Heart Failure/Cardiomyopathy

Educational purpose and learning objectives

The educational purpose of this rotation is to give the fellow the experience in dealing with patients with heart failure in all its stages and various presentations and to introduce them to pre- and post-cardiac transplantation evaluation and management. Specific learning objectives include gaining expertise in the following areas:

  • Inpatient management of patients with decompensated heart failure,
  • Determination of the need for and selection of devices including left ventricular assist devices, intra-aortic balloon and other investigational devices
  • Inpatient consultation of patients with heart failure
  • Emergency room evaluation of patients with heart failure,
  • Outpatient management of heart failure patients
  • Right heart catheterization and endomyocardial biopsy,
  • Integration of results from invasive, noninvasive and blood tests in determining the presence, etiology and severity of heart failure
  • Cost-effective management of hospitalized patients with cardiac disease
  • Assessment of patients for cardiac transplantation
  • Postoperative management of cardiac transplant recipients
  • Outpatient management of transplant recipients
  • Inpatient management of complications and long-term morbidities that occur in post- cardiac transplantation patients.

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Teaching methods

These include teaching rounds with attending staff and direct faculty supervision of procedures such as cardiac catheterization and endomyocardial biopsy. The fellows will attend:

  • Regularly-scheduled heart failure and heart transplant clinics
  • Didactic sessions and meetings
    • Weekly Heart Transplant Meeting and Referral Tracking Meeting
    • Monthly Heart Failure Didactic Conference

Disease mix/patient characteristics

The patient population seen at UCSD represents a broad and representative mixture of the heart failure population in that includes patients of varying age, gender, race, socio-economic status etiology of heart failure, severity of heart failure, etc. In addition, patients with heart failure due to systolic dysfunction as well as those with preserved systolic function are both well represented.

Type of clinical encounters/procedures/services

Admissions, ER evaluations, consultations and out-patient visits are generally seen first by the fellow and then together with the faculty attending. Fellows are strongly encouraged to assist with procedures and are expected to directly review all primary data on patients referred for evaluation.

Level of fellow supervision by faculty

Independent analysis of patient information by the fellow is encouraged, but all inpatients and consultations are seen by the faculty and reviewed with the fellow. All major clinical decisions are discussed by the fellow and faculty. Faculty will directly supervise procedures performed in the catheterization laboratory.

Schedule

  Monday
Tuesday
Wednesday
Thursday
Friday
AM
HF Conference
7 - 8 a.m.

Transplant Rounds
8 - 9:30 a.m.

HF Rounds
9:30 - 11 a.m.
Transplant Rounds
8 - 9:30 a.m.

HF Rounds
9:30 - 11 a.m.

Pre Txp Conference
Transplant Rounds
8 - 9:30 a.m.

HF Rounds
9:30 - 11 a.m.
TXP CONF
7 - 8 a.m.

Transplant Rounds
8 - 9:30 a.m.

HF Rounds
9:30 - 11 a.m.

Cardiac Cath
8 a.m. - 12 p.m.
Transplant Rounds
8 - 9:30 a.m.

HF Rounds
9:30 - 11 a.m.

Cardiac Cath
8 a.m. - 12 p.m.
 PM Transplant Clinic Heart Failure Clinic Heart Failure Clinic Txp Clinic
(Barnard/Greenberg)

HF Clinic
(Adler)

Hillcrest Clinic
(Silva)
Hillcrest Clinic

Reading list

  • Hosenpud and Greenberg’s “Congestive Heart Failure”
  • Greenberg and Barnard’s “Handbook of Heart Failure”
  • HF Fellow Handbook
  • HF DropBox (fellow to be given access when rotation starts)

Lectures/meetings

Lectures/meetings will include a weekly heart failure case conference and a transplant selection meeting. In addition, the fellow is expected to present 1-2 cases from the heart failure service during the weekly Cath Lab conference.

Call

The fellow will take no overnight call. Home call will alternate weekly with the heart failure fellow. The rotating fellow will also be expected to come in 1-2 weekends of the month to assist with the inpatient service.

Pathological material and other educational resources

Teaching files of interesting echocardiograms, angiograms, and stress tests are available on-line on the hospital's digital cardiac imaging system. Pre-transplantation cardiac biopsy specimens are reviewed on a bi weekly basis during Referral Selection Meeting.

Method of resident evaluation

ACGME core competencies are evaluated monthly by the attending faculty. These evaluations are discussed with the fellows and forwarded to the program director.

First-year fellows are expected to have an introductory level of exposure to guidelines and treatment regimens for heart failure, as well and an introductory level of experience in the hemodynamic assessment of patients with heart failure and cardiac transplantation. Specifically, first-year fellows should:

  1. Master the examination and evaluation of patients with heart failure with significant attending supervision and input
  2. Perform right heart catheterization with minimal attending input and left heart catheterization with direct attending supervision
  3. Perform right heart biopsy under direct attending supervision.

Second-year and third-year fellows are expected to show full competency in the treatment of patients with heart failure, as well as competency in performance and interpretation of right heart catheterization. Specifically, second-year and third-year fellows should:

  1. Master the examination and evaluation of patients with heart failure with minimal attending supervision and input
  2. Perform right and left heart catheterization with minimal attending input
  3. Perform right heart biopsy with minimal attending supervision.

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 between 4 and 8 outpatients during half-day clinic session at the UCSD cardiomyopathy/heart failure outpatient clinic. They will round on the inpatient heart failure service, and perform both right heart catheterizations and right ventricular biopsies in heart failure/transplant patients.
  2. Medical Knowledge: Fellows will gain experience in both ambulatory and inpatient care and management of patients with heart failure. The treatment plan for each patient seen by the fellow will be reviewed by the faculty attending. Fellows will gain knowledge through discussions with faculty and also through didactic lectures, self-assessment case review sessions, and self-directed reading.
  3. Interpersonal and Communication Skills: Fellows will interact with patients and their families, nursing staff, clinic staff, and pharmacists. They will be expected to keep accurate, timely-signed medical records, clinic dictations, discharge summaries and procedure reports.
  4. Professionalism: Fellows will gain experience in the respectful treatment of all the above-mentioned groups, and will also 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 cases they encounter, and facilitate the education of internal medicine residents rotating on the CCU service. Fellows will present cases and discuss pertinent literature during journal club or weekly catheterization conference.
  6. Systems-Based Practice: Fellows will deal first-hand with patient concerns regarding costs of medications and health care in general. They will advocate for quality patient care and work with multiple allied health professionals to facilitate prompt medical testing and procedures. Fellows will address cost-benefit concerns in patients who become candidates for heart transplantation.