Heart Failure

Educational Purpose: The educational purpose of this rotation is to provide the fellow with the knowledge and experience necessary to evaluate and treat patients with advanced heart failure.  The rotation is structured for the fellow to engage in clinical management of inpatient and outpatient heart failure patients, including the performance and interpretation of relevant diagnostic studies under the direct supervision of an attending physician. These patients will include those being considered for ventricular assist devices (VAD) and cardiac (and possibly other organ) transplantation.  

By the end of this rotation, the fellow is expected to be able to assess and treat a wide variety of heart failure syndromes at a level commensurate with their level of cardiovascular training.  The fellow should be knowledgeable about the indications and contraindications for VAD, thoracic organ transplantation, the use of hemodynamics in selection of treatment measures, and the use of pharmacologic agents for heart failure. 

The fellow will have an opportunity to become familiar with the UNOS criteria for selection and prioritization of patients for cardiac transplantation, witness organ harvesting methods, and participate in the management of the acute and chronic post transplant patient.  The fellow will become familiar with the use of treatments to prevent organ rejection and participate in cardiac catheterization procedures and cardiac biopsies on post-transplant patients.  The fellow should also become facile at communicating information to referring physicians, verbally when necessary, and to deal with him/her on a professional level.  The competencies involved include medical knowledge, system-based practice, practice-based learning, and interpersonal and communication skills.   

Overall Goals:
To become competent in the evaluation and treatment of advanced heart failure patients. (COMPETENCIES: medical knowledge, professionalism, practice-based learning, systems-based  practice)
To learn how to use cardiac catheterization laboratory procedures for hospitalized and outpatients with advanced heart failure and cardiac transplants. (COMPETENCIES: patient care, medical knowledge, practice-based learning, systems-based practice)
To have an understanding of the potential complications involving heart failure and transplantation, and how to manage such complications (COMPETENCIES: patient care, medical knowledge, practice-based learning, systems-based practice)
To have an understanding of the potential complications involving ventricular assist devices and how to manage such complications (COMPETENCIES: patient care, medical knowledge, practice-based learning, systems-based practice)
To learn to function as a member of a multidisciplinary team  within the cardiovascular disease service mission (COMPETENCIES: patient care, professionalism, interpersonal and communication skills, systems-based practice)
To have an understanding of appropriate utilization of these resources using evidence based, cost conscious care (COMPETENCIES: practice-based learning, systems-based practice)

Competency-Based Learning Objectives:
Demonstrate competency in the performance and interpretations of cardiac catheterization and cardiac biopsy studies in the advanced heart failure / transplant population. (COMPETENCIES: patient care, medical knowledge, practice based learning, systems-based practice.
Demonstrate knowledge of the indications and contraindications for thoracic organ transplantation (COMPETENCIES: patient care, medical knowledge).
Demonstrate knowledge of the indications and contraindications for ventricular assist devices for both bridge to transplant and destination therapy (COMPETENCIES: patient care, medical knowledge).
Demonstrate knowledge of the potential complications of cardiac transplantation and VAD therapy and management of such complications (COMPETENCIES: patient care, medical knowledge, practice-based learning, systems-based practice)
Formulate a plan of treatment for advanced heart failure patients, including end of life care.  (COMPETENCIES: patient care, medical knowledge, interpersonal and communication skills).
Efficiently and effectively document in writing the observations, measurements, and conclusions, that will be entered into the medical record (COMPETENCIES: medical knowledge, system-based practice, practice-based learning, interpersonal and communication skills)
Demonstrate effective communication with consulting providers, and other physicians and supporting staff (COMPETENCIES: communication and interpersonal skills, professionalism)

Goals & Objectives by PGY Level:
PGY 4:
1.   Demonstrate competency in the performance and interpretations of cardiac catheterization and cardiac biopsy studies in the advanced heart failure / transplant population
2.   Demonstrate the knowledge of indications and contraindications for ventricular assist devices and thoracic organ transplantation
3.   Demonstrate knowledge of the management and potential complications related to ventricular assist devices, cardiac transplantation, other advanced heart failure therapy, and management of related complications.
4.   Develop team leadership skills and be able to formulate a plan for the treatment of advanced heart failure patients, including end of life care.  
5.   Efficiently and effectively document in writing the observations, measurements, and conclusions, that will be entered into the medical record
6.   Demonstrate effective communication with consulting providers, and other physicians and supporting staff
7.   Effectively work in an interdisciplinary fashion for the evaluation and continued management of candidates and recipients of advanced heart failure therapies
8.   Develop outpatient skills in the evaluation and management of patients who are pre or post transplant/device therapies.

PGY 5:
1. Further build upon the skills developed in the PGY-4 year. 

Mix of Diseases:  Fellows will be exposed to a wide range of patients with heart failure of varying etiologies, including pulmonary heart disease, cardiomyopathies and advanced coronary heart disease.  Fellows will be exposed to a variety of advanced heart failure therapies including outpatient inotropic therapy, ventricular assist devices, and cardiac transplantation. In the post-organ transplant patient, the fellow will be exposed to new and chronic heart transplant patients, including multi organ transplants.  

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.  Fellows are also expected to attend the weekly multidisciplinary heart failure/transplant meetings and present patients in whose care they are involved.
Procedures:  Fellows will be trained in a variety of procedures used in caring for patients with advanced heart failure including (but not limited to) placement of hemodynamic monitoring with Swan-Ganz catheters, right heart catheterizations, and cardiac biopsies (both for diagnostic purposed and surveillance post-cardiac transplantation).  Fellows will be expected to understand the management and troubleshooting associated with mechanical circulatory support systems such as balloon pumps, ventricular assist devices (both temporary percutaneous and permanent devices), ECMO, etc.  Fellows will also be trained in the administration of pharmacologic agents commonly used in the management of advanced heart failure and transplant patients.  Fellows are encouraged to take advantage of the unique opportunity to participate in organ harvesting, ventricular assist device implantation, and cardiac transplantation surgery.


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.  
www.acc.org; 
www.heart.org.  (Practice guidelines)
MEDLINE: http://medlineplus.gov/ 
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 supervising attending assigned for rounds
o Fellows may interact with other attendings during the rotation such as the patient’s heart failure cardiologist, the CCU attending, and attendings from the cardiothoracic transplant team
One dedicated advanced heart failure/transplant fellow
One PGY 4 or 5 general cardiology fellow
Support staff including advanced heart failure/VAD/transplant ARNPs, device technicians/ engineers, transplant psychologists and social workers

Attending Responsibilities:
Supervises and assumes ultimate responsibility for care and management of patients on the service
Conducts daily rounds with the fellows on the service and device a daily plan of care
Responsible for providing verbal and written feedback to the fellow
Supervises bedside and catheterization laboratory procedures

Fellow Responsibilities:
Initial consultation:
o Obtain the initial history and physical examination of all new consultations including a thorough review of prior treatments, laboratory testing, imaging studies, etc
o Formulate a plan of care that will be presented to the attending physician and/or the multidisciplinary team for advanced heart failure therapies.  Communicate this plan of care to the primary/consulting physicians
o Dictates initial reports as part of the patient’s medical record
Fellows will be responsible for the daily follow up of patients on the service and conducting rounds with the attending to formulate a plan of care.  The fellow will document the plan in a formal note (dictated or written in the electronic record preferred) and communicate the plan with the primary care team and other members of the multidisciplinary team when appropriate.
Fellows along with the attending(s) will determine the need for invasive diagnostic procedures and initiation of advanced heart failure therapies.
Fellows will participate in procedure (see above) under the supervision of their attending.  They will determine indications and contraindications for these procedures and review finding with the attending to see how care will be changed.  Fellows will be responsible for post-procedural care along with dictation of the procedure.
Fellows will participate in the selection of patients for research protocols and protocol procedures
Responsible for keeping a log of all procedures in New Innovations
Attend the weekly multidisciplinary team meeting for patients cared for by the advanced heart failure/transplant team.  This is usually held every Monday at 1pm in the Highland Professional Building. The fellow will be responsible for presenting inpatients on the service.
Attend the weekly advanced heart failure/transplant clinic along with assigned Cardiology continuity clinics 
Attends all divisional conferences
Completes a written evaluation of the attending
 

Comments