||This one-year fellowship is offered to those who have completed a general cardiology fellowship (PGY7 level or greater) and are seeking advanced training in the subspecialty of heart failure, cardiac transplantation and mechanical circulatory support leading to American Board of Internal Medicine subspecialty certification. The program will be ACGME accredited in July 2013.
Salpy V. Pamboukian MD MSPH
|Fellows in this comprehensive program will acquire knowledge & experience in the following areas:
Advanced Heart Failure Cardiology
Mechanical Circulatory Support (MCS)
I. Advanced Heart Failure Cardiology
- Performance of efficient initial assessment directed at the four major components of heart failure evaluation:
- Etiology and contributing factors
- Hemodynamic status at rest and cardiac reserve
- Adequacy of current therapy to relieve symptoms, prevent disease progression, and prevent unexpected mortality
- Potential for surgical intervention
- Individualize the medication regimen for heart failure at every stage from left ventricular dysfunction through advanced heart failure
- Describe components of decision making regarding hospital admission for patient with chronic heart failure
- Understand, evaluate and manage patients with many forms of cardiomyopathy
- Specific skills:
- Ability to interpret hemodynamics, coronary angiography, echocardiograms, and nuclear studies for diagnosis and decisions regarding heart failure
- Ability to interpret cardiopulmonary exercise tests and prescribe exercise regimen for patients with cardiac disease
- Understanding of evaluation, indications, and expectations for revascularization and valve replacement in patients with poor systolic function.
- Systematic approach to diagnosis and therapy of contributing factors to clinical heart failure with preserved left ventricular ejection fraction
- Understanding of benefits and risks of bi-ventricular pacemakers and implantable defibrillators for patients with cardiac dysfunction
- Application of appropriate indications and contra-indications for cardiac transplantation and common post-transplant complications
- Understanding of indications for and common post-operative and long-term outpatient surveillance and complications for mechanical circulatory support devices
- Appropriate and compassionate counseling of patients and families regarding prognosis and plans, including end-of-life issues
- Critical review of basis of evidence for decision-making
- Advanced Heart Disease journal
- Thorough understanding major multi-center clinical trials in heart failure
- Completion of independent investigations with fellow as first author (encouraged by not mandatory),
- formulation of working hypotheses
- design of interventions and case report forms
- preparation of IRB application with assistance
- participation in data analysis
- drafting of primary results
- presentation to Advanced Heart Disease team
- preparation of abstract
- outline and draft of manuscript
II. Transplantation Cardiology
- Understanding evaluation process and patient selection criteria for heart transplantation
- Participating in documentation and communication with multi-disciplinary team.
- Identifying and managing pulmonary hypertension in patients listed for cardiac transplantation
- Understanding allosensitization and approaches to sensitized patients.
- Understanding of listing status and knowledge of the roles of United Network of Organ Sharing (UNOS) and Organ Procurement Organizations (OPO).
- Synthesis of information necessary to decide suitability of donor heart for transplantation
- Participation in procurement of donor organ and observation of implantation surgery.
- Early post-operative management of transplant patients, including initiation of immunosuppression.
- Outpatient management of immunosuppression including minimization of immunosuppression and corticosteroid tapering.
- Performance of endomyocardial biopsies (varied level of proficiency goal)
- Interpretation of endomyocardial biopsies.
- Understanding treatment of rejection including hyperacute, acute cellular, antibody mediated and late acute rejection.
- Outpatient therapy to decrease risk of complications following transplantation including use of prophylactic medical regimens.
- Recognition and management of other common complications following transplantation:
- Renal dysfunction
- Skin malignancy, other malignancies
- Hemodynamic, echocardiographic, nuclear, and angiographic evaluation of coronary artery disease following transplantation
- Evaluation and patient selection for re-transplantation
- Identify and communicate compassionately with patients at end-of-life for referral to palliative care team
- Thorough understanding major multi-center clinical trials in cardiac transplantation
III. Mechanical Circulatory Support (MCS)
- Evaluation of patients and appropriate candidate selection for MCS
- Documentation and communication with multi-disciplinary team
- Understanding MCS indications eg. Bridge to transplant (BTT), destination therapy (DT)
- Understanding of appropriate device types for given indications
- Understanding of basic mechanical components of currently available ventricular assist devices
- Ability to recognize and respond to common device alarms
- Understanding need for and methods of pre-operative medical optimization
- Management of post-operative patients during their initial implant stay including management of:
- Right ventricular dysfunction and indications for right sided mechanical circulatory support
- Recognition and management of tamponade
- Post-operative systemic hypertension
- Re-introduction of oral heart failure therapy
- Initiation and management of anti-coagulation and anti-platelet therapy
- Drive line care
- Patient and family education
- Discharge preparations and transition to home
- Interpretation and management of changes in pump parameters
- Evaluation and management of long-term complications of MCS therapy including:
- Neurologic complications
- Ischemic stroke
- Hemorrhagic stroke
- Device related: drive line, pump pocket
- Non-device related
- Aortic insufficiency
- Late term RV dysfunction
- Device malfunctions
- Need for non-cardiac surgery or other procedures
- Evaluating need and indications for re-hospitalization for patients with MCS.
- Hemodynamic, echocardiographic, and radiologic evaluation of patients with MCS and interpretation of test results.
- Understanding of device end-of-life manifestations
- Experience with palliative care and termination of mechanical support
- Thorough knowledge of current bases of evidence for outcomes with available devices
In addition, fellows will receive training in the field of pulmonary arterial hypertension including evaluation of patients with possible PAH, selection of pulmonary vasodilator therapy and long term management utilizing goal-directed therapy.
The fellowship includes assignments in the subspecialty outpatient clinic, the inpatient service and the biopsy suite. The inpatient rotation takes place in the Heart Transplant ICU, a dedicated 20 bed in-patient ICU supervised by the heart failure attendings.
As fellows gain experience and demonstrate growth in their ability to care of patients, they will assume roles that permit graded and progressive responsibility.
Deepak Acharya, MD
Robert Bourge, MD
Renzo Loyaga-Rendon, MD, PhD
Salpy V. Pamboukian MD MSPH
Sumanth Prabhu, MD
Jose Tallaj, MD
- Interviews are scheduled after the first of the year with appointments beginning on July 1.
- For more information, see Application Information.