Cardiac Cath Rotation

Educational Purpose:  A body of basic information underpins the practice of cardiovascular angiography including cardiac and coronary anatomy, vascular anatomy, cardiac physiology, vascular biology and pathology, hemostasis, pathophysiology of ischemia, pharmacology, radiology imaging and radiation safety, intracoronary imaging and coronary flow physiology, device design and performance and clinical management strategies. The purpose of the cardiac catheterization rotation is to train fellows in these principles along with allowing fellows to obtain the technical skills to perform coronary and vascular angiography, left ventricular angiography, and hemodynamics measurements.  This includes the development of appropriate medical knowledge and technical skills that will ensure proper application, interpretation and performance of angiographic techniques. The fellows will have intensive experience working with world-class interventional cardiologists early and throughout their training.  This is a technically and intellectually rich experience for them.
 Overall Goals:
·         Be competent in the provision of comprehensive care in patients diagnosed with coronary artery disease requiring coronary angiography and intervention. Understand the usefulness and limitations of coronary angiography procedures.  (COMPETENCIES: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning, systems-based practice)
·         Learn how to apply evidence-based, cost conscious strategies to diagnose and manage patients undergoing cardiac catheterization procedures. (COMPETENCIES: patient care, medical knowledge, practice-based learning)
·         Learn to function as a member of a multidisciplinary team treating patients undergoing interventional cardiac procedures. (COMPETENCIES: patient care, professionalism, interpersonal and communication skills, systems-based practice)
·         Be able to participate in family meetings and be an effective communicator (COMPETENCIES: Interpersonal and communication skills, professionalism)
·         Have an understanding of utilization of resources and appropriate levels of care in patients with coronary disease, valvular heart disease and atrial septal defect; and peripheral vascular disease undergoing interventions.  (COMPETENCIES: medical knowledge, practice-based learning, systems-based practice)
 
Competency-Based Learning Objectives:
·         Function as effective team leaders and teachers in caring for patients undergoing procedures in the cardiac catheterization lab. (COMPETENCIES: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning, systems-based practice)
·         Demonstrate competency in history and physical examination of patients undergoing coronary angiography. (COMPETENCIES: patient care, interpersonal and communication skills) 
·         Discuss the diagnosis and management of patients with the cardiac conditions requiring invasive procedures and angiography. (COMPETENCIES: medical knowledge, interpersonal and communication skills)
·         Demonstrate the organizational skills necessary to supervise the care of patients in the cardiac catheterization laboratory.  (COMPETENCIES: patient care, practice-based learning, system-based practice)
·         Effectively cross-cover for patients undergoing angiography when other team members are not available (COMPETENCIES: professionalism, patient care, interpersonal and communication skills)
·         Function effectively as a member of a multidisciplinary team (COMPETENCIES: interpersonal and communication skills, professionalism, system-based practice, patient care)
·         Demonstrate effective communication with patients, families, colleagues and staff (COMPETENCIES: communication and interpersonal skills, professionalism)
·         Demonstrate ability to oversee effective discharge planning for patients who underwent angiography and revascularization.  (COMPETENCIES: patient care, medical knowledge, systems-based practice)
·         Demonstrate an understanding of the indications and contraindications for various types of procedures, including hemodynamic invasive monitoring with Swan-Ganz catheters, arterial catheter monitoring, intra-aortic balloon pump, percutaneous and surgical revascularization. (COMPETENCIES: patient care, medical knowledge)
 
Goals & Objectives per PGY level:
PGY 4:
1.      Function as team leaders and teachers in caring for patients undergoing coronary angiography.
2.      Demonstrate competency in history and physical examination of patients undergoing coronary angiography
3.      Discuss the diagnosis and management of patients with the cardiac conditions requiring invasive procedures and angiography
4.      Demonstrate the organizational skills necessary to supervise the care of patients in the cardiac catheterization laboratory
5.      Effectively cross-cover patients undergoing angiography when other team members are not available
6.      Function effectively as a member of a multidisciplinary team
7.      Demonstrate effective communication with patients, families, colleagues and staff
8.      Demonstrate ability to oversee effective discharge planning for patients who underwent angiography and revascularization.
9.      Demonstrate an understanding of the indications and contraindications for various types of procedures, including hemodynamic invasive monitoring with Swan-Ganz catheters, arterial catheter monitoring, intra-aortic balloon pump, mechanical circulatory support, and percutaneous and surgical revascularization.
10.  Learn how to apply evidence-based, cost conscious strategies to diagnose and manage patients undergoing cardiac catheterization procedures.
11.   Have an understanding of utilization of resources and appropriate levels of care in patients with coronary disease, valvular heart disease and atrial septal defect; and peripheral vascular disease undergoing interventions. 
 
PGY 5:
1.      Continue to build upon the goals and objective of PGY-4 year.
2.      Gain more experience and mastery over complex interventional procedures and hemodynamic tracing.
 
PGY 6:
1.    Continue to build upon the goals and objectives of PGY-4 and 5.

2.    Gain experience in interventional cardiology and begin formal technical training specific to interventional cardiology.

 
Mix of Disease: Fellows will be exposed to a variety of cardiovascular disease during this rotation including but not limited to: acute coronary syndrome (including primary PCI), chronic ischemia heart disease, non-cardiac chest pain, peripheral vascular disease, aortic disease, cardiomypathies, heart failure including cardiogenic shock, pericardial disease including tamponade, congenital heart disease, pulmonary hypertension, and complications of prior interventions.  Patients cared for will be over the age of 18 and will be well balanced in terms of male and female patients.  Pregnant patients may be encountered.
 Teaching Methods:
·         Patient-Centered Teaching/Learning:  Case based teaching will take place prior to, during, and after procedures carried out in the cardiac catheterization lab.  Emphasis will be placed on the approach and evaluation of the patient complaint, evidence based medicine, as well as means to efficiently search for answers to clinical questions.  Fellows are expected to identify knowledge gaps and search for answers to their questions on a routine basis.  
·         Conferences/Didactic Learning: Given the high time demand of rotations in the cardiac catheterization laboratory, fellows will be excused from conference attendance.  However, attendance is encouraged.  In addition, attendance at Interventional Conferences is encouraged.
 Procedures:
Learning Aspects Of Pre-Procedural Phase (COMPETENCIES: Patient Care, Medical Knowledge, and Professionalism):
·         Patient selection- understand the indications for coronary angiography
·         Establish a patient-physician relationship
·         Obtain informed consent and discuss alternatives with patients
·         Review pre-procedure laboratory data and non-invasive studies
·         Identify possible contraindications for angiography and catheterization
 Learning Aspects Of The Procedural Phase (COMPETENCIES: Patient Care, Medical Knowledge):
·        Appropriate selection of catheters and devices
·        Obtain appropriate angiographic views
·         Interpretation of angiograms
·         Procedure pharmacotherapy and conscious sedation dealing with life-threatening complications
 
Learning Aspects Of Post-Procedure Phase (COMPETENCIES:  Patient Care, Medical Knowledge, Professionalism, System-based Practice, Practice-based Learning)
·    Post-procedure vascular access care
·    Post-procedures orders and pharmacotherapy
·    Medical record documentation and procedure dictation
·    Discharge and follow-up care planning
·    Communication of results to patient, family and consultants
 
Pathologic Material/Educational Resources:
·         The fellows will review EKGs, chest X-rays, cardiac catheterizations, CT scans, 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:
·         One attending available in the cardiac catheterization lab at all times.  Fellows will interact with a variety of attendings during the rotation.
·         1-2 diagnostic cardiology fellow(s)
·         One dedicated interventional fellow
Attending Responsibilities:
·        Supervises and assumes ultimate responsibility for the procedure being performed in the cardiac catheterization lab and post-procedural care
·        Reviews the fellows pre-procedural evaluation including indications and potential contraindications for all patients undergoing a procedure
·        Reviews methods to limit complications in all patients undergoing a procedure
·        Responsible for providing verbal and written feedback to the fellow regarding technical skills, pre- and post- procedural care.  Evaluation of responsibility includes assessment of the thoroughness of pre-procedural evaluation and clinical follow-up, reliability, and interpersonal interaction with patients, other physicians and laboratory staff.
 
Fellow Responsibilities:
·         Be aware of the case load for any given day in the cardiac catheterization lab and assist in prioritizing patient procedures
·         Obtain a thorough history and physical examination on all patients including a thorough pre-procedure evaluation, reviewing all indications and contraindications for procedures
·         Review all prior laboratory testing, non-invasive studies, and coronary angiograms
·         Determine appropriateness of all patients referred for cardiac catheterization
·         Obtain written informed consent on all patients prior to the start of any procedure
·         Discuss all patients with the supervising attending who is ultimately responsible for patient care
·         Determine any additional treatments or medications necessary for a patient prior to undergoing cardiac catheterization.  These may include premedication for iodine allergy or to prevent contrast induced nephropathy.
·         Perform indicated procedures under the supervision of the attending physician.  Procedures will include but not be limited to: right and left heart catheterization, left and right ventriculography, coronary angiography, cardiac biopsy, peripheral angiography, closure device deployment/placement, and exposure to coronary and peripheral interventions.
·         Provide appropriate documentation of all procedures performed including written summaries on the chart and dictation to be kept as part of the patient’s medical record.  The standard for completion of dications of a cardiac catheterization report is within 24-hours of the procedure or sooner.
·         Provide appropriate post-procedural care including access site hemostasis, medical follow-up, and communication with the referring physician regarding findings and recommended plan or care
·         Responsible for the maintenance of detailed records in the form of an electronic logbook that contains clinical information for each patient studied and/or treated in the laboratory. Documentation must include a patient identifier, the procedure performed, assisting physicians and procedure outcomes, including any complications.  The laboratory director will review this data for future attestation of clinical competence.
·         Attend divisional and fellow conferences when able.  It is also recommended to attend interventional conferences while on cardiac catheterization rotations.

Catheterization Lab Resources and Links:



Recommended Reading List:
  • Moscucci M.  Grossman’s Cardiac Catheterization, Angiography, and Intervention, 8th Edition.  2014. 
  • Kern, Morton.  The Cardiac Catheterization Handbook, 6th Edition.  2016.
  • Braunwald.  Heart Disease, 6th Edition.  2001.     
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George Marzouka,
Jul 1, 2014, 9:08 PM
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George Marzouka,
Jul 1, 2014, 9:08 PM
Ċ
George Marzouka,
Jul 1, 2014, 9:08 PM
Ċ
George Marzouka,
Jul 1, 2014, 9:08 PM
Ċ
George Marzouka,
Jul 1, 2014, 9:08 PM
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