Cardiothoracic Critical Care Training – The Evolving Landscape

Critical Care Medicine and its growth:

Over the past few decades, critical care medicine has rapidly evolved into the cornerstone of modern healthcare. The recent pandemic made us aware of the need for critical care specialists. The demand for intensive care services has continued to rise in response to the increasing complexity and acuity of both medical and surgical conditions. This escalating need globally is reflected by the increased proportion of hospital beds allocated to intensive care units (ICUs), highlighting their essential role in managing life-threatening conditions. Critical care physicians are at the forefront of managing an increasing population of patients facing life-threatening conditions and are tasked with leading multidisciplinary care of these patients, applying cutting-edge medical and technological support in the most challenging clinical scenarios. 

Role of Critical Care Anesthesiology

Critical care anesthesiology stands at the intersection of perioperative medicine and intensive care.¹ Globally, many intensivists are trained anesthesiologists, reflecting the natural overlap between these disciplines. Anesthesiologists excel in critical care due to their proficiency in managing complex physiological states, extensive pharmacology knowledge, expertise in advanced airway management, hemodynamic monitoring, and life-sustaining technologies. In many countries, anesthesiologists are not only the backbone of perioperative care but also serve as leaders in critical care, where they apply their skills to critically ill patients, whether pre- or post-surgical or experiencing medical emergencies. The training of an anesthesiologist equips them to care for critically ill patients in both pre- and post-surgical contexts, as well as in medical emergencies. This dual competency allows anesthesiologist to manage the full spectrum of critical illness improving outcomes across various domains of care.  

Cardiothoracic Intensive Care Unit

In 1956, the first ICU dedicated to postoperative cardiac surgery patients was established at Saint Mary’s Hospital in Minnesota, marking a pivotal moment in the evolution of cardiac critical care.² Since then, the characteristics of patients admitted to cardiothoracic surgical intensive care units (CTICUs) have evolved dramatically. Modern CTICUs are not only focused on traditional cardiac and thoracic surgeries but also treat a wide variety of complex aorto-vascular pathologies, structural heart disease, multi organ transplants and various forms of shock. The use of mechanical circulatory devices has become routine further expanding the scope of care. As the complexity of care continues to increase cardiothoracic critical care continues to evolve requiring advanced competencies. The American Heart Association now recommends dedicated cardiac critical care intensivists, recognizing the increasing complexity and specialized care required for these patients. This endorsement highlights the growing need for intensivists with expertise in this critical area.³

Anesthesiologists as Leaders in Cardiothoracic Critical Care

In the early days of CTICU surgeons primarily led the management of these specialized units. However, in the past few decades, anesthesiologists have increasingly assumed a pivotal role in caring for patients in these highly specialized units. A recent survey revealed that up to 70% of critical care anesthesiologists now practice within CT-ICUs, highlighting the growing prominence of this discipline in the management of complex cardiac and thoracic surgical patients.⁴

Anesthesiologists are uniquely equipped for this role due to the comprehensive training they receive during residency, which typically includes rotations in critical care (minimum of four months), cardiac anesthesiology (two months), and thoracic anesthesiology (one month). This training provides a solid foundation in advanced airway management, invasive monitoring, and basic echocardiography. Additional exposure during anesthesiology critical care fellowships, with two to four months of CTICU-specific training, further equips anesthesiologists with the specialized skills needed to care for critically ill cardiothoracic patients. This comprehensive exposure to cardiac critical care, combined with the breadth and depth of training, positions anesthesiologists to excel in CTICUs and significantly contribute to improved patients’ outcomes. However, given the increasing complexity of patients within CTICUs, subspecialized training beyond the scope of general cardiothoracic critical care is essential to meet the demands of modern practice and optimize patient outcomes.⁵ Expertise in advanced hemodynamics, both perioperative transthoracic and transesophageal echocardiography, managing complex shock states, and most importantly, the proficiency in the full spectrum of mechanical circulatory support devices from decision making to weaning is essential to optimize outcomes and meet the evolving demands of cardiothoracic critical care. 

Key Competencies: Advanced Hemodynamics, Echocardiography and Mechanical Circulatory Support 

Basic competencies in cardiothoracic critical care have already been proposed.⁵ In addition to these, it is critical for intensivists to master advanced hemodynamics and shock management, perioperative and critical care echocardiography, and possess proficiency in managing mechanical circulatory support devices to meet the demands of modern CTICUs. These advanced competencies allow intensivists to deliver high-level care for patients with complex shock states or advanced heart failure, where precision and expertise in life-support technologies are paramount.

Current Educational Pathway and Challenges 

Currently, most anesthesiologist-intensivists practicing in CTICUs are board certified in critical and some have additional training in cardiothoracic anesthesiology. Over the past decade, there has been a notable increase in critical care anesthesiology fellowship programs and positions. Furthermore, the number of trainees pursuing dual fellowship training in cardiothoracic and critical care anesthesiology has increased, underscoring the importance of a combined skill set. However, despite these, significant challenges remain in formalizing a standardized training pathway. One major challenge is the considerable variability among fellowship programs, particularly regarding case variety exposure and educational curricula. This inconsistency may limit the development of the comprehensive expertise. Additionally, the lack of standardized case benchmarks and competency assessments results in disparities in skill acquisition. There is a need to address these challenges and establish uniform competencies, training pathways and standardizing curricula to ensure that the future anesthesiologists are well equipped to meet the evolving demands of cardiothoracic critical care. 

Proposed Pathway 

We propose the following pathways based on the literature coming out of the cardiology critical care training pathways to cardiothoracic critical care, emphasizing a core foundation in critical 

care medicine (Figure 1). Both pathways are designed to ensure comprehensive training in the critical areas of cardiothoracic intensive care, focusing on advanced hemodynamics and shock management, perioperative and critical care echocardiography, and the management of mechanical circulatory support devices. These pathways provide a structured yet flexible framework, allowing trainees to develop expertise tailored to their career goals. Integrating robust training experience with these pathways aims to produce clinicians capable of excelling in the rapidly evolving field of cardiothoracic critical care. A similar pathway could be considered for anesthesiologists considering a career in transplant or obstetrics critical care. 

Conclusion 

The increasing complexity of patients in CTICUs underscores the growing demand for cardiothoracic intensivists with a multidisciplinary skill set. Anesthesiologists with our robust foundation in perioperative and critical care medicine are uniquely positioned to meet this demand. We should work towards refining training pathways and addressing goals in educational structures to better prepare future anesthesiologist intensivist to manage the nuances of CTICU care. and drive innovation in this field. We call upon the American Board of Anesthesiology, the American Society of Anesthesiologists, Society of Critical Care Medicine, the Society of Critical Care Anesthesiologists, and the Society of Cardiovascular Anesthesiologists to collaborate on establishing clear competencies and structured curricula to address the growing unmet need for highly trained cardiothoracic intensivist, ensuring better patient outcomes and leadership in this evolving field. 

Figure 1

*- Anesthesiology training should provide a total of a year of echocardiography training between electives, cardiothoracic anesthesiology, and critical care training. 

# Integrated training focuses on cardiac critical care with touchpoints with other critical care subspecialities.

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