Congenital Heart Disease

Educational Purpose:  Remarkable advances in surgical and catheter management of congenital heart disease (CHD) have allowed greater than 85% of children with CHD to survive to adulthood. It is estimated that there are now over 1 million adult survivors with CHD in North America alone.  Adults with CHD have special health care needs and often present complex combinations of problems requiring specialized care.  Today, most patients with adult CHD continue to follow with their pediatric cardiologists, as adult medical cardiologists tend to have insufficient training and exposure to this group of patients.  The educational purpose of this rotation is to provide adult cardiovascular fellows with exposure to the diagnosis and management of adult patients with congenital heart disease both prior to and after corrective procedures.  This level of training should allow for sufficient knowledge to manage simple adult CHD and to recognize the moderate or complex diseases and obtain the appropriate consultations or referrals for proper care.

Fellows may participate in this 2-4 week elective rotation in order to develop additional training and exposure beyond what is available in the regular course of training.  At this time, further subspecialty training in adult congenital heart disease is not available at our institution.

Overall Goals & Competency-Based Learning Objectives:
To understand the basic embryology, anatomy, pathology, physiology, and genetics of adults with common congenital heart defects (COMPETENCIES: patient care, medical knowledge)
Recognize and evaluate common, simple congenital heart lesions and the sequelae of the more commonly repaired congenital heart defects.  Fellows should always consider consultation and collaborative patient management with a Level 2- or 3-trained specialist or pediatric cardiologist when major management decisions are made for adults with CHD and for periodic discussions of ongoing care. (COMPETENCIES: patient care, medical knowledge, interpersonal skills and communication, professionalism, practice-based learning and improvement, systems based practice)
To understand the diagnosis (history, exam, EKG, x-rays, echocardiography) of common lesions expected to be encountered in adults, operated or not (COMPETENCIES: patient care, medical knowledge)
To obtain exposure to the evaluation of CHD with various diagnostic modalities during usual clinical rotations such as electrocardiography, electrophysiology, transthoracic and transesophageal echocardiography, nuclear cardiology, and the cardiac catheterization laboratory [including invasive transcatheter techniques]). Exposure to other advanced imaging techniques now commonly utilized in CHD (e.g., magnetic resonance imaging [MRI] and computed tomography [CT]) is highly desirable. (COMPETENCIES: medical knowledge, systems based practice)
To understand the management of patients with common congenital heart defects presenting in adulthood and be able to provide genetic counseling, care during pregnancy, endocarditis prophylaxis, and management during non-cardiac surgery (COMPETENCIES: patient care, medical knowledge, interpersonal skills and communication)
To understand specific issues relevant to cyanotic CHD and Eisenmengers syndromes (COMPETENCIES: patient care, medical knowledge)
Obtain a general knowledge of the outcomes, residua, sequelae, and complications of management, of invasive catheter-based therapy, and of surgical palliation, correction, or repair (COMPETENCIES: patient care, medical knowledge, systems based practice)
To work as part of a comprehensive care team (COMPETENCIES: interpersonal skills and communication, professionalism, systems bases care)

Goals & Objectives by PGY level:
PGY 6:
1. Understand the basic embryology, anatomy, pathology, physiology, and genetics of adults with common congenital heart defects
2. Recognize and evaluate common, simple congenital heart lesions and the sequelae of the more commonly repaired congenital heart defects.  
3. To understand the diagnosis (history, exam, EKG, x-rays, echocardiography) of common lesions expected to be encountered in adults, operated or not 
4. To obtain exposure to the evaluation of CHD with various diagnostic modalities during usual clinical rotations such as electrocardiography, electrophysiology, transthoracic and transesophageal echocardiography, nuclear cardiology, and the cardiac catheterization laboratory [including invasive transcatheter techniques]). Exposure to other advanced imaging techniques now commonly utilized in CHD (e.g., magnetic resonance imaging [MRI] and computed tomography [CT]) is highly desirable. 
5. To understand the management of patients with common congenital heart defects presenting in adulthood and be able to provide genetic counseling, care during pregnancy, endocarditis prophylaxis, and management during non-cardiac surgery
6. To understand specific issues relevant to cyanotic CHD and Eisenmengers syndromes 
7. Obtain a general knowledge of the outcomes, residua, sequelae, and complications of management, of invasive catheter-based therapy, and of surgical palliation, correction, or repair
8. To work as part of a comprehensive care team

Mix of Diseases:  Fellows will be exposed to a wide range of adults with congenital heart disease including but not limited to atrial septal defects, ventricular septal defects, patent ductus arteriosis, tetralogy of Fallot, transposition of the great arteries  (e.g., atrial baffle and arterial switch operations), single ventricle (e.g., Fontan operation), and ventricular outflow tract lesions (all levels of
aortic and pulmonic stenosis and coarctation of the aorta). Patients may range in age from pediatric patients seen in consultation with the pediatric cardiologist; however, the focus should be on adults over the age of 18 years old.  The gender mix will usually be balanced and exposure to pregnant patients is expected.

Teaching Methods:
Patient-Centered Teaching/Learning: Teaching will take place at the bedside of patients on telemetry floors, intensive care units, and cardiac catheterization laboratories, together with the attending physicians, with additional discussion during weekly conferences.   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.  Topics will be covered on adults with congenital heart disease.

Procedures:  Fellows will be allowed to participate in a variety of procedures involving patients with adult CHD including transthoracic and transesophageal echocardiography, cardiac catheterization and coronary angiography with exposure to catheter based interventional techniques.  Fellows are encouraged to gain exposure to common palliative and corrective surgical procedures when possible.

Pathologic Material/Educational References: 
The fellows will review EKGs, chest X-rays, cardiac catheterizations, CT scans, stress tests and echocardiograms as indicated by the patient’s cardiac condition.  
https://cincinnatiachdcourse.org  The material was recorded at the 2011 ACHD Program in Cincinnati.
www.acc.org; 
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(s) (may vary)
1 Adult Cardiology Fellow
Pediatric Cardiology Fellows

Attending Responsibilities:
Supervises and assumes ultimate responsibility for the care of the patients on the service
Supervises and assumes ultimate responsibility for the performance and interpretation of all procedures
Conducts rounds with the team during which he/she reviews clinical information, formalizes management plan, and performs patient-centered teaching.
Responsible for providing verbal and written feedback to the fellow

Fellow Responsibilities:
Read about congenital heart defects and their unique surgeries prior to starting the rotation.  This will provide the knowledge base to build on during your rotation.
Attend the daily conference at 7:30AM (7AM on Wednesdays) in North Wing 1st floor to discuss interesting patients with the pediatric cardiology team
Participate in daily rounds with the team and follow the adult patients with CHD assigned to your care
See new consultations on adult patients and formulate a plan of care with the team
Time should be spent in both the echocardiograph and cardiac catheterization laboratories when possible working directly with the attendings
Attendance at outpatient clinics is encouraged to obtain exposure to this group of patients with adult CHD
Attends all divisional conferences
Attend assigned Cardiology clinics 
Completes a written evaluation of the attending
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