ABTS Cardiothoracic Surgery

Curriculum Outline

Acknowledgement: Substantial portions of this

Outline are based on the Intercollegiate Surgical
Curriculum Programme, Cardiothoracic Surgery Syllabus,
August 2007

April 2, 2011

Overview

The ABTS has created this document to outline what the well trained thoracic surgeon should know as he/she finishes a
residency. This outline augments rather than supplants the role program directors and faculty play in the professional and
personal maturation of residents during their education. The recommendation from a residency program that a resident
enter the certification process of the ABTS plays a crucial role to help define for the public what should be required of a
competent thoracic surgeon. Thus, the ABTS acknowledges the successful path to being a complete surgeon is more
than a curricular outline. Since residents may graduate from an ACGME approved Thoracic Surgical program and be
ready for ABTS certification with no other Board or regulatory approval, we must strive to provide an improved
educational process addressing the art and science of medicine. The acquisition of professionalism as well as
interpersonal and communication skills may not adequately stress some of the art of becoming a surgeon. Certainly,
intangibles such as professional appearance, communication, informed consent, and management of end of life issues
are examples of skills applicants should develop. The ABTS endorses this knowledge and skills based outline realizing
that individual programs are the critical element in developing an ABTS candidate with maturity, sound judgment, and a
commitment to improving systems of healthcare and lifelong learning.
2
 Table of Contents

Title Pages

Tabular overview of basic knowledge, 4-9

Clinical and Technical status

Core Surgical Foundation 10-22

Basic knowledge 10-12
Core surgical skills 12-13
Assessment and management of the surgical patient 13-16
perioperative management and critical care
Assessment and management of the trauma patient 16-18
Surgical care of the pediatric patient 18
Surgical care of the geriatric patient 18
Organ and tissue transplantation 19
Core general surgical diseases 19-22
Diseases of the GI tract and abdomen 19-20
Diseases of the head and neck 20
Breast disease 20-21
Genitourinary disease 21
Neurology and neuro-surgery 21

Professional behavior and leadership skills 21-22

Cardiovascular Surgery 23-30

General management of a patient undergoing 23-24
cardiac surgery
Cardiopulmonary bypass myocardial 24-25
protection and circulatory support
Ischemic heart disease 25
Heart valve disease 25-26
Great vessel disease 26-27
Peripheral vascular disease 27-28
Cardiac conduction system disorders 28
Diseases of the pericardium and myocardium 29
Heart failure and cardiac transplantation 29-30
Cardiothoracic trauma 30

Thoracic Surgery 31-41

General management of a patient undergoing 31-32
thoracic surgery
Neoplasm of lung 32
Benign lung conditions 33-35
Disorders of the pleura 35-36
Disorders of the chest wall 36

3
 Disorders of the diaphragm 36-37
Disorders of the mediastinum 37
Endoscopy 38
Disorders of the airway 38-39
Management of benign esophageal disorders 39-40
Management of esophageal neoplasia 40-41
Lung transplantation 41

Congenital Heart, Lung and Thoracic Disease 41-44

Congenital heart disease 41-43
Congenital thoracic disease 43-44

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 INTEGRATED 6 YEAR CURRICULUM
TOPICS BY SURGICAL FOCUS: Basic Knowledge

TOPIC CORE SURGICAL GENERAL THORACIC ADULT CARDIAC CONGENITAL SURGERY

FOUNDATION SURGERY SURGERY
Anatomy Thorax Tracheobronchial tree and See Core Surgical Foundation Basic embryology of the
Gross, surface and imaging Abdomen lungs Heart, pericardium and great heart, lungs, great vessels
anatomy of: Pelvis Thoracic inlet, neck and vessels Coronary anatomy and
Limbs mediastinum Coronary anatomy variants
Head and neck Esophagus and upper GI tract Valvular anatomy Location and course of the
Spine Chest wall and diaphragm Anatomy of the peripheral conduction system in
Pleura vascular system congenital heart disease
Anatomy of cardiac Anatomy as it pertains to
innervations vascular conduits
including aortopulmonary
shunts
Physiology Homeostasis See Core Surgical Foundation See Core Surgical Foundation Fetal circulation &
Thermoregulation Myocardial cellular circulatory changes at birth
Metabolic pathways and physiology Relevant general physiology
abnormalities Electrophysiology of childhood
Blood loss and hypovolemic Physiology of congestive Hemodynamics, physiology
shock heart failure and measurement
Sepsis and septic shock including shunt
Fluid balance and fluid calculations, PVR, SVR
replacement therapy Physiology of pulmonary
Acid base balance vasculature
Bleeding and coagulation Immature myocardial cell
Nutrition physiology
Pulmonary physiology, Electrophysiology, including
ventilation and gas conduction disorders
exchange Acid base balance (including
Metabolic response to trauma Ph and alpha stat CPB
Digestive, renal and hepatic mgmt)
physiology Physiology of pediatric
Cardiac arrhythmia cardiopulmonary bypass
including low-flow and
circulatory arrest.

5
 Pharmacology Analgesics See Core Surgical See Core Surgical Foundation Specific drugs used in the
Antibiotics Foundation Drugs used in the treatment treatment of congenital
Anesthetics Bronchodilators of hypertension, heart heart disease (beta
Cardiovascular drugs failure and angina blockers, ACE inhibitors,
(inotropes, vasodilators Inotropes, vasodilators and Digoxin, Diuretics, PGE1)
and vasoconstrictors, vasoconstrictors Specific dosing and
antiarrhythmic drugs, application of inotropes,
nitric oxide antagonists) anti-arrhythmic drugs,
Antiplatelet, anticoagulant hemostatic drugs,
and thromobolytic drugs antiplatelet, anticoagulant
Hemostatic drugs and thrombolytic drugs,
Respiratory drugs analgesics, antibiotics,
Drugs used for management anesthetic agents, and
of endocrine disorders vasodilators (systemic and
(including diabetes) pulmonary) in the
Familiarity with drugs used in pediatric population
the treatment of common
malignancies
Bronchodilators
H2 antagonists and proton
pump inhibitors
Drugs used in transplantation
Antilipid agents
Steroids
Pathology Inflammation See Core Surgical See Core Surgical Foundation Effect of growth and
General pathological Wound healing Foundation Atheroma, medial necrosis pregnancy
principles including: Cellular injury Myocardial infarction and
Tissue death including complications
necrosis and apoptosis Endocarditis
ARDS Pericarditis
Systemic inflammatory Tumors of the heart
response
Bleeding disorders and HIT
Vascular disorders (including
atherosclerosis)
Disorders of growth,
differentiation and
morphogenesis
Surgical immunology

6
 Pathology of neoplasia
Tumor classification and
biology
Cancer staging and grading
Principles of cancer therapy
including surgery,
radiotherapy (and
radiation safety),
chemotherapy and
hormone therapy
Principles of cancer screening
Microbiology Bronchopulmonary infections See Core Surgical Foundation See Core Surgical Foundation
including TB Intrapleural sepsis Antibiotic prophylaxis for
Blood borne organisms and cardiac surgery
viruses
Wound and soft tissue
infections
Sources of postop infections
Principles of disinfection and
sterilization
Antibiotics including
prophylaxis and resistance
Hospital acquired infections
Imaging Plain film xrays See Core Surgical Foundation ECHO
Principles and indications for CT PET/CT Cardiac catherization
diagnostic and interventional MRI/MRA Quantitative V/Q scanning
imaging including: PET/CT Sestamibi scanning
Echocardiography
Ultrasonography

7
 TOPICS BY SURGICAL FOCUS: Basic Clinical and Technical Skills
TOPIC CORE SURGICAL
FOUNDATION
Surgical Skills Knowledge Principles of hand washing,
scrubbing and gowning
Choice of anesthetic agent
Classification of surgical
wounds
Principles of wound
management
Suture and needle choice
Choice of instrument
Techniques of hemostasis
Biopsy techniques
Indications, types and
management of drains
Principles of anastomosis
Principles of endoscopy
Seldinger technique
Principles of laparoscopy and
thoracoscopy
Patient Management and Preoperative
Clinical Skills Assess the surgical patient
Elicit appropriate history
Produce timely, complete and
legible clinical records
Manage any pre-operative
problems appropriately
Propose and initiate surgical
or non-surgical
management as
appropriate
Take informed consent for
straightforward cases
Intraoperative
OR team attitude and
communication
Principles of patient safety
and time out protocols
Administration of local
GENERAL THORACIC
SURGERY
Open versus minimally
invasive approaches to
thorax
Early and late complications
of thoracic incisions
Postoperative analgesia,
including epidural, PCAs
and paravertebral catheter
techniques
History and Examination
System specific and general
history and examination,
including drug history,
identification of
comorbidity and functional
status
Data interpretation
Routine hematology and
specific biochemical
investigations
Chest radiograph and ECG
CT, including contrast
enhanced CT
MRI and PET
Respiratory function tests
Ventilation/perfusion scan
Blood gases
Esophageal function tests and
ADULT CARDIAC
SURGERY
Diagnosis, evaluation and
treatment of heart disease
Risk assessment (including
when not to operate)
Cardiopulmonary
resuscitation (open chest)
Cardiac arrhythmias
diagnosis and management
Cardiac rehabilitation
Wound infection and sternal
disruption
Cardiac tamponade
Interpretation of:
Hemodynamic data
ECG including exercise data
Coronary angiography
Cardiac cath hemodynamics
Echo including 2D, Doppler
and transthoracic, stress
PEDIATRIC CARDIAC
SURGERY
Proficiency with the anatomy,
pathophysiology, natural
history, management, and
results of the following
conditions or procedures:
Patent ductus arteriosus
Atrial septal defect
Ventricular septal defect
Coarctation
PA banding and shunts
Transposition of the great
arteries/switch procedure
Tetralogy of Fallot
Vascular rings
History and Examination
Cardiovascular system and
general history and
examination of child or
adult with congenital heart
disease
Data Interpretation
Routine hematology and
biochemical investigations
Chest radiograph and ECG
Cardiac catheterization data
including interpretation of
hemodynamic data, shunt
and
resistance calculation
Basic congenital heart disease
imaging interpretation
Diagnosis, assessment, and
treatment of common
8
 anesthesia contrast studies echo congenital heart disease
Surgical prepping and Risk assessment and Nuclear cardiology Collaborative and
drapping stratification Cardiac MRI complimentary role of
OR leadership and teaching Management of post-thoracic CT angiography interventional cardiology
skills surgical complications Management of Risk assessment and
Perioperative Postoperative management of complications of cardiac stratification
Assess and manage pain control surgery Basic pediatric intensive care
patients in the Treatment of cardiac to include ventilator
perioperative periodnoting arrhythmias management
increased risks Physiotherapy and Perioperative management of
Assess and manage rehabilitation adults and children
bleeding including the use Understanding thoracic- following congenital heart
of blood products specific ventilatory surgery
Assess and manage techniques (eg, lung Mechanical assist (IABP,
common complications isolation) VAD, ECMO)
Assess, plan and manage Indications for heart or lung
post-operative fluid transplantation referral
balance Management of
Direct nutritional complications of surgery
management Cardiopulmonary
resuscitation
Diagnosis and treatment of
common congenital
cardiac arrhythmias
Wound infection and sternal
dehiscence

9
 Technical Skills Knot tying (single handed, Tracheostomy Saphenous vein harvest Sternotomy - open and close
double handed, Fiberoptic bronchoscopy Median sternotomy Thoracotomy - open and
instrument, superficial, Esophagoscopy Intra-aortic balloon close
deep) Correct positioning of patient placement Preparation for and
Incision of skin and for thoracic surgery Groin access management of
subcutaneous tissue Select, perform and close cardiopulmonary bypass
Closure of skin, subcutaneous thoracic incisions, including partial bypass
tissue and fascia including lateral, anterior, Basic ECMO techniques,
Tie and suture ligation muscle sparing, median cannulation, and
Utilize diathermy sternotomy and VATS management.
Facile tissue retraction incisions
Insertion and fixation of Endoscopic suturing and Basic Surgical management
drains stapling techniques of uncomplicated cases
Appropriate application of Patent ductus arteriosus
instruments and respect for Atrial septal defect
tissues Coarctation
Ability to assist PA banding and shunts
Urethral catheterization
Airway management and
intubation
Fundamentals of
interventional and
endovascular techniques
Minimally invasive camera
skills
Open stapling techniques
Arterial cannulation
Peripheral and central venous
cannulation
Pulmonary artery
catheterization
Chest tube insertion and
removal
Thoracentesis
IABP insertion and removal

COMPETENCY TABLE: Medical Knowledge; Patient Care; Practice Based Learning/Improvement;

10
Interpersonal and Communication skills; Professionalism; Systems Based Practice

11
 CORE SURGICAL FOUNDATION

Core Surgical Foundation Goal: Become competent in the basic management of surgical
patients in preparation for a cardiothoracic surgical training focus, while acquiring the personal
attributes needed to fulfill the professional competencies.

Core Basic Knowledge

Anatomy
Gross anatomy, surface anatomy and imaging anatomy of:
Thorax
Abdomen
Pelvis
Limbs
Head and neck
Spine

Physiology
Homeostasis
Thermoregulation
Metabolic pathways and abnormalities
Blood loss and hypovolemic shock
Sepsis and septic shock
Fluid balance and fluid replacement therapy
Acid base balance
Bleeding and coagulation
Nutrition
Cardiopulmonary physiology, ventilation and gas exchange
Metabolic response to trauma
Digestive, renal and hepatic physiology
Cardiac arrhythmia

Pharmacology
Analgesics and antiemetics
Antibiotics
Anesthetics
Cardiovascular drugs (inotropes, vasodilators and vasoconstrictors, antiarrhythmic
drugs, nitric oxide antagonists)
Antiplatelet, anticoagulant, and thromobolytic drugs
Hemostatic drugs
Respiratory drugs
Drugs used for management of endocrine disorders (including diabetes)
Familiarity with drugs used in the treatment of common malignancies
Bronchodilators

12
 H2 antagonists and proton pump inhibitors
Drugs used in transplantation
Antilipid agents
Steroids

Pathology
General pathological principles including:
Inflammation
Wound healing
Cellular injury
Tissue death including necrosis and apoptosis
ARDS
Systemic inflammatory response
Bleeding disorders and HIT
Vascular disorders (including atherosclerosis)
Disorders of growth, differentiation, and morphogenesis
Surgical immunology
Pathology of neoplasia
Classification of tumors
Tumor biology including metastasis
Principles of staging and grading of cancers
Cancer therapy including surgery, radiotherapy and radiation safety,
chemotherapy and hormone therapy
Principles of cancer screening

Microbiology
Bronchopulmonary infections including Tb
Surgically important microorganisms including blood borne viruses
Organisms involved in wound and soft tissue infections (cellulitis, abscesses, necrotizing
fasciitis, gangrene)
Sources of nosocmial infection
Sepsis and septic shock
Principles of disinfection and sterilization
Antibiotics including prophylaxis and resistance

Imaging
Principles and indications for diagnostic and interventional imaging including:
Plain film x-rays (CXR, KUB, pelvis)
Body CT
MRI/MRA
PET/CT
VQ scan
Echocardiography

13
 Ultrasonography

Core Surgical Skills-

Preoperative patient management
Knowledge (see core basic knowledge)
Patient risk stratification
Operative vs. non-operative decisions
Optimize patient status for surgery

Technical Skills
Concise and appropriate history taking
Maintenance of complete and legible medical records
Assessment of surgical patient
Preparation of patient for OR
Perform informed consent
Perform safe hand-offs and patient safety initiatives
ACLS, FLS, and ATLS certification

Operating Room Basics

Knowledge
Principles of hand washing, scrubbing, and gowning
Use of anesthetic agents (local, topical, conscious sedation, general)
Patient positioning, prepping, and draping
Instrument recognition and use
Ties, sutures, and needle selection
Importance of surgical timeout/patient safety
Patient transport to ICU or recovery (postoperative debriefing)
Wound healing and management
Classification of wounds
Communication and team skills

Technical skills-Basic
Manual skills
Intubate and manage an airway
Knot tying (one or two handed, instrument, knot pusher)
Incisions (initiation and closure)
Suturing (skin, fascia, and blood vessels)
Hemostasis (diathermy, tie or suture ligation)
Biopsy techniques/principles
Endoscopic principles/techniques
Assistant skills (retraction, anastomosis set-up, camera etc)
Port Set-up/introduction for thorascopic/laparoscopic surgery
Use and application of stapling devices

14
 Endovascular skills
Seldinger technique for venous and arterial lines
Central venous and Swan-Ganz line placement
IABP placement and removal
Tube placement
Foley catheter
Chest tube/ drain placement
Thoracentesis

Intraoperative care
Safety in the OR including patient positioning and avoidance of
nerve/pressure related injuries
Sharps safety
Diathermy, laser use
Infection risks
Radiation use and risks
Tourniquet use including indications, effects and complications
Principles of local, regional and general anesthesia
Principles of invasive and non-invasive monitoring
Prevention of venous thrombosis
Surgery in hepatitis and HIV carriers
Attention to fluid balance/homeostasis

ASSESSMENT AND MANAGEMENT OF THE SURGICAL PATIENT

PERIOPERATIVE MANAGEMENT AND CRITICAL CARE

Goal: To demonstrate the relevant knowledge, skills and attitudes in assessing and managing all
aspects of patient care in the perioperative period, including the identification of risks and
management of complications and preposing surgical and nonsurgical options.

Knowledge
Pre-operative assessment and management
Cardiorespiratory physiology
Diabetes mellitus and other relevant endocrine disorders
Fluid balance and homeostasis
Renal failure
Pathophysiology of sepsis prevention and prophylaxis
Thrombophylaxis
Laboratory testing and imaging
Risk factors for surgery and scoring systems
Pre-medication and other preoperative prescribing
Principles of day surgery

Postoperative care
Post-operative monitoring/hemodynamic assessment

15
 Cardiorespiratory physiology
Pharmacologic support of the circulation
Fluid balance and homeostasis
Diabetes mellitus and other relevant endocrine disorders
Renal failure
Pathophysiology of blood loss
Pathophysiology of sepsis including SIRS and shock
Multi-organ dysfunction syndrome
Methods of postoperative analgesia

To assess and plan nutritional management

Effects of malnutrition, both excess and depletion
Metabolic response to injury
Methods of screening and assessment of nutritional status
Methods of enteral and parenteral nutrition

Hemostasis and Blood Products

Mechanism of hemostasis including the clotting cascade
Pathology of impaired hemostasis e.g. hemophilia, liver disease, massive hemorrhage
Components of blood
Alternatives to use of blood products
Principles of administration of blood products
Patient safety with respect to blood products

Coagulation, deep vein thrombosis, and embolism

Clotting, antithrombotic, and fibrinolytic mechanisms
Effect of surgery and trauma on coagulation
Tests for thrombophilia and other disorders of coagulation
Methods of investigation for suspected thromboembolic disease
Principles of treatment of venous thrombosis and pulmonary embolism including
anticoagulation
Role of V/Q scanning, CT pulmonary angiography, D-dimer and thrombolysis
Prophylaxis of thromboembolism
Risk classification and management of DVT
Knowledge of methods of prevention of DVT, mechanical and pharmacological

Antibiotics
Common pathogens in surgical patients
Antibiotic sensitivities
Antibiotic side-effects
Principles of prophylaxis and treatment

Metabolic and endocrine disorders in relation to perioperative management

Pathophysiology of thyroid hormone excess and deficiency and associated risks from
surgery
Causes and effects of hypercalcemia and hypocalcemia

16
 Complications of corticosteroid therapy
Causes and consequences of adrenal insufficiency
Complications of diabetes mellitus
Causes and effects of hyponatremia
Causes and effects of hyperkalemia and hypokalemia
Causes and effects of hyopmagnesemia and hypermagnesemia

Patient/Management Clinical Skills

History and examination of a patient from a medical and surgical standpoint
Construct a differential diagnosis
Pre-operative assessment and management
Plan investigations
Interpretation of pre-operative investigations
Management of co-morbidity
Resuscitation
Team working and planning
Active participation in clinical audit events
Taking consent for intermediate level intervention: emergency and elective
Written clinical communication skills
Interactive clinical communication skills: patients
Interactive clinical communication skills: colleagues
Appropriate preoperative prescribing including premedication
Intraoperative care
Safe conduct of intraoperative care
Correct patient positioning
Avoidance of nerve injuries
Management of sharp injuries
Prevention of diathermy injury
Postoperative care
Writing of operative records
Assessment and monitoring of patients condition
Postoperative analgesia
Fluid and electrolyte management
Detection of impending organ failure
Initial management of organ failure
Principles and indications for dialysis
Recognition, prevention and treatment of postoperative complications
Respiratory care
Assessment on arrival
Sedation
Methods of respiratory support
Ventilator weaning and extubation
Extubation failure
Chronic ventilation and tracheostomy
Principles of VAP prevention

17
 Hemostasis and Blood Products
Recognition of conditions likely to lead to diathesis
Recognition of abnormal bleeding during surgery
Appropriate use of blood products
Management of the complications of blood product transfusion
Coagulation, deep vein thrombosis, and embolism
Recognition of patients at risk
Awareness, diagnosis and management of pulmonary embolism and DVT
Role of duplex scanning, venography, and d-dimer measurement
Initiate and monitor treatment of venous thrombosis and pulmonary embolism
Initiation of prophylaxis
Antibiotics
Appropriate prescription of antibiotics
Assess and plan preoperative nutritional management
Knowledge of nutritional assessment tools and requirements
Knowledge of nutritional support options (enteral, parenteral)
Metabolic and endocrine disorders
History and examination in patients with endocrine and electrolyte disorders
Investigation and management of thyrotoxicosis and hypothyroidism
Investigation and management of hypercalcemia and hypocalcemia
Peri-operative management of patients on adrenal replacement therapy
Peri-operative management of diabetic patients
Investigation and management of hyponatremia
Investigation and management of hyperkalemia and hypokalemia
Recognizing and managing adrenal insufficiency and excess

ASSESSMENT AND MANAGEMENT OF THE TRAUMA PATIENT

Goal: To assess, initiate and manage the injured patient.

Knowledge
General
Scoring systems for assessment of the injured patient
Major incident triage
Differences in children

Shock
Pathogenesis of shock
Shock and cardiovascular physiology
Metabolic response to injury and loss of thermoregulation
Adult respiratory syndrome
Indications for using uncross matched blood

Wounds and soft tissue injuries

18
 Gunshot and blast injuries
Stab wounds
Human and animal bites
Nature and mechanism of soft tissue injury
Principles of management of soft tissue injuries
Principles of management of traumatic wounds
Compartment syndrome

Burns
Classification of burns
Principle of management of burns

Fractures
Principles of management of fractures and their complications

Organ specific trauma

Pathophysiology of thoracic trauma
Pneumothorax
Head injuries including traumatic intracranial hemorrhage and brain injury
Spinal cord injury
Peripheral nerve injuries
Blunt and penetrating abdominal trauma
Vascular injury including iatrogenic injuries and intravascular drug abuse
Crush injury
Principles of management of skin loss including use of skin grafts and skin flaps

Patient Management/Clinical Skills

General
ACLS and ATLS certification
History and examination
Investigation including interpretation of imaging
Referral to appropriate surgical subspecialties
Resuscitation and early management of patient who has sustained thoracic, head, spinal,
abdominal or limb injury
Resuscitation and early management of the multiply injured patient

Specific problems
Management of the unconscious patient
Initial management of skin loss
Initial management of burns
Prevention and early management of the compartment syndrome

Technical Skills and Procedures

Classification of surgical wounds
Principles of wound management
Intubation and airway management

19
 FAST scan
ED thoracotomy

SURGICAL CARE OF THE PEDIATRIC PATIENT

Goal: To assess and manage neonates and children with surgical problems, understanding the
similarities and differences from adult surgical patients.

Knowledge
Physiological and metabolic response to injury and surgery
Fluid and electrolyte balance
Thermoregulation in children
Principles of vascular access in children
Knowledge of local child protective services and procedures
Understanding of the challenges of working in partnership with children and families
Recognize the possibility of abuse or maltreatment
Recognize limitations of own knowledge and experience and seek appropriate expert
advice

Patient Management/Clinical Skills

History and examination of the neonatal and pediatric surgical patient (with particular
attention to the respiratory and cardiovascular status)

SURGICAL CARE OF THE GERIATRIC PATIENT

Goal: To assess and manage geriatric patients with surgical problems, understanding the
similarities and differences from adult surgical patients.

Knowledge
Cardiovascular physiologic changes with aging
Pulmonary physiology changes with aging
Renal changes with aging
Endocrine changes with aging
Gastrointestinal changes with aging
Changes in pharmacotherapy with age
Age specific adjustments in nutritional therapy
Understanding of the challenges of working in partnership with elderly patients and
families
Recognize the possibility of abuse or maltreatment
Recognize limitations of own knowledge and experience and seek appropriate expert
advice

Patient Management/Clinical Skills

History and examination of the aging surgical patient (with particular
attention to the respiratory and cardiovascular status)

20
ORGAN AND TISSUE TRANSPLANTATION

Knowledge
Principles of transplant immunology including tissue typing, acute, hyperacute and
chronic rejection
Principles of immunosuppression
Tissue donation and procurement (including anatomy, organ preservation, and ischemic
time
Basic principle of organ allocation (UNOS)
Indications for whole organ transplantation
Definition of brain death

Patient Management/Clinical Skills

Evaluation of pre-transplant patient, including appropriate testing
Evaluation and management of donor
Monitoring of post-transplant patient
Management of acute and chronic rejection

Technical Skills
Cannulation and preservation of harvested organs

CORE GENERAL SURGICAL DISEASES (Excluding Cardiothoracic)

Goal: To access and initiate the investigation and management of common surgical conditions;
to have a sufficient understanding of these conditions and how they relate to a cardiothoracic
surgical career; to gain insight when specialty consultation is needed.

DISEASES OF THE GI TRACT AND ABDOMEN (Excluding Esophagus)

Knowledge
Presenting signs and symptoms (including abdominal pain, abdominal swelling, change in bowel
habits, GI bleeding, rectal bleeding, dysphagia, dyspepsia, jaundice) to include the following
conditions:
Appendicitis
Gastrointestinal malignancy
Inflammatory bowel disease
Diverticular disease
Intestinal obstruction
Mesenteric ischemia
Adhesions
Peritonitis
Intestinal perforation
Peptic ulcer disease
Benign and malignant hepatic, gallbladder, and pancreatic disease

21
 Hemorrhoids and perianal disease
Abdominal wall stomata
Adrenal gland disease

Patient Management/Clinical Skills

Examination of the acute abdomen
Evaluation and treatment of primary and metastatic tumors
Basic recognition, localization, and management of GI bleeding
Interpretation of diagnostic and imaging studies
Preop and periop management of patients undergoing abdominal surgery

Technical Skills
Standard techniques for laparotomy and exploration
Standard laparoscopic techniques, and exploration
PEG/open gastrostomy/jejunostomy
Basic bowel anastomosis (open, hand-sewn, and stapled)
Treatment and repair of splenic and hepatic injury
Pyloroplasty
Small and large bowel resection
Creation of stoma

DISEASES OF THE HEAD AND NECK

Knowledge
Lumps in the neck
Epistaxis
Upper airway obstructions
Benign and malignant skin lesions
Benign and malignant lesions of the mouth and tongue
Thyroid and parathyroid disease

Patient Management/Clinical Skills

Head and neck exam, including thorough lymph node examination
Management of acute airway obstruction including call for expert help
Recognizing benign and malignant skin lesions
Management of acute thyroid/parathyroid crises

Technical Skills
Laryngoscopy
Lymph node biopsy
Excision of skin lesion
Fine needle aspiration

BREAST DISEASE
Knowledge
Breast lumps and discharge

22
 Benign and malignant breast lumps
Mastitis and malignant breast lumps

Patient Management/Clinical Skills

Breast exam
Understand the different surgical procedures, including multimodality therapy

GENITOURINARY DISEASE
Knowledge
Urinary retention
Renal failure
Genitourinary malignancy
Urinary tract infection
Sources of hematuria
Obstructive uropathy (including BPH)

Patient Management/Clinical Skills

Urinary catheter management
Recognize urinary retention and pharmacologic management
Managing low and high urinary output
Recognition and treatment of urosepsis
Basic management of hematuria

Technical Skills
Urethral catheterization

NEUROLOGY AND NEURO-SURGERY

Knowledge
Neurologic exam, assessment, and anatomy
Differential diagnosis of acute and chronic altered neurologic status
Fundamental knowledge of ICP and lumbar drain monitoring
Principles and use of cerebral oximetry
Basic interpretation of cerebral imaging, EEG, and EMGs
SIADH and Diabetes Insipidus

Patient Management/Clinical Skills

Evaluation and management of acute neurologic decompensation
Manage acute anoxic brain injury (including air embolism)
Management of SIADH and Diabetes Insipidus
Manage acute stroke and seizure disorders
Brain death certification
Manage acute spinal cord injury related to CV Surgery

PROFESSIONAL BEHAVIOR AND LEADERSHIP SKILLS

23
Goals: To acquire and demonstrate interpersonal and communication skills that result in the
effective exchange of information and collaboration with patients, their families, and health
professionals; in addition, to demonstrate a commitment in carrying out professional
responsibilities and adhere to ethical principles.
To provide good clinical care, while respecting the patients privacy and autonomy
To be a good communicator
Recognize fatigue and stress within the surgical team
To teach and to train younger colleagues and students
To keep up to date and know how to analyze data
To understand and manage people and resources within the health environment
Be able to lead a team and delegate responsibility and roles
To promote good health
Practice ethical and legal obligations of a surgeon (patient privacy, HIPPA)
To have the competence and ability in obtaining informed consent
To understand the importance of a living will
To maintain comprehensive, timely, and legible medical and operative records
To be sensitive and responsive for a diverse patient population, including issues in
gender, age, culture, race, religion, disabilities, and sexual orientation

24
 GENERAL MANAGEMENT OF A PATIENT UNDERGOING CARDIOVASCULAR
SURGERY

Knowledge
Physiology
See Core Surgical Foundation
Myocardial cellular physiology
Electrophysiology
Physiology of congestive heart failure

Anatomy
See Core Surgical Foundation
Heart, pericardium and great vessels
Coronary anatomy
Valvular anatomy
Anatomy of the peripheral vascular system
Anatomy of cardiac innervation

Pathology
See Core Surgical Foundation
Atheroma, medial necrosis
Myocardial infarction and complications
Intrinisic myocardial disorders (IHSS, myocardial noncompaction)
Endocarditis
Pericarditis
Tumors of the heart
Sequelae of chest wall and mediastinal radiation

Pharmacology
See Core Surgical Foundation
Drugs used in the treatment of hypertension, heart failure, and angina
Inotropes, vasodilators and vasoconstrictors

Microbiology
See Core Surgical Foundation
Antibiotic prophylaxis for cardiac surgery

Imaging
See Core Surgical Foundation
Echo
Cardiac cath

Patient Management/Clinical Skills

General
Diagnosis, evaluation and treatment of heart disease

25
 Risk assessment (including when not to operate)
Cardiopulmonary resuscitation (open chest)
Cardiac arrhythmias diagnosis and management
Cardiac rehabilitation
Wound infection and sternal disruption
Cardiac tamponade
Interpretation of:
Hemodynamic data
ECG including exercise data
Coronary angiography
Cardiac cath hemodynamics
Echo including 2D, Doppler and transthoracic, stress echo
Nuclear cardiology
Cardiac MRI
CT angiography
Management of complications of cardiac surgery
Develop strategy for patients s/p XRT to the chest requiring thoracic surgery

Technical Skills
Median sternotomy
Intra-aortic balloon placement
Peripheral arterial and venous cannulation technique
Utilize alternative incisions for post XRT patients

CARDIOPULMONARY BYPASS, MYOCARDIAL PROTECTION, AND

CIRCULATORY SUPPORT

Basic Knowledge
Metabolic response to CPB
Temperature regulation
Principles of myocardial preservation
Physiology of balloon pump
Anatomy of femoral triangle and thoracic inlet and neck

Specific Knowledge
Principles and practice of CPB
Relevant equipment and technology and its application
Monitoring during CPB
Priming fluids and hemodilution
Acid base balance pH and alpha stat
Neuropsychological consequences of CPB
Cell salvage and blood conservation
Cardioplegia solutions and delivery modes
Noncardioplegic techniques of preservation
Intra-cardiac balloon pump indications for use, patient selection and complications

26
Patient Management/Clinical Skills
Coordination of perfusionist, anesthesiologist, and surgeon
Patient selection for mechanical circulatory support
Management of balloon pump
Conduct of CPB problem solving and trouble shooting
Weaning from bypass and decannulation
Recognize and manage acute complications of CPB

Technical Skills
Cannulation and institution of CPB
Repeat sternotomy with pericardial dissection, cardiac mobilization
Techniques and appropriate delivery of cardioplegia
Femoral or axillary cannulation and decannulation
Insertion and removal of aortic balloon pump
Open chest cardiopulmonary resuscitation

ISCHEMIC HEART DISEASE

Knowledge
Atheroma, medial necrosis
Diagnosis, investigation and treatment of ischemic heart disease
Results of surgery: survival, graft patency, recurrence
Arterial revascularization
Redo coronary artery surgery
Role of PCI and nonoperative treatment
Hybrid approaches
Complication of MI and ischemic heart disease: VSD, mitral regurgitation, aneurysm
On and off pump techniques
Role of TMR

Patient Management/Clinical Skills

Preop cardiovascular assessment including general history and exam, conduit
assessment, drug history, comorbidities, and risk assessment
Interpretation of cardiac hemodynamics
Imaging interpretation
Postop management including complications

Technical Skills
Mammary artery/radial artery harvest, venous conduit procurement
Proximal and distal coronary anastomosis (on pump and off pump)
Repeat coronary artery surgery
Complications of ischemic heart disease including post infarct VSD, mitral
regurgitation and left ventricular aneurysm
Minimally invasive conduit procurement
Combined coronary and carotid intervention

27
HEART VALVE DISEASE

Knowledge
Anatomy of cardiac chambers and valves
Valve physiology and hemodynamics
Calculation of valve area and regurgitant fraction
Anatomy of conduction system
Pathophysiology of valve incompetence and stenosis
Consequences of valve disease on cardiac function and morphology
Pathophysiology of mixed valve disease and combined valve pathology
Combined valvular and ischemic heart disease
Endocarditis and prosthetic valve endocarditis
Indications for operative management including: valve replacement/repair
(mechanical, biologic stented and stentless grafts, homografts and autografts)
Valve design: materials, anticoagulation and biomechanics
Results of surgery survival, long-term functional status, valve thrombosis,
endocarditis, bleeding
Alternative surgical approaches to valve surgery including thoracotomy,
transseptal/transapical approaches, minimal access surgery, and percutaneous approaches

Patient Management/Clinical Skills

Diagnosis, investigation and assessment of valvular heart disease
Determination of need and timing of surgical intervention valve disease
Cardiovascular system and general history and exam including drug history,
identification of comorbidity and risk assessment
Echo interpretation (thoracic and transesophageal)
Management of postop heart valve patient including complications
Medical management of endocarditis
Valve selection
Long-term anticoagulation and antibiotic prophylactic guidelines

Technical Skills
Aortic valve and root surgery: repair and replacement
Mitral valve surgery: repair and replacement
Tricuspid valve surgery: repair and replacement
Pulmonary valve and right ventricular outflow tract surgery: repair and replacement
Combined valve and graft surgery
Surgical strategies for managing small aortic root

GREAT VESSEL DISEASE

Knowledge
Vascular pathology (including atherosclerosis, inherited and acquired disorders)
Blood supply of the spinal cord
Spinal cord and cerebral preservation
Traumatic aortic transection

28
 Results of surgery survival, complication rates
Role of endovascular stenting
Medical management of great vessel disease
Knowledge of thromboembolic disease

Patient Management and Clinical Skills

Cardiovascular system and general history and exam including identification of
comorbidity and risk assessment
Interpretation of CT scan, MRI, aortography
Medical management of great vessel disease
Selection of patients for surgery
Management of postop patients including complications
Medical and surgical management of venous obstructive disease
Medical and surgical management of acute and chronic pulmonary embolic disease

Technical Skills
Intraop monitoring
Spinal cord and cerebral protection
Bypass and non-CPB strategies for major aortic surgery
Surgery for acute dissection of thoracic aorta
Aortic root replacement for acute and chronic aortic root disease
Complex aortic surgery, including aortic arch surgery, descending aortic and
thoraco-abdominal aortic surgery
Endovascular stenting
Pulmonary embolectomy
Great vessel venous reconstruction

PERIPHERAL VASCULAR DISEASE

Knowledge
Carotid artery disease and transient ischemic attacks
Aneurysmal disease
Leg ulceration
Atherosclerotic arterial disease
- aortic
- acute and chronic limb ischemia
Embolic and thrombotic arterial disease
Venous insufficiency
Diabetic ulceration
Pseudoaneurysms
Complication of vascular access

Patient Management/Clinical Skills

Vascular exam (including interpretation of ankle: brachial index)
Recognition and management of DVT
Recognition and management of acute limb ischemia

29
 Recognition and management of visceral ischemia

Technical Skills
Saphenous vein harvest
Vascular anastomosis
Embolectomy
Fasciotomy

CARDIAC CONDUCTION SYSTEM DISORDERS

Basic Knowledge
Anatomy of normal conduction pathways
Anatomy and influence of sympathetic and parasympathetic nervous system on cardiac
conduction
Characteristics of atrial conduction disorders (sinus node dysfunction, atrial flutter, atrial
fibrillation, Wolf-Parkinson-White syndrome, AV Node Reentry)
Characteristics of ventricular conduction disorders [ventricular tachycardia
(monomorphic vs. polymorphic), ventricular fibrillation, left bundle branch block,
right bundle branch block]
Risk factors for post-operative atrial fibrillation

Specific Knowledge
Adverse consequences of atrial and ventricular arrhythmias and current medical therapies
Indications for pacemaker placement for atrial and ventricular disorders
Indications and timing for automatic implantable cardiac defibrillators
Indications for epicardial lead placement
Indications for cardiac resynchronization therapy
Complications of intravascular leads (perforation, infection, great vessel stenosis)
Indications for and complications of catheter ablation

Patient Management/Clinical Skills

Select appropriate patient and lesion set for lone and concomitant surgery for atrial
fibrillation and define the success rates
Manage anti-coagulation and anti-arrhythmic medication after surgery for atrial
fibrillation
Manage post-operative atrial fibrillation
Complications of transvenous lead extraction
Determine the need for emergent operation after complications of ablation and lead
extraction
Select appropriate patients for the surgical treatment of cardiac dysrhythmias
Manage temporary cardiac pacing in the peri-operative setting

Technical Skill
Implant pacemakers and leads
Repair perforation after complication of ablation or lead extraction

30
 Perform an atrial fibrillation operation

DISEASES OF THE PERICARDIUM AND MYOCARDIUM

Knowledge
Anatomy of the pericardium
Pathology of the pericardium (benign, malignant, inflammatory)
Pathophysiological consequences of pericardial constriction and tamponade
Clinical and imaging techniques used to detect pericardial disease
Pericarditis (primary and post pericardiotomy)
Materials used for pericardial replacement
Complications following pericardial surgery
Indications for pericardial reconstruction
Cardiac tumors
HOCM

Patient Management/Clinical Skills

Interpretation of laboratory, physiological and imaging techniques, including echo
Recognition and assessment of pericardial tamponade and constriction
Recognition of pericardial herniation and cardiac strangulation
Postop management of patients following pericardial surgery
Management of cardiac tumors
Diagnosis and management of HOCM

Technical Skills
Needle aspiration of pericardial fluid with echo guidance
Pericardial window (subxiphoid, thoracoscopic approach)
Pericardiectomy for relief of constriction
Myocardial tumor resection
Surgical treatment of HOCM

HEART FAILURE AND CARDIAC TRANSPLANTATION

Knowledge
Etiology and natural history of heart failure
Modes of action and interaction of commonly used drugs in heart failure
Evaluation and management of advanced heart failure
Non-operative and operative strategies (CRT, AICD, SAVER, conventional
revascularization, valve repair/replacement)
Indications for acute and chronic mechanical assistance
Pathophysiology of nonpulsatile flow
Indications and assessment for heart transplantation
Acute and chronic cardiac rejection
Results of heart transplantation and non-transplant interventions for heart failure

31
Patient Management/Clinical Skills
Cardiovascular and general history and exam: preoperative assessment for cardiac
transplantation
Management of brain-dead donor
Management of postop transplant patient including complications
Familiarity with immunossupressant therapy
Diagnosis and treatment of device failure
Management of acute post-cardiotomy heart failure

Technical Skills
Familiarity with donor retrieval
Familiarity with cardiac transplantation technique
Surgical revascularization for ischemic cardiomyopathy
Ventricular remodeling surgery
Mitral valve repair for heart failure
Provision and management of acute mechanical ventricular support
Familiarity with extracorporeal and intracorporeal VADs

CARDIOTHORACIC TRAUMA

Knowledge
The mechanism and patterns of injury associated with blunt, penetrating, and
deceleration injuries to the chest
Indications and use of appropriate investigations in thoracic trauma management
Indications for thoracotomy in trauma

Patient Management/Clinical Skills

Post-ACLS definitive care of blunt, penetrating and deceleration injuries to the chest
Recognition and management of immediately life threatening situations:
obstructed airway, tension pneumothorax, massive hemothorax, open
chest wound, flail chest, and cardiac tamponade
Recognition and assessment of potentially life threatening situations:
lung contusion, bronchial rupture, blunt cardiac injury, intrathoracic bleeding,
esophageal injury, simple pneumothorax and major vascular injury

Technical Skills
(Core surgical skills plus)
Pericardiocentesis and subxiphoid window for tamponade
Various approaches to expose thoracic trauma
Repair of cardiac injuries
Repair of esophageal injuries
Repair of bronchial injuries
Repair of aortic transection
Repair of other great vessel injuries

32
GENERAL MANAGEMENT OF A PATIENT UNDERGOING THORACIC SURGERY

Basic Knowledge
Physiology, Pathology (see core)

Anatomy
Tracheobronchial tree and lungs
Thoracic inlet, neck, mediastinum and diaphragm
Esophagus, upper GI tract, and colon
Pleura and chest wall

Pharmacology
See core
Bronchodilators

Microbiology
See core
Management of intrapleural sepsis

Imaging
See core
PET/CT
V/Q scanning
Sestamibi scanning

Clinical Knowledge
Open versus minimally invasive approaches to thorax and abdomen
Early and late complications of thoracic incisions, and abdominal incisions

Clinical Skills
History and Examination
System specific and general history and examination, including drug history,
identification of comorbidity and functional status

Data Interpretation
(See core knowledge)

Patient Management
Risk assessment and stratification
Management of post-thoracic surgical complications
Postoperative management of pain control
Treatment of cardiac arrhythmias
Physiotherapy and rehabilitation
Understanding thoracic-specific ventilatory techniques (e.g., lung isolation)

33
Technical Skills
See core skills plus
Endoscopy
Bronchoscopy
Tracheostomy
Correct positioning of patient for thoracic surgery
Select, perform and close thoracic incisions, including lateral, anterior, muscle sparing,
median sternotomy and VATS incisions

NEOPLASM OF LUNG

Knowledge
Benign and malignant tumors of trachea, bronchus, lung
Epidemiology, genetic signatures, presentation, and diagnosis
Staging including all staging tools (CT, CT/PET, EBUS, EUS, Mediastinoscopy)
Multimodality management of thoracic malignancy
Non-resectional techniques (SBRT, RFA, etc)
Survival and recurrance patterns
Postop complications (BP fistula, space problems, empyema, prolonged air leak, etc.)
Surgical palliative techniques (stents, RFA, etc.)
Secondary and metastatic neoplasms of the lung

Patient Management/Clinical Skills

Clinical assessment to establish clinical stage (radiologic interpretation)
Assessment of function and risk
Diagnosis and management of non-thoracic metastatic lesions
Postop management including complications such as empyema, bronchopleural fistulae,
space issues, prolonged air leak, pneumonia, chylothorax, hemorrhage, etc.

Technical Skills
Surgery for benign and malignant conditions of the lungs (open and VATS)
Wedge resection
Lobectomy
Segmentectomy
Bilobectomy
Sleeve lobectomy
Resection with chest wall, including reconstruction techniques
Pneumonectomy
Carinal pneumonectomy
Extrapleural pneumonectomy
Pancoast tumors
Extended resections (SVC, spine, etc.)
Repeat resections for benign and malignant conditions of the lung, including completion
pneumonectomy
Clagett procedure and Eloesser flap

34
 Soft tissue flaps for stump coverage

BENIGN LUNG CONDITIONS

Bronchiectasis
Knowledge
Medical therapy
Role of surgery
Criteria for surgical resection
Diagnostic studies

Patient Management/Clinical Skills

Familiarity with medical therapy
Clinical evaluation and assessment for possible surgery

Technical Skills
Resection

Bacterial Infections
Knowledge
Community acquired pneumonias
Nosocomial pneumonias
Aspiration pneumonia
Lung Abscess
Pneumonia in the immunocompromised host
Antibiotic therapy

Patient Management/Clinical Skills

Clinical assessment
Techniques for culture
Interpretation of imaging
Advanced ventilator management (prone position)
Familiarity with medical therapy
Management of lung abscess

Tuberculosis and Atypical Mycobacteria

Knowledge
Epidemiology and screening
Clinical presentation
Medical treatment
Indications for surgery, including complications and outcome

Patient Management/Clinical Skills

Familiarity with medical therapy
Management of complications of Tb

35
 Timing and preparation of patients who are candidates for surgery

Technical Skills
Resection techniques (open and VATS)
Bronchial stump coverage

Mycotic Infections
Knowledge
Epidemiology of various fungal diseases
Diagnosis cultures/serology
Imaging
Manifestations of:
Histoplasmosis
Aspergillus
Coccidioidomycosis
Blastomycosis
Pulmonary cryptococcus
Mucormycosis

Patient Management/Clinical Skills

Familiarity with medical therapy
Role of Surgery

Parasitic Diseases
Knowledge
Hydatid disease
Epidemiology
Complications
Laboratory testing
Imaging
Diagnostic techniques
Familiarity with medical therapy
Surgical treatment

Interstitial Lung Disease

Knowledge
Categorization
Presentation, laboratory and physiological testing, and imaging
Diagnostic options
Role of lung biopsy

Patient Management/Clinical Skills

Assessment of surgical risk, probability of effecting treatment change

Technical Skills
Open and VATS lung biopsy

36
Emphysema and Bullae
Knowledge
Etiology, pathology and physiology of COPD
Smoking cessation measures and outcomes
Imaging and physiological (V-Q scan, pulmonary function, DLCO, etc.)
techniques
Surgical techniques and results used in the treatment of nonbullous emphysema
and bullae
Lung volume reduction surgery: patient selection, criteria, and surgical
techniques
Indications for bullectomy

Patient Management/Clinical Skills

Interpretation of imaging and pulmonary function
Patient selection with assessment of function and risk
Postop management of patients undergoing surgery for emphysema or
complications of the disease
Familiarity with pulmonary rehabilitation

Technical Skills
Procedures to deal with secondary pneumothorax and bullae by open and VATS
techniques
Lung volume reduction surgery, unilaterally and bilaterally, using open and
VATS techniques

DISORDERS OF THE PLEURA

Knowledge
Anatomy and physiology of the pleura
Inflammatory, infective and malignant diseases of parietal and visceral pleura
Pneumothorax (spontaneous, secondary, catamenial)
Complex pleural effusion/empyema
Mesothelioma
Hemothorax
Chylothorax
Fibrous tumor of the pleura

Patient Management/Clinical Skills

Chest drains insertion, management, removal and
treatment of complications
Interpretation of imaging of the pleura
Multimodality management of mesothelioma
Medical and surgical management of pleural disease, including radiological, open and
VATS techniques
Techniques to deal with failure of primary treatment

37
Technical Skills
Open and VATS procedures for uncomplicated pleural problems, (pneumothorax,
effusions, hemothorax, etc.) including drainage, biopsy, lytic therapy, and
pleurectomy
Open and VATS procedures for empyema, including techniques for decortication
Advanced techniques of pleural space obliteration
Surgical options for malignant mesothelioma
Resection of other pleural tumors

DISORDERS OF THE CHEST WALL

Knowledge
Anatomy of chest wall
Chest wall tumors
Congenital lesions (e.g. pectus deformities)
Thoracic outlet syndrome
Inflammatory/infectious conditions affecting the chest wall
Clinical, laboratory and imaging techniques used in the evaluation of chest wall
pathology
Techniques used in the diagnosis of chest wall disease
Techniques used to resect the sternum and chest wall, physiological and cosmetic
sequelae
Techniques of chest wall reconstruction (prosthetic and muscle flaps)

Patient Management/Clinical Skills

Interpretation of laboratory, physiological, and imaging techniques
Patient selection for operation
Diagnose and manage patients with thoracic outlet syndrome

Technical Skills
Chest wall biopsy and choice of appropriate technique (incisional biopsy, excisional
biopsy, FNA, core biopsy)
Chest wall resection for benign and malignant diseases, in combination with resection
of underlying lung
Selection and insertion of prosthetic materials for reconstruction
Surgery for complications of chest wall resection, and repeat surgery to resect recurrent
chest wall conditions
Complex chest wall reconstruction (muscle flaps)
Supraclavicular and transaxillary first rib approach to thoracic outlet syndrome
Chest wall deformity repair

DISORDERS OF THE DIAPHRAGM

Knowledge

38
 Anatomy and physiology of the diaphragm
Pathology of the diaphragm
Clinical, physiological and imaging techniques in the assessment of diaphragmatic
abnormalities
Physiologic consequences of diaphragmatic herniation or paresis
Surgical techniques used to biopsy and resect diaphragmatic tumors
Situations in which replacement of the diaphragm is required and reconstructive materials

Patient Management/Clinical Skills

Interpretation of physiological and imaging techniques
Patient selection
Management of patients after diaphragmatic operation

Technical Skills
Resection, repair and reconstruction of diaphragm
Diaphragmatic plication
Familiarity with diaphragmatic pacing

DISORDERS OF THE MEDIASTINUM

Knowledge
Anatomy of the mediastinum
Congenital, benign, infectious and malignant (primary and secondary) conditions of the
mediastinum
Systemic conditions associated with the mediastinum
Clinical, laboratory and imaging techniques used in the diagnosis and assessment of
patients with mediastinal disease
Myasthenia gravis: medical, surgical and periop management
Staging of thymoma
Oncologic treatment of malignant diseases of the mediastinum, including
multidisciplinary care (Thymoma, germ cell cancers)
Surgical techniques for the treatment of myasthenia gravis, mediastinal cysts and
tumors, complications, and results

Patient Management/Clinical Skills

Clinical history and exam
Interpretation of laboratory, physiological and imaging techniques
Patient selection with assessment of function and risk
Postop management and recognition of complications
Selection of appropriate routes for biopsy and excision of mediastinal tumor and cysts

Technical Skills
Biopsy of mediastinal masses
Thymectomy for myasthenia gravis
Resection of mediastinal tumors, including extended resection of adjacent structures

39
ENDOSCOPY
Knowledge
Endoscopic anatomy of larynx, trachea, bronchi, esophagus, stomach
Thoracic lymph node stations (including foregut)
Role of rigid and flexible bronchoscopy in the investigation of airway and pulmonary
disease
Role of rigid and flexible esophogoscopy in the investigation of esophageal disease
Role of mediastinoscopy, Chamberlain procedure or extended mediastinoscopy,
endobronchial ultrasonography (EBUS), and endoscopic esophageal
ultrasonography (EUS) in the staging of malignant and benign conditions of
the thorax
Anesthetic management and ventilating management during rigid and flexible endoscopy
Types of bronchial and esophageal stents
Application of lasers, PDT, cryotherapy, radiofrequency ablation, and endomucosal
resection (EMR) in Barretts or malignant esophageal disease
Nonsurgical ablative airway techniques

Patient Management/Clinical Skills

Choice of endoscopic techniques to stage thoracic malignancies
Choice of endoscopic techniques to palliate thoracic malignancies
Indications for postop bronchoscopy

Technical Skills
Rigid and flexible bronchoscopy
Rigid and flexible esophagoscopy
Mediastinoscopy
Chamberlain procedure
Familiarity with EBUS and EUS
Endobronchial and esophageal stenting
Bronchoscopic and esophageal biopsy, including management of complications
VATS approaches for biopsy and resection
Endoscopic management of tumors core-out, stents, laser, PDT
Techniques of esophageal dilation

DISORDERS OF THE AIRWAY

Knowledge
Anatomy of the larynx, trachea, and bronchus
Inflammatory, infectious, benign and neoplastic diseases of the airways
Symptoms, signs of airway disease
Techniques for surgical resection of the trachea
Bronchoplastic procedures and the limitations of these techniques
Medical and oncologic airway disease treatments

40
 Presentation, investigation, and management of anastomotic complications following
airway surgery
Presentation, evaluation, and treatment of fistulas in the aerodigestive tract due to benign,
malignant and iatrogenic causes

Patient Management/Clinical Skills

Interpretation of laboratory and imaging techniques
Diagnosis and assessment of airway obstruction
Patient selection with assessment of function and risk
Postop care of patients after airway surgery

Technical Skills
Sleeve resection of the trachea for simple benign conditions
Sleeve resection of the main bronchi, including lobectomy
Techniques for the relief of major airway obstruction, including stenting, core-out,
PDT, dilation, cryotherapy, etc.
Airway resection for tumors and complex benign conditions, and techniques for airway
reconstruction, anastomosis, and laryngeal release
Repeat resections for recurrence and complications of prior resection
Management of fistulas in the aerodigestive tract by surgical and endoscopic techniques

MANAGEMENT OF BENIGN ESOPHAGEAL DISORDERS

Knowledge
Esophageal and gastric anatomy
Anatomy of small and large intestine as related to reconstruction
Pathophysiology
Motility disorders (esophageal sphincter dysfunction, achalasia,
esophageal spasm
Diverticula (Zenkers, epiphrenic)
GE reflux and types of hiatal hernias sliding and paraesophageal
Trauma (blunt, penetrating, iatrogenic perforations, radiation-induced,
caustic ingestion, drug-induced)
Infection (Candida, herpetic)
Strictures (reflux-induced, caustic, anastomotic)
Tracheoesophageal fistula
Barretts esophagus
Diagnostic procedures and their interpretation
Imaging: radiography (Barium swallow/UGI series), CT scan, nuclear medicine
(gastric emptying, GE reflux)
Esophageal function tests (manometry, pH studies)
Drugs used in the treatment of GE reflux and dysmotility disorders
Treatment options for achalasia (pneumatic dilation, botox, surgery)

Patient Management

41
 General and specific history and exam, including previous surgery, identification of
comorbidity and risk assessment
Non-operative and operative options for treatment
Management of the postop patient
Management of postop complications

Technical Skills
Open and laparoscopic fundoplication (Belsey, Nissen, Dor, Toupet)
Open and laparoscopic esophagomyotomy
Reoperations (after failed anti-reflux/hiatal hernia surgery or surgery for motility
disorders)
Surgical treatment (Stent, Repair, Diversion) of esophageal perforation
Open or minimally invasive resection/esophagomyotomy for diverticula (Zenkers,
epiphrenic)

MANAGEMENT OF ESOPHAGEAL NEOPLASIA

Knowledge
Anatomy of the esophagus and its anatomical relationships from cricopharyngeus
to cardia, including details of blood supply and lymphatic drainage
Anatomy of the stomach, including its anatomical relationships, blood supply and
lymphatic drainage
Anatomy of the colon including its blood supply
Etiology and epidemiology of esophageal cancer
Metaplasia-dysplasia sequence
Role of induction therapy
Diagnosis, staging, and treatment options for esophageal cancer
Risk assessment of patients undergoing esophageal resection
Staging of esophageal cancer
Esophageal resection options
Palliative procedures (stents, laser, PDT, radiation therapy)
Treatment options for high grade dysplasia or very early esophageal cancer
Screening and prevention

Patient Management/Clinical Skills

Interpretation of staging tests
Risk assessment
Management of post-esophagectomy patient
Identification and management of post-resection complications (acute and chronic)
Long-term follow up and management of recurrence

Technical Skills
Mobilization of esophagus, stomach and colon
Esophageal resection (including different approaches)
Esophageal reconstruction including interposition techniques

42
 Jejunostomy
Management of intraoperative complications

LUNG TRANSPLANTATION

Knowledge
Patient and donor selection criteria
Basic pharmacology of immunosuppression
Reperfusion injury
Results of lung transplantation

Patient Management/Clinical Skills

History and exam including identification of comorbidity and risk assessment
Management of postop lung transplant patient
Management of acute and chronic complications of lung transplantation
Management of rejection

Technical Skills
Familiarity with donor retrieval, single and bilateral lung transplant, and management of
anastomotic complications

CONGENITAL HEART, LUNG AND THORACIC DISEASE

Knowledge Congenital Heart Disease

Physiology

Hemodynamics; physiology and measurement including shunt calculations, PVR, SVR

determinations
Physiology of Left-to-Right shunts and Right-to-Left shunts
Physiology of pulmonary vasculature and changes with development
Basic conduction disorders
Acid base balance (including Ph stat and alpha stat CPB mgmt)
Physiology of pediatric cardiopulmonary bypass including hypothermia, low-flow, and
circulatory arrest.

Anatomy
Basic embryology of the heart, lungs, great vessels
Coronary anatomy and variants
Location and course of the conduction system in congenital heart disease
Anatomy as it pertains to vascular conduits including aortopulmonary shunts
Basic anatomy of atrial septum and ventricular septum
Basic concepts of cardiac position, situs, atrioventricular and ventriculoarterial
connections

43
Pathophysiolology
Basic concepts of volume and pressure overload

Pharmacology
Specific drugs used in the treatment of congenital heart disease (beta blockers, ACE
inhibitors, Digoxin, Diuretics, PGE1, nitric oxide, systemic vasodilators)
Specific dosing and application
General indications and use of inotropes, anti-arrhythmic drugs, hemostatic drugs,
antiplatelet, anticoagulant and thrombolytic drugs, analgesics, antibiotics,
anesthetic agents, and vasodilators (systemic and pulmonary) in the pediatric
population

Clinical Knowledge
Proficiency with the anatomy, pathophysiology, natural history, management, and
results of the following conditions or procedures:
Mechanisms of cyanosis
Manifestations of congestive heart failure in infants and children
Patent ductus arteriosus
Atrial septal defect
Ventricular septal defect
Coarctation
PA banding and shunts
Transposition of the great arteries/arterial switch procedure
Tetralogy of Fallot
Vascular rings
Familiarity with anatomy, pathophysiology, natural history, management, and results of
the following congenital conditions or procedures.
Functional single ventricle leading to single ventricle pathway and principles of
treatment (Fontan procedure)
Congenital aortic stenosis/insufficiency (Konno, Ross procedure)
Rastelli procedure
Hypoplastic left heart and Norwood procedure
Truncus arteriosus
Double outlet right ventricle
VSD, Pulmonary atresia, and MAPCAs
Pulmonary atresia and intact septum
Partial and complete atrioventricular septal defects
Mitral valve disease
Tricuspid valve disease including Ebsteins anomaly
Interrupted aortic arch
Total anomalous pulmonary venous drainage
Extra Corporeal Membrane Oxygenation
Transplantation Heart and Lung
Vascular sling (Anomalous origin of LPA from RPA)

Patient Management/Clinical Skills

44
History and Examination
Cardiovascular system and general history and examination of child or adult with
congenital heart disease

Data Interpretation
Routine hematology and biochemical investigations
Chest radiograph and ECG
Cardiac catheterization data including interpretation of hemodynamic data, shunt and
resistance calculation
Basic congenital heart disease imaging (Echo, MRI, CT) interpretation

Patient Management
Diagnosis, assessment, and treatment of common congenital heart disease
Collaborative and complementary role of interventional cardiology
Risk assessment and stratification
Basic pediatric intensive care to include ventilator management
Perioperative management of adults and children following congenital heart surgery
Mechanical assist (IABP, VAD, ECMO)
Indications for heart or lung transplantation referral
Management of complications of surgery
Cardiopulmonary resuscitation
Diagnosis and treatment of common congenital cardiac arrhythmias
Wound infection and sternal dehiscence

Technical Skills
Sternotomy - open and close
Thoracotomy - open and close
Preparation for and management of cardiopulmonary bypass including partial bypass
Basic ECMO techniques, cannulation, and management.
Basic Surgical management of uncomplicated cases:
Patent ductus arteriosus
Atrial septal defect
Coarctation
PA banding and shunts
Ventricular septal defect

Knowledge Congenital Thoracic Disease

Familiarity with anatomy, pathophysiology, natural history, management, and
results of the following congenital conditions or procedures:
Congenital lung disease (cystic adenomatoid malformation, congenital lobar
emphysema, sequestration
Foregut duplication cysts
Diaphragmatic hernia and eventration
Esophageal atresia/fistula
Diagnosis, assessment, and treatment of common congenital pulmonary and
esophageal disease

45
Congenital thoracic disease imaging interpretation

46