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ABA Adult Cardiac Anesthesiology (ACA) Examination Content Outline A. Foundations of Adult Cardiac Anesthesiology 1. Anatomy * a. Embryological development * Primitive heart structures * Timing of development * Blood flow to the fetus and newborn * b. Cardiac Anatomy * i. Chambers and valves * ii. Coronary circulation * iii. Great vessels and surrounding structures * iv. Conduction system * c. Thoracic anatomy * i. Lungs * ii. Chest wall * iii. Vascular structures * d. Histology of the heart 2. Physiology * a. Electrophysiology * Ion channels * Currents * b. Cardiac cycle * i. Pressure-volume relationships * ii. ECG timing * iii. Valvular function * c. Ventricular function * i. Systolic function * Myocardial contractility * Myocardial oxygen balance * LV vs RV * ii. Diastolic function * d. Regulation of circulation and blood volume * i. Arterial pressure * Systolic, diastolic, mean and perfusion pressures * Systemic and pulmonary vascular resistance * Baroreceptors * Peripheral receptors * Reflexes * ii. Venous return * Vascular compliance and venous capacitance * Blood volume and distribution * iii. Central * Vasomotor center * Hypothalamic-Pituitary-Adrenal Axis --- B. Preoperative Evaluation of the Patient for Cardiac Surgery 1. Non-invasive cardiovascular evaluation and interpretation * a. Electrocardiography * b. Echocardiography * c. Evaluation of cardiac ischemia * i. Stress testing (ECG, ECHO) * ii. Myocardial nuclear scintigraphy * SPECT * PET * d. Cardiovascular imaging * MRI * CT 2. Cardiac catheterization procedures and diagnostic interpretation * a. Left-sided tracings * i. Normal pressures and waveforms * ii. Valvular pathologies * Stenotic * Regurgitant * b. Right-sided tracings * i. Normal pressures and waveforms * ii. Valvular pathologies * Stenotic * Regurgitant * iii. Shunt calculations * c. Angiography 3. Oral medications – pharmacology and perioperative management * a. Blood pressure * i. Beta-blockers * ii. ACE inhibitors * iii. Other medications * b. Antidiabetic agents * c. Antiarrhythmics * d. Diuretics * e. Statins * f. Anti-platelet agents * i. Dual anti-platelet therapy * ii. ADP inhibitors * g. Anticoagulants * i. Warfarin * ii. Direct oral anticoagulants * h. Guideline-directed medical therapy for heart failure 4. Preoperative optimization * a. Anemia and blood conservation * b. Prehabilitation --- C. Intraoperative Monitoring of the Patient Undergoing Cardiac Surgery 1. ECG monitoring 2. Arterial pressure monitoring * a. Invasive and noninvasive differences * b. Site specific indications, contraindications and limitations * c. Complications * d. Waveform analysis * Pulse pressure variation 3. Central venous pressure monitoring * a. Cannulation sites and insertion techniques * b. Complications * c. Pressures and waveforms 4. Pulmonary arterial catheterization * a. Pressures and waveforms * b. Cardiac output measurement * Thermodilution vs other methods * c. Mixed venous oxygen saturation 5. Alternate methods of cardiac output assessment * Esophageal Doppler * Bioimpedance 6. Transesophageal echocardiography * a. Contraindications * b. Evaluation of myocardial function * EF * Cardiac output calculation * Strain * c. Evaluation of valvular function * d. Evaluation of intracardiac masses * e. Evaluation of cannulas and devices 7. Neurophysiologic monitoring * Cerebral oximetry * Peripheral oximetry 8. Temperature monitoring 9. Coagulation monitoring * a. Activated clotting time (ACT) * b. Viscoelastic testing * TEG * ROTEM --- D. Management of Cardiopulmonary Bypass (CPB) 1. Anticoagulation issues * a. Heparin pharmacology and management * b. Altered heparin responsiveness * Heparin resistance * c. Heparin-induced thrombocytopenia * i. Diagnosis * ii. Management * iii. Heparin alternatives * d. Antifibrinolytic therapy 2. The CPB circuit * a. Cannulation considerations * i. Central cannulation * ii. Alternate cannulation sites * iii. Aortic cross-clamp * iv. Complications during cannulation * b. Cardioplegia * i. Delivery * ii. Effects * c. Flow and line pressures * d. CPB effects on pharmacokinetics and pharmacodynamics 3. Temperature management * a. Effects of hypothermia * b. Rewarming * c. Inflow and outflow temperatures * d. ABG interpretation * Alpha-stat vs pH-stat * e. Cold agglutinins 4. Physiological disturbances of CPB * a. Respiratory * b. Renal * c. Hematological * d. Neurological * e. Endocrine 5. Separation from CPB * a. Resuming cardio-respiratory function * i. Inotropes * ii. Vasopressors * iii. Vasodilators * Intravenous * Nitrates * Phosphodiesterase inhibitors * Inhaled * Nitric oxide * Prostaglandin * b. Pacing considerations * c. Reversal of anticoagulation * i. Protamine pharmacology * ii. Protamine reactions 6. Complications after CPB * a. Myocardial stunning * b. Vasoplegia * c. Coagulopathy 7. Treatment of bleeding * a. Transfusion of blood products * b. Pharmacologic agents --- E. Mechanical Circulatory Support 1. Intra-aortic balloon pump * a. Indications and contraindications * b. Placement * c. Timing * d. Complications 2. Temporary ventricular assist devices * a. Indications and contraindications * b. Intraoperative management * i. Role of TEE * ii. Anesthetic considerations * c. Percutaneous devices * i. Transvalvular microaxial continuous flow devices * Impella * ii. Trans-septal centrifugal devices * TandemHeart 3. Durable ventricular assist devices * a. Indications and contraindications * b. Intraoperative management for LVAD placement * i. Role of TEE * ii. Interpretation of VAD parameters * iii. Complications after LVAD placement 4. Extracorporeal membrane oxygenation (ECMO) * a. Indications and initiation of support * i. VA * ii. VV * iii. Other * b. Anticoagulation considerations * c. Complications * d. Anesthetic management * e. Weaning strategies --- F. Cardiac Diseases 1. Cardiomyopathy * a. Types * i. Dilated * ii. Ischemic vs non-ischemic * iii. Hypertrophic * iv. Restrictive * v. Other * Viral * Peripartum * Arrhythmia-induced * b. Medical and interventional management * i. Pharmacological interventions * ii. Pacing therapy * c. Surgical interventions * i. Septal ablation and myectomy * ii. Ventricular remodeling procedures 2. Chronic heart failure * a. Systolic heart failure (HFrEF) * i. Etiology * ii. Diagnostic criteria and testing * b. Diastolic heart failure (HFpEF) * i. Etiology * ii. Diagnostic criteria and testing * c. Medical and interventional management * i. Pharmacologic agents * ii. Cardiac resynchronization therapy * iii. Prophylactic ICD placement indications * d. Surgical interventions * i. Durable MCS * ii. Heart transplant and allocation status * Anesthetic considerations * Immunosuppression * Graft dysfunction * Primary * Delayed 3. Pericardial disease * a. Cardiac tamponade * i. Etiology * ii. Diagnosis * CXR * CVP/PAC waveforms * Echocardiography * iii. Anesthetic management and goals * iv. Treatment * Pericardiocentesis * Pericardial window * b. Constrictive pericarditis * i. Etiology and diagnosis * ii. Pericardiectomy 4. Ischemic heart disease * a. Risk factors * b. Determinants of myocardial oxygen requirements and delivery * c. Silent ischemia * d. Acute coronary syndrome * i. Clinical presentation * ii. ECG and echocardiographic findings * iii. Cardiac catheterization * e. Treatment * i. Pharmacological * ii. Interventional cardiology procedures * PCI and stent placements * Complications * No-reflow * In-stent restenosis * Dissection * iii. Surgical (CABG) * Indications for revascularization * Anesthetic management for patients with coronary disease * Alternate surgical techniques and anesthetic implications * Off pump * Minimally invasive * Robotic * Conduit considerations * Vein vs arterial * Site of harvest * Complications 5. Rare cardiac diseases * a. Neoplastic disease * i. Types * Benign * Malignant * ii. Anesthetic considerations * b. Infiltrative disease * i. Types * ii. Anesthetic considerations * c. Storage disease * i. Types * ii. Anesthetic considerations * d. Endomyocardial causes * i. Types * ii. Anesthetic considerations * e. CTEPH and pulmonary thromboendarterectomy --- G. Valvular Heart Disease 1. Aortic stenosis * a. Etiologies * i. Subvalvular * ii. Valvular AS * Pathophysiology * Congenital * Acquired * b. Diagnosis and severity assessment * i. Pressure waveforms * ii. Echocardiography * c. Treatment * i. Medical management * ii. Structural heart interventions * TAVR * Anesthetic management * Postprocedure complications * iii. Surgical AVR * Timing considerations * Anesthetic management for severe aortic stenosis 2. Aortic regurgitation * a. Etiologies * b. Diagnosis and severity assessment * i. Pressure waveforms * ii. Echocardiography * c. Treatment * i. Medical management * ii. Surgical management * Timing of intervention * Anesthetic management for severe aortic regurgitation * CPB considerations * LV venting * Cardioplegia 3. Mitral stenosis * a. Etiologies * i. Rheumatic disease * ii. Non-rheumatic causes of MS * b. Diagnosis and severity assessment * i. Pressure waveforms * ii. Echocardiography * c. Treatment * i. Medical management * ii. Surgical management * Timing of intervention * Anesthetic management for severe mitral stenosis 4. Mitral regurgitation * a. Mechanisms of MR * i. Primary vs secondary * ii. Carpentier classification * b. Acute vs chronic * c. Diagnosis and severity assessment * i. Pressure waveforms * ii. Echocardiography * d. Treatment * i. Medical management * ii. Percutaneous procedures * iii. Surgical management * Timing of intervention * Anesthetic management for severe mitral regurgitation * Repair vs replacement considerations * Surgical complications * Minimally invasive approach 5. Tricuspid regurgitation * a. Etiologies * Primary vs secondary * b. Diagnosis and severity assessment * i. Pressure waveforms * ii. Echocardiography * c. Treatment * i. Percutaneous interventions * ii. Surgical management * Indications for replacement vs repair * Anesthetic management for severe tricuspid regurgitation 6. Tricuspid stenosis * a. Etiologies * b. Diagnosis and severity assessment * i. Pressure waveforms * ii. Echocardiography * c. Treatment * i. Percutaneous interventions * ii. Surgical management * Indications for replacement * Anesthetic management for severe tricuspid stenosis 7. Prosthetic heart valves * a. Evaluation * i. Echocardiography * ii. Other imaging modalities * b. Complications 8. Endocarditis * a. Diagnosis * i. Clinical manifestations * Risk factors * Symptoms * ii. Laboratory abnormalities * iii. Echocardiographic evaluation * b. Surgical treatment * c. Complications --- H. Adult Congenital Heart Disease 1. General considerations * a. Corrected vs partial vs uncorrected lesions * b. Cyanotic vs acyanotic lesions * c. Existence of conduits * d. Pulmonary hypertension and Eisenmenger physiology * e. Single ventricle (Fontan) physiology * f. Repeat sternotomy considerations 2. Pulmonary valve disease * a. Echocardiographic diagnosis * b. Structural heart interventions * c. Surgical replacement 3. Considerations for specific lesions * a. Atrial septal defect * b. Ventricular septal defect * c. Aortic coarctation * d. Ebstein anomaly * e. Tetralogy of Fallot * f. Transposition of the great vessels --- I. Thoracic Aortic Disease 1. Acute aortic syndromes * Dissection * Intramural hematoma * Penetrating aortic ulcer * Trauma * a. Clinical presentation and complications * b. Diagnosis * CXR * Echo * CT * c. Classification systems * Stanford * DeBakey * d. Medical management * e. Surgical management * i. Indications for surgery * ii. Cannulation sites for CPB * iii. Complications * f. Anesthetic goals * g. Circulatory arrest considerations * i. Hypothermia * ii. Cerebral protection * Pharmacologic * Antegrade perfusion * Retrograde perfusion 2. Ascending and arch aneurysms * a. True vs pseudoaneurysm * b. Risk factors * Connective tissue disorders * Bicuspid aortic valve * c. Diagnostic modalities * d. Crawford classification system for thoracoabdominal aneurysms * e. Surgical treatment * i. Size indications for surgery * ii. Circulatory arrest considerations 3. Descending aortic aneurysms * a. TEVAR * b. Open repair * i. One-lung ventilation management * ii. Left heart bypass considerations * iii. Complications * Spinal cord ischemia * Renal failure * Recurrent laryngeal nerve injury * c. Spinal cord protection * i. Monitoring strategies * SSEP * MEP * ii. Pharmacologic strategies * iii. CSF drainage * Placement * Management * Complications * iv. Spinal perfusion pressure --- J. Electrophysiology Procedures 1. Advanced arrhythmia identification and management 2. Pacemaker insertion * a. Indications for PPM and ICDs * b. Types of PPM * i. Biventricular pacing (CRT) * ii. Leadless pacemakers * iii. Implantable cardioverter defibrillators (ICD) * iv. Subcutaneous ICD (S-ICD) * c. Perioperative management of cardiovascular implantable electrical devices * d. Modes of pacing * e. Anesthetic considerations for PPM lead extractions 3. Ablations: anesthetic considerations * a. SVT * b. Atrial fibrillation and atrial flutter * c. Convergent procedure * d. Ventricular tachycardia 4. Left atrial appendage occluder devices 5. Cardioversion considerations * Pharmacologic * Electrical 6. Radiation safety --- K. Postoperative Considerations 1. Pulmonary * a. Advanced mechanical ventilation modes * b. ARDS * c. TRALI * d. Considerations for liberation from mechanical ventilation 2. Cardiac * a. Management of arrhythmias * b. Coronary graft dysfunction * c. Tamponade * d. LV, RV, or biventricular failure * e. Vasoplegia 3. Hematologic * a. Management of coagulopathy * b. Need for return to OR 4. Pain control * a. Sedation considerations * b. Multimodal analgesia * c. Regional anesthesia for cardiac surgical patients * d. Ultrasound anatomy for chest wall nerve blocks 5. Neurologic * a. Delayed emergency * Stroke * Seizure * b. Postoperative cognitive dysfunction * c. Delirium --- L. Other Topics 1. Research methodology and statistical analysis * a. Fundamentals of research design and conduct * b. Interpretation and presentation of data 2. Practice management * a. Costs of medical and anesthesia care * i. Principles of healthcare funding and payment * ii. Cost-conscious practice * b. Efficient OR staffing and scheduling * i. Subspecialization issues * Pediatrics * Cardiac * Regional * Obstetric coverage * ii. Anesthesia care team and scope of practice * c. Population health * Perioperative surgical home * Enhanced recovery * i. Population-based health determinants * ii. Resources to improve access * iii. Healthcare disparities between populations * d. Clinical informatics * i. Electronic medical record systems * Costs * Benefits * ii. Artificial intelligence and machine learning * e. Documentation, coding and billing * i. Compliance with documentation requirements * ii. Accuracy, clarity and specificity of medical records * iii. Coding integrity, audits and insurance denials 3. Quality Improvement and patient safety * a. Definitions * i. Medical error * ii. Adverse events * iii. Sentinel events * iv. Misuse of medications and technology * v. Human factors and mindfulness * vi. Systems thinking and technology design * b. Medication errors * i. Assessment and prevention * ii. Medication reconciliation * iii. Information technology to reduce medication errors * c. Crisis management and teamwork * i. Simulation training * ii. Crisis manuals and cognitive aids * iii. Teamwork training * iv. Handoff communication * v. Preoperative and procedural checklists * d. Quality Improvement basics * i. Design, analysis and implementation of QI projects * ii. Data collection * iii. QI metrics * iv. Patient satisfaction measurement * v. Value-based care incentives * vi. Pay-for-performance * e. Performance assessment * i. Individual benchmarking * ii. Group and facility scorecards * iii. Public reporting * Federal Quality Payment Program * Anesthesia registries * iv. Change management methods * Peer review and morbidity and mortality conferences * Lean Six Sigma * QI and the 5S process * Value stream mapping * Failure mode and effects analysis * Root cause analysis * v. Barriers to QI 4. Diversity, Equity and Inclusion (DEI) in healthcare * a. Surgical outcomes * b. Barriers * i. Systematic racism * ii. Colorism and shadeism * iii. Sexism * iv. Discrimination against orientation, gender identity, language, national origin, ethnicity, religion, immigration or citizenship status, age, familial status and disability * v. Bias * vi. Implicit bias * vii. Microaggression * viii. Stereotype threat * c. Approaches to improvement * Individual level * Interpersonal level * Community level * Organizational level * Policy level * Cultural competency * Gender competency * Upstander vs bystander * Allyship vs performative action * Tokenism vs representation * Assortativity vs homophily * d. DEI in the workplace * e. DEI in academia * i. Leadership * ii. Scholarship * Representation of diversity and race-related topics in research * Importance of language in reports discussing racial inequities 5. Healthcare disparities * a. Social determinants of health * Race * Language * Education status * Religion * Housing * Nutrition * Geographic location * Rural vs urban * Access to care * Quality of care * Health coverage * b. Maternal healthcare disparities * Maternal mortality and morbidity * Pain management * c. ICU disparities and outcomes 6. Ethics and medico-legal issues * a. Professionalism * i. Disclosure of errors or adverse events * ii. Professional behavior * Honesty * Integrity * Compassion * Respect * Altruism * Conflicts of interest * Response to marketing * iii. Recognizing limitations in expertise and seeking guidance * iv. Reporting unsafe conditions and fitness for work * v. Recognizing and responding to unprofessional behavior * vi. Evidence-based practice * b. Patient autonomy and decision making * i. Informed consent and shared decision making * ii. Advance directives * iii. DNR orders * iv. Medical orders for life-sustaining treatment * v. Healthcare proxy laws and limitations * vi. Patients refusing transfusion or other treatments * c. Legal and regulatory issues * i. Elements of medical malpractice * Duty * Breach of duty * Causation * Damages * ii. Legal actions and consequences * National Practitioner Data Bank * Closed Claims findings * Professional liability insurance * iii. Laws related to controlled substances * Opioids * Cannabinoids * iv. Patient privacy issues * Confidentiality * Access to records * Protected health information * v. HIPAA * d. Primary certification, recertification and maintenance of certification * Professional standing * Lifelong learning * Cognitive knowledge * Clinical practice assessment * Systems-based practice * e. Research ethics * i. Justice * ii. Autonomy * iii. Beneficence * iv. Nonmaleficence * v. Ethical standards in research design * Scientific validity * Fair subject selection * Favorable risk-benefit profile * vi. Institutional review board * vii. Informed consent in research * viii. Conflicts of interest and financial disclosure * f. Clinician wellness and self-care * i. Burnout * ii. Sleep deprivation * iii. Adaptations for clinical disability * iv. Substance abuse