Division of Cardiology, Fellowship Training ProgramCardiac Catheterization LaboratoryGoals & Objectives

Educational purpose: To teach fellows in cardiology all aspects of comprehensive invasive and interventional cardiac care, including selection of patients for procedures, indications and contraindications for procedures, how to safely perform invasive/interventional procedures, and how to care for patients following such. This course will specifically include instruction in (but not limited to) the following:

A. Understand the indications, limitations, complications and medical and surgical implications of the findings at cardiac catheterization and angiography, as well as a general understanding of related interventional procedures.

B. Understand the pathophysiology of cardiovascular disease and the ability to interpret hemodynamic and angiographic data and to use these data to select cases for surgical and catheterization-based therapeutic procedures.

C. Obtain a basic understanding of radiation physics, radiation safety, fluoroscopy and radiologic anatomy.D. Understand the fundamental principles of shunt detection, cardiac output determination and pressure waveform

recording and analysis. E. Learn to perform pulmonary artery catheterization with flow-directed catheters by the percutaneous (subclavian,

femoral and internal jugular) route. F. Learn the proper techniques of diagnostic left heart catheterization and angiography by percutaneous (brachial

and femoral) approaches.G. Learn to perform insertion and operation of temporary right ventricular pacemakers.H. Learn to perform and interpret the results of therapeutic pericardiocentesis.I. Learn intra-aortic balloon counterpulsation indications, insertion and management.

Teaching Methods:The content will be gained during educational conference, care of patients before, during and after, catheterization procedures,as well as during individual discussion of case issues with a cath lab attending. Cardiology fellows will spend a minimum of

fourmonths rotating on the Cardiac Catheterization Service. The first three to four months of training are spent at the Baltimore VAMedical Center, where they will perform over 100 procedures under the direct supervision of the catheterization lab attending.The remainder of the time spent in the catheterization laboratory will be at the University of Maryland Catheterization

Laboratory.This lab has a much higher volume than the Baltimore VAMC, which allows the fellow to be exposed to a wide variety of

patientsreferred to the catheterization lab.

Mixes of Diseases:Fellows will be exposed to patients with the following types of diseases:

Chronic and acute coronary syndromes Congestive heart failure Valvular heart disease Congenital heart disease Pericardial disease Aortic and peripheral vascular diseases

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

Types of Encounters:These will include the assessment of all patients prior to cardiac catheterization. This includes review of the medical record, obtaining a history and performing a physical exam to assess for indications and contra-indications to the procedure. Cases will be discussed with the attending in the catheterization lab prior to performing the procedure. After completion of the

recommended procedure, which is performed under the direct supervision and presence of an attending physician, the fellow has the responsibility of directing the post procedure management related to the catheterization, including learning to assess for complications of the procedure. This is done under the guidance of the attending cardiologist.Reading List / Educational Material:

Cardiac Catheterization. In Heart Disease, 6th Edition, Eugene Braunwald, editor. Pgs 359 – 386 Cardiac Catheterization, Angiography, and Intervention, 5th Edition. Baim DS, Grossman W. Coronary Interventional Procedures: Clinical Competence Statement (J Am

Coll Cardiol 1998; 31: 722-43) Physician Knowledge to Optimize Patient Safety and Image Quality in

Fluoroscopically Guided Invasive Cardiovascular Procedures: ACCF/AHA/HRS/SCAI Clinical Competence Statement on (J Am Coll Cardiol 2004; 44: 2259–82

Catheterization Laboratory Standard: ACC/SCAI Clinical Expert Consensus Document (J Am Coll Cardiol 2001; 37: 2170-214)

Pathologic material will incl ude review of endomyocardial biopsy specimens

Level of Supervision:Fellows will be directly supervised at all times during each procedure by an attending cardiologist with specific training and credentialing in invasive / interventional cardiology.

Research Experience

The Fellow in Cardiology will have many opportunities to participate in research both during his/her rotation in the catheterization lab, as well as during individual dedicated research months. A meaningful experience will include discussion of hypothesis and study design, data acquisition, data analysis and submitting the study for peer review.

Eval uation Process Fellows will be evaluated by the teaching attendings in the cardiac cath lab, and by the director of the lab. Fellows will be evaluated upon the basic six competencies established by the ACGME as follows:

Patient Care:Competency: Provides compassionate, appropriate, and effective health 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, pericardial disease, cardiac transplantation, and disorders of cardiac rhythm.

4) Demonstrates the clinical skills necessary to safely perform and select patients for cardiac catheterization.

Medical Knowledge:Competency: Demonstrates knowledge of concepts involved in patient selection for catheterization, contraindications to catheterization, procedural and radiographic safety for catheterization, and interpretation of procedurally derived data.

1) Understand the indications, limitations, complications and medical and surgical implications of the findings at cardiac catheterization and angiography, as well as a general understanding of related interventional procedures.

2) Understand the pathophysiology of cardiovascular disease and the ability to interpret hemodynamic and angiographic data and to use these data to select cases for surgical and catheterization-based therapeutic procedures.

3) Obtain a basic understanding of radiation physics, radiation safety, fluoroscopy and radiologic anatomy.4) Understand the fundamental principles of shunt detection, cardiac output determination and pressure waveform

recording and analysis. 5) Learn to perform pulmonary artery catheterization with flow-directed catheters by the percutaneous (subclavian,

femoral and internal jugular) route.

6) Learn the proper techniques of diagnostic left heart catheterization and angiography by percutaneous (brachial and femoral) approaches.

7) Learn to perform insertion and operation of temporary right ventricular pacemakers.8) Learn to perform and interpret the results of therapeutic pericardiocentesis.9) Learn intra-aortic balloon counterpulsation indications, insertion and management.

Practice Based Learning:Competency: Evaluates each new patient individually and addresses new problems / questions encountered through assimilation of scientific evidence as part of improving care practices.

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:Competency: Demonstrates interpersonal and communication skills that result in effective information exchange with patients, their families and professional associates.

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:Competency: Demonstrate commitment to carrying out professional responsibilities, adhearance to ethical principles and sensitivity to a diverse patient population.

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:Competency: Demonstrate awareness and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

1) Understands, accesses, utilizes and evaluates effectiveness of resource providers, and systems to provide optimal cardiac rehabilitation 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