Cardiology Fellowship Training Schedule

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ROTATION IN THE CATHETERIZATION LABORATORY
CARDIOLOGY FELLOW CURRICULUM
 

At the end of the rotation, the cardiology fellow will be familiar with and will have the skills to perform the procedures listed below.  Apart from learning the technical skills, it is equally important for the fellow to be cognizant of and familiar with the complete care of a patient undergoing these various procedures.  Specifically, this includes the evaluation of the patient pre-procedure, being familiar with complications and how to treat them during procedures and being involved and knowledgeable about the care of the patient after the procedure.

The following is the list of procedures that are performed in the cardiac catheterization laboratory.

1.) Diagnostic right and left heart catheterizations.

2.) Selective coronary angiography and graft angiography.
 

3.) Left ventriculography, aortography

4.) Percutaneous angioplasty including balloon angioplasty, stent placement, rotational atherectomy, directional atherectomy, laser angioplasty.
 

5.) Intervasuclar ultrasound.

6.) Placement of intra-aortic balloon pump.

The next list consists of procedures that are infrequently done.
1.) Endomyocaridal biopsy.

2.) Intracoronary Doppler flow studies.

3.) Aortic valvuloplasty.

During the rotation, the fellow may be exposed to all the above procedures but will not be expected gain familiarity with all of them. The procedures with which the fellow must be most familiar with and gain technical expertise include:

1.) Right and left heart catheterization.

2.) Coronary angiography and Graft angiography.

3.) Placement of temporary transvenous pacemaker wires.

4.) Placement of intra-aortic balloon pumps.

The rotation is not intended to be procedure intensive and the fellow is expected to be involved in the care of the patients undergoing these procedures.  In order to accomplish these goals the follow are the specific fellow responsibilities:

1.) All inpatients that are scheduled to undergo procedures should be seen by the cath fellow and a short note should be in the cart summarizing the fellow’s findings, thoughts and plans.  It is expected that the fellow will perform the procedure on these patients with the attending.  Before the procedure is performed the fellow will discuss the case very briefly with the responsible attending.  After the case is done the discussion will continue regarding disposition and plans for therapy.  The fellow is then expected to see the patient after the procedure either with or without the attending to discuss plans with the patient and to look for complications.

2.) Since outpatients show up on the day of the procedure and there is not enough time for fellow evaluation, the fellow is expected to briefly familiarize himself or herself with the case and be involved in those cases he or she has done this pre-procedure work-up.  The post-procedure follow up remains the same.
 

3.) The fellow is expected to review the hemodynamic and cine angiographyic data with the attending before completing the procedure report.

4.) It is not expected that the fellow be involved in every case that is done in the cath lab.  Our general recommendation is that the fellow do a maximum of five cases a day.  This number may be either less or more depending on how busy the lab is.  This does not mean that the fellow leaves the cath lab when his or her “quota” for the day is fulfilled.  It is recommended that the fellow stay till at the diagnostic cases for the day are done.
 

5.) It is recommended that the fellow not scrub on a case that he or she has not evaluated the pre-procedure unless the attending invites him or her to do so.  Seeing patients the day before, examining charts of outpatients the previous day, being efficient during the day in evaluating patients and being available in the cath lab are for prolonged lengths of time will therefore increase the number of cases a fellow can perform during a given day.

6.) Fellows will be evaluated for their cognitive as well as technical skills and

Fellows are also asked to meet with the director of the catheterization laboratory a few days prior to the beginning of the rotation to discuss their goals and our expectations.

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CARDIAC INTENSIVE CARE – CICU University Hospitals

CARDIOLOGY FELLOW CURRICULUM

OVERVIEW

The coronary care unit at University Hospitals of Cleveland is a 20-bed acute care facility.  The team rotating through the unit usually consists of four medical residents, one fellow, and an attending physician.  The fellow is expected to play an integral role in patient assessment and care, appropriate utilization of unit beds and education of the house staff.

OBJECTIVES

I. GOALS

By the end of their month in the coronary care unit the fellows will be expected to familiarize him/herself with the current literature on the management of acute ischemic syndromes including unstable angina and myocardial infarction.  They will be expected to know the current advances in the thrombolytic literature as well as the use of current anti-platelet agents and anti-thrombins in the management of acute ischemic syndromes.  The fellows will also learn the appropriate use of revascularization procedures including percutaneous and surgical as well as medical management of chronic ischemic heart disease.  They will learn about the management of both ventricular and supraventricular arrythmias.  They are expected to know the appropriate use of echocardiography in acute coronary care unit and at times will be expected to perform emergent echocardiograms in acutely ill patients.  The interpretation of these echocardiograms will be primarily the responsibility of the fellow.  The fellow will also be expected to be educated on the use of management of acute congestive heart failure, management of cardomyopathies, valvular heart disease as well as pericardial disease. It will also be appropriate to learn the appropriate use of thrombolytic therapy in the management of acute pulmonary embolism.

II. EDUCATIONAL OBJECTIVE

The fellows will play an integral role in the education of the house staff.  The fellow is expected to contribute on rounds both by bringing in the appropriate literate for the house staff and proving his/her perspective on the management of patients.  The fellow is expected to be intimately involved in the patient care and be familiar with the results of the diagnostic and therapeutic procedures other patients have had.  It is the expectation that all the procedures performed on the patients in the CICU including cardiac catheterizations, angioplasties, echocardiogram and stress tests will be reviewed daily by the team.

III. BED UTILIZATION

The fellow is expected to come in early in the morning to screen the new admissions that were admitted to the ICICU overnight.  With acutely ill patients, the fellow will make the initial determination on the need for emergent procedure and will discuss them with the attending physician immediately first thing in the morning.  The patients who no longer warrant acute coronary care will also be identified by the fellow and appropriate measures will be taken to transfer them out of the intensive care unit as soon as possible.

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ECHOCARDIOGRAPHY LABORATORY – University Hospitals

CARDIOLOGY FELLOW CURRICULUM

OVERVIEW

The echocardiography laboratory is committed to providing the best clinical service 24 hours a day, 7 days a week.   The on-call schedule has been established that applies to sonographers, cardiology fellows and echocardiography attendings that permits the lab to provide this service.

It is recognized that ultrasound is a revolving technology in a rapid phase of development and improvement, with an expanding list of clinical indications.  The core cardiology training symposium (COCATS) has defined three levels of expertise. The cardiology program at UH will provide Level 2 training for all cardiology fellows.  This level of training provides the candidate the necessary knowledge and experience to be capable of performing and interpreting an M0mode, 2 dimensional Doppler examination independently under the supervision of a laboratory director.  The third level of expertise will enable the trainee to direct an echocardiography laboratory, as well as perform various special ultrasound procedures (transesophageal, stress, intra-operative echocardiography).

OBJECTIVES

I. EDUCATIONAL OBJECTIVE

Fellowship training in echocardiography should include instruction in the basic aspects of ultrasound, but only those fellows who go beyond the basic level are trained sufficiently for independent interpretation of echocardiographic studies.  Every trainee should be education in physical principles and instrumentation of ultrasound and cardiovascular anatomy, physiology and pathophysiology, both in regard to the cardiovascular system in general and in relationship to the echocardiogram in particular.  At all levels of training, trainees should be required to perform the echocardiographic and Doppler examination to integrate their understanding of three dimensional cardiac anatomy.  The trainees should master the relation between the echocardiographic examination and surgical and medical management of the patient.  Every cardiology fellows should be exposed to and familiar with the clinical performance, interpretation, strengths and limitations of two-dimensional echocardiographic Doppler technology and its multiple clinical applications.

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CONSULTS – University Hospitals

CARDIOLOGY FELLOW CURRICULUM

OVERVIEW

The Consult unit at University Hospitals of Cleveland is a team consisting of one fellow and an attending physician.  There may be both medical residents and medial students on an elective rotation on this team.  The fellow is expected to provide specialized cardiology consultative service at University Hospitals.

OBJECTIVES

I. GOALS

The primary objective for this rotation is to provide service and communication and continuity with patients in all areas of University Hospitals, including “non T3/T5”patients, non-“medical” patients on T3/T5 and such diverse sites as MacDonald Women’s Hospital and Hanna House.

II. EDUCATIONAL OBJECTIVE – Service and Communication

To provide the cardiology fellows with an in-depth exposure to the broad gamut of cardiovascular problems encountered in a tertiary hospital setting with particular emphasis on the inter-relationship of cardiovascular disease and other med/surg, including all cardiology consults request on patients following CT surgery.

III. EDUCATIONAL OBJECTIVE – Continuity

At days end and on weekends, the fellow will "sign out” selected patients requiring follow-up to the CICU fellow on call, who is also responsible for emergency consults at night and on weekends, in turn ensuring continuity with the unusual CT/Consult staff the following weekday or Monday morning.  The call schedule has evolved in such a fashion that the CT/Consult fellow and attending round "short-call” on Saturday morning on the CT/Consult service patients and then sign out the appropriate individuals for the reminder of the weekend.

METHODLOGY

Fellows will generally be responsible for seeing all new consults (with exception of medial or general cardiology T3/T5 patients or patients for whom specific EP consultation has been requested), writing the initial consult and subsequent follow-up notes, gathering and collating lab and diagnostic studies on an ongoing basis and presenting consults to the service attending at a pre-arranged time.  Selected current literature will be utilized, reference and/or discussed with copies to chares as appropriate.

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DIVISON OF NUCLEAR MEDICINE

GOALS AND RESPONSIBILITES FOR CARDIOLOGY FELLOWS

In order to provide a meaningful cardiology rotation for Cardiology Fellows in the Division of Nuclear Medicine, the following goals and responsibilities are delineated.  The rotation is intended to provide one or more months of basic introduction to nuclear cardiology and is not specifically designed to prepare physicians for credentialing or licensing in nuclear cardiology.  Requirements for such training leading to licensure are formally outlined by the U.S. Nuclear Regulator Commission and joint committees of documentation of time and effort spent by fellows in the Division of Nuclear Medicine to help fulfill these mandated training requirements.

Also, Cardiology Fellows are invited and encouraged to initiate or collaborate in on-going research projects in nuclear cardiology, including single-photon (SPECT) and positron emission tomography (PET), as well as all aspects of correlative imaging.

GOALS

The Cardiology Fellow should have and integrated understanding of both the basic science and clinical aspects of routine nuclear cardiology imaging procedures.

I. Imaging Procedures – Cardiovascular System

    A. General considerations including relevant anatomic and physiologic relationships for imaging

    B.  Myrocardial perfusion imaging

1. Radiopharmaceuticals including thallium-201 and Tc-99m sestamibi
2. Selection of study type; protocols for treadmill or pharmacologic sress
3. Methods:
a. Planar
b. SPECT
c. Quality Control
4. Clinical Applications
5. Computers/image processing and quantification
6. Image and data interpretation
7. Correlative imaging

1. Principles of gated equilibrium imaging
2. Ejection fraction determinations for left and right ventricles
3. Regional wall motion assessment
4. Methods:
a. First Pass
b. Gated Equilibrium
c. Phase and Amplitude Imaging
5. Clinical applications

1. Radiopharmaceuticals for perfusion and metabolic imaging
2. Quantification of myocardial blood flow
3. Identification of viable myocardium

1. Exercise
2. Pharmacologic stress methods
        a. Dipyridamole
        b. Adenosine
        c. Dobutamine

II. Basic Physics and Instrumentation

    A. Principles of radiation sources and interactions

    B. Radionuclide production

    C. Image formation and statistics

    D. Radiation dosimetry

    E. Basics of detectors/gamma cameras/PET

    F. Computer architecture

    G. Clinical techniques/procedures

III. Radiopharmaceuticals

    A. Basics of radiochemistry for cardiac agents

1. Thalilum-201
2. Technetium-99m
3. Positron emitters

IV. Radiation Safety Principles

    A. Sources of radiation exposure

    B. Proper handling of radiopharmaceuticals

    C. Principles of radiation protection

    D. Regulations and licensing

Responsibilities and Duties:

1. The Cardiology Fellow should be present in the Division of Nuclear Medicine during normal hours of operation from 8 a.m. to 5 p.m. except for scheduled classes, conferences, and lunch breaks.  The fellow will also be excused for regularly scheduled outpatient clinic responsibilities.  However, he or she should not routinely be assigned for “pulled” to other clinical areas.

2. Part of the fellow’s responsibilities will involve participation in the stress laboratory’s operation at the discretion of that area’s supervisor.  Treadmill and pharmacologic stress testing is an integral part of nuclear cardiology.

3. Notify the Nuclear Medicine attending physical or the division secretary if you leave the division.

4. In the course of a month-long rotation, fellows should spend sufficient time with the technical staff to become familiar with the basics of radiopharmacy, radiation safety practices, gamma camera operation, and computer acquisition of images.

5. Fellows will participate along with assigned Radiology Residents and Nuclear Medicine attending staff in all regular nuclear cardiology reading sessions.  These normally take place in early-to-mid afternoon.

6. Fellows will prepare a monthly nuclear cardiology didactic/case study conference with the assistance and participation of a Nuclear Medicine attending physician.  This conference is part of the Division of Cardiology Conference Series and is usually scheduled for the first and third Tuesdays of each month at 7:30 a.m. in the Nuclear Cardiology conference room

7. A nuclear cardiology reference library of books and current review-type articles is available in Nuclear Medicine for use by the fellows during their rotations.  Recommendations and additions are welcome.

8. Fellows are not required to become involved in research activities during a normal rotation.  However, all are invited and encouraged to propose new projects and/or collaborate in ongoing projects in nuclear cardiology.

9. It is important for the fellow to document time spent in nuclear cardiology training.  The Nuclear Medicine division secretary maintains records regarding rotations, attendance, procedures performed, etc. for physicians-in-training.  Be sure to communicate closely with her.

10. If a fellow has an interest in ultimately becoming fully credentialed and able to be licensed by USNRC as an authorized user of radioisotopes for nuclear cardiology, current regulations of USNC and specialty societiess should be reviewed on an individual basis.

References

1. Medical Use of Byproduct Material.  United States Nuclear Regulatory Commission Rules and Regulations – Title 10, Chapter 1, Code of Federal Regulations – Energy.  Part 25.  November 30, 1992.

2. Cerqueria MD and Shattuc S.  Training and credentialing in nuclear cardiology: a fact sheet.  American Society of Nuclear Cardiology, Spring 1994.

3. Components of Professional Competence of Nuclear Medicine Physicians – American Board of Nuclear Medicine.  J Nucl Med 35:1234-1235, 1994.

4. Depuey EG, Borer JS, et al.  Cardiovascular nuclear medicine training guidelines.   J Nucl Med 35:169-178, 1994.

5. Cerqueria MD and Wackers FJ.  The knowledge base for nuclear cardiology training.   J Nucl Card `:114-116, 1994.

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STRESS TESTING AND CARDIAC REHABILITATION

CARDIOLOGY FELLOW CURRICULUM

During the stress testing rotations, the Cardiology Fellows will obtain experience in performing and interpreting various types of exercise and pharmacologic stress testing protocols.  This will be accomplished via on-site performance and supervision of testing, formal stress test interpretation sessions with the designated Stress Test Reader and Nuclear Reader and review of the literature.

Cardiology Fellows will have exposure to the inpatient Cardiac Rehabilitation program and participate in the outpatient program at the Chagrin Highlands office.

GOALS

In order to facilitate the Cardiology Fellow’s training in stress testing and cardiac rehabilitation, the following educational goals have been delineated.  At the completion of these rotations, the fellow will have an integrated understanding of both the basic science and clinical aspects of stress testing and rehabilitation.  The fellow will be competent to perform and interpret tests, screen patients appropriately, institute emergency treatments and advise further evaluation as clinically indicated.

1. Exercise Physiology

· Cardiovascular and pulmonary response to exercise
· Extracardiac effects of exercise
· Physiology of cardiac ischemia

· Exercise Stress Testing
· Pharmacologic Stress Testing
· Cardiac Rehabilitation

· Electrocardiographic measurement

Lead systems
Types of ST segment displacement
Mechanism of ST segment displacement
Measurement of ST segment displacement
R wave, P wave and/or T wave changes
ST/HR slope
Rate responsive to exercise
Arrhythmias

· Non-electorcardiographic measurements

Blood pressure
Rate-Pressure product
Symptoms
Oxygen consumption or estimate of
Working capacity

    · Requirements and informed consent
    · Preparation for test
    · Exercise Stress Tests
            Treadmill tests
            Bicycle tests
            Arm exercise tests
            Heart rate or workload targeted tests
    · Comparison of Various Protocols
            Bruce protocol
            Modified Bruce protocols
            Naughton protocol
            CAEP protocol
            Ramp protocol
            Cycle protocol
            Arm ergometer protocol
    · Pharmacologic Stress Tests
            Dipyridamole/ Adenosine
            Dobutamine/ Arbutamine
    · Imaging Studies
            ECHO/Contrast
            Nuclear: technetium, thallium
            PET

    · Absolute contraindictions
    · Relative contraindications
    · Risks reported in the literature
    · Indications for test termination
    · Management during the postexercise period
    · Emergency procedures and treatment
    · Equipment, drugs and supplies necessary for test safety
    · Legal implications

    · Sick sinus syndrome
    · Supraventricular arrhythmias
    · Ventricular arrhythmias
    · AV block
    · Right bundle branch block
    · Left bundle branch block
    · Preexcitation syndrome

    · Disease prevalence
    · Baye’s theorem
    · Sensitivity and specificity
    · Predictive value and relative risk
    · Time of onset of ST depression
    · Magnitude of ST depression
    · Time of recovery of ST depression
    · Exercise duration
    · Effect of previous Myocardial infarction
    · Factors associated with false positive results

    · Stress testing after MI
    · Stress testing after surgical or catheter interventions
    · Stress testing in women
    · Stress testing before and after cardiac transplantation
    · Stress testing and congestive heart failure
    · Stress testing  for arrhythrmia and pacemaker evaluation
    · Stress testing and the hypertensive patient
    · Effects of Digitalis and other drugs on stress testing
    · Stress testing and myocardial viability

    · Inpatient rehabilitation  (Phase I)
    · Early post-discharge exercise testing and rehabilitation
    · Outpatient rehabilitation programs (Phase II and III)
    · Risk factor modification and comprehensive cardiac rehabilitation

    · Physical conditioning
    · Effects of exercise training
    · Selection of patients for exercise testing and training
    · Exercise prescription: formulation and advancing
    · Risks of exercise training
    · Exercise rehabilitation as a component of comprehensive cardiac rehabilitation
    · Psychosocial factors
    · Vocational rehabilitation

    ·  Evaluation of patients prior to testing
    · Supervision of stress tests in the nuclear and non-imaging labs
    · Work with the stress test nurse specialist and CV technician in the care of patients and conduct of tests
    · Be responsive to the medical needs and safety of patients in the laboratory
    · Promptly respond to concerns of the nurse specialist and implement emergency treatments as appropriate
    · Promptly communicate abnormal test results to the Stress Reader and referring physicians
    · Interpret tests and finalize reports with the scheduled Stress Reader
    · Meet above goals with on-site training and supplemental reading as needed
    · Participate in the Phase II outpatient sessions
    · Participate in stress laboratory educational sessions and journal club
    · Formulate and deliver a rehabilitation program educational session for patients

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ARRHYTHMIA/ELECTROPHYSIOLOGY ROTATION

LEARNING OBJECTIVE

The Arrhythmia/Electrophysiology rotation provides cardiology Fellows with a firm foundation of knowledge regarding the evaluation and management of patients with disturbances of cardiac rhythm.  During their two-month rotation in Electrophysiology Cardiology Fellows spend time on the inpatient arrhythmia consultative service at University Hospitals.  This rotation exposes the Cardiology fellows to patients with a variety of rhythm disturbances including tachyarrhythmias, bradyarrhythmias, and syncope of unknown origin.

This experience provides the Cardiology fellows with an understanding of arrhythmia diagnosis and management, the indications of pacemaker therapy, electrophysiologic testing, drug or device therapy, and pacemaker function and programming.  The trainee will be exposed to non-invasive and invasive techniques including ambulatory electrocardiographic monitoring, event recorders, exercise testing for arrhythmia assessment, tilt-table testing, signal average electrocardiography, invasive electrophysiologic testing, and implantation of cardiac arrhythmia control devices.

The Fellow will be exposed to programming and follow-up surveillance of permanent pacemakers and ICDs both on inpatients as well as outpatients seen in Pacemaker-ICD Clinic.  Fellows learn the various features of approved and investigational pacemakers and ICDs, the indications for the use of such devices, and the basic fundamentals of how such devices are implanted, programmed, and monitored.

REQUIREMENTS

During the arrhythmia/electrophysiology rotation, cardiology Fellows will attend the Monday and Friday, 7:30 to 8:30am Electrophysiology Conference.  In-depth discussions and review of topics in clinical cardiac electrophysiology are reviewed for the Cardiology and Electrophysiology Fellows.  During these conferences, the Fellows will be exposed to basic fundamentals of normal electrophysiology, the differential diagnosis and mechanisms of supraventricular and ventricular arrhythmias and basic electrogram interpretation.  These conferences provide the fellows with an understanding of the arrhythmias that are suitable targets for catheter ablation as well as the risks and benefits of this approach.

An additional and important components of the arrhythmia/electrophysiology rotation for Cardiology Fellows involves time spent in the Clinical Electrophysiology Laboratory participation in intracardiac electrophysiology studies that have been refereed from the clinical consult service to the Electrophysiology Laboratory.  During this time, Fellows acquire experience with the performance and interpretation of intracardiac electrophysiology studies.  In addition, under the supervision of the EP Attending, Fellows will perform elective cardioversion on patients referred from the clinical electrophysiology service for conversion of atrial arrythmias.  Cardiology Fellows interested in a more in-depth exposure to invasive electrophysiology can choose to take an additional elective rotation in the third year of their cardiology training in the clinical EP laboratory.

During the arrhythmia/electrophysiology rotation, Cardiology Fellows are expected interpret ambulatory ECG recordings (Holter monitors an event monitors0 under the supervision of Dr. Niraj Varma, Director of the ECG and Holter Laboratory.  Dr. Varma will review and over read the ambulatory ECG recordings with the Cardiology Fellows.

CONGENITAL HEART DISEASE/PÆDIATRIC CARDIOLOGY

CARDIOLOGY FELLOWS CURRICULUM

The rotation is intended to provide one month of basic introduction to congenital heart disease.  In order to enhance the pediatric cardiology experience for Cardiology Fellows, the following goals have been delineated.  Also, Cardiology fellows are invited and encouraged to initiate or collaborate in on-going research project in pediatric cardiology.

RESPONSIBILITY OF THE FELLOWS

The Adult Cardiology Fellow will spend one month in Pediatric Cardiology.  Other than his or her clinic, the entire month must be with Pediatric Cardiology.  During this rotation, there are not in-patient responsibilities.  The fellow will attend all Pediatric Cardiology Clinics except during the time he or she has their own clinic.  These clinics will include the “congenital adult” clinic at the Landerbrook Office.  The fellow will be required to present one clinical case conference with a member of Pediatric Cardiology as a case  to the Division of Cardiology based on a patient seen during the “congenital adult” clink.  If there is no clinic then the fellow should spend his or her time reading and working with Dr. Lineman on interpreting electrocardiograms.  If there is free time the fellow may be in the Echo Lb or Cath Lab as per his or her own interest.  The fellow will give one talk during the month to the other in the elective and to DR. Lineman and will attend talks given by others during the elective.  The fellows will attend all conferences including the Adult Cardiology Grand Rounds if time allows.
 

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LAST UPDATED 11/1/4/2003  plb