• INTRODUCTION
• CLINICAL CARE OPPORTUNITIES
• TEACHING OPPORTUNITIES
• CLINICAL RESEARCH OPPORTUNITIES
• LAB RESEARCH

The fellowship program consists of one year of training in anesthesiology and life support of adult patients undergoing primarily cardiac and thoracic surgery. There will be some exposure to major vascular surgery as well. The year is structured to meet the ACGME requirements for the individual who seeks fellow-level training in cardiothoracic anesthesiology. Learning opportunities in clinical practice, teaching, and research are offered and involve a combination of the following activities:
 

1. Clinical experience in anesthesia and intensive care of patients undergoing cardiac, thoracic or vascularsurgery. The training is at a level more advanced than usually available in a core anesthesiology residency program. There is a wide variety of case experience, ranging from straightforward coronary artery revascularizations to complex, aortic surgeries, including many repeat sternotomies, and heart and lung transplantation.   In addition to the clinical experience, a comprehensive didactic program includes multidisciplinary core lectures covering the full range of cardiac, thoracic and vascular anesthetic and surgical topics.
   


2. One-month experience managing postoperative cardiac, thoracic and vascular surgical patients allows further development of perioperative management skills.


3. Electives are offered for perfusion services, interventional cardiology and electrophysiology, pediatric cardiac surgery (limited enrollment), research, critical care and transthoracic echocardiography.
   
   
4. 3 months dedicated to training in Transesophageal echocardiography (TEE). 6 weeks of training includes a combined rotation with cardiology and OR experience, and 6 weeks of training is dedicated OR TEE. During the cardiology time, the fellow will be performing transthoracic (TTE), dobutamine stress (DSE), and awake-sedated TEE studies . This program is structured to allow fellows to meet the NBE criteria for Perioperative TEE certification after this one year of training.


5. TEE training includes didactic as well as hands-on instruction. Lectures are held weekly, plus weekly echo reading sessions with anesthesiology and cardiology faculty. The lecture series covers a broad spectrum of echo topics over the course of the year, and then this knowledge is converted to practice with review of interesting cases via interactive learning sessions. Weekly echo reading sessions allow all the fellows to review interesting cases from our vast echo library.


6. Clinical research in anesthesiology, echocardiography and intensive care. Each fellow is expected to participate in clinical investigation during this fellowship year. There are a variety of ongoing projects from which to choose, including echo rounds or case reports submissions.


7. Teaching experience including lecturing and tutoring in cardiac, vascular and thoracic anesthesiology, cardiopulmonary resuscitation, critical care medicine, cardiovascular physiology and pharmacology. Additionally, fellows will gain experience supervising anesthesiology residents in the OR.
   
   
8. Study and research in a basic science or clinical discipline closely related to cardiothoracic anesthesiology.
   

Dr. Jerrold Levy, Director or
Dr. Kathryn Glas, Associate Director
and Fellowship Program Director
Cardiothoracic Anesthesiology
Emory University Hospital
1364 Clifton Road NE
Atlanta, Georgia 30322-1104
Phone: (404) 778-5793
Fax: (404) 778-3940
email: Jerrold.Levy@emoryhealthcare.org
email: Kathryn.Glas@emoryhealthcare.org

Emory Healthcare includes 3 teaching hospitals, which performed 2,766 cardiac surgical operations in 2003. In addition to Emory University (EUH), Crawford Long Hospitals (CLH) and Children’s Healthcare of Atlanta (CHOA), cardiac surgery is performed at Grady Memorial Hospital (GMH) and Veterans Administration Medical Center (VAH), which brought the total numbers of heart operations to 3,019 in the calendar year 2003. The faculty of the Cardiothoracic Anesthesia Division of the Emory Department of Anesthesiology provides care for all cardiac and thoracic patients at EUH, CLH, CHOA and VAH. Fellow OR training and TEE training will be evenly divided between EUH and CLH. ICU training occurs at EUH. Each fellow will provide care at the VAH approximately once per month.

• Emory University Hospital · is a 600-bed tertiary referral hospital in which more than 800 cardiac and 480 thoracic surgical procedures are performed each year in adult patients. The Cardiothoracic anesthesiology fellow functions in both learning and teaching capabilities during cardiac surgical procedures. Early in the fellowship year, a fellow administers anesthesia to patients in relatively good physical condition who are undergoing more or less routine cardiac operations. Subsequently the fellow is assigned more complex and challenging cases. Later in the year, a fellow is given increasing responsibility for supervising residents providing anesthesia for cardiac and thoracic operations. Our goal is to increase the fellow's knowledge and experience to the point where s/he can competently assume full responsibility for patient management and be both effective and comfortable in the role of an independent practitioner.

  Our program includes all facets of anesthesia care for surgical patients with coronary, valvular, and congenital heart disease, heart and lung transplantation, lung disease and thoracoabdominal aortic aneurysms. Experience is gained in medical and surgical treatment of dysrhythmias, management of acute and chronic heart failure, clinical pharmacology and physiology, uses of cardiac assist devices, fluid and electrolyte balance, hyperalimentation, and all aspects of immediate postoperative care. The most sophisticated invasive and noninvasive monitoring techniques (e.g. transesophageal and epicardial echocardiography) are used in most patients. Opportunities to learn the technical procedures and to operate the cardiopulmonary bypass machine are offered. TEE training at EUH involves both echo lab and OR experience.
  
  Anesthesia care for thoracic surgical procedures emphasizes the use of one-lung ventilation and pulmonary vasodilators, such as nitric oxide. A busy thoracic transplant service has provided the opportunity to participate in complex single and double lung transplant procedures. In addition to operations on the lung, a variety of diagnostic procedures including bronchoscopy and mediastinoscopy are performed.
  
  The post cardiac surgical intensive care units are included in the Division of Cardiothoracic Anesthesiology. Fellows spend a minimum of 4 weeks on the Critical Care Medicine Service. In addition to direct patient care, the fellow is given the responsibility of directing the critical care team of anesthesiology residents. Fellows demonstrating excellence are offered the opportunity to serve as assistant attending physician / junior faculty. It is possible to arrange extended periods in the surgical ICU's. The training program for a fellow in the intensive care units is at a higher level of expertise than that provided in the usual anesthesiology residency. At the conclusion of the rotation, a fellow should be able to diagnose and treat effectively all aspects of acute cardiac failure as well as multi system organ failure. He will have become experienced in the use of cardiovascular drugs, ventilator support, hyperalimentation, renal dialysis, intraaortic balloon counter pulsation, and other therapeutic modalities. Because many patients undergoing cardiac surgery have other systemic diseases, the fellow can often gain experience in the medical management of neurological, pulmonary, renal, endocrine, metabolic, infection and coagulation problems.




• Crawford Long Hospital is a 583-bed general community hospital in which more than 1300 cardiac and 300 thoracic surgical operations occur annually. The caseload is similar to EUH, although all transplant operations occur at EUH. Off-pump coronary revascularization (OPCAB) is performed here on over 70% of the patients. This busy clinical service gives fellows the opportunity to see aspects of care that resemble private practice settings, even though all members of the operative team are employees of Emory Healthcare.
  


• Children's Health Care of Atlanta at Egleston Children's Health Care of Atlanta at Egleston is a 235-bed major pediatric referral and teaching hospital in which 584 cardiac operations with cardiopulmonary bypass (CPB) and including the most complex congenital lesions and transplantation are performed each year. In addition, there are 170 cardiac operations, which do not involve CPB. The cardiac catheterization lab has a busy EP and invasive service, where anesthesia provides care for 290 patients per year. Fellows may elect to spend time on the cardiac anesthesiology service at this pediatric hospital, either as part of their 12-month adult cardiac fellowship, or in addition to it, as a 3 to 6 month rotation.
  


• Veterans Administration Hospital is a 550-bed hospital in which 100-150 cardiac surgical operations are performed annually. Fellows spend time at the VA on a rotating basis. TEE is performed on the majority of patients.



• Grady Memorial Hospital is a 1000+ bed county hospital in which approximately 100 cardiac surgical procedures are performed each year. The emphasis is on patients with thoracic and cardiac trauma as well as multi-system disease. The Anesthesiology program, under the direction of Raphael Gershon MD, emphasizes both the intraoperative and postoperative management of patients with multi system injuries. Dr. Brooker has developed an echo service, and TEE is being used for monitoring and diagnosis of trauma patients. Special rotations to Grady Memorial Hospital can be arranged for those fellows who desire such experience.

Fellows are encouraged to participate in teaching students on the cardiothoracic anesthesiology service at Emory University. These students include: fourth year medical students taking a one-month elective in Cardiothoracic anesthesiology or cardiac surgical intensive care, anesthesia residents (CA-2) during their four months on the Cardiothoracic anesthesiology and intensive care services, and physician's assistants studying for the Master of Medical Science degree in Anesthesiology. Once competence in the anesthetic and life support management of cardiothoracic surgical patients has been demonstrated, the CT fellow is given the opportunity to supervise CA-2 residents beginning their rotations on the CT service.

The Division of Cardiothoracic Anesthesiology conducts weekly seminars, journal clubs and conferences related directly to cardiothoracic anesthesiology and intensive care. These meetings are under the direction of the cardiothoracic anesthesiology faculty, but the fellows participate in the organization and presentation of the programs. It is expected that each fellow will be responsible for at least one major seminar and one conference during the year. Twice monthly, there are combined conferences with the cardiothoracic surgical attending, fellow and resident staff. In addition, there are opportunities to make presentations at other departmental and institutional conferences and at local and national meetings. The cardiac faculty sponsors a postgraduate course for intraoperative TEE each year. Drs. Levy, Ramsay, Glas and Tanaka are actively involved in national lectureships. Dr. Ramsay is the president-elect of the Society of Cardiovascular Anesthesiologists. The fellows attend, and some make presentations, to audiences of anesthesiologists, surgeons, cardiologists and perfusionists.

Extensive clinical research is performed in the operating rooms and intensive care units of Emory University Hospital in cooperation with the faculty and fellows of the cardiology and cardiac surgery divisions. Individual Cardiothoracic anesthesiology faculty also conducts clinical investigations at the other hospitals affiliated with the Emory School of Medicine. Dr. Ramsay has clinical trials to evaluate novel monitoring devices. He also has an on-going interest in Perioperative Ischemia, and he is a member of the McSPi study group. Clinical problems related to cardiovascular pharmacology and physiology are of great interest. The cardiovascular effects of various anesthetic agents including opioids, tranquilizers, hypnotics, volatile anesthetics, and muscle relaxants have been studied. Drs. Levy and Tanaka are evaluating cardiovascular drugs such as vasodilators, inotropes, antiarrhythmics, autonomic blocking drugs, calcium channel blockers, and a variety of experimental drugs. Drs. Glas and Staples participate in clinical studies looking at echocardiography and outcomes in cardiac surgery. New monitoring techniques, both invasive (e.g. heart catheterization) and noninvasive (e.g. transesophageal echocardiography), are utilized in our busy operating suites. Studies dealing specifically with cardiopulmonary bypass involving brain protection, hemodilution, hypothermia, cardioplegia, anaphylaxis and coagulation problems have been performed. The development and execution of specific research protocols by the fellows is encouraged, as is their participation in ongoing clinical and laboratory investigations.

Extensive research training is also available in the surgical intensive care units. Research in these units has included studies of cardiovascular drugs, the assessment of monitoring techniques such as the various modifications of central venous and pulmonary artery catheters, evaluation of the effects of hyperalimentation in the perioperative period, investigations into changes in the immune system after cardiac surgery, studies of different modes of ventilation, development of infusion schemes for continuous analgesia and sedation, and evaluation of various cardiac pacing modalities.

Extensive studies in the area of pharmacokinetics of anesthetic, analgesic, sedative, and cardiovascular drugs have been performed. Sophisticated assays for virtually all anesthetic, autonomic and cardiovascular drugs are available in our analytical laboratories.

Investigations of cardiovascular and pulmonary pharmacology and physiology are performed in the laboratories of the Departments of Anesthesiology, Surgery, and Medicine in the Woodruff Memorial Building adjacent to Emory University Hospital. Among the Cardiothoracic anesthesia faculty, Dr. Levy's work focuses on mechanisms of anaphylaxis, the actions of drugs on vascular smooth muscle, and modifiers of blood coagulation. Dr. Tanaka performs clinical and laboratory investigations relating to vascular and coagulation research. Dr. Sniecinski has done work involving ischemic preconditioning. In collaboration with cardiac surgeons, there are opportunities for studies of cardiopulmonary bypass in animals. The animal laboratory is equipped for invasive monitoring, echocardiographic and angiographic studies, and other techniques for evaluating cardiovascular function.

The above studies utilize a broad spectrum of research techniques including blood gas analysis, chromatography, spectrophotometry, radioisotopes, sophisticated animal models, and statistical data analysis. Research fellows are encouraged at the beginning to join an ongoing project as part of a team, and those who are interested in an academic career have the opportunity to pursue their own projects. The goal is to gain experience in experimental design, interpretation of data (including statistics), and presentation of results and conclusions in peer-reviewed journals and at meetings of national scientific and medical organizations.