Revised 4/10/2023

Division of Cardiology, Fellowship Training ProgramCardiac ElectrophysiologyGoals & Objectives

Educational Purpose:To achieve excellence in the training of second and third year cardiology residents in the diagnosis and management of arrhythmia disorders and symptoms, including when to use noninvasive and invasive diagnostic and therapeutic modalities and follow-up.Fellows will fully learn the indications, contradictions, risks, limitations, sensitivity, specificity, and predictive accuracy, and appropriate techniques for evaluating patients with a wide variety of rhythm disorders.

Teaching Method:The content will be gained during educational conference and teaching rounds, outpatient/inpatient consultations,pacemakerclinic, ICD clinic, care of patients before, during and after, electrophysiologic studies, electrocardiography, therapeutic electrophysiologic procedures, pacemaker implantation, defibrillator implantation, and arrhythmia surgery. By the completion of their two months of training, the resident will be expected to have familiarity with most aspects of clinical cardiac electrophysiology.

Mixes of Disease:Fellows will be exposed to patients with a wide range of electrophysiologic problems, including:1. Sinus node dysfunction;

A. Differentiation of sinus node dysfunction from chronotropic incompetenceB. Role of noninvasive testing (stress tests and Holter monitoring)C. Role of invasive measures (SACT, SNRT, etc.)

2. AV and intraventricular block;A. Role of noninvasive evaluation (Holter, ECG)B. Use of invasive testing (Intracardiac intervals, AV node curves, etc.)

3. Supraventricular arrhythmias;4. Ventricular arrhythmias;5. Clinical conditions including unexplained syncope, aborted sudden death, palpitations, WPW

syndrome, Long QT Syndrome;6. Conditions leading to non-pharmacologic modalities of arrhythmia therapy (e.g., ablation, ICD

implantation, surgery).

Patient Characteristics:Fellows will be exposed to adult and geriatric patients of both genders and a wide range of socioeconomic and racial backgrounds.

Types of Encounters:

Cardiology residents will spend a minimum of two months rotating on the Electrophysiology Service of the University of Maryland. This time will be distributed among well-defined experiences in a number of specific settings listed below which are designed to assure that all the educational objectives are met:

Electrophysiology LaboratoryThe electrophysiology laboratory experience will result in exposure to the accepted indications for

invasive EP procedures, techniques, and pre and post-operative management of diagnostic and therapeutic procedures in patients with cardiac arrhythmias. It will be assured that there is a sufficient range of patients with major disorders, including sinus node dysfunction, AV and intraventricular block, supraventricular and ventricular

Revised 4/10/2023arrhythmias, WPW syndrome, unexplained syncope, sustained ventricular tachycardia and aborted sudden death, and palpitations. The resident is expected to master the techniques of venous catheterization, and begin to understand the recording and interpretation of intracardiac signals.

Inpatient and Outpatient ConsultantsThe cardiology resident will attain familiarity of arrhythmia consultation on patients with the entire spectrum of arrhythmia disorders. The settings in which consultations will be performed include the CCU, SICU, MICU, inpatient wards, outpatient clinics, and emergency room.

Intensive Care UnitsThe cardiology resident will acquire the skills of arrhythmia management in the ICU setting by actively participating in the care of critically ill patients having recurrent arrhythmias. This will include the proper use of antiarrhythmic agents, pacing, defibrillation, cardiopulmonary resuscitation, evaluation for ischemia, and arrhythmia ablation.

ICD ImplantationThe cardiology resident will achieve familiarity in the evaluation of patients for ICD implantation, implantation of single and dual chamber ICD systems, defibrillation threshold testing, anti-tachycardia pacing testing, and low energy cardioversion testing. The resident will learn the indications for ICD placement and will become familiar with device interpretation, programming, and post-operative management.

ICD ClinicThe cardiology resident will learn outpatient management of patients with implanted arrhythmia devices including device interpretation and reprogramming, interpretation of delivered therapies, interpretation of stored intracardiac electrograms, and determination of the indications for device replacement.

Pacemaker ImplantationThe cardiology resident will learn the indications for pacemaker implantation, intraoperative testing, and post-operative management.

Pacemaker ClinicThe cardiology resident will learn the techniques of pacemaker follow-up, reprogramming, indications for device replacement, and evaluation of defective leads.

Educational ConferencesThe resident will attend conferences to compliment their patient care educational activities. These will include Journal Club, clinical case conferences, EGG conferences, research conferences (to analyze research paradigms, research findings, and develop research protocols), didactic lectures, cardiology Grand Rounds, and clinical electrophysiology teaching rounds.

Research ExperienceThe cardiology resident will have the opportunity to participate in research pertaining to clinical or basic electrophysiology. A meaningful experience will include discussion of hypothesis and study design, data acquisition, data analysis and submitting the study for peer review.

Reading List: ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices (1998)

JACC 31:1175-209. Consensus Statement on Indications, Guidelines for Use, and Recommendations for Follow-up of

Implantable Cardioverter Defibrillators. (2001) PACE 24:262-268. ACC/AHA Guidelines for the Management of Patients with Atrial Fibrillation (2001) JACC 38:1231-

Revised 4/10/20231265.

ACC/AHA Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation and Cardioversion.(2000) JACC 36: 1725-1736.

Personal and Public Safety Issues Related to Arrhythmias tht may Affect Consciousness: Implications for Regulation and Physician Recommendations. (1996) Circ 94:1147-1161.

Tilt Table Testing for Assessing Syncope (1996). JACC 28:263-275. A Randomized Study of the Prevention of Sudden Death in Patients with Coronary Artery Disease.

(1999) NEJM 341:1882-90. Preliminary Report: Effect of Encainide and Flecainide on Mortality in a Randomized Trial of

Arrhythmia Suppression After Myocardial Infarction. (1989) NEJM 321:406-412. Effect of the Antiarrhythmic Agent Moricizine on Survival after Myocardial Infarction. (1992) NEJM

327:227-233. A Comparison of Antiarrhythmic Drug Therapy with Implantable Defibrillators in Patients

Resuscitated from Near-Fatal Ventricular Arrhythmias. (1997) NEJM 337:1576-1583. Prophylactic Use of Implanted Cardiac Defibrillators in Patients at High Risk for Ventricular

Arrhythmias after Coronary-Artery Bypass Graft Surgery. (1997) NEJM 337:1569-1575. Improved Survival with an Implanted Defibrillator in Patients with Coronary Disease at High Risk for

Ventricular Arrhythmia. (1996) NEJM 335:1933-1940.Texts:

Clinical Cardiac Electrophysiology by Josephson Cardiac Electrophysiology by Zipes and Jalife

Faculty SupervisionThe fellow will be supervised directly by a faculty member in each of the above settings. It is the faculty member’s responsibility to assure that the procedure or patient evaluation is being performed appropriately and to educate the fellow in proper techniques and procedures. This includes assessing the fellow’s knowledge of the etiology, pathogenesis, clinical presentation and natural history of the diseases involved and the decision-making process in designing a course of treatment. Feedback will be given to the fellow continuously in all areas, at the end of each one-onth rotation by the supervising electrophysiologist completing the formal evaluation and twice a year in a meeting with the program director. Evaluations will be based upon direct observation and will based upon the following six competencies:

Evaluation:Fellows will be evaluated according to the following six competencies:

Patient Care:1) Gathers essential and accurate information about the patient through interviews,

examination, and complete history and by appropriately accessing adjunctive sources of information to this obtained from the patient and/or family members.

2) Makes informed diagnostic and therapeutic decisions based on patient information, current scientific evidence, clinical judgment, and patient preference

3) Carries out patient management plans based on age, diagnosis and psychosocial issues, including, but not limited to, management of patients with ischemic heart disease, congestive heart failure, valvular heart disease, and disorders of cardiac rhythm.

Medical Knowledge:1) Understands invasive and non-invasive evaluation of syncope2) Understands invasive and non-invasive evaluation of supraventricular tachycardia3) Understands invasive and non-invasive evaluation of ventricular tachycardia4) Understands invasive and non-invasive evaluation of bradycardia and heart block5) Understands pharmacotherapy as it relates to treatment of arrhythmias6) Understands indications for temporary and permanent pacemaker implantation7) Understands indications for insertion of an internal cardioverter/defibrillator

Revised 4/10/2023Practice-Based Learning and Improvement:

1) Uses feedback to identify areas for improvement.2) Seeks opportunities to strengthen deficits in knowledge/skills.3) Demonstrates initiative in researching current scientific evidence and applying it to

problems encountered during daily practice.

Interpersonal and Communication Skills:1) Communicate effectively with other members of a multi-disciplinary team, working

effectively with others as a leader of the health care team, member or consultant.2) Maintains comprehensive, timely and legible medical record demonstration and

correspondence related to patient care activities.3) Provides accurate and timely feedback to referring physician.4) Actively listens and elicits appropriate information from the patient and/or family members

and colleagues.

Professionalism:1) Recognizes ethical dilemmas and utilizes / seeks out appropriate consultation where

needed.2) Obtains informed consent from patient and/or family member/legal guardian.3) Adheres to the laws and rules governing the confidentiality of patient information.4) Engages in ethical business practices and adheres to the institution’s Code of Conduct.

Systems Based Practice:1) Understands, accesses, utilizes and evaluates effectiveness of resource providers, and

systems to provide optimal cardiac therapy.2) Understands different medical practice models and delivery systems and how to best

utilize them to care for the individual patient.3) Practices quality, cost-effective health care.4) Advocates and facilitates patient advancement through the health care system