During the first year, fellows are introduced to cardiac catheterization at the Baltimore Veterans Affairs Medical Center, where they average two to four cases per day under the direct supervision of an attending cardiologist. Fellows are expected to learn indications and contraindications to catheterization, how to perform right and left heart catheterization, coronary angiography, and ventriculography, as well as how to interpret hemodynamic data and coronary angiograms. During the second and third years, fellows are assigned to the University of Maryland catheterization lab, where the volume is much greater, with a much greater focus on advanced techniques of intravascular ultrasound, doppler flow wire analysis, and coronary intervention.
Fellows participate in all procedures, in conjunction with attending staff and two interventional fellows. The lab is active in balloon valvotomy, atrial septal and patent foramen ovale closure, endomyocardial biopsy, and the use of percutaneous support devices such as Tandem Heart and the Impella catheter. A weekly cardiac catheterization 'core' conference, as well as a weekly clinical conference based on film review and clinical decision making form part of the didactic training.
Primary Cardiology Service (PCS)
During the first year, each fellow will spend approximately 3 months on the PCS service. In conjunction with an attending cardiologist, medical residents and interns, and a PharmD, they will care for patients in the Cardiac Intensive Care Unit and the stepdown telemetry unit. Typical patients on this service include those with acute myocardial infarction, complex coronary interventions, complex rhythm disorders and ablations, valvular heart disease and congestive heart failure.
Complex Cardiology Service (CCS)
During the second and third years, our fellows participate in the care of the most challenging patients in cardiology within our Cardiac Intensive Care Unit, under the direction of one of our Advanced Heart Failure attendings. Patients on this service include those with cardiogenic shock, patients awaiting transplantation or transplant patients with complications, and patients requiring advanced circulatory support, as provided by left and right ventricular assist devices. The CCS team, comprised of one fellow, one attending, a PharmD, and medical residents and interns, also care for patients with advanced pulmonary hypertension and complex adult congenital heart disease. This rotation is considered a "keystone" experience by many of our fellows.
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 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 transesophageal echo. 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 over 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 lecture with case study review.
Clinical Cardiac Electrophysiology
Fellows are introduced to EP during the latter half of their first year of training. In this way, fellows are able to make a decision about whether or not they wish to pursue electrophysiology as a career path based upon first-person knowledge. The rotation is composed of consultative electrophysiology, involvement in diagnostic intracardiac studies and 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.
While Nuclear Cardiology is under the auspices of Radiology, the director is a renowned cardiologist -- Dr. Vasken Dilsizian. While on this rotation, fellows will actively participate in all aspects of Nuclear Cardiology, from performance of dynamic tests, to interpretation of myocardial perfusion scans, gated acquisition and PET scanning. Fellows will learn key concepts of nuclear imaging, and will participate in a Nuclear conference. While two months are required training, most fellows choose to pursue another two months of nuclear training during their third year as part of fulfilling requirements for eligibility for nuclear licensure.
The Baltimore Veterans Affairs Medical Center is directly attached by footbridge to the University of Maryland Medical Center. It was the very last of the VA hospitals built; hence, it is the most modern. During the 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.
Cardiac Rehabilitation / Congenital Heart Disease
During this one month combined rotation, fellows experience cardiac rehabilitation services firsthand, and also engage in an experience in congenital heart disease. The former is accomplished at one of our 'sister' institutions -- Baltimore Washington Medical Center. Experience in congenital heart disease is accrued by working with our Division of Pediatric Cardiology. Fellows may participate in all aspects of Pediatric Cardiology including interpretation and performance of echos, catheterization, and outpatient evaluation. Fellows have elected in the past to split these two rotations and develop a more concentrated approach to adult congenital heart disease.
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, nuclear cardiology, etc. 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. Anything is possible, but planning under the supervision of the program director is essential.
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