unit XXXII - TRACHEA CONGENITAL AND ACQUIRED ABNORMALITIES

UNIT OBJECTIVE:
At the end of this unit the resident understands congenital and acquired diseases of the trachea and adjacent structures, knows the physiology of tracheal abnormalities, and knows how to perform operative and non-operative management.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understands congenital abnormalities and idiopathic diseases of the trachea;

• Understands the etiology, presentation and management of acquired tracheal strictures and their prevention;

• Understands the etiology, presentation, diagnosis and management of tracheoesophageal fistulas and tracheoinnominate artery fistulas;

• Knows the operative approaches to the trachea and techniques of mobilization;

• Knows the methods of airway management, anesthesia and ventilation for tracheal operations;

• Knows the principles of tracheal surgery and release maneuvers;

• Understands the complications of tracheal surgery and their management;

• Understands the etiology, presentation, and principles of airway trauma management;

• Understands the radiologic evaluation of tracheal abnormalities.

CONTENTS:

• Radiologic assessment of the trachea and bronchi

  • Plain x-rays

  • CT scans

  • MRI

  • Barium swallow

• Stricture of the trachea

  • Post-intubation

  • Post-tracheostomy

  • Post-traumatic

• Anesthesia for tracheal operations

  • Methods of airway control

  • Extubation concerns

• Operative approaches to the trachea

  • Reconstruction of the upper trachea

  • Reconstruction of the lower trachea

  • Mediastinal tracheostomy

• Tracheostomy and its complications

  • Tracheal stenosis

  • Tracheo-esophageal fistula

  • Tracheo-innominate artery fistula

  • Persistent tracheal stoma

• Airway trauma

  • Airway control

  • Evaluation of associated injuries

  • Principles of repair (primary and secondary)

  • Protecting tracheostomies

C. Neoplasms

UNIT OBJECTIVE:
At the end of this unit the resident has a working knowledge of neoplasms affecting the trachea and adjacent structures, and performs operative and non-operative management.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Knows the types, histology, and clinical presentation of tracheal neoplasms;

• Understands the radiologic evaluation and operative management of tracheal neoplasms;

• Understands the methods of airway management;

• Knows the indications for and the use of radiotherapy and chemotherapy

CONTENTS:

• Neoplasms of the trachea

  • Benign

  • Malignant

  • Metastatic

• Operative techniques

  • Resection of tracheal tumors

  • Methods of tracheal reconstruction

  • Operative approaches

• Prosthetics

  • Silastic prosthetics

  • Stents

  • Types of tracheostomy tubes and tracheal T-tubes

• Airway management

  • Bronchoscopic "core out"

  • Laser

Unit XXXIII - CHEST WALL

A. Anatomy, Physiology and Embryology

UNIT OBJECTIVE
During the training program the resident:

• Learns the normal and abnormal anatomy of the chest wall;

CONTENTS:

• Chest wall embryology

  • Ectodermal, mesodermal, endodermal

• Chest wall anatomy

  • Skeletal

  • Muscular

  • Neural

  • Vascular

  • Relationships to adjacent structures

• Diagnostic tests to define chest wall anatomy

  • Chest x-ray

  • CAT scans

  • MRI scans

  • Nuclear scans

  • Pulmonary function tests

• Major flaps of the chest wall and their vascular pedicles

  • Latissimus dorsi

  • Pectoralis major

  • Serratus anterior

  • Trapezius

  • Intercostal

  • Pleural

  • Pericardial fat pad

  • Rectus abdominis

  • Omental

  • Vascularized rib graft

Unit XXXIV - CHEST WALL ACQUIRED ABNORMALITIES AND NEOPLASMS

UNIT OBJECTIVE:
At the end of this unit the resident understands acquired abnormalities and neoplasms of the chest wall and performs biopsy, incision, resection, reconstruction, and stabilization of the chest wall.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understands the diagnosis and management of various chest wall infections;

• Evaluates and diagnoses primary and metastatic chest wall tumors, knows their histologic appearance, and understands the indications for incisional versus excisional biopsy;

• Learns the surgical incisions to expose components of the chest wall and interior thoracic organs;

• Knows how to perform surgical resections of primary and secondary chest wall tumors

• Knows the radiologic characteristics of tumors;

• Knows the indications for and methods of prosthetic chest wall reconstruction (e.g., methylmethacrylate, Marlex®, Gortex®, Vicryl®, and Dacron® mesh) and reconstruction with muscle flaps

• Knows the types of chemotherapy and radiotherapy (induction neo-adjuvant and adjuvant therapy) of chest wall tumors and the indications for preoperative and postoperative therapy;

• Knows the management of osteoradionecrosis of the chest wall.

CONTENTS:

• Malignant neoplasms of the chest wall

  • Chondrosarcoma

  • Osteogenic sarcoma

  • Myeloma

  • Ewing's sarcoma

  • Metastatic lesions

  • Lung cancer invading the chest wall

• Benign neoplasms of the chest wall

  • Fibrous dysplasia

  • Chondroma

  • Osteochondroma

• Eosinophilic granuloma

Unit XXXV - TRAUMA OF THE CHEST WALL

UNIT OBJECTIVE:
At the end of this unit the resident understands the pathophysiology of chest wall injury, and knows how to diagnose, resuscitate and treat trauma patients.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Evaluates patients with blunt or penetrating chest wall injury;

• Understands the physiology and mechanics of operative drainage of the thoracic cavity;

• Understands the operative and non-operative management of chest wall injuries;

• Understands the pathophysiology of flail chest.

CONTENTS:

• Thorax

  • Rib fracture

  • Flail chest

  • Sucking chest wounds

  • Diagnosis and management

  • Associated injuries

• Pneumothorax

  • Simple

  • Tension

  • Diagnosis and treatment

• Hemothorax

  • Diagnosis

  • Operative and non-operative management

Unit XXXVI - TRACHEOBRONCHIAL AND PULMONARY TRAUMA

UNIT OBJECTIVE:
At the end of this unit the resident understands the pathophysiology of tracheobronchial and pulmonary trauma, and diagnoses, resuscitates and treats patients with these injuries.

LEARNER OBJECTIVES:

• Understands clinical presentation and radiologic findings of tracheobronchial injury;

• Understands the principles of airway management;

• Understands the bronchoscopic findings of tracheobronchial and pulmonary injury;

• Understands the management of tracheobronchial and pulmonary injury;

• Understands the injuries associated with tracheobronchial and pulmonary injury.

CONTENTS:

• Tracheobronchial injury

  • Signs and symptoms

  • Radiologic findings

  • Diagnosis and management

• Airway control

  • Intubation

  • Bronchoscopy

  • Emergency tracheostomy

  • One-lung ventilation

  • High-frequency ventilation

• Pulmonary contusion

  • Signs and symptoms

  • Pathophysiology

  • Radiologic findings

  • Operative and non-operative management

• Penetrating injury

  • Signs and symptoms

  • Indications for operation

  • Management of peripheral injuries

  • Management of hilar injuries

  • Air embolism

Unit XXXVII - DIAPHRAGM

A. Anatomy, Physiology and Embryology

UNIT OBJECTIVE:
At the end of this unit the resident understands the anatomy, physiology, and embryology of the diaphragm and its relationship to adjacent structures, and knows how to interpret radiographic

LEARNER OBJECTIVES
Upon completion of this unit the resident:

• Knows the embryologic origin of the diaphragm

• Understands the anatomy of the diaphragm and adjacent structures;

• Understands the neural and vascular supply of the diaphragm and the pathologic consequences of injury

• Understands imaging studies for assessing the diaphragm

• Understands the consequences of incisions in the diaphragm

• Understands developmental anomalies of the diaphragm.

Unit XXXVIII - DIAPHRAGMATIC TRAUMA

UNIT OBJECTIVE:
At the end of this unit the resident understands the pathophysiology of diaphragmatic trauma, and diagnoses, resuscitates, and treats patients with these injuries.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understands the presentation, evaluation, and treatment of blunt and penetrating diaphragmatic injuries;

• Understands the evaluation and management of associated injuries;

• Knows the presentation of delayed diaphragmatic injury, its diagnosis and management

CONTENTS:

• Blunt trauma

  • Signs and symptoms

  • Radiologic findings

  • Indication for operation

  • Operative approach

  • Techniques of repair

  • Delayed presentation

  • Associated injuries

• Penetrating trauma

  • Signs and symptoms

  • Radiologic findings

  • Operative approaches and techniques of repair

  • Management of associated injuries

Unit XXXIX - MEDIASTINUM AND PERICARDIUM

A. Anatomy, Physiology and Embryology

UNIT OBJECTIVE:
At the end of this unit the resident understands the anatomy, physiology and embryology of the mediastinum and pericardium, the relationships of adjacent structures, and knows ho to apply findings of invasive and non-invasive tests to patient management.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understands the anatomic boundaries of the mediastinum and the structures found within each region;

• Understands the embryologic development of structures within the mediastinum and the variations and pathologic consequences of abnormally located structures

• Understands the radiologic assessment of the mediastinum including CT scan, MRI, contrast studies, and angiography

• Understands the aberrations caused by pericardial abnormalities and their effects on the heart and circulation.

CONTENTS:

• Superior mediastinum

  • Major structures

  • Diagnostic studies

• Anterior mediastinum

  • Major structures

  • Diagnostic studies

• Middle mediastinum (visceral compartment)

  • Major structures

  • Diagnostic studies

• Posterior mediastinum (paravertebral sulcus)

  • Major structures

  • Diagnostic studies

Unit XL -  CONGENITAL ABNORMALITIES OF THE MEDIASTINUM

UNIT OBJECTIVE:
At the end of this unit the resident understands congenital mediastinal abnormalities and knows how to perform operative and non-operative management.

LEARNER OBJECTIVES:

Upon completion of this unit the resident:

• Is able to diagnose mediastinal cysts;

• Is familiar with the symptoms associated with mediastinal abnormalities;

• Knows the indications for operations involving the mediastinum and the anatomic approaches.

• Know how to read and interprets plain radiographs, CT scans, MRI's and contrast studies of congenital abnormalities of the mediastinum;

• Knows how to diagnoses and manage patients with congenital abnormalities of the mediastinum;

• Knows how to perform operations for congenital abnormalities of the mediastinum

CONTENTS:

• Mediastinal cysts

• Pericardial cysts

• Cystic hygroma

• Bronchogenic cysts

• Esophageal duplications

• Operative and non-operative management

• Symptoms of mediastinal abnormalities

Unit XLI - ACQUIRED ABNORMALITIES OF THE MEDIASTINUM

UNIT OBJECTIVE:
At the end of this unit the resident understands acquired mediastinal abnormalities and knows how to perform operative and non-operative treatment.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

• Understands mediastinal infections and their management;

• Understands the diagnostic tests available;

• Recognizes the histologic appearance of benign and malignant mediastinal neoplasms;

• Understands the neoplastic and non-neoplastic mediastinal diseases;

• Understands the operative management of benign and malignant mediastinal neoplasms;

• Understands chemotherapy and radiotherapy in mediastinal neoplasm management.

CONTENTS:

• Anterior mediastinal tumors

  • Thymoma

  • Thyroid

  • Teratoma

  • Lymphoma

  • Germ cell tumor

  • Histologic appearance

  • Management (operative and non-operative)

• Middle mediastinal tumors

  • Lymphoma

  • Hamartoma

  • Cardiac tumors

  • Histologic appearance

  • Management (operative and non-operative)

• Posterior mediastinum (paravertebral sulcus)

  • Neurilemoma

  • Neurofibroma

  • Pheochromocytoma

  • Ganglion neuroma

  • Dumbbell neurogenic tumor

  • Histologic appearance

  • Management (operative and non-operative)

• Mediastinal infection

  • Postoperative

  • Primary

  • Management (operative and non-operative)

  • Diagnostic tests

• Plain radiographs

  • CT scans

  • MRI

  • Contrast studies

  • Radionucleotide studies

  • Ultrasound

• Fine needle aspiration

• Core biopsy

• Mediastinoscopy

• Serologic tests

Unit XLII - ESOPHAGUS

Unit XLIII - VIDEO ASSISTED THORACIC SURGERY

Unit XLIV - ENDOBRONCHIAL INTERVENTIONS

[European School for Cardio-Thoracic Surgery]