Â鶹AV

General Information

Location: Â鶹AV Health Centre
Number of fellowship positions: 1 fellow
Duration: 1 year fellowship
Name of hospitals involved in training & % time spent by the fellow in each institution: 100% of the trainee’s time will be at the Â鶹AV Health Centre,specifically at the Royal Victoria Hospital.
Fellowship Program Director: Dr. Benoit de Varennes

Background

Â鶹AV and the Â鶹AV Health Centre have developed a strong expertise in complex cardiac surgery using innovative repair an replacement techniques for tructural valve disease and cardiac failure. In particular, the institution had been a leader in mitral valve repair, aortic valve repair, aortic valve replacement using percutaneous echniques, and mechanical support of the failing heart. The practice of cardiac surgery has continued to move away from coronary artery disease and become more focused on valvular pathology and treatment of the failing ventricle. In addition, there is a growing impetus to address these problems using minimally invasive techniques via smaller ncisions, different anatomical approaches, and even percutaneous routes. The advent of the Hybrid operating room which is equipped to do both open and closed cardiac surgical procedures, underlines the shift in the practice and the shift in the required skills set.

The traditional skills of cardiac surgeons using open techniques for coronary artery disease and valve replacement are no longer sufficient to treat all patients but there will continue to be a need for very competent cardiac surgeons trained in the traditional manner and this continues to be the focus of residency training. The growth in cardiac surgery, however, will come from minimally invasive approaches and approaches using the percutaneous routes. This skill set requires a focused year of training to understand the pathology and physiology of cardiac disease from the perspective of repair rather than replacement, and a focus on interventional catheter-based techniques for percutaneous approach present at Â鶹AV and the Â鶹AV Health Centre.

Research Activity

Fellowship candidates will be required to do 25% of their time towards clinical research during their 1-year fellowship. This could be part of epidemiological reviews of the Cardiac Surgery database of nearly 10 000 patients, on going clinical trails in mitral valve repair, percutaneous aortic valve replacement (TAVI), and quality of life studies. AS is presently the case in the Resident Training Program, the fellow will be assigned a research supervisor and will be required to have three Research Committee meetings over the year to follow progress of work.

Publications

Publications and presentations at international and national meetings are a requirement of the fellowship. As is presently the case in the Resident Training Program, the fellow will be supported to attend one meeting per year.

Mission

The mission of the fellowship training is to provide the necessary experience in valve repair, percutaneous replacement, and catheter –based skills to practice cardiac

Teaching Faculty

Dr. Renzo Cecere (Division Head, Cardiac Surgery, Â鶹AV): Repair and support of the failing ventricle using valve repair, and mechanical support, short and long term, inserted using open and minimally invasive techniques.

Dr. Benoit de Varennes (Cardiac Surgeron, Â鶹AV Health Centre): Complex adult cardiac surgery with emphasis on mitral valve repair both at the acquired and congenital levels. Percutaneous valve implantation.

Dr. Kevin Lachapelle (Program Director, Cardiac Surgery, Â鶹AV): Adult cardiac surgery with emphasis on aortic valve repair and minimally invasive approach to aortic valve replacement using catheter-based skills.

Dr. Patrick Ergina (Cardiac Surgeon, Â鶹AV Health Centre): Adult cardiac surgery with emphasis on minimally invasive approach to coronary artery disease and revascularization.

Dr. Joe Martucci (Interventional Cardiologist, Â鶹AV Health Centre): Catheter-based interventions for structural heart disease.

Dr. Nicola Piazza (Interventional Cardiology, Â鶹AV Health Centre): Catheter-based interventions for structural heart disease.

Academic Facilities

The fellow will have access to the same facilities for clinical and academic pursuits as do the residents. This includes web access to on-line journals via Â鶹AV, access to video library via CTSnet, cardiac surgery training curriculum through the Thoracic Surgery Directors Association and the Program Director, access to both the adult and pediatric, as well as the adult database at the Â鶹AV Health Centre, access and training at the Â鶹AV Medical Simulation Centre.

Fellow Duties and Responsibilities

The fellow will share responsibilities with the senior and/or chief resident of the service with regards to on-call. As instituted in the training program, this call will be no more than 1 in 3 from home. The fellow will be directly supervised by the attending surgeon and will not be the senior supervisor of the senior or chief residents.

The operative/interventional responsibilities will be distributed between the Cardiac Surgery theatre and the Interventional Suite in the catheterization laboratory. There will be a one to two days per week on heart valve repair techniques, one day per week on catheter-based interventions for structural valve disease, one day per week for assisting and teaching residents on routine cardiac surgical cases and one day per week for clinical-based research activities. The total operative experience therefore at the Royal Victoria Hospital will be three operating days per week. This will not affect the senior or chief resident exposure to adult cardiac surgical cases. Due to the complex nature of these interventions, the Senior and Chief residents are rarely primary surgeons. They will continue to be first and second assistants with delegated tasks for each complex procedure, as is the present situation.

While at the Royal Victoria Hospital, the fellow will participate in all of the Cardiacsurgery Teaching activities including Monday 5:30 p.m. Teaching Rounds, Thursday morning Service Rounds, Technical Skills training 4 times a year and Combined CardiacSurgery/Cardiology Rounds 6 times a year at noon on Fridays. The fellow will be responsible for presentation at Morbidity and Mortality Rounds, all cases for which he was involved and responsible. In addition, the fellow will attend the Structural Valve Clinic on Thursday 9:00 a.m. and attend bi-weekly TAVI rounds Wednesday 7:30 a.m. While at the Royal Victoria Hospital, the fellow will take call in concert with the other senior and chief residents, and will not have operative priority apart from the O.R. for which the fellow is assigned. As with the senior and chief residents, the fellow will be expected to teach on regular ward rounds to both the junior residents and students. The fellow will have complete support of the Program Director as well as the Program Coordinator in the same fashion as the residents. As with the residents, the fellow will be subsidized to attend one North American meeting per year up to $1,000. It is also expected that the fellow will have one research project per year to be determined by the Fellowship Program Director.

Goals and Objectives

The goals and objectives of the fellowship are an extension of the Goals and Objectives of Training of the Cardiac Surgery Training Program of Â鶹AV and those of the Specialty Requirements of the royal college of Physicians and Surgeons of Canada (LINK). It is important that the fellow be familiar with these as there is an expectation that the objectives of training have been, for the most part, previously attained by the fellow. This document will be reviewed with the fellow by the Program Director prior to commencement.

MEDICAL EXPERT

Knowledge

• Aortic valve anatomy pathology in health and disease
• Aortic stenosis and treatment modalities and results for both open and percutaneous approaches
• Approach and results of Open, trans femoral, trans aortic, and trans subclavian
• route to aortic valve replacement
• Catheters, wires, dilators used for percutaneous approaches
• Classification of aortic regurgitation and types of associate repairs
• Valve sparing, root remodeling , leaflet repair
• Mitral valve anatomy and pathology in health and disease
• Classification of mitral valve regurgitation with types of associated repair
• Mitral valve ring, chordeal replacement, re-implantation, sliding plasty
• Pathophysiology of the failing ventricle
• Device selection for supporting the failing venticle
• Indications for intervention on valvular disease
• Appropriate selection of incisions and open vs closed approach for minimal invasive techniques
• Appropriate patient selection for various procedures
• Indications for intervention on the failing ventricle in acute and chronic states
• Advantages and disadvantages of Scoring sytems to evaluate risk
• Radiation safety
• Function of a hybrid intervention room

Skills

The fellow will be able to:

• Perform various incisions and approaches for minimally invasive cardiac surgery
• Place and navigate catheters in the arterial system, using best practice
• Crimp the aortic valve
• Accurately position the aortic valve using radiography and echo
• Implant percutaneous aortic valve using radiography from the femoral, apical or thoracic approach
• Address complication of the aorta, femoral and subclavian arteries
• Address complications related to valve migration
• Insert percutaneous and placement of right and left ventricular assist devices.
• Insert mitral valve rings
• Place artificial chords
• Re-implant chordea
• Sliding leaflet plasty
• Perform valve sparing surgery
• Perform aortic valve leaflet reduction

COMMUNICATOR

• Obtain cardiac history from patients and their relatives in the elective and emergency condition
• Supervise junior residents in history and physical examination
• Lead scheduled daily rounds with a combined team of nurses, residents and students.
• Write clear notes, including pre-operative indications for surgery and post-operative reports at least every other day.
• Make sure an appropriate discharge summary has been performed either by the medical student or the junior resident, and is appropriately sent to the referring cardiologist and family doctor.
• Communicate directly with attending staff members on problems with patients as well as the with ICU attending and staff.

COLLABORATOR

• Work with multidisciplinary teams on the ward, in the operating room, and in the ICU.
• Coordinate and identify social concerns regarding patients and consult appropriately with allied health care professionals, including social workers, physiotherapists, occupational therapists.
• Advise attending staff appropriately and consult medical specialists and allied health care professionals when needed.
• Run and coordinate multidisciplinary rounds on the ward.

MANAGER

• Attempt to use evidenced based medicine during management of patients and refer to appropriate literature.
• Record, along with data collectors, complications on the service according to the Division of Cardiac Surgery standards. These will be presented at Morbidity and Mortality Rounds.
• Prepare to run Morbidity and Mortality Rounds and present on specific topics and review literature.

HEALTH ADVOCATE

• Involve patients and families in primary and secondary prevention of coronary artery disease.
• Counsel the patients appropriately under exercise, diet, rehabilitation, and smoking sensation.
• Insure that the patient has appropriate follow-up with cardiologist, Wound Clinic or cardiac surgeon.
• Be sure the patient understands the risks and benefits of cardiac medications, including Coumadin.
• Make sure the patient understands the issues of prevention regarding thrombosis and bleeding in a patient with mitral valve repair or replacement.
• Be able to appropriately prescribe lipid lowering medications.

SCHOLAR

• Develop a self directed reading and consulting strategy with other professionals.
• Contribute to Service Rounds via presentations and knowledge gained through case experiences and literature.
• Be responsible for teaching junior residents and medical students on the service as well as allied health care professionals. This would occur, when appropriate, during daily rounds and organize at least once a week ‘walk around rounds’ with members of the service.
• Do regular reading around specific cases, and when appropriate perform a literature review.
• Participate actively in all scheduled rounds.

PROFESSIONAL

The fellow will become an example to other members of the team and promote the following:

• Deliver the highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behavior.
• Practice medicine ethically consistent with the obligations of a physician

Curriculum

The curriculum is based on clinical exposure, rounds and selected topics, interdisciplinary meetings, simulation training, clinical research and personal study with readings.

Clinical Exposure

• 40 percutaneous aortic valve replacements
• 100 mitral valve repairs
• 20 aortic valve repairs
• 10 percutaneous ventricular support

Rounds

Teaching Rounds......Mondays at 17:30
Service Rounds.........Thursdays at 7:30
Journal Club..............6 times per year
Cardiology Rounds....4 times per year
TAVI Rounds.............alternating Wednesdays at 7:30
Cath Rounds..............Fridays at 7:00
Dobell Visiting Professor Day
Stikeman Visiting Professor Day

Clinical research

Clinical research project with work over one year and presentation at national meetings

Simulation training

Simulation-based exposure to training in catheter-based skills.

• Learning basic procedures, manipulation of catheters, minimizing radiation