Cardiothoracic Surgery Pathway Introduction Sites and Personnel Description of Pathway Cardiothoracic Surgery Course Cardiology Elective Pulmonary Elective Radiology Elective Free Elective Goals and Objectives Textbooks Evaluation Faculty Curriculum Committee

Introduction

Heart disease is the most common cause of death in the Western world. In the United States alone, 5.5-7.5 million individuals have symptomatic myocardial ischemia because of atherosclerotic CAD. In 1945 the first shunt operation for "blue babies" was introduced. In 1953, extracorporeal circulation was successfully performed in Philadelphia, opening the doors to a world capable of treating congenital and adult cardiac disease. In 1961, replacement of heart valves became a reality. In 1967, the birth of modem coronary revascularization was realized. Since then, coronary artery bypass grafting (CABG) has become the most commonly performed major operative procedure in the adult U.S. population. At present, over 400,000 CABG operations are done annually in. the U.S. The Tenet Delaware Valley hospital network is one of the country's largest providers of cardiovascular care. The volume of open heart surgery within the system exceeded 4,600 cases for 1996. Every aspect of adult and congenital cardiac surgery is represented at the various Divisions, including CABG, valve repair and replacements, transplantation, Ventricular Assist Devices (VAD), cardiomyoplasty, ventricular remodeling, laser recanalization and minimally invasive techniques are being performed.

In addition to the abundance of open heart procedures, a variety of non-cardiac thoracic surgery is available within the system. Thoracic oncology, video-assisted thoracoscopic surgery (VATS), lung volume reduction and thoracic trauma are within the spectrum of chest diseases treated. A close relationship between several specialties, including pulmonary medicine, oncology, internal medicine, radiology, pathology and emergency medicine is fostered by the multidisciplinary nature of thoracic disorders. An affiliation with the Fox Chase Cancer Center has provided additional expertise in this field.

Finally, a strong exposure to critical care management in the intensive care unit and technical skills in the operating room is provided. The interaction with attendings, residents, fellows, physician assistants and perfusionists provide additional educational resources. Furthermore, laboratory and clinical research continues to flourish with student and resident participation.

In summary, the fourth year discipline-based pathway in cardiothoracic surgery is an educational, multidisciplinary experience whose purpose is to produce a high quality, motivated and well-rounded student-physician capable of recognizing cardiothoracic pathology and knowledgeable about its treatment.

Return to top of page

Pathway Director:
Drexel University COM
John Entwistle, III, M.D., Ph.D.
Hahnemann University Hospital
Broad & Vine, Mail Stop 111
Philadelphia, PA 19102-1192
(215) 762-7802 Phone
(215) 762-1858 Fax

Associate Course Coordinator:
Todd Nixon, M.D.
(215) 762-7802 Phone
(215) 762-1858 Fax

Coordinator:
Tom Concannan
(215) 762-7802 Phone
(215) 762-1858 Fax

Associate Directors, and Teaching Sites:

Site	Associate Director	Site Coordinator	Students Per Rotation
HUH	Todd Nixon, M.D. Hahnemann University Hospital Dept. of Cardiothoracic Surgery Broad & Vine St. Mail Stop 111 Philadelphia, PA 19102-1192 (215) 762-7802 Phone (215) 762-1858 Fax	Tom Concannan (215)762-7802 Phone (215)762-1858 Fax	3
AGH	George J. Magovern, Jr., M.D. Allegheny General Hospital 320 E. North Avenue Pittsburgh, PA 15212 (412) 359-3711 Phone (412) 359-3878 Fax	Patty Olsack (412)359-3711 Phone (412)359-3878 Fax	3

Return to top of page

Click here for a summary table of the Cardiothoracic Surgery Pathway.

Cardiothoracic Surgery Course
Hahnemann University Hospital
Fourth year students rotating on the cardiothoracic surgery service at HUH will be provided an in-depth education in cardiac and thoracic anatomy and physiology. Rounds in the ICU and cases in the operating room will reinforce the didactic conferences given twice a week (Tuesday and Saturday). An appreciation for cardiac and thoracic pathology is provided by virtue of the large volume of material available at this site. A complete understanding of the principles of cardiopulmonary bypass and its effects on the body's organ systems will be taught. In addition to the abundance of coronary and valvular operations, site-specific procedures include cardiac transplantation and ventricular assist devices. A basic understanding of immunology will be addressed in order to appreciate the issues of transplant rejection.

An additional advantage of the HUH-site for cardiothoracic surgery is the presence of residents and fellows in cardiothoracic surgery. These are individuals who have completed their general surgery training and are, therefore, senior level instructors. As a resource to student education, they are invaluable. Along with the Attendings, the Residents and Fellows will provide a practical avenue of learning with respect to the constant issues of patient care, both in the Intensive Care Unit and on the floors. Such skills as arterial line insertion, central line placement, and chest tube insertion will be addressed by these individuals. A growing thoracic surgery service will provide students with a well-rounded experience in chest pathology. An increasing number of video-assisted thorascopic procedures (VATS) will give students an in-depth understanding of this state-of-the-art technique. Ventilator management, understanding of PFT's, interpretation of chest radiology (plain film, CT, MRI) will be emphasized. Specific case conferences will highlight the preoperative presentation, intraoperative findings and postoperative outcome. Since bronchogenic cancer is a leading cause of death in our population, special attention to this disorder will be provided, including collaboration with oncology and radiation oncology. Finally, basic science and experimental research protocols and projects are constantly being introduced into the clinical setting. Students will be encouraged to participate.

AGH
Fourth year students rotating on the Cardiothoracic Surgery Service at AGH will be provided with a complementary experience to the one they receive at HUH. In addition to the coronary and valvular cardiac operations, AGH surgeons offer cardiomyoplasty and laser recanalization. Furthermore, the AGH preoperative evaluation, intraoperative techniques, and postoperative management will provide the student with additional experience by which to compare and contrast with the HUH approach. Specific research projects are available. Students interested in these areas are welcome to investigate the possibility of participating in these fields.

Cardiology Elective
A rotation in cardiology is a natural complement to cardiac surgery. It is fundamental to the understanding of cardiovascular disease to appreciate both the surgical and medical aspects of this discipline. Therefore, we strongly recommend a rotation in cardiology at one of the major Delaware Valley institutions. Exposure to heart failure, electrophysiology, echocardiography, nuclear cardiology, and cardiac catheterization will be provided during this rotation.

Pulmonary Elective
An understanding of pulmonary medicine is critical to the application of thoracic Surgery. Since most pulmonary diseases are treated non-surgically, it becomes imperative to understand the pathophysiology of thoracic disorders and to be knowledgeable of the indications for surgical intervention. By rotating through this service, an additional exposure to pulmonary function tests, bronchoscopy, pulmonary radiography and clinical assessment of patients will be provided.

Radiology Elective
For both cardiac and non-cardiac thoracic diseases, a necessary skill is the interpretation of chest films. By rotating through a formal radiology course, the exposure to plain films, CT scans and MRI is maximized, and the expertise of the radiologist is directly available.

Free Elective
During this rotation, students may choose a course or experience at their discretion. However, we recommend several options. One option is a rotation at St. Christopher's Hospital for Children. This is a unique environment from which to learn high quality pediatrics. The cardiothoracic care for children is top quality, and any student rotating in the cardiology or cardiothoracic services will be rewarded by this experience. Similarly, a rotation at Fox-Chase Cancer Center is equally worthwhile. State-of-the-art cancer therapy is represented at this institution. Finally, a cardiothoracic rotation at an away site is another option. Students who have an interest in a particular institution may want to exercise this option.

Return to top of page

1. thorough understanding of cardiac anatomy and physiology
2. A thorough understanding of thoracic anatomy and physiology
3. A thorough understanding of adult cardiac disease, specifically coronary artery disease, aortic and mitral valve disease, end-stage-heart disease/cardiomyopathy as it relates to transplantation and mechanical ventricular assistance, pericardial disease and cardiac trauma
4. A thorough understanding of adult thoracic and mediastinal disease specifically bronchogenic carcinoma, interstitial lung disease, emphysema, thoracic infection (tuberculosis, fungal, empyema), mediastinal pathology (tumors, infection cysts, etc.), pleural diseases and chest trauma
5. A thorough understanding of critical care management, including cardio-pulmonary resuscitation, ventilatory care, central venous and Swan-Gans catheters, inotropic agents, antiarrhythmic agents, intraaortic balloon pumps, ventricular assist devices, recognition of low cardiac output states, etc.
6. A thorough understanding of cardiopulmonary bypass
7. Exposure to endoscopy, including bronchoscopy, mediastinoscopy and thoracoscopy
8. Exposure to cardiac catheterization, echocardiography, nuclear cardiology and electrophysiology
9. A thorough understanding of normal and abnormal chest roentgen ography, including chest CT-scan, Magnetic Resonance Imaging and angiography
10. A thorough, hands-on experience in the Operating room to assist in all cases, with emphasis on an appreciation for the indications for surgery, principles in technique and conduct of the operation
11. Exposure to laboratory and clinical cardiothoracic research with potential for manuscript preparation and publication
12. An opportunity to experience organ procurement (via ambulance, helicopter, or airplane) and implantation for orthotopic heart transplantation
13. An opportunity to observe transplant follow-up and endomyocardial biopsy to detect rejection at the Heart Failure/ Transplant Clinic
14. An opportunity to follow-up on cardiac and thoracic cases at the weekly clinic.

Return to top of page

Manual of Perioperative Care in Cardiac and Thoracic Surgery. Second edition. Bojar, RM. Blackwell Scientific Publications, Boston, MA, 1994.

Surgery of the Chest. Sixth edition. Sabiston, DC, Jr. M.D., Spencer FC, M.D.. W.B. Saunders, Philadelphia, 1995.

Return to top of page

The student and clinical preceptor will meet at the end of the rotation to review comments and recommendations from evaluations provided by the Curriculum Committee during the rotation period.

Return to top of page

This will consist of Dr. Entwistle and Dr. Nixon, Assistant Professors in Cardiothoracic Surgery at HUH. In their current capacities as Director of the CCU and CT Surgery Student Education, they are appropriate personnel for this position. This committee reviews all students on the pathway on a quarterly basis. Based on the students' experiences and exit interviews, revisions will be made for the following year's pathway.

Return to top of page