Cardiac Electrophysiology Program

Educational purpose and learning objectives

Cardiac Electrophysiology Program rotations take place for two months during fellowship. During these rotations, the fellow will:

  • Obtain experience and training in the diagnosis and management of bradyarrhythmias and tachyarrhythmias
  • Learn the indications and limitations of invasive and non-invasive electrophysiology tests
  • Learn the fundamentals of pharmacologic and nonpharmacologic therapy, including antiarrhythmic drugs, device therapy and ablation

The trainee will be exposed to noninvasive and invasive techniques related to the diagnosis and management of patients with cardiac arrhythmias, including ambulatory ECG monitoring, event recorders, exercise testing, tilt table testing, invasive electrophysiology testing, and implantation of pacemakers and ICDs. The trainee will be taught ECG and intracardiac hallmarks of arrhythmias via formal ECG conferences, didactic lectures and conferences, and on the EP consultation service.

During consultations, the trainee will gain first-hand experience in arrhythmias and their management in patients with:

  • Congenital heart disease
  • Acquired heart disease
  • Recent surgery (cardiac and non-cardiac)
  • Recent cardiac transplantation.

An important component of training for the fellow is to learn the fundamentals of cardiac pacing, including recognition of normal and abnormal pacemaker function, indications for temporary and permanent pacing, pacing modes, and the general approach to programming and surveillance requirements for pacemakers and defibrillators. The trainee will receive formal instruction in insertion, management and follow-up of temporary pacemakers, including pacing and sensing threshold testing. The fellow will insert a minimum of 10 temporary pacemakers by the end of clinical training. The trainee will also be taught the indications and technique for elective and emergency cardioversion.

Advanced training for additional skills in Cardiac Electrophysiology, including permanent pacemaker implantation and management and assisting on electrophysiology studies and ablations, is available on special elective rotation.

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Facilities and resources available

CCEP program facilities available at UCSD Medical Center and VA Medical Center for patient care, education and training, research, include a dedicated Electrophysiology Laboratory, CCU, ICU, Heart Station, Cardiac Catheterization Laboratory, Ambulatory Clinic, Pacemaker & ICD Clinic, Cardiac Surgery, Ancillary Personnel (e.g. secretary, nurses, technicians), Arrhythmia Research Laboratory.

Teaching methods

The current teaching methods include:

  • In-patient consultative teaching rounds with attending physicians
  • Out- patient clinic sessions with attending supervision
  • Didactic teaching sessions
  • Device interrogations and other non-invasive testing with attending supervision
  • Electrophysiologic studies and ablations with attending supervision and instruction

Disease mix/patient characteristics

The disease variability is quite wide within the fellowship program, in part due to the various institutions included in the program (UCSD Medical Center, San Diego VA Medical Center and Jacobs Medical Center). The age range of treated patients is quite broad. Overall, the gender representation is approximately equal (though most patients at the VA Medical Center are male). The majority of patients tend to be middle-aged to elderly.

Fellowship timetable during EP rotation

  Monday Tuesday
Wednesday Thursday Friday
AM VA Clinic Area 2
(Krummen)
UH/VA Case UH/VA Case UH/VA Case
(Feld)
UH/VA Case
PM UH Case UH/VA Case UH/VA Case UH/VA Case UH/VA Case

EP Studies at Jacobs Medical Center: Drs. Green, Feld, Hsu, Narayan, Krummen, Chen

EP Studies at VA Medical Center: Drs. Narayan, Krummen

Attending coverage of the EP consult service

  • UH/SCVC: Green, Feld, and Hsu
  • VA Medical Center:  Narayan and Krummen

EP attending timetables

UCSD/SCVC procedural schedule. Please refer to online schedules for UCSD/VAMC

  Monday Tuesday Wednesday Thursday Friday
AM Feld/Hsu/Green Feld Feld/Hsu Bui/Whitwam Feld
PM Feld/Hsu/Green Hsu/Green Feld/Hsu Krummen/Narayan/
Chen/Green
Feld/Green

VAMC schedule

  Monday Tuesday Wednesday Thursday Friday
AM Arrhythmia and Device Clinic Device/SVT Ablation Ablation Ablation
PM Device/SVT Device/SVT Device or Ablation Arrhythmia and Device Clinic Device or Ablation

UH/SCVC clinic schedule

  Monday Tuesday Wednesday Thursday Friday
AM Narayan/Krummen (SCVC) Green (Hillcrest) Green (SCVC) Feld/Hsu (SCVC) Green (SCVC)
PM       Feld/Hsu (SCVC)  

All Cardiovascular Disease residents rotating on the CCEP service are required to attend 2-3 half-day clinics per week. The Cardiovascular Disease resident will see several patients during each clinic with arrhythmias, pacemakers or defibrillators. After performing a history and physical exam, interpreting the ECG, and performing pacemaker or ICD interrogations (with assistance of the EP staff), the patient will be presented to the attending for determination of further treatment and follow-up.

Type of clinical encounters/procedures/services

All Cardiovascular Disease fellows rotating on the CCEP service are required to attend two UCSD clinics and 1-2 VA Medical Center clinic each week. The fellow will see several patients during each clinic with arrhythmias or implanted devices (Loop recorders, pacemakers or defibrillators). After performing a history and physical exam, interpreting the ECG, and performing any pacemaker or ICD interrogations (with assistance of the EP staff), the patient will be presented to the attending for determination of further treatment and follow-up.

All patients referred to the Clinical Cardiac Electrophysiology (CCEP) service for outpatient procedures (i.e. <24 hour stay), including diagnostic electrophysiology procedures, catheter ablation, pacemaker and ICD implantation, tilt tests, and cardioversions, may be admitted for observation to the CCEP service, where they will be evaluated and treated by the CCEP service fellow under the direct supervision of the CCEP faculty attending.

All patients admitted for inpatient treatment (i.e. >24 hours) are to be admitted to the Cardiology service, where the Internal Medicine residents and general cardiology fellow will provide continuous patient care under supervision of the admitting CCEP attending.

Night and weekend call

The Cardiovascular Disease resident is not required to take night or weekend call, but attendance at weekend rounds on any patients that the fellow is taking care of is encouraged. This should be coordinated with the attending scheduled to be on call.

CCEP conferences and educational resources

The Cardiovascular Disease resident is required to attend the CCEP program clinical conferences each Wednesday and Thursday at 8:00 a.m. The conference locations will be circulated on a dedicated CCEP conference schedule and available from Pam Alford at the beginning of the academic year. Each conference has a different focus.

Wednesday lecture is a Core Lecture from the curriculum (once per week), and Journal Club and Research Conference (once each per month). The Core Lectures cover required didactic subjects and are presented by the CCEP faculty, with some topics presented by senior fellows. These lectures are comprehensive and current reviews of each assigned topic, and require textbook and current literature reading in preparation.

Thursday conference will take the form of a Clinical Case Conference. At Clinical Case Conference, several current cases will be discussed that represent common and straight-forward arrhythmias, or unusual and complex arrhythmias, and the salient points of each case will be discussed in detail by the CCEP faculty with the residents. The CCEP fellow is also responsible for selecting and presenting one or two articles at Journal Club each month, which will be presented and then discussed by the CCEP clinical team.

Clinical EP procedures are reviewed three days a week, usually after completion of all cases that day, by the CCEP attending with the CCEP resident for interpretation of tracings, findings, diagnosis and treatment plan. Cardiovascular Disease residents and students are encouraged to attend these study interpretation sessions. In addition to these CCEP conferences the Cardiovascular Disease resident must continue to attend Cardiology Grand Rounds and Catheterization Conference held each week while on the CCEP service rotation. The Cardiovascular Disease resident should also attend the VA weekly ECG conference.

Level of fellow supervision by faculty

The Cardiovascular Disease fellows are responsible for seeing and evaluating all new consultations to the CCEP service. The Cardiovascular Disease fellow will round on all in-patients by 8:30 a.m. New patients will be seen and presented to the attending on EP Consult service the same day whenever possible, but certainly within 24 hours. Continuing care and communication with referring physicians is the responsibility of the Cardiovascular Disease fellow with the supervision of the CCEP attending on the consult service. Interrogation and programming of pacemakers and ICDs on inpatients may be performed by the Cardiovascular Disease fellow on the CCEP Consult service under supervision of a CCEP subspecialty fellow or attending.

When Cardiovascular Disease fellows have completed their duties with respect to new consultations and inpatient follow-up, they should report to the Electrophysiology laboratory or clinic. During the diagnostic portion of any cardiac electrophysiology procedures, the Cardiovascular Disease fellow on service is to be present whenever possible and will be instructed in the techniques of venous access and electrophysiologic recording. This instruction may be provided in part by the CCEP subspecialty fellow, under the direct supervision of the CCEP attending. All other aspects of the EP procedure and/or pacemaker and ICD implantation are performed by the CCEP fellow under supervision of the CCEP attending. Following venous cannulation and catheter placement, the Cardiovascular Disease fellow will observe the EP procedure as it progresses with additional teaching provided by the CCEP attending (including relevant reviews and summaries of the findings, interpretation of tracings, diagnosis, and subsequent treatment plans). Subsequent interpretation of EP tracings may also be reviewed by the CCEP fellow with the Cardiovascular Disease fellow.

Reading list

  • Fogoros: “Introduction to Electrophysiologic testing” Prystowsky
  • Klein “Basics of Cardiac Electrophysiology”
  • Josephson’s “Cardiac Electrophysiology”, 3rd edition
  • UCSD CCEP Reading Packet on CD-ROM
  • General Cardiology texts, including:
    • Hurst’s “The Heart”
    • Braunwald’s “Heart Disease”

Pathologic material and other educational resources

Teaching files and electrophysiologic tracings of interesting electrophysiologic studies and ECG case demonstrations are available on the hospital’s digital imaging system. Dr. Narayan and Feld have also made several teaching cases on print and digital format.

Method of fellow evaluations

The Cardiovascular Disease fellow must complete an evaluation of each attending and the CCEP rotation in general upon completion of their rotation on the CCEP Service. These forms will be forwarded to the fellow via e-mail from the cardiology fellowship director.

The Cardiovascular Disease fellow will be evaluated by the appropriate CCEP faculty member at the end of each rotation. ACGME core competencies will be evaluated monthly by the attending faculty. These evaluations will be discussed with the fellows and forwarded to the program director. First-year fellows are expected to have a mean score of 5 or above on the standard 1-9 scale of the 6 ACGME core competencies. Second-year fellows are expected to have a mean score of 6 or above on the standard 1-9 scale of the 6 ACGME core competencies; third-year fellows (when applicable) are expected to have a mean score of 7 or above.

Expectations of senior fellows are more rigorous than those of more junior fellows. During the first year of training, the fellow is expected to (1) perform a history, physical exam, and consultation with significant attending input and supervision; (2) understand the basic indications for electrophysiologic testing; (3) perform elective cardioversion with directed attending supervision; and (4) assist minimally during electrophysiologic testing procedures. At the end of the second year of fellowship training, the fellow is expected to (1) perform a history, physical exam, and consultation with minimal attending input and supervision; (2) interpret electrophysiologic recordings of common conduction system abnormalities (i.e., atrial fibrillation, SVT, VT, heart block); (3) perform elective cardioversion with minimal attending supervision; and (4) assist during electrophysiologic testing procedures and pacemaker insertions.

Educational purposes and ACGME Core Competencies

Specific activities during this rotation that will enhance the fellows’ skills in the 6 core competencies:

  1. Patient Care: Fellows will see numerous patients on the inpatient EP consult service and in the outpatient clinics. They will assist in electrophysiologic studies, ablation procedures, and pacemaker implantations, and will learn to maximize patient comfort during these procedures.
  2. Medical Knowledge: Fellows will gain experience and knowledge in electrophysiology during the performance of EP studies, temporary and permanent pacemaker implantation, electrical cardioversion, and pacemaker interrogation; during ECG teaching rounds with attending faculty, during weekly EP teaching conference, during review of teaching files, and during self-directed reading and review.
  3. Interpersonal and Communication Skills: Fellows will interact with attending physicians, electrophysiology sub-specialty fellows, EP technologists, and nursing staff. They will be expected to keep accurate, timely-signed medical records and procedure reports.
  4. Professionalism: Fellows will gain experience in the respectful treatment of all the above-mentioned groups, and will maintain accurate procedure logs and their hospital privileges.
  5. Practice-Based Learning: Fellows are expected to gain knowledge from self-directed literature review concerning interesting EP cases they encounter. Fellows may present cases and discuss pertinent literature during EP conference, journal club, and weekly catheterization conference.
  6. Systems-Based Practice: Fellows will interact with various medical centers and systems while arranging transfers of patients for electrophysiologic procedures. They will consider cost-effectiveness when deciding whether to recommend EP procedures and/or implanted devices (e.g., implantable cardiac defibrillators and bi-ventricular pacemakers) for patients with arrhythmias or heart failure.