1 Cardiovascular/Thoracic Surgery CAQ Blueprint Content Area Percentage 1. Cardiac 40 2. Thoracic 15 3. Vascular 5 4. Assist Devices 5 5. ICU Management 15 6. Clinical Skill Requirements 5 7. Pharmacotherapy 10 8. Quality Metrics 5 The following clinical tasks apply to all categories below: – Patient presentation – Anatomy and physiology – Preoperative evaluation and management – Invasive and noninvasive imaging – Operative and non-operative intervention – Postoperative management 1. CARDIAC (40%) o Non–ST-segment elevation A. Aortic disease myocardial infarction • Aneurysm • Incomplete revascularization Root o • Prinzmetal variant angina Arch o • Post infarct complications Ascending o Dressler syndrome Pseudoaneurysm o o Left ventricular aneurysm • Aortic root disorders o Left ventricular wall rupture • o Connective tissue disorders Papillary muscle rupture • Dissection o o Ventricular septal defect B. Congenital conditions • Revascularization techniques and • Anomalous origin of the coronary artery conduits • Atrial septal defect • Coarctation of the aorta • Patent ductus arteriosus D. Electrophysiologic disorders • Patent foramen ovale • Atrial fibrillation/flutter • Persistent left superior vena cava • Blocks (atrioventricular, bundle branch, • Tetralogy of Fallot complete) • Ventricular septal defect • Bradycardia C. Coronary artery disease • Device-related infection • Acute coronary syndrome • Intraventricular conduction delay o Stable angina • Paroxysmal supraventricular tachycardia o Unstable angina • Tachycardia-bradycardia syndrome o ST-segment elevation myocardial • Torsades de pointes infarction • Ventricular tachycardia/fibrillation • Wolff-Parkinson-White syndrome DI. Pericardial conditions • Cardiac tamponade 2 • Constrictive pericarditis o Aortic stenosis o Iatrogenic o Bicuspid aortic valve o Idiopathic • Endocarditis Infectious o o Acute/subacute/chronic infective • Pericardial effusion Annular abscess Hemorrhagic o o o Heart block o Infectious Leaflet perforation Neoplastic o o o Native valve o Postcardiotomy Noninfective Radiation-induced o o o Prosthetic valves o Traumatic • Mitral valve disease o Uremic Mitral regurgitation • Restrictive pericarditis o o Mitral stenosis o Mitral valve prolapse o Papillary muscle rupture F. Structural heart disease o Systolic anterior motion • Acute heart failure (systolic and diastolic) • Tricuspid valve disease Tricuspid regurgitation o Ischemic disease o o Myocarditis o Postpartum o Sepsis o Takotsubo o Valvular disease • Chronic heart failure (systolic and 2. THORACIC (15%) diastolic) A. Esophageal disease o Alcohol-induced • Achalasia o Dilated • Barrett esophagus Drug-induced o • Diverticula Hypertrophic (subaortic stenosis) o • Dysmotility Idiopathic o • Infectious Esophageal ring (Schatzki); esophageal o stricture o Infiltrative Ischemic • Esophageal tumors o Benign neoplasm o Restrictive o Rheumatic . Leiomyoma o Carcinoma o Tachycardia-induced o Valvular . Staging, treatment, and prognosis o . • Right ventricular heart failure Adenocarcinoma . G. Trauma Squamous cell • Aortic: transection, dissection • Esophageal ulcer • • Cardiac: contusion, penetrating, iatrogenic Gastroesophageal reflux disease • • Pericardial: pericarditis, effusion Hiatal hernia H. Tumors • Paraesophageal hernia • Fibroelastoma • Rupture, esophagus • Left atrial myxoma o Tears and perforations B. Congenital conditions • Right atrial myxoma • I. Valvular disease Arteriovenous malformation • • Aortic valve disease Bronchogenic cyst Aortic insufficiency (regurgitation) • Diaphragmatic hernia o • Esophageal duplication cyst • Pulmonary sequestration • Sternal deformities 3 C. Lung disease • Dissection • Cancer (non–small-cell and small-cell) B. Carotid disease o Cancer staging, treatment, and • Hyperperfusion post carotid prognosis endarterectomy o Pancoast tumor • Stenosis, dissection, hyperplasia o Metastatic • Symptomatic, asymptomatic o Carcinoid neoplasm C. Peripheral artery disease • Obstructive disease • Compartment syndrome Chronic obstructive pulmonary disease o • Mesenteric disease • Parenchymal disease • Occlusive, dissection, aneurysms, Pneumoconiosis o pseudoaneurysms Sarcoidosis o • Renal artery stenosis Tuberculosis/Ghon complex o • Thoracic outlet syndrome • Pulmonary nodules D. Peripheral venous disease • Restrictive disease • Insufficiency CI. Mediastinal disease • Thrombosis • Anterior neoplasms E. Trauma Germ cell tumor o • Aortic transsection o Lymphoma o Myasthenia gravis o Thymoma • Posterior neoplasms o Neurogenic tumors • Penetrating injury CII. Pleural disease • Retroperitoneal hemorrhage • Effusions Chylothorax o 4. ASSIST DEVICES (5%) o Exudates . Empyema Indications, contraindications, complications, . Malignant management of: o Hemorrhagic A. Intra-aortic balloon pump o Transudative (hydrostatic leakage) B. Extracorporeal membrane oxygenation • Mesothelioma C. Left ventricular assist device CIII. Trauma D. Percutaneous ventricular assist device • Diaphragmatic injury E. Right ventricular assist device • Flail chest • Hemopneumothorax • Hemothorax 5. ICU MANAGEMENT (15%) • Pneumothorax A. Cardiovascular o Catamenial Disease states: o Iatrogenic • Cardiac tamponade o Open, sucking wound • Heart failure o Spontaneous • Hypertension o Tension • Hypotension • Sternal fractures • Ischemic changes • Pericarditis • Shock o Cardiogenic o Distributive o Hypovolemic o Obstructive Skills: • Electrocardiographic interpretation 3. VASCULAR (5%) A. Aortic disease • Hemodynamic monitoring/management • Pacing and rhythm management • Aneurysm 4 • Resuscitation • Wound infection B. Endocrine Skills: Disease states: • Incision and drainage • Adrenal disorders • Negative pressure wound therapy • Endocrine neoplasms • Wound debridement • Hyperglycemia • Hypoglycemia F. Neurology • Thyroid disorders Disease states: C. Gastrointestinal • Cerebral ischemia, transient Disease states: • Cerebrovascular accident • Abdominal compartment syndrome • Delirium • Bowel obstruction • Nerve injuries • Bowel perforation o Brachial plexus • Clostridium difficile gastroenteritis o Laryngeal • Colitis o Phrenic Radial • Constipation o • Paraplegia • Diarrhea • Seizure disorders • Hemorrhage • Substance withdrawal • Ileus • Malnutrition • Mesenteric ischemia • Postoperative nausea and vomiting Skills: • Ulcers • Pain management • Sedation G. Pulmonary Disease states: • Acute lung injury/acute respiratory distress Skills: syndrome • Enteral support • Atelectasis D. Hematology • Barotrauma Disease states: • Chronic obstructive pulmonary disease • Anemia • Empyema • Coagulopathy • Laryngeal/tracheal edema • Heparin-induced thrombocytopenia • Pleural effusion • Postoperative hemorrhage • Pneumonia • Thrombocytopenia • Pneumothorax • Pulmonary embolism Skills: • Respiratory failure • Subcutaneous emphysema • Anticoagulation therapy • Blood component therapy • Chest tube management • Hemostasis monitoring Skills: • Thromboelastography • Arterial blood gas analysis • Chest tube management E. Infectious disease Disease states: • High-flow oxygen therapy • Bloodstream infections • Noninvasive ventilation • Endocarditis • Pulmonary hygiene • Pneumonia • Tracheostomy • Sepsis • Ventilator management • Systemic inflammatory response syndrome (SIRS) H. Renal • Urinary tract infection Disease states: • Acid-base disorders • Acute kidney injury 5 • Electrolyte abnormalities • Atrial fibrillation correction • End-stage renal disease • Bentall procedure • Oliguria • Closure of atrial and ventricular septal Skills: defects • Bladder pressure monitoring • Conduit harvesting (endoscopic and open) • Fluid and electrolyte management o Arterial • Renal replacement therapy . Internal thoracic artery • Total parenteral nutrition support . Radial artery o Venous . Greater saphenous vein 6. CLINICAL SKILL REQUIREMENTS (5%) . Lesser saphenous vein Indications, contraindications, complications • Coronary artery bypass grafting related to: • David procedure • Excision of cardiac tumors and aneurysms A. Imaging • Mitral valve repair/replacement • Arteriography • Pericardial window • Cardiac catheterization • Pericardiectomy • Cardiac stress testing • Pericardiocentesis • CT angiography • Surgical aortic valve replacement • CT scan • Thrombectomy • Echocardiography • Transcatheter aortic valve replacement • Electrocardiography • Transplantation • Esophageal manometry • Tricuspid valve repair/replacement • Esophageal ultrasonography Thoracic: • MR angiography • Bronchoscopy • MRI • Cervical mediastinoscopy • Myocardial perfusion imaging • Chest wall reconstruction • PET/CT scan • Clagett procedure • Radionuclide studies • Decortication • Venous and arterial ultrasonography • Diverticulectomy • X-ray studies • Endobronchial ultrasonography Barium swallow x-ray study o • Esophagectomy B. Invasive/noninvasive procedures • Esophagogastroduodenoscopy • Arterial line placement • Navigation bronchoscopy • Central venous access/Swan-Ganz • Nissen fundoplication catheterization • Parasternal mediastinotomy • Chest tube placement/thoracentesis (Chamberlain) • Emergency resternotomy • Pleurodesis • Intra-aortic balloon pump placement/ • Resection of benign and malignant lesions removal • Sympathectomy • Peripheral vessel examination • Thoracotomy o Ankle-brachial index Modified Allen test • Transthoracic needle biopsy o • Video-assisted thorascopic surgery o Vein mapping • Pulmonary function studies (VATS) • Transvenous pacing • Wound management C. Operative procedures Cardiac: • Ascending aortic replacement 6 Vascular: • Corticosteroids •