Cardiovascular Anesthesia and Critical Care (TGH)

(8–10 positions per year)

Clinical Curriculum

The 12-month fellowship consists of 9 months spent in the OR’s and 3 months in the CVICU. About 6 weeks are dedicated to TEE training, which is considered a core clinical skill. Up to 8 weeks of academic time can be allocated. The goal is for fellows to be able to complete approximately 120 open chest cardiac cases per year involving CPB, of which about 50% will be valve repair or replacement, complex adult congenital repairs, root repair or replacement, LVAD insertion, heart transplants, TEVAR's, and TAAA’s. Off-pump coronary artery bypass (OPCAB), minimally invasive CABG, and valve surgeries are also done on a regular basis.

An elective cardioversion list is scheduled weekly. Arrhythmia ablation as well as pacemaker insertion, including biventricular and epicardial systems; insertion of aortic stents (coarctation); device closure of ASD’s, VSD’s, LAA's, and perivalvular leaks; percutaneous valve repair (including MitraClips); and replacement (including TAVI’s) have become integral parts of the cardiovascular anesthesiologist's duties.

Heart transplants and ventricular assist devices are managed under the heart failure program. The centre performs an average of 30–40 heart transplants and 30–40 ventricular assist devices per year.

The CVICU is a 27-bed unit that is managed by the department of cardiovascular anesthesia in conjunction with the department of cardiovascular surgery. The anesthesia fellow's weekday coverage is from Monday to Saturday, and the evening and overnight calls alternate with those of the cardiac surgical fellows. During the time in the CVICU, the fellow will become proficient in the management of post-operative cardiac surgical patients, including heart transplants and ventricular assist devices.

Call duties

Currently, cardiac OR calls are done from home on a rotational basis. The Cardiac OR call will include, on average, 2 weekends per month, with weekday calls as well. Cardiac anesthesia fellows can expect to be scheduled for calls 4–7 times per month. The anesthesia CVICU fellows do a week of daytime calls, Monday to Saturday, followed by a week of night calls on Monday, Wednesday, Friday, and Sunday. This arrangement can be changed. During the 12-month fellowship, fellows will complete about 12 weeks of CVICU.

Potential applicants from countries with limits on working hours should note that no such legislation exists in Canada. It would be impossible to gain the level of experience for which we are known if there were. However, we aim to make sure no one works >24 hours unless they have had sufficient rest and wish to finish their overnight cases.

Education Curriculum

TEE reading sessions are mandatory for fellows. Wednesdays comprise a formal didactic TEE topic, followed by relevant clinical cases. Thursdays have a formal reading session where challenging or illustrative cases from the previous week are reviewed.

There are several multi-disciplinary rounds in the hospital that are weekly, and fellows are strongly encouraged to attend if there is no conflict with their clinical duties. These rounds include cardiovascular didactic and triage rounds, congenital heart rounds, and heart transplant rounds.

Weekly teaching sessions are held Tuesdays at 17:00, covering various TGH practice-specific topics. Monthly professor rounds are organized on Mondays at 17:00. Departmental rounds are scheduled for Friday mornings at 07:30. Monthly cardiac-fellows-directed rounds are organized by the cardiac-fellows group around core topics related to cardiac anesthesia, normally held on Mondays at 17:00.

Research

Participation in research and education is expected. Research is integrated into the fellowship, with academic time provided to those involved in projects, with a goal of one non-clinical day per week up to a maximum of 40 days over a 12-month fellowship period. There are ongoing trials in which they may participate, or they may embark on their own individual research projects.

Participation and presentation at academic conferences are encouraged. Travel grants are available for research presentations at eligible North American meetings.

Application Requirements and Process

The fellowship is aimed at anesthesiologists in their early professional careers. Interested applicants need to have successfully completed all the required anesthesia examinations, be registered with the official regulatory authorities, and have at least 5 years of anesthesia training and experience at an academic centre. (1 of the 5 years may include a rotational year, also known as an internship, a houseman year, and a medical officer year).

Experience as a staff anesthesiologist based in the operating room in an academic setting for 1-2 years is strongly advised. Your clinical anesthesia practice should be current, and exposure during the preceding three years of a fellowship should have a strong operating room component.

You will need to have significant experience managing life-threatening situations such as massive transfusions, cardiac failure, critical vasoplegia, hemodynamically unstable arrythmias, and profound fluid shifts before you start this fellowship. This is not the opportunity to acquire this experience; you will need to be comfortable and able to manage independently in such situations when you arrive. We are here to teach you the technically demanding subspecialty of cardiac anesthesia, preferably so that you go on to do cardiac anesthesia in your consultant life, not give you an opportunity to gain “big case experience.”

It is very hard to come to a new country with a completely different medical system and culture, possibly in a second language, and jump straight into doing some of the most complex anesthesia there is. We often offer people a 6–12-month placement in our Advanced Clinical Practice (ACP) fellowship, which offers excellent experience in non-cardiac cases in its own right, as a way into our program with a “softer landing." It’s an opportunity to get used to our department and Canadian practice without the intensity of the cardiac fellowship and for us to get to know you with a view to offering you a cardiac fellowship if all goes well.

A current and valid ACLS certification is a requirement.

Applicants need to apply by using the online platform.

Shortlisted candidates will be contacted 12–18 months before the tentative start date for reference letters and to further the application. Please do not send any reference letters until requested to do so.

Successful candidates will be notified about 9–15 months ahead of a potential start date. An interview might be required.

Begin Your Application

Applicants must apply using the online platform.

Applications for January 2025 have closed.

If you are interested in applying for July 2025, please complete this online application form.

If you are interested in applying for January 2026, please complete this online application form.

Send direct inquiries to

Dr. Adam Snyman
Coordinator, Fellowship Program
Toronto General Hospital, 200 Elizabeth Street, EN3-438
Toronto, ON, Canada M5G 2C4
adam.snyman@uhn.ca