Advanced Cardiac Imaging

Educational Purpose:  The educational purpose of this rotation is to gain a general understanding of the indications and appropriate use of a variety of advanced imaging modalities used in the care of patients with cardiovascular disease.  These modalities include contrast and non-contrast cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR), in addition to radionuclide imaging and advanced Echocardiographic modalities described previously.  Fellows will receive training that would provide at least basic understanding of the methods, utility, and application of CCT and CMR in the practice of cardiovascular medicine.  

The level of training offered (generally COCATS level 1) will provide at least 1 dedicated month of exposure to cardiac CT and MR, giving the fellow a working knowledge of these advanced imaging modalities; however, it may not provide the skills necessary to independently interpret cardiac CT and MR studies.  Further training beyond what is offered within the fellowship program is encouraged if a fellow seeks the level 2 or 3 training necessary for independent interpretation.

Fellows will become well versed in the clinical application of cardiac CT and MR to the care of patients with cardiovascular disease.  Correlation with other diagnostic modalities will be emphasized.  Fellows will also be expected to communicate information, verbally when necessary, to the physician requesting the service, and deal with him/her on a professional level

Overall Goals & Competency-Based Learning Objectives:
To identify the indications and basic image acquisition techniques involved cardiac CT and MR (COMPETENCIES: patient care, medical knowledge)
To understand the basic types of cardiac CT and MR studies and their indications (COMPETENCIES: medical knowledge)
To understand the use of cardiac CR and MR in cardiovascular anatomy, physiology, and pathophysiology in the overall care of patients with cardiovascular disease (COMPETENCIES: patient care, medical knowledge, systems based practice)
To understand the basic physics of advanced cardiac imaging, radiation safety, the basics of scan performance, safety issues in performance, side effects (and their treatment) of medications used currently including beta blockers and nitrates, post-processing methods, and basics of interpretation as compared with other cardiovascular imaging modalities including echocardiography, nuclear cardiology, and invasive cardiac and vascular x-ray angiography (COMPETENCIES: patient care, medical knowledge, systems based practice)
To understand the use of intravenous administration of iodinated contrast including contrast injection methods, adverse events and their treatments, and contrast kinetics (COMPETENCIES: patient care, medical knowledge)
Actively participate in performance and image acquisition of cardiac CT and MR.  Hands-on training is important, not to develop technical expertise, but rather as a valuable aid to learn tomographic cardiac anatomy, integrate planar views into a 3D framework, and understand the distinction between reliable and unreliable data (COMPETENCIES: patient care, medical knowledge, practice-based learning and improvement, systems based practice)
To understand the sources of artifacts (breath-holding, gating, or arrhythmias) and how these affects image interpretation (COMPETENCIES: patient care, medical knowledge)
Actively participate in cardiac CT and MR study interpretation under the direction of a Level 2 or Level 3 trained physician mentor either in the department of cardiology or radiology.  There should be mentored interpretation of at least 50 cases and may include studies from an established teaching file or previous cardiac CT cases (COMPETENCIES: patient care, medical knowledge, practice-based learning and improvement, systems based practice)
To integrate the information obtained from cardiac CR and MR studies with other diagnostic modalities in cardiovascular medicine including EKG, angiography, echocardiography, radionuclide imaging, and hemodynamics data (COMPETENCIES: patient care, medical knowledge, practice-based learning and improvement, systems based practice)
To establish a professional, working relationship with radiology faculty to help interpret non-cardiac findings (COMPETENCIES: patient care, medical knowledge, professionalism, interpersonal skills and communication, practice-based learning and improvement)
Communicate effectively the risk and benefits of the procedure to the patient (COMPETANCIES: patient care, interpersonal skills and communication, systems based practice)
Provide professional presentation of imaging findings to patient and family members in a compassionate and informative manner with appreciation of cultural, spiritual and social context of wellness and illness. Provide complete and accurate report to consulting physicians and care teams (COMPETANCIES: patient care, interpersonal skills and communication, professionalism, systems based practice)
Understand and utilize the multidisciplinary resources necessary to perform advanced imaging studies and  collaborate with other members of the health care team to assure comprehensive cardiac care (COMPETANCIES: patient care, interpersonal skills and communication, professionalism, practice-based learning and improvement)

Goals & Objectives by PGY level:
PGY 6:
1. Attend lectures on the basic concepts of cardiac CT and MR and conduct continued self-study reading material
2. To understand the basic types of cardiac CT and MR studies and their indications 
3. To understand the basic physics of advanced cardiac imaging, radiation safety, the basics of scan performance, safety issues in performance, side effects (and their treatment) of medications used currently including beta blockers and nitrates, post-processing methods, and basics of interpretation as compared with other cardiovascular imaging modalities including echocardiography, nuclear cardiology, and invasive cardiac and vascular x-ray angiography 
4. To understand the use of intravenous administration of iodinated contrast including contrast injection methods, adverse events and their treatments, and contrast kinetics
5. Actively participate in performance and image acquisition of cardiac CT and MR.  Hands-on training is important to understand the distinction between reliable and unreliable data
6. To understand the sources of artifacts (breath-holding, gating, or arrhythmias) and how these affects image interpretation 
7. Actively participate in cardiac CT and MR study interpretation.  There should be mentored interpretation of at least 50 cases (and may include studies from an established teaching file or previous cardiac CT cases ) to achieve level 1 certification
8. To integrate the information obtained from cardiac CR and MR studies with other diagnostic modalities in cardiovascular medicine including EKG, angiography, echocardiography, radionuclide imaging, and hemodynamics data
9. To establish a professional, working relationship with radiology faculty to help interpret non-cardiac findings
10. Communicate effectively the risk and benefits of the procedure to the patient 
11. Provide professional presentation of imaging findings to patient and family members in a compassionate and informative manner with appreciation of cultural, spiritual and social context of wellness and illness. Provide complete and accurate report to consulting physicians and care teams 
12. Understand and utilize the multidisciplinary resources necessary to perform advanced imaging studies and  collaborate with other members of the health care team to assure comprehensive cardiac care

Mix of Diseases:  Fellows will be exposed to a variety of cardiovascular diseases requiring advanced cardiac CT and MR including (but not limited to) coronary artery disease (both native and bypass graft evaluation), cardiomyopathies, valvular heart disease, pericardial disease, arrhythmic substrates, aortic disease, pulmonary vascular abnormalities, and congenital heart disease.  These modalities may be used in both acute and chronic illness and to help guide research protocols.  Fellows may also be exposed to non-cardiac findings on imaging modalities.  Patients will be over the age of 18 years old and the gender mix will be balanced.  Exposure to pregnant patients will be avoided for cardiac CT due to radiation safety concerns but may occur for cardiac MR imaging.

Teaching Methods:
Patient-Centered Teaching/Learning: Fellows will receive direct instruction from the attending physician in the cardiac CT and MR imaging areas with additional instruction in certain procedures by qualified technicians on service.  Fellows are expected to identify knowledge gaps and search for answers to their questions on a routine basis.   
Conferences/Didactic Learning:  Fellows are expected to attend the Division of Cardiology Fellows’ Core Curriculum Lectures given throughout the academic year in addition to the departmental Grand Rounds.  The Thursday Imaging Lecture Series will cover a variety of topics in advanced cardiac imaging.

Procedures: Fellows will be exposed to a variety of procedures used to acquire cardiac CT and MRI.

Pathologic Material/Educational Resources:
The fellows will review EKGs, chest X-rays, cardiac catheterizations, stress tests and echocardiograms as indicated by the patient’s cardiac condition.  
Up to Date: http://www.uptodate.com/home/index.html
PubMed: www.ncbi.nlm.nih.gov/pubmed/ 
Text books:  Cardiology textbooks are available in the Hospital Library and the Calder Medical Library.
Institutional access for http://www.cardiosource.org  and CardiosourcePlus with ACCSAP7.

Evaluations: Fellows will be evaluated by their supervising attending physician(s) using a competency-based system on New Innovation.  Feedback will be provided during and at the end of the rotation.

Supervision Policy: Direct/Indirect with direct supervision immediately available.

Team Structure:
Supervising Attending (may vary)
1-2 Cardiology Fellow(s)
Various support staff including imaging technologists and ARNPs

Attending Responsibilities:
Supervises and assumes ultimate responsibility for the performance and interpretation of all advanced imaging modalities
Responsible for providing verbal and written feedback to the fellow

Fellow Responsibilities:
Determine appropriateness of all patients referred for advanced cardiology imaging
Perform acquisition of cardiac CT and MR when able
Interpret the results of the imaging test and provide a preliminary reading that will be reviewed with the attending physician for accuracy prior to reporting in the medical record
Communicate abnormal results to the referring physician (and the patient when appropriate) and provide a suggested plan of care 
Responsible for keeping a log of all procedures/studies in New Innovations
Attends all divisional conferences
Attends assigned Cardiology Clinics
Completes a written evaluation of the attending
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