Cardiac Catheterization Rotation

The cardiac catheterization rotation is designed to enable fellows to achieve competence at the level expected of a new practitioner. Fellows will be trained to do the following:

• Acquire clinical and technical skills to apply to patient care
• Establish a solid medical knowledge base
• Implement compassionate, appropriate and effective patient care

Practice-based learning experiences and Involvement in Quality Improvement Programs

The program integrates practice-based learning experiences and fellow involvement in quality improvement programs. The rotation also includes didactic learning in the form of weekly conferences and reviews of scientific literature, in addition to bedside teaching. Fellows will be mentored to effectively communicate information to patients, their families and other health care professionals, as well as to adhere to high ethical principles. The fellowship also provides a system-based practice experience to involve fellows in the larger health care system.

Trainees in the cardiac catheterization rotation are expected to develop their skills in clinical problem solving, diagnosis and implementation of optimal therapeutics. They are also expected to refine their interviewing and interpersonal communication skills to help navigate system issues impacting patient care. Fellows are expected to be highly involved in patient care and be familiar with the results of diagnostic tests and therapeutic procedures.

Continuity of Care Training

Fellows are expected to be involved with the pre-, post- and intra-procedural care to understand the importance of continuity of care. Fellows are expected to review the appropriate literature, provide perspective on clinical management and present at a weekly case-based catheterization conference, which also includes didactic lectures by interventional fellows and faculty. Senior fellows are expected to demonstrate increased clinical leadership and independence in diagnostic catheterization procedures. All fellows are expected to progress in the six Accreditation Council for Graduate Medical Education (AGME) competencies and to communicate effectively with:

• Cardiologists
• House staff
• Nursing staff
• Referring physicians
• Technicians
• Other members of the health care team

Cardiac Catheterization Laboratory Rotations

The cardiac catheterization laboratory rotations are integrated between University Hospitals Cleveland Medical Center and the Louis Stokes Cleveland VA Medical Center. UH Cleveland Medical Center has five state-of-the-art and fully equipped cardiac cath labs and the Louis Stokes Cleveland VA Medical Center has two. The catheterization laboratory physician staff primarily responsible for fellow training is largely, but not exclusively, the same at both institutions.

Attending catheterization laboratory physicians are expected to closely oversee cardiology fellows' performance and reinforce their understanding of etiology, pathogenesis, clinical presentation and natural history of cardiovascular diseases.

Principle Teaching Methods

Direct supervision of patient care: The cardiology catheterization laboratory attending provides supervision to the catheterization laboratory team that consists of:

• General cardiology fellow
• Interventional fellow
• Nursing staff
• Technicians

Case-based learning/direct observation of procedures: Cardiology fellows perform procedures under the direct supervision of the catheterization laboratory attending who is responsible for pre- and post-procedure teaching of fellows and intra-procedure education.

Fellows should review all cases with an attending physician before catheterization procedures. This discussion includes:

• Diagnostic options
• Potential therapies
• Previous diagnoses and test results
• Review of other medical co-morbidities
• Review of pathogenesis

Attending physicians are expected to review current literature, guide fellow reading targeted at specific patient disease processes or procedures and discuss routine patient management on a daily basis. Several cases per week should be selected for more in-depth literature review and discussed in detail with the attending or presented at an appropriate divisional conference.

Conferences

A variety of conferences have been formulated to optimize the training experience of cardiology fellows in the catheterization laboratory. Fellows are expected to attend the weekly divisional clinical case conference as well as the monthly morbidity and mortality (M&M) conference. Cardiology Grand Rounds attendance is also mandated. A number of more focused conferences have been implemented for catheterization laboratory-based fellow education.

The interventional conference at UH Cleveland Medical Center is a weekly 60-minute conference devoted in part to literature reviews of key invasive cardiology topics. Interventional fellows are primarily responsible for these presentations. In-depth case review sessions are also done at these conferences to go over interesting, challenging or problematic cases. Interventional conference at the VA is a joint cardiology/cardiac surgery conference held weekly. Fellows rotating through the catheterization laboratory are expected to attend these conferences since there is great educational merit for general fellows regarding diagnostic catheterization.

Clinical Cardiac Catheterization Training

Patient characteristics: Patient mix at UH Cleveland Medical Center is typical for a tertiary academic medical center cardiac catheterization laboratory. A wide spectrum of cases at differing levels of acuity/complexity is encountered, including patients with the following conditions, among others:

• Aortic dissection
• Arrhythmia
• Cardiogenic shock
• Heart failure
• Hypertension
• Hypertrophic cardiomyopathy
• Myocardial infarction
• Peripheral arterial disease
• Pulmonary hypertension
• Stable and unstable angina
• Structural and congenital heart disease
• Valvular disease

The current catheterization laboratory volume at UH Cleveland Medical Center is approximately 2,400 cases per year. Patients come from a diverse socio-economic spectrum. The Louis Stokes Cleveland VA Medical Center provides experience and exposure to a sizable and different patient population which further enhances the fellowship training. Current catheterization laboratory volume at the VA is approximately 1,400 cases per year.

Fellows typically perform approximately 75-100 diagnostic catheterization procedures during each month that they are in the catheterization laboratory. Fellows spend two months at the Louis Stokes Cleveland VA Medical Center during their first year of fellowship. Second-year fellows spend two months at the UH Cleveland Medical Center catheterization laboratory. Third-year fellows may elect to spend a month or two at the UH Cleveland Medical Center catheterization laboratory.

Cardiac Catheterization Procedures

Fellows have the opportunity to learn basic and advanced diagnostic catheterization procedures under the direct supervision of an experienced invasive cardiologist.

Principle Educational Materials

An array of invasive cardiology textbooks is readily available at both UH Cleveland Medical Center and Louis Stokes Cleveland VA Medical Center catheterization laboratories for easy and quick reference. In addition, fellows have access to the libraries located in both hospitals. Computer access for literature searches via online journals is readily available. Fellows are expected to be proficient in obtaining requisite information on pathophysiology from standard textbooks and medical literature. Current therapeutics should be guided by the medical literature with particular weight given to clinical guidelines and consensus statements issued by the following organizations:

• American College of Cardiology
• American Heart Association
• Heart Failure Society of America
• Heart Rhythm Society
• Society for Coronary Angiography and Intervention

Level of Supervision by Faculty

All catheterization laboratory fellows are supervised by the attending of record, according to the institutional policy on attending supervision that is included in our departmental policies.

Objectives by Post-Graduate Year

Catheterization laboratory fellows will be responsible for patients they are performing diagnostic catheterization procedures on. They will work closely with a catheterization laboratory attending to be sure appropriate treatment plans and discharge plans are implemented following a procedure. On occasion, patients may require admission to an inpatient cardiology team.

Pertinent clinical information will be given to an accepting attending physician and cardiology fellow by a catheterization laboratory fellow to ensure continuity. Catheterization laboratory fellows have 24-hour a day access to a catheterization laboratory attending to discuss patient management. Catheterization laboratory fellows have no on-call responsibility during the catheterization laboratory rotation.

While both first- and second-year fellows rotate through the catheterization laboratory, expectations and independence vary by the level of training. Specific personal goals and expectations for further development are assessed before the rotation begins. These will be related to the fellows' learning portfolio and should take into account fellows' prior performance, degree of competence, comfort and experience. Senior fellows are expected to demonstrate increased clinical leadership in patient care and independence in diagnostic catheterization procedures; moreover, it is expected that senior fellows will not only master the subject content necessary to care for patients with cardiovascular disease but will also develop sophistication and maturity of clinical judgment. Thus, fellowship is a continuous process of professional and academic growth, with each individual progressing at a somewhat different pace.

For More Information

For more information on the Cardiac Catheterization Rotation, please contact:

Medhi Shishehbor, DO, MPH, PhD
Mehdi.Shishehbor@UHhospitals.org