Educational Goals and Objectives:

The Advanced Coronary Surgery fellowship at MSM is designed to train an individual in various aspects of state-of-the-art surgical coronary revascularization, It is a one-year fellowship after a formal 6-8 year cardiovascular/cardiothoracic surgery education and expects Advanced Coronary Surgery fellows to have full experience in all areas of general cardiovascular surgery prior to starting the Advanced Coronary Surgery fellowship. The ultimate goal of the Advanced Coronary Surgery training program is to teach the requisite cognitive and technical knowledge of state-of-the-art CABG in alt its forms, varieties and complexities. This includes indications and contraindications for the procedures, pre- and post-procedure care, management of complications, and analysis and interpretation of the hemodynamic, radiographic and angiographic data. The cardiac surgery operating rooms and cardiac surgery ICU at MSM provide an excellent platform for the teaching of the core knowledge bases of coronary anatomy, pathology, physiology, and pathophysiology that should be possessed by all dedicated coronary surgical specialists.

The progress of the Advanced Coronary Surgery Fellowship is monitored on a daily/weekly basis during the entire year by the Program Director/Chairman and the Fellow is expected to become fully proficient in performing all aspects of surgical coronary revascularization, such as the harvest of multiple arterial conduits, deployment of multiple arteries in complex arterial revascularization of the coronary circulation, proficiency in intraoperative Doppler graft assessment and ultrasonic imaging assessment of coronary conduits/anastomoses. mastery of techniques for cardiopulmonary bypass as they apply to CABG, the appropriate use of saphenous vein. conduits, minimizing aortic manipulation during both on-pump and off-pump CABG, techniques to minimize mortality/morbidity/infection during CABG, Hybrid Coronary Revascularization. The Advanced Coronary Fellow will scrub with the Program Director and other faculty cardiac surgeons on a routine basis, typically multiple times weekly, and be under the direct tutelage of the Program Director. The Fellow is expected to adopt the collaborative Heart Team culture of Mount Sinai Heart at Mount Sinai Morningside and interact with all faculty/staff in the Departments of Cardiovascular Surgery and Cardiology and throughout the hospital respectfully and collaboratively. The Fellow is also expected to perform clinical research related to surgical coronary revascularization and to write articles in this field. Each Fellow will be assigned one or two clinical research projects to be completed during the fellowship year.

These will involve quasi- independent work under close supervision of the Program Director, other faculty members of the Department of Cardiovascular Surgery at MSM and their extramural collaborators.

Qualifications

Patient Care

All fellows must provide patient care that is compassionate, appropriate, and effective for the medical and surgical treatment of cardiovascular diseases, especially coronary artery disease

1.  Fellows will obtain and document appropriate history taking, physical exam, and laboratory interpretation skills for cardiovascular patients on the consult service and in the outpatient ambulatory clinic. They will supervise residents on morning round who are caring for patients in the cardiac intensive care unit and telemetry services and assist in the formulation of an appropriate medical plan. Advanced Coronary Fellows will supervise general cardiac surgery fellows, NP's and PA's in performing admissions, rounds, consults, progress notes as well as procedures such as line placement, chest tube placement, thoracentesis, resuscitation etc. Advanced Coronary Fellows will personally perform all of these tasks as indicated and when necessary.
2.  Fellows also will supervise admissions and follow up orders appropriately, will conduct daily work rounds. and act as team leaders on the inpatient service. They wilt also participate in the consult service and outpatient ambulatory clinic. Fellows will perform diagnostic procedures and interventions as indicated.

Responsibilities

Overall Rotation PGY 7 Specific Goals and Objectives:

At the end of First Quarter fellows should be able to:

• Precisely perform sternotomy and sternal closure according to MSM protocols
• Proficiently perform intraoperative epi-aortic ultrasound of the ascending aorta and interpret the findings in Safely and reliably cannulate and decannulate the aorta and right atrium for cardiopulmonary bypass.
• Develop some facility in skeletonized harvest of internal mammary arteries with the Harmonic Scalpel.
• Understand the MSM CABG Pathway and direct patient care compliant with the Pathway.
• Understand the indications for CABG, the risk factors for adverse outcomes after CABG.
• Understand the considerations necessary for expert management and evaluation of preoperative patients with coronary artery disease
• Understand the appropriate use of saphenous vein conduits
• Understand techniques for minimizing aortic manipulation during both on-pump and off-pump CABG
•  Safely and precisely construct proximal anastomoses on the ascending aorta both on-pump and off-pump (understand the features and technical use of the Heartstring clampless facilitating device for construction of proximal anastomoses with application of an aortic clamp).
•  Demonstrate proficiency in intraoperative Doppler graft assessinent and ultrasonic imaging assessment of coronary.conduits/anastomoses.
•  Begin to construct distal anastomoses.
•  Lear the suture patterns for distal anastomoses on all territories of the heart to optimize precision of grafting. Perform distal anastomoses on the anterior and inferior wall of the heart.

At the end of the Second Quarter fellows should be able to:

Perform all of the First Quarter specific Iearning goals and objectives with increasing skill plus:

• Safely harvest one internal mammary artery in skeletonized fashion with the Harmonic Scalpel in less than
• Begin to harvest two internal mammary arteries in skeletonized fashion with the Harmonic Scalpel Open, close, cannulate and decannulate for cardiopulmonary bypass without direct assistance of faculty Attending surgeon(s).
• Perform proximal anastomoses with clampless facilitating devices, including the Heartstring device.
•  Gradually expand experience in construction of distal anastomoses. Perform many distal anastomoses.on the anterior and inferior walls. Begin to approach distal anastomoses on the lateral wall of the heart.
•  Develop an understanding of state-of-the-art revascularization strategies for patients presenting with routine patterns of coronary artery disease.
•  Perform as an independent surgeon in the preoperative evaluation, management and preparation of patients with surgical coronary artery disease

At the end of the Third Quarter fellows should be able to:

• Perform all of the above Quarter specific learning goals and objectives with increasing skill plus:
• Safely harvest skeletonized BITA
• Demonstrate proficiency with construction of clampless proximal anastomoses using the Heartstring device if necessary.
• Safely, precisely and reliably construct distal coronary anastomoses on the anterior and inferior walls.
• Demonstrate independent proficiency in the management of postoperative CABG patients in the ICU and on the step-down unit.

At the end of the Fourth Quarter fellows should be able to:

• Perform all of the above Quarter specific learning goals and objectives with increasing skill plus:
• Safely and proficiently harvest skeletonized BITA.
•  Safely and proficiently construct proximal anastomoses on the ascending aorta with both venous and. arterial conduits using clampless techniques.
•  Demonstrate finesse in construction of distal anastomoses on the anterior, inferior and lateral walls of the left ventricle:
•  Achieve some experience with sequential and complex composite grafting with multiple arterial conduits.
•  Develop an understanding of subtle clinical scenarios that represent a threat to patient safety and optimal outcomes and understanding of advanced techniques to mitigate against those threats.
•  Understand the key elements of "rescue" of a surgical coronary bypass patient from adverse outcomes in the operating room; ICU and ward.