Rotations - Cardiovascular Disease Fellowship
Primary Cardiology Service (PCS) | Advanced Heart Failure Service (AHFS) | Baltimore VAMC | Echocardiography | Consultative Cardiology | Cardiac Catheterization | Cardiac Electrophysiology | Nuclear Cardiology | Congenital Heart Disease | Electives
During the first year, each fellow will spend two months on the PCS service. In conjunction with an attending cardiologist, medical house staff, a PharmD and a Care Coordinator, they manage patients with primary cardiac disorders in the Cardiac Intensive Care Unit (CCU) and the primary cardiac unit (PCU), stepdown telemetry unit.
Typical patients on this service include those with acute myocardial infarction, those who have undergone complex coronary interventions, patients with complex rhythm disorders or who have undergone complex ablations, valvular heart disease and congestive heart failure.
The AHFS team is comprised of two fellows, two nurse practitioners and a resident under the direction of an advanced heart failure attending. Trainees participate in the care of complex cardiac patients requiring advanced therapies like left ventricular assist devices (LVADs), evaluation for cardiac transplant and on intravenous inotropes or vasodilators for pulmonary hypertension.
Fellows engage in multi-disciplinary collaboration to provide optimal care for AHFS patients, interacting with other cardiac sub-specialties, pediatric cardiology, vascular surgery and CT surgery, as well as LVAD engineers.
This rotation is considered a "keystone" experience by many of our fellows.
The Baltimore Veterans Affairs Medical Center is directly attached to the University of Maryland Medical Center. It was the very last of the VA hospitals built, making it the most modern.
During their second year, our fellows rotate to the BVAMC Cardiac Intensive Care Unit, where they are expected to lead the team of medical residents and interns, direct consultative services, and participate in the interpretation of echos.
We view this as an opportunity for our fellows to be 'acting attendings,' while still having active support and supervision from our faculty.
Fellows rotate in echocardiography in their first year, learning basic skills of wall motion analysis and ventricular function, evaluation of regurgitant and stenotic valvular lesions, evaluation of intra-cardiac shunts, gradients, and evaluation of pericardial disease.
First-year fellows also participate in the performance and evaluation of pharmacologic and exercise stress echocardiography.
Fellows in the second and third years of training who choose to participate in echo learn the skills necessary for performance and interpretation of trans-esophageal echo (TEE). They are also exposed to real time 3-D echo, dyssynchrony studies, echo-guided pericardiocentesis, advanced tissue Doppler evaluations and advanced concepts such as speckle tracking.
The all-digital echo lab boasts more than 10,000 trans-thoracic studies, 1,200 trans-esophageal studies, and 1,200 stress echo studies annually. Studies are available for review anywhere within the hospital. Fellows participate in a weekly echo conference that incorporates didactic lectures with case study review.
First year trainees spend two months rotating on the consultative cardiology service. Medicine house staff, nurse practitioners and medical students rotate on this service under the direction of an attending physician. A wide array of pathologies is seen including acute coronary syndromes, pulmonary hypertension, arrhythmias and connective tissue and malignancy-associated cardiac conditions.
UMMC's R Adams Cowley Shock Trauma Center is also a referral base for the consultative services for cardiac conditions complicating trauma. Objectives of the consultative service include both management of cardiac conditions as well as mastering the role of being an effective and efficient consultant. The service also offers opportunities for engaging in teaching medical house staff and medical students.
During the first year cardiac catheterization rotation, fellows are introduced to the sub-specialty at the Baltimore Veterans Affairs Medical Center, while second and third year cardiac catheterization rotations are based at the University Cath Labs.
Fellows participate actively in obtaining arterial and venous access, and perform cases under the direct supervision of an attending interventionalist. Procedural competence obtaining access, utilizing vascular closure devices, and performing and interpreting right and left heart catheterization is obtained, as well as:
- Exposure to procedures such as pericardiocentesis
- Evaluation of coronary lesions with fractional flow wire and Doppler ultrasound
- Placement of Impella left ventricular assist devices and intra-aortic balloon pumps
- Endomyocardial biopsies
- Percutaneous coronary intervention
Fellows can engage in structural heart interventions including ASD/PFO closure, aortic and mitral valvuloplasty, TAVR and Mitra-Clip procedures.
Rotation objectives also include understanding the indications and contraindications to procedures performed in the Cath Lab, interpretation of coronary angiography and ventriculography as well as hemodynamic studies including constriction-restriction studies, valve interrogations, pulmonary hypertension and vasodilator challenge studies and exercise hemodynamics.
Formal cardiac catheterization rotation didactics include a weekly cardiac catheterization core conference, as well as a weekly clinical conference based on film review and clinical decision-making.
Fellows are introduced to EP during their first year of training and then again in either their second or third years. Through this early exposure, fellows are able to inform decisions regarding pursuing cardiac electrophysiology as a career path based upon first-person knowledge.
The rotation is composed of consultative electrophysiology, involvement in diagnostic intracardiac studies and VT and SVT ablations, insertion and testing of pacemakers and internal defibrillators, and cardioversion. Each Thursday morning of the rotation begins with a discussion amongst all of the staff of the complicated cases, as well as a didactic session.
Nuclear Cardiology is under the auspices of Radiology and is directed by Dr. Vasken Dilsizian, a renowned cardiologist who is also boarded in Nuclear Medicine.
On this rotation, fellows actively participate in all aspects of Nuclear Cardiology, from performance of dynamic tests, to interpretation of myocardial perfusion scans, gated acquisition and PET scanning. Two months are required for cardiovascular fellowship training, however most fellows choose to pursue an additional two months of nuclear training in order to fulfill requirements for eligibility for nuclear licensure and independent practice of nuclear studies.
During this one-month rotation, fellows engage in outpatient and inpatient experiences with patients with congenital heart disease. This experience is multi-disciplinary with interactions with the Division of Pediatric Cardiology, including pediatric cardiologists, pediatric cardiac imaging specialists and pediatric interventional cardiologists, electrophysiologist and CT surgeons.
Fellows may participate in all aspects of Pediatric Cardiology including interpretation and performance of echos, catheterization, and outpatient evaluation. The hallmark didactic conference of this rotation is a weekly multi-disciplinary meeting to discuss complex congenital cases of the week.
Fellows choose electives according to career plans and academic interests. These may include increased exposure to any of the 'traditional' aspects of cardiovascular disease, such as cardiac catheterization, electrophysiology, echocardiography, transesophageal echocardiography and nuclear cardiology.
In recent years, trainees have utilized elective time to obtain training and certification in vascular studies through a collaboration with the Division of Vascular Surgery. Fellows have also chosen to spend more time in the interpretation of cardiac MRI and cardiac CT during these elective blocks.
Some fellows have used this time to expand their research interests, including basic science research in extended blocks, while others have participated in 'away' electives, including international and third-world experiences as well as specialized pulmonary hypertension and cardiac surgery electives.
Anything is possible, but planning under the supervision of the program director is essential.