The three-year ACGME-accredited Cardiovascular Diseases Fellowship provides rigorous academic and clinical experience in various areas of general cardiovascular disease in full compliance with the 2008 Task Force 1: Training in Clinical Cardiology Statement and the American College of Cardiology. General fellows will build their clinical cardiology diagnostic and treatment skills predominantly through the first two years, while polishing their clinical expertise and/or engaging in skills refinement directed toward a particular subspecialty or research in their third year.
At the completion of their training, all fellows will be expected to:
- demonstrate mastery of the cardiovascular anatomy, physiology, pathophysiology and treatment and their integration into other medical and surgical specialties.
- demonstrate proficiency as a clinical cardiology consultant on all levels of primary, secondary and tertiary care, from the ambulatory clinic to the cardiac intensive care unit.
- demonstrate proficiency in performing and interpreting all aspects of basic cardiac diagnostics, including electrocardiography, echocardiography, cardiac stress testing, nuclear cardiology, cardiac CT and MRI, vascular sonography, diagnostic ambulatory and invasive electrophysiology, and invasive cardiac and vascular catheterization.
- demonstrate familiarity with techniques, post-operative care and basic manipulation of various aspects of cardiac treatment devices including: invasive hemodynamic monitoring, bedside pericardiocentesis, emergent and elective direct current external cardioversion, temporary transvenous pacing, permanent pacemaker and defibrillator placement and interrogation, cardiac ablation, percutaneous coronary intervention, septal closure, valvuloplasty, atrial appendage exclusion, circulatory support devices (intra-aortic balloon pump, Impella, ECMO, VADs) and open heart surgery.
- develop skills in didactic and clinical medical teaching.
- develop skills in evidence based medicine integration, literature search and critical interpretation, and familiarity with the major and landmark cardiovascular clinical trials.
- meaningfully participate in clinical research, professionally present lecture topics and complete at least one original research manuscript preparation and grant exploration.
Areas of Onsite Training
- Cardiac Intensive Care Unit
- Cardiac Telemetry Unit
- Consultation Service
- Nuclear Cardiology and Cardiac Stress Testing
- Cardiac Magnetic Resonance Imaging
- Cardiac Computerized Tomography
- Vascular Sonography
- Cardiac Catheterization/Interventional Service
- Cardiac Electrophysiology Service
- Cardiothoracic Surgery and Vascular Surgery
- Continuity Clinic
- Night and Weekend Calls
- Clinical Rotations Requirements
Areas of Offsite Training
- Advanced Heart Failure and Transplant (Required at Columbia Medical Center)
- Pediatric and Congenital Cardiology (Arranged as an elective)
One cardiac fellow, who works in direct collaboration with the Cardiac Telemetry Unit fellow, staffs the six-bed CCU. The fellow also manages the eight-bed post PCI recovery unit. Patients following ST-elevation myocardial infarction, severe non-ST-elevation myocardial infarction and unstable angina, cardiogenic shock or other hemodynamic instabilities with complicated cardiac disease, severe heart failure, and life-threatening arrhythmias are admitted to this unit. In addition to perfecting their physical examination skills, and critical treatment planning, fellows become proficient in performing insertion and interpretation of Swan-Ganz catheters, complex central venous access, pericardial drainage, temporary transvenous pacemakers, arterial line placement, intra-aortic balloon counterpulsation, impella support, noninvasive hemodynamic monitoring and ventilator management. Fellows will also lead the team of medical residents and students in directing patients' care and overall management of patients from admission to discharge. Twice daily teaching rounds are conducted with the attending on service.
[ top ]
One cardiac fellow, working in collaboration with the CCU fellow manages the 33-bed telemetry unit. During this rotation fellows begin to understand the pathophysiology, diagnosis and treatment of the basic cardiac conditions such as evaluation for acute coronary syndromes, treatment for unstable angina and non-ST elevation myocardial infarction, chronic and acute decompensated heart failure, tachyarrhythmias and bradyarrhythmias, and triaging patients with various hemodynamic instabilities or needs for in-hospital cardiac testing. They also head the team of medical residents and students in leading guideline directed care and overall management of patients from admission to discharge. Daily teaching rounds are conducted with the telemetry attending physicians on service.
[ top ]
The consultation service at NewYork-Presbyterian Brooklyn Methodist Hospital is managed by two fellows and provides an ample opportunity for the fellows to be involved in the care of patients with an extraordinary diversity of cardiovascular diseases. During this rotation the fellows will develop the medical knowledge base and cognitive abilities necessary to offer diagnostic and management support, and also master basic skills required for effective consultation. These include the ability to determine the question being asked, communicate effectively with the requesting physician, make specific and accurate recommendations, define contingency plans, offer appropriate educational information and, when appropriate, provide follow-up care.
[ top ]
NewYork-Presbyterian Brooklyn Methodist Hospital has a very busy state-of-the-art echocardiography laboratory that performs more than 11,000 transthoracic echocardiograms and over 500 transesophageal echocardiograms annually. Training includes hands-on acquisition and interpretation of transthoracic and transesophageal images with digital storage and retrieval technology. Every fellow will learn the basic aspects of cardiac ultrasound, including physical principles, "knobology", instrumentation, cardiovascular anatomy, cardiovascular physiology, and cardiovascular pathophysiology. Fellows will also become adept at performance and interpretation of transesophageal echocardiograms and understand the basics of conscious sedation administration. On average, our fellows personally perform 75 to 100 transesophageal echocardiograms during their second and third year echocardiography rotations. Given the expertise of our noninvasive faculty members and the high volume of the procedures, all our fellows graduate with level II training in echocardiography as outlined in the 2003 ACC/AHA Clinical Competence Statement on Echocardiography. The majority of our fellows become board certified by the National Board of Echocardiography prior to their graduation from the program.
[ top ]
The nuclear cardiology laboratory performs over 2600 nuclear procedures annually. The nuclear cardiology laboratory includes two nuclear cameras and two treadmill exercise suites. Procedures performed include treadmill exercise tests, myocardial perfusion imaging (planar and SPECT) with ECG-gated imaging and radionuclide ventriculography (MUGA). The pharmacologic stress testing includes vasodilator stress with both dipyridamole and adenosine and inotropic stress testing with dobutamine. The goals of this rotation include becoming proficient in interpretation of stress tests and nuclear angiographic correlation, appropriate imaging modality selection, understanding of quality control issues in the "hot lab" and on cameras and becoming proficient in radiation safety, physics, pharmaceuticals and gamma camera technology. Fellows will also have the opportunity to directly conduct and interpret cardiac stress testing with nuclear imaging at the Interfaith Medical Center with assistance from certified nuclear technicians. All fellows have the opportunity to receive level II training as described by 2008 Task Force 5: Training in Nuclear Cardiology. Most of the fellows become certified by the Certification Board of Nuclear Cardiology upon graduation from the fellowship.
[ top ]
Fellows also have the opportunity to spend a significant amount of time in the Cardiac Magnetic Resonance (CMR) Center and become familiar with CMR rest and stress protocols. All fellows receive level I training in CMR, which provides basic background knowledge in CMR and is sufficient for the practice of adult cardiology and referral for CMR evaluation. Fellows who wish to practice the clinical subspecialty of CMR, including independent interpretation of CMR studies or to pursue a career in CMR and to direct a CMR laboratory have the option of achieving level II or level III training. The specific requirements for the advanced training in CMR may be found in Task Force 12: Training in Advanced Cardiovascular Imaging (CMR) document. In addition to clinical imaging experience, fellows have the opportunity to get involved in one of the numerous ongoing clinical projects in cardiovascular imaging. There is an active patient database that can be used for research. These activities have resulted in a number of national presentations and publications by cardiology fellows.
[ top ]
Third-year fellows will receive at least one month of one-on-one teaching from an experienced cardiac CT expert. This experience will include hands-on manipulation and reading of cardiac CT images and daily clinical read-out sessions. A bank of existing studies and an active daily imaging schedule provide extensive and deep resources for learning. By the end of the rotation fellows will have a basic understanding of cardiac CT technology and become proficient in 3D and other post processing techniques. Requirements for certification in cardiac CT performance and interpretation can be found in the document Task Force 13: Training in Advanced Cardiovascular Imaging (Computed Tomography).
[ top ]
Throughout their fellowship, all fellows receive instruction and training in noninvasive vascular diagnostic physiology and interpretation, with a core focus on vascular sonography during the third year noninvasive rotation. With over five onsite American Board of Vascular Medicine certified faculty members and the high volume of procedures performed, fellows receive expansive instruction and develop proficiency in all major facets of vascular sonography interpretation. Most of the fellows become certified by the American Board of Vascular Medicine upon graduation from the fellowship.
[ top ]
NewYork-Presbyterian Brooklyn Methodist Hospital has a very active cardiac catheterization laboratory, which consists of two fully equipped catheterization suites with state-of-the-art digital x-ray systems, one fully equipped hybrid surgical-catheterization suite with automated C-arm technology and one as needed bi-plane x-ray suite. Over 3500 diagnostic angiograms, 1500 interventional procedures and 80 primary emergent PCI for STEMI are performed annually. The procedures offered include diagnostic left and right heart catheterizations with coronary angiography, balloon angioplasty, coronary stent placement, various atherectomy procedures, and structural and valvular heart disease repair. All complex revascularization procedures, including primary PCI for STEMI, unprotected left main coronary stenting and chronic total occlusion recanalization are performed on a routine basis, with or without ventricular assist devices, such as intra-aortic balloon counterpulsation or the Impella. Patients are evaluated for pulmonary arterial hypertension and are studied for response to therapeutic agents. Fellows become proficient in pre- and post-catheterization management, arterial cannulation, performance of right heart and left heart catheterizations with coronary angiograms, advanced image interpretation (including bypass grafts) understanding of coronary physiology using fractional flow reserve, intravascular ultrasound and OCT. NewYork-Presbyterian Brooklyn Methodist Hospital fellows participate in the cardiac catheterization laboratory at Interfaith Medical Center, which performs nearly all catheterizations via the radial approach. In addition, clinical fellows have an opportunity to participate in research activities in the laboratory. There is an extensive patient database that can be used for clinical research. All graduating fellows acquire level II training in diagnostic cardiac catheterization as outlined in the 2008 COCATS 3 Training Statement: Task Force 3. NewYork-Presbyterian Brooklyn Methodist Hospital also offers two ACGME accredited fourth-year positions dedicated to training in interventional cardiology.
[ top ]
Three dedicated faculty members and a large number of health care professionals staff the cardiac electrophysiology section. Two positions for a two-year CCEP Fellowship are ACGME accredited. There are two dedicated electrophysiology laboratories with state-of-the-art equipment, consisting of a biplane x-ray suite, intracardiac echocardiography, and magnetic mapping systems as well as access to hybrid cardiothoracic surgical suites for complex cases. A full range of electrophysiology procedures is performed in these laboratories, including complex ablations for SVT, intracardiac and epicardial VT and AF, loop recorder, pacemaker, defibrillator, resynchronization and subcutaneous defibrillator device insertion, and lead extraction. The CCEP section also has a growing hybrid AF ablation and LARIATÂ® atrial exclusion device delivery program. A busy arrhythmia and device clinic, in which clinical fellows can participate, is held weekly. Opportunities for clinical research are available.
[ top ]
Third-year fellows will spend a total of one month in vascular and cardiothoracic surgery learning about pathophysiology of arterial atherosclerosis, surgical management of severe coronary and peripheral arterial disease that are not amendable to percutaneous therapy and they will have an opportunity to take part in the management of patients in the preparation for surgical procedures and post-operatively, and also to scrub in along with surgeons for elective and emergent cases in the operating room.
[ top ]
Third-year fellows will also spend one month on a very busy, yet tremendously academic, cardiac transplant service at the NewYork Presbyterian Hospital-Columbia University Medical Center. Fellows will learn about all aspects of managing advanced heart failure, pulmonary hypertension, complex congenital heart disease, and heart transplantation. They will participate in the perioperative preparation of patients, understand the physiology of denervation, be responsible for postoperative management including selection of immunosuppressive therapy and learn post transplant complications, including infectious and malignant disease. On leaving the clinical rotation, the fellow will be familiar with advanced medical and surgical intervention for late stage heart failure, have developed clinical judgment to independently recognize, manage and treat complications and be proficient in interpretation of diagnostic studies pertinent to advanced heart failure and transplantation.
[ top ]
Interested third-year fellows can arrange external rotations in dedicated pediatric cardiology and adult congenital cardiology services at either the Columbia University Medical Center or the Weill Cornell Medical Center of NewYork Presbyterian Hospital to further their clinical, academic or research interests. Major emphasis will be on chronic ambulatory management of patients surviving into adulthood, physical examination skills, management of structural cardiomyopathies, noninvasive diagnostic imaging, arrhythmia management, and networking within the congenital cardiology community of academic and treatment resources.
[ top ]
The Division has a strong commitment to providing rewarding research experiences for cardiology fellows. There are a number of prospective data sets that fellows have access to which include follow up data on all patients who have undergone a cardiac MR, all patients who have had cardiothoracic surgery, and finally an integrated databank for all cardiac catheterizations, echocardiograms, and stress testing that have been performed at NYPBMH since 2004. Fellows will start their research experience with the selection of a mentor and a project topic during their first year of fellowship. Fellows will be encouraged to initiate their projects in the beginning of the second year of fellowship. During the third year of fellowship, if the project has progressed, the fellow is encouraged to submit abstracts for oral or poster presentations to major national and international conferences. If the project is accepted, the fellow is expected to prepare the abstracts for presentation and move towards manuscript preparation. In addition, the Division of Cardiology is very heavily involved in the number of national multicenter trials. Fellows are welcome to submit queries and proposals for data analysis. The complete list of trials may be found here.
[ top ]
The outpatient clinic is an important part of cardiovascular training and all fellows spend a mandatory half-day per week in either one of the outreach clinics or NewYork-Presbyterian Brooklyn Methodist Hospital cardiology clinics. In the clinic, fellows develop knowledge and understanding of primary and secondary prevention of ischemic and structural heart disease, appropriate follow-up of patients with disorders such as advanced heart failure, basic arrhythmia, peripheral vascular disease, malignant hypertension, etc. Fellows will also gain skills in the business and management of ambulatory cardiac clinics, and take on greater responsibilities in on-call care and diagnostic planning as their experience grows.
[ top ]
The fellow on-call is not required to stay in the Hospital at all times but should be able to come to the Hospital at any time during the call to evaluate critically ill patients. In the case of ST-segment elevation myocardial infarction, the fellow on-call must present to evaluate the patient as the primary cardiac responder within 15 minutes of initial page and responsibility includes, but is not limited to, timely activation of cardiac catheterization laboratory on-call team. A large cardiology fellows call room suite is conveniently located across the street from the main Hospital for those fellows choosing to remain on campus during call. On weekends, the fellow on-call is responsible for all cardiac issues and service/faculty consultations that may arise in addition to supervising the CCU-telemetry units. The fellow will also partake in emergency room telephone or bedside triage of patients to the cardiac units at NewYork-Presbyterian Brooklyn Methodist Hospital and field emergency calls from the Interfaith Medical Center. Generally, the on-call training is very front-loaded to quickly build experience and competency and first-year fellows are on-call one weekend per month and one weekday per week with reduced call frequency during the second and third years.
[ top ]
A portion of catheterization laboratory, echocardiography, nuclear cardiology, and electrophysiology experience is conducted at the Interfaith Medical Center during three months in first year, two months in second year and one month in third year.
Depending on individual fellow focus, additional noninvasive, catheterization laboratory, electrophysiology, research or offsite approved experiences can be structured during third year elective months.
Vacations are taken as four separate non-concurrent seven-day weeks during any month other than CCU-telemetry or consultations.