Adult Cardiovascular Intensive Care (CVICU) (TGH)

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(2–3 positions per year)

Brief Description of Fellowship

The fellowship is designed to gain expertise in the management of critically ill patients that present with severe cardiovascular morbidity. These patients can range from post-operative cardiac surgical patients to those in cardiogenic/circulatory shock. Management of these high-acuity patients involves advanced training in cardiovascular conditions and an understanding of how non-cardiovascular comorbidities effect the cardiovascular patient. Technology plays a major role in caring for these patients. Care becomes highly specialized and technologically advanced. Cardiac surgical procedures include CABG, valves and myectomies. We also provide complex aortic surgery, cardiac transplantation/mechanical circulatory support, minimally invasive cardiac surgery and complex adult congenital repairs as we are the referral center for all of Canada.

The CVICU at Toronto General Hospital is a 27-bed unit run by the department of Anesthesia alongside Cardiac and Vascular Surgery. The fellow will gain experience in the post-operative care of cardiac surgical patients including heart transplants, ventricular assist devices and short term mechanical circulatory support (BiVAD, TandemHeart, ECMO). Multidisciplinary rounds are the standard in CVICU and the Advanced Heart Failure service rounds on all of the cardiac transplant, mechanical support or cardiogenic shock patients on a daily basis.

Academic involvement during the fellowship is expected and is project-based. This can include epidemiology studies, literature-related qualitative / quantitative research and quality improvement projects. The fellow will work with faculty to develop a research question and actively participate in research to help answer the question. There will be opportunities to present your work at the Department of Anesthesiology and Pain Medicine’s Shield’s Day or other local/international conferences.

Goals and Objectives

1. Medical Expert

Fellows must demonstrate basic knowledge and clinical competence in managing the following conditions/topics commonly encountered in the peri-operative care of cardiac and vascular surgery patients:

1.1  Pathophysiology and clinical management of patients who are pre-operative and post operative patients with unstable coronary artery disease, cardiomyopathy of multiple etiologies (ischemic, congenital, alcoholic, etc), congestive heart failure, cardiac tamponade, valvular heart disease, electrophysiologic disease/arrhythmias, and aortic dissections/aneurysms.

1.2. Non-invasive and invasive cardiovascular evaluation including electrocardiography (EKG), transthoracic echocardiography, transesophageal echocardiography, pulmonary artery catheterization, stress testing, and cardiovascular imaging.

1.3. Interpretation and understanding of invasive cardiovascular evaluation and therapy including cardiac catheterization, angioplasty, and percutaneous coronary intervention.

1.4. Non-invasive pulmonary evaluation including pulmonary function tests, blood gas and acid-base analysis, pulmonary imaging.

1.5. Pharmacokinetics and pharmacodynamics of medications commonly prescribed for medical management of adult cardiovascular patients such as inotropes, chronotropes, vasoconstrictors, and vasodilators.

1.6. Invasive cardiovascular monitoring and interpretation: arterial, central venous, pulmonary artery, mixed venous saturation, and cardiac output.

1.7. Post-operative physiologic effects of cardio-pulmonary bypass on cardiac, respiratory, neurologic, metabolic, endocrine, hematological and renal systems. Know how to manage some of the more common complications of cardiopulmonary bypass including vasoplegia and neurological complications.

1.8. Be able to recognize the parameters that are used to assess post-operative blood loss and bleeding and have a basic understanding for the rational use of reversal agents, blood products, transfusion goals and strategies.

1.9. Placement and management of patients with circulatory assist devices including intra-aortic counterpulsation devices; left ventricular assist device (LVAD), right ventricular assist device (RVAD), and bi-ventricular assist device (BiVAD), and extra-corporeal membrane oxygenation (ECMO).

1.10. Knowledge and peri-operative management of pacemaker devices including placement and modes of action.

1.11. Management of post-operative ventilation and weaning of patients who undergo fast-track/routine cardiac surgical procedures as well as patients with complex post-operative course and ventilator dependent respiratory failure (ARDS/ALI/TRALI).

1.12. Pain management of adult cardiovascular surgery patients post-operatively along with our multidisciplinary Acute Pain Service.

1.13. Management of temporary and transvenous pacemakers in post-operative cardiac surgical patients.

2. Communicator

2.1 Ability to establish professional therapeutic relationships with patients and their families.

2.2 Perform family meetings to discuss treatment decisions and end of life care in a compassionate and empathetic manner.

2.3 Document and share written and electronic information about the medical encounter with other health care professionals to optimize clinical decision-making, patient safety, confidentiality and privacy.

3. Collaborator

3.1 Demonstrate how to direct rounds and coordinate care effectively with other health care professionals and colleagues within the health care system.

3.2 Coordinate care with referring services, Cardiac Surgery, Vascular Surgery, Medical Surgical ICU and reinforce safe and effective continuity of care.

4. Leader

4.1 Practice effectively on teams, within organizations and systems to deliver effective critical care medicine directed at the cardiac/vascular patient.

4.2 Engage in physician leadership through stewardship of healthcare resources including bed allocation.

5. Health Advocate

5.1 Be responsible to the health care needs of the individual patient in a biopsychosocial context with maintenance of integrity and respect of that patient's unique needs in a socially accountable manner.

6. Scholar

6.1 Commitment to continuous enhancement of own professional activities through participation in self-directed learning, and attendance at educational meetings and/or conferences.

6.2 Teach effectively students, residents, the public and other health care professionals.

6.3 Locate and integrate best available evidence into practice; demonstrate ability to critically appraise research as it relates to clinical practice.

6.4 Contributions to creation of medical knowledge within your specialty of cardiovascular critical care (i.e. original research/QI projects)

7. Professional

7.1 Demonstrate commitment to your patients by applying best practice guidelines and adhering to the highest ethical standards.

7.2 Engage in physician-led self-regulation within your profession (i.e. call schedule, attend M&M’s) and strive to improve the care of your patients.

7.3 Demonstrate a commitment to physician health and well-being in order to promote sustainable practice in the demanding field of critical care medicine.

Call Duties

Cardiovascular Critical Care fellows participate in a structured call schedule designed to provide graduated clinical autonomy and exposure to high-acuity cardiovascular critical care. Fellows can expect approximately two weekends per month on call during the fellowship year.

Call responsibilities include a combination of in-house and home call coverage, with a maximum frequency of 1 in 4 in-house call and 1 in 3 home call. Call schedules may vary depending on unit needs, staffing, and fellowship complement.

Every effort is made to maintain a sustainable and supportive training environment while ensuring fellows gain the clinical experience required for advanced cardiovascular critical care practice.

Research

Participation in research, quality improvement, and medical education is an expected component of the Cardiovascular Critical Care Fellowship. Protected academic time is available for fellows involved in scholarly projects, with a goal of approximately one non-clinical day per week, up to a maximum of 40 academic days during a 12-month fellowship period.

Fellows may participate in ongoing clinical research and quality improvement initiatives within the CVICU or develop individual projects with faculty mentorship. Areas of focus may include cardiovascular critical care, ECMO, mechanical circulatory support, perioperative outcomes, heart transplantation, and post-cardiac surgical critical care.

While completion of large prospective studies within a single fellowship year may not be realistic, fellows are encouraged to contribute meaningfully to ongoing projects through study design, REB submissions, data analysis, manuscript preparation, or quality improvement work. Review articles, narrative reviews, book chapters, and educational publications are also achievable within the fellowship year, particularly with early planning and mentorship.

Participation in academic conferences and educational activities is strongly encouraged. Fellows are expected to contribute to resident and medical student teaching, multidisciplinary rounds, and divisional academic activities. Support for conference presentations and eligible travel funding may be available.

Eligibility Criteria and Applications Requirements

The Cardiovascular Critical Care Fellowship is intended for physicians early in their consultant or attending career who are seeking advanced training in the management of critically ill cardiovascular patients. Applicants must have successfully completed all required specialty examinations, be eligible for medical licensure in Ontario, and have completed formal specialty training in disciplines such as Anesthesiology, Critical Care Medicine, Cardiology, or Cardiac Surgery. Significant prior exposure to adult critical care is required.

Applicants should possess substantial experience managing high-acuity patients and life-threatening conditions including cardiogenic shock, severe hemodynamic instability, massive transfusion, vasoplegia, malignant arrhythmias, respiratory failure, and complex perioperative physiology. Fellows are expected to arrive with a strong foundation in critical care practice and the ability to function independently in demanding clinical environments. The fellowship is designed to provide advanced subspecialty training in cardiovascular critical care rather than introductory exposure to critical illness management.

Given the complexity of the patient population and the technological demands of the unit, previous experience in academic tertiary or quaternary care environments is strongly encouraged. Familiarity with invasive hemodynamic monitoring, vasoactive medications, mechanical ventilation, and multidisciplinary critical care practice is highly advantageous. Exposure to cardiac surgical or cardiovascular ICU patients prior to fellowship is preferred.

International applicants should recognize that transitioning into a new healthcare system and clinical culture can be challenging, particularly in a highly specialized cardiovascular intensive care environment. In select circumstances, applicants may be advised to pursue additional general critical care or advanced clinical training before undertaking dedicated cardiovascular critical care fellowship training.

A current and valid ACLS certification is required for the duration of the fellowship.

If the country where you obtained your medical training does not have English as the primary language, you must demonstrate effective communication in English as it is the language of instruction and patient care. We may request language proficiency documents where appropriate, in line with the minimum scores set out in the FMRAC Model Standards for Medical Registration in Canada:

• International English Language Testing System (IELTS) academic version within the last 24 months at the time of application, and achieved a minimum score of 7.0 in each of the four components in the same sitting; or
• Occupational English Test - Medicine (OET-Medicine) within the last 24 months at the time of application, with a minimum grade of B in each of the four subsets in the same sitting; or
• Canadian English Language Proficiency Index Program-General (CELPIP-General) Test within the last 24 months at the time of application, with a minimum score of 9 in each of the four skills in the same sitting.

Fellowship start dates are typically in January and July each year; this may be flexible depending on availability. Applications must be submitted through the University of Toronto fellowship application platform. Applications generally open approximately 24 months and close 12 months prior to a potential fellowship start date.

Shortlisted candidates will be contacted approximately 10–16 months prior to a tentative start date to provide reference letters and continue the application process. Interviews are required. Please do not send reference letters unless specifically requested.

Successful applicants are generally notified approximately 6–12 months before the anticipated fellowship start date.

Begin Your Application

Applicants must apply using the online platform.

• If you are interested in applying for January 2027, please complete this online application form (closes July 31, 2026).
• If you are interested in applying for July 2027, please complete this online application form (closes Dec 31, 2026).
• If you are interested in applying for January 2028, please complete this online application form (closes Dec 31, 2026).
• If you are interested in applying for July 2028, please complete this online application form.

Send direct inquiries to:

Supervisor Details:
Konstantinos Alexopoulos, MD FRCPC
Toronto General Hospital
Department of Anesthesia and Pain Management
200 Elizabeth St 3EN427b
Toronto ON M5G 2C4
Email: konstantinos.alexopoulos@uhn.ca
Phone: 416-340-5164
Fax: 416-340-3698