The Cardiovascular Catheterization Laboratory in the Sulpizio CVC is a second- and third-year fellow rotation. Fellows play an integral role in the daily work of the laboratory and are also expected to make contributions to conferences and clinical research efforts.
Educational purpose and learning objectives
Fellows are expected to obtain knowledge regarding the indications for the various procedures that are performed in the catheterization laboratory. These procedures include:
- Right and left catheterization
- Coronary angiography
- Peripheral angiography
- Right ventricular biopsy
- Evaluation of pulmonary hypertension
- Intraaortic balloon pump placement
Interventional procedures include:
- Angioplasty with stenting
- Cutting balloons
- Fractional flow reserve
- Transseptal catheterization
- Septal defect closures
- Peripheral vascular interventions
In addition to understanding the indications and the techniques, fellows needs to become trained in the follow-up of these patients including recognition and treatment of the complications that arise from these procedures.
By the end of their training, fellows are expected to become competent in the performance of:
- Arterial and central venous sheath placement
- Right and left heart catheterization
- Diagnostic coronary angiography (including native coronary arteries, saphenous vein grafts, and internal mammary arteries)
- Left ventriculography
- Interpretation of coronary and peripheral angiography Percutaneous closure of sheath insertion sites Percutaneous right heart biopsy
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Fellows will be taught in didactic conferences and during cardiac catheterization conference, but also (and primarily) by direct supervision of the attending physician during cath lab procedure. Initially fellows will be expected to scrub in and observe procedures, then to participate actively in the procedures, and finally to act as primary operator. Catheterization films will be reviewed together with the attending physician prior to procedure report dictation.
The majority of catheterization cases are performed in patients with coronary artery disease, though a significant fraction of cases are performed in patients with (1) nonischemic cardiomyopathy, (2) valvular heart disease, (3) peripheral arterial disease, and (4) cerebrovascular atherosclerosis. There are slightly more male patients than female.
Patients are generally first evaluated by the fellow in the Procedure and Treatment Unit (for outpatients) and in the hospital (for inpatients). The fellow is expected to perform a thorough evaluation and ensure the completion of the history/physical prior to the procedure. Following the catheterization, the fellow is expected to re-evaluate the patient for any postprocedural problems or complications.
The degree of fellow participation in the catheterization procedure is based on the fellow’s level of experience. During the first year of training, the fellow is not expected to be able to do an entire procedure by him or herself. By the end of the third year of training, however, the fellow should be able to perform a procedure with minimal input from the attending. This includes not only selecting and engaging the catheters, but selecting and planning the best angiographic views and selecting the optimal hemodynamic evaluation for patients with valvular heart disease.
- Braunwald: "Heart Disease"
- Hurst's "The Heart"
- Baim and Grossman: "Cardiac Catheterization, Angiography, and Intervention."
All catheterization images (including teaching studies) are digitally stored and available for fellow review.
ACGME core competencies are evaluated monthly by the attending faculty. These evaluations are discussed with the fellows and forwarded to the program director.
Second-year fellows are expected to have a mean score of 6 or above on the standard 1-9 scale of the 6 ACGME core competencies; third-year fellows are expected to have a mean score of 7 or above. Expectations of third-year fellows are more rigorous than those of more junior fellows.
The degree of fellow participation in the catheterization procedure is based on the fellow’s level of experience. During the first year of training, the fellow is not expected to be able to do an entire case by him or herself: significant attending supervision and input will be required. By the end of the third year of training, however, the fellow should be able to perform a case with minimal input from the attending. This includes not only selecting and engaging the catheters, but selecting and planning the best angiographic views and selecting the optimal hemodynamic evaluation for patients with valvular heart disease.
Specific activities during this rotation that will enhance the fellows’ skills in the 6 core competencies:
- Patient Care: Fellows will learn how to maximize patient comfort and stability during elective cardiac catheterization, They will gain experience in the management of patients with acute coronary syndromes, acute MI, cardiogenic shock and peripheral vascular disease.
- Medical Knowledge: Fellows will gain knowledge and first-hand experience in vascular access, right- and left-heart catheterization, coronary angiography, and vascular closure devices. Each case will be supervised (and later reviewed with the fellow) by a faculty attending. They will learn during catheterization conference, during review of teaching files, and during self-directed reading.
- Interpersonal and Communication Skills: Fellows will interact with referring physicians, catheterization lab technologists, nurses, and administrative staff. They will be expected to maintain accurate, timely-signed medical records and procedure reports.
- Professionalism: Fellows will gain experience in the respectful treatment of all the above-mentioned groups, and will also maintain accurate procedure logs and their hospital privileges.
- Practice-Based Learning: Fellows expected to gain knowledge from self-directed literature review regarding interesting cath lab cases they encounter, and facilitate the education of internal medicine residents rotating through the CCU service (as many patients on this service undergo cardiac catheterization). They will present cases during weekly catheterization conference and discuss pertinent literature.
- Systems-Based Practice: Fellows will interact with various medical centers and systems while arranging transfers of patients for angiographic procedures. They will consider cost-effectiveness when deciding whether to recommend medical treatment, percutaneous coronary intervention, or coronary artery bypass surgery for patients with coronary artery disease.