historically, cardiac surgeons in canada completed general surgery followed by a fellowship in cv / ct / cvt. during the 1990s, the canadian cardiac surgery training programs changed to six-year "direct-entry" programs following medical school. the direct-entry format provides residents with experience related to cardiac surgery they would not receive in a general surgery program (e.g. echocardiography, coronary care unit, cardiac pathology, etc.). typically, this is followed by a fellowship in either adult cardiac surgery, heart failure/transplant, minimally invasive cardiac surgery, aortic surgery, thoracic surgery, pediatric cardiac surgery or cardiac icu. contemporary canadian candidates completing general surgery and wishing to pursue cardiac surgery often complete a cardiothoracic surgery fellowship in the united states. the royal college of physicians and surgeons of canada also provides a three-year cardiac surgery fellowship for qualified general surgeons that is offered at several training sites including the university of alberta, the university of british columbia and the university of toronto.