Interventional Cardiology Fellowship

1. The fellow should understand and be proficient in all areas of General Cardiology prior to beginning the fourth year. These skills must be reviewed and utilized during the fourth year so that fellows continue to be excellent Cardiologists as they are learning the field of interventional cardiology.

2. The fellow will understand appropriate patient selection for invasive and interventional cardiac procedures. The fellow will understand specific device and technique selection for interventional procedures.

3. The fellow must understand contraindications and potential complications of all invasive and interventional procedures and be able to communicate these with patients and other physicians.

4. The fellow will understand cardiac and vascular system anatomy including possible anatomical variants and pathological states.

5. The fellow will be able to perform all forms of diagnostic cardiac catheterization and intravascular procedures. This includes ability to obtain arterial access through the femoral, brachial, radial, and direct cut-down approach; and venous access using internal jugular, subclavian, femoral, and direct cut-down approach. Diagnostic procedures include right heart catheterization, right ventriculography, pulmonary, arteriography, endomyocardial biopsy, left heart catheterization, coronary arteriography, left ventriculography, aortography, selective renal aerteriography, iliac and femoral arteriography, subclavian and internal mammary artery arteriography, coronary bypass graft angiography, and intravascular ultrasound.

6. The fellow will be familiar with the performance and indications for all forms of interventional therapy and will be exposed to and proficient at most of these procedures. Interventional procedures currently performed at our institution include percutaneous transluminal coronary angioplasty (PTCA), intracoronary stent placement, rotational atherectomy, directional atherectomy, alcohol septal ablation for IHSS, aortic and mitral balloon valvuloplasty, renal artery angioplasty and stenting, and iliac artery angioplasty and stenting. Other related procedures include intra-aortic balloon pump (IABP) insertion, temporary transvenous pacemaker insertion, and pericardiocentesis.

7. The fellow will be able to interpret hemodynamic and angiographic data obtained during invasive and interventional procedures.

8. The fellow will understand the use of adjunctive pharmacologic therapy for interventional procedures including the use of aspirin, theinopyridines, thrombolytics, glycoprotein IIb, IIIa, receptor blockers, direct thrombin inhibitors, nitrates, calcium channel blockers, beta blockers, angiotesin converting enzyme inhibitors, and the entire range of cardiovascular drugs.

9. The fellow will gain experience in the pre- and post-care of patients undergoing invasive and interventional procedures.

10. The fellow will understand the limitations of interventional techniques and proper patient selection for cardiovascular surgical procedures.

11. The fellow will be able to integrate data from the diagnostic and interventional procedures as well as non-invasive data to form a thoughtful, correct, and cost-effective treatment plan.

12. The fellow will understand basic radiation physics and safety with respect to cardiac catheterization laboratory equipment.

13. The fellow will understand the proper use of iodinated contrast agents and avoidance of toxicity. The fellow will understand the differences between ionic and non-ionic contrast agents.

14. The fellow will understand the processes of restenosis after coronary procedures as well as the process of disease progression. The fellow will understand current ways to prevent restenosis and disease progression.

Most of the teaching in the fourth year is “hands-on” experience with conference and didactic teaching that complements the learning experience. In most cases, the fellow will perform a history and physical on the patient and review available non-invasive data. This is done to help decide if the procedure is indicated and to plan effective treatment strategy. The attending and fellow will then discuss the case to make sure there is agreement on plans. During invasive and interventional procedures, both the attending and fellow are “scrubbed in” and stand side by side performing the procedure. This gives the opportunity for ongoing discussion of the procedure, techniques, and results. After procedures are completed, the fellow and the attending review the data generated and the results obtained to plan the continuing care of the patient.  The fellow will communicate with other housestaff involved in the care of the patient and will be essential in educating other residents and fellows about invasive and interventional procedures. Fellows will have the opportunity to follow-up patients after invasive and interventional procedures in the outpatient setting.

Conferences related to cardiology are held almost daily. Cardiac catheterization conference is held weekly. All aspects of cardiac catheterization are discussed during this conference which is geared toward all of the cardiology fellows and is attended by fellows, cardiology attendings, and cardiovascular surgery attendings. This conference has a varied format. Some cath conferences focus on a single procedure or disease process. The fellow presents the patient history and physical and appropriate ancillary data and cardiac catheterization data. The fellow then presents the relevant research data on the topic. Attendings or fellows who have relevant comments or data or questions add to the discussion. Some cath conferences center on a complicated case in which the audience is encouraged to help decide management of the patient. Other cath conferences are “show-and-tell” where several interesting cases are shown with brief discussion about each. There will be a new conference starting with the first group of fourth year fellows entitled Interventional Conference. In this conference we will review most of the recent interventional cases to discuss approach used, device and equipment selection, results, and complications. This conference will be attended by the interventional fellows, the interventional program director, and available interventional attendings. Other conferences held on a regular basis within the division are: Interesting Case Conference (weekly), Echocardiography Conference (weekly), General Cardiology Conference/Board Review (weekly). Also, the Department of Medicine holds a weekly Grand Rounds conference.

A. Mix of Disease
Interventional fellows will be exposed to a wide variety of pathologic entities. These include acute coronary syndromes, acute myocardial infarction, chronic ischemic heart disease, post CABG patients, congestive heart failure, post cardiac transplant patients, valvular heart disease, hypertrophic obstructive cardiomyopathy, peripheral vascular disease, congenital heart disease, pulmonary embolism, as well as patients with multiple cardiac and complicating medical problems.

B. Patient Characteristics
The Medical University of South Carolina is both a tertiary referral center and a major local hospital serving Charleston and surrounding communities. Patients are generally over the age of 18, with no real upper limit on age. Patients younger than 18 are occasionally seen because of our international status in the treatment of Hypertrophic Obstructive Cardiomyopathy (HOCM / IHSS). Fellows will be exposed to “bread and butter” community cardiology problems through admissions from the emergency room and referrals from community physicians, as well as encountering rare cardiac problems referred from around the Southeast and the world.

C. Types of Clinical Encounters
Interventional Fellows will have interaction with patients before, during, and after procedures in both the outpatient and inpatient settings. For outpatients scheduled for an invasive procedure, the fellow will take a directed history and physical, explain the procedure to patients and family, answer questions, and make sure patients is properly prepared for the procedure. The fellow performs the invasive / interventional procedure with the attending. The fellow is the responsible for the post care of the patients including medication adjustment and discharge planning. For inpatients, the fellow reviews the available data and prepares the patient for the procedure. The fellow is encouraged to follow these patients throughout their hospitalization to assess the response to the therapy. Fellows will see patients in the outpatient setting for general cardiology problems and also to decide appropriate interventional therapy before procedures and to follow short and long-term results after procedures.

A wide variety of procedures are performed at our institution.

Diagnostic procedures include:
Left heart catheterization, coronary arteriography, left ventriculography, aortography, selective renal arteriography, iliac and femoral arteriography, coronary bypass graft arteriography, intravascular ultrasound, right heart catheterization, endomyocardial biopsy, right ventriculography, and pulmonary arteriography.

Interventional procedures include:
Percutaneous transluminal coronary angioplasty (PTCA), intracoronary stent placement, rotational atherectomy, directional atherectomy, alcohol septal ablation for HOCM / IHSS, renal artery angioplasty and stenting, iliac artery angioplasty and stenting, aortic and mitral balloon valvuloplasty.

Other related procedures include:
Intra-aortic balloon pump insertion (IABP), temporary transvenous pacemaker placement, and diagnostic and therapeutic pericardiocentesis.

Fellows will be required to perform research. Each fellow will conceive an idea for a clinical study and will write the protocol, obtain appropriate IRB approval (if necessary), perform study/collect data, and write up the study for submission for publication. This will be done with a faculty advisor. Most of the interventional faculty are actively involved in clinical research and have multiple projects ongoing. The fellows are encouraged to get involved in these studies as well.

Fellows are expected to stay current in the field by reading cardiology journals including JACC, AHJ, Circulation, AJC, Catheterization and Cardiovascular Intervention, as well as other relevant journals. Several excellent textbooks are recommended for fellows, including: Heart Disease by Braunwald, The Heart by Hurst, Cardiac Catheterization, Angiography and Intervention by Grossman and Baim, Diagnostic and Therapeutic Cardiac Catheterization by Pepine, Strategies in Coronary Interventions by Ellis, and Hemodynamic Rounds by Kern, among others.

Each fellow is encouraged to attend one of the major interventional conferences during the year. If funding is available, the division will send the fellows to either the TCT conference or the ACCIS conference.