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Tips For Adult Cardiothoracic Anesthesiology (ACTA) Fellowship

Adult Cardiothoracic Anesthesiology (ACTA) is a one year fellowship following the completion of an anesthesiology residency. The application process is run by San Francisco Match (SFMatch) and begins in November of the applicant’s CA-2 year.

Compared to critical care anesthesiology (CCA), the ACTA fellowship is more competitive with virtually all available spots being filled each cycle. Some institutions offering dual tracks for applicants interested in the synergy provided by both ACTA and CCA fellowships. This was my situation as an applicant having completed CCA and ACTA fellowships in 2018 and 2019, respectively.

Here are some tips for ACTA fellows (links are Amazon affiliate links):

READ A TEXTBOOK

At the time of this writing, ACTA’s board certification is in a procedure – advanced perioperative transesophageal echocardiography (TEE). Although this is changing in the next few years, it stresses the importance of TEE training as a fellow. I recommend either Mathew’s Clinical Manual and Review of Transesophageal Echocardiography or Perrino’s A Practical Approach to Transesophageal Echocardiography as a basic TEE text to read in the first three months of fellowship. Vegas’ Perioperative Two-Dimensional Transesophageal Echocardiography: A Practical Handbook is a great handbook to carry around the ORs. And a shameless plug for my EchoTools iOS app! 😉

In general, Kaplan’s Cardiac Anesthesia: In Cardiac and Noncardiac Surgery is a great reference textbook for cardiac anesthesia from which I read chapters throughout fellowship.

“ECHO-VISION”

It’s a complex double-valve case. Your surgical colleagues just clamped the venous cannula – you’ve just come off of cardiopulmonary bypass (CPB). The patient’s heart rate is junctional at 45 bpm. The mean arterial pressure is 35 mmHg. The right ventricle is sitting outside the chest wall. The respiratory rate on the ventilator is 6 breaths per minute.

…but you’re “doing the echo (TEE)” and oblivious to everything.

We ALL get this tunnel vision at the most inopportune times. Learn to let go off the TEE probe and use your fundamental skills as an anesthesiologist first. Your eyes should tell you how the right ventricle is looking in the field. Your monitors should give you an idea of how your combination of inotropes, pressors, vasodilators, etc. are working. Your labs should guide electrolyte replacement, fluid choice, glycemic control, etc.

TEE is an essential tool to evaluate the valve replacement/repair in this case, but don’t let it distract you from the patient’s clinical status. At this point in the case, I use the TEE to look for reasons we might need to go back on CPB. I’ll do a more thorough exam once we’ve reversed heparinization.

STAY ORGANIZED

Compared to other disciplines within anesthesiology, ACTA cases demand a different level of efficiency and organization. You’ll be in charge of administering powerful hemodynamic medications. You’ll have a workspace including cerebral oximeters, PA catheters, lumbar drains, evoked potential monitors, double lumen tubes, TEE, rapid transfusers, infusion pumps, etc. Many of your patients will also be transported intubated to the ICU with many of the aforementioned equipment still in situ.

During the first few weeks of fellowship, I’d mentally replay my workday looking for ways to optimize efficiency so the next day I could implement those strategies. Although this might not change patient care directly, I’d argue a clean and organized workstation does ensure patient safety during times of acute decompensation. Oh! And do your case logs each day! 🙂

ARCHIVE YOUR ECHOS

Most TEE machines have a USB input to allow users to export either DICOM images or AVI/JPEG files. Some machines even have the option to deidentify patient information prior to export. Keep an archive of deidentified “interesting” echocardiograms to use for lectures, research, etc.

I recommend the Samsung FIT Plus USB drive (affiliate link) – it’s fast, ships quickly from Amazon, and very portable!

IMMERSE YOURSELF

Constantly look for ways to immerse yourself in the variety of cases ACTA fellows must master. If you’ve got some time after your CABG, go to the other ORs and look at the TEEs for congenital heart cases, complex valve repairs, mechanical circulatory support implantation, etc. If there’s an opportunity to do an extra transplant, DO IT! This isn’t the same as doing your 100th laparoscopic cholecystectomy as a resident. Every lung transplant you do will be a little different. Not all ECMO decannulations are smooth. This year will often be the last part of your formal medical training as a physician – put in the time to master your trade.

If you’ve completed or are enrolled in an adult cardiothoracic anesthesiology fellowship, drop me a comment below with your tips as well! 🙂

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