Interventional Fellowship Program


The Creighton University, Division of Cardiology, Interventional Fellowship program at Creighton University Medical Center is a one year training program geared toward obtaining clinical competence in coronary intervention. The fellow will experiencethe full range of coronary diagnostic and interventional techniques including PTCA, stent placement, IVUS, FFR, etc. The fellow will become competent in both femoral as well as the radial approach. The majority of our interventions are performed via the radial approach. In addition to coronary intervention, the fellow will become experienced in carotid renal and peripheral interventions. This program functions as an integral component of the general cardiology fellowship program. It is accredited by the Accreditation Council for Graduate Medical Education (ACGME).

Requirements: To be eligible, applicants must have successfully completed three years of cardiovascular training by the time of enrollment.

I. Training Program Goals and Structure

    A. The Faculty

    The faculty consists of the current five interventional cardiologists (Drs. Paul Biddle, Michael Del Core, Tom Lanspa, Michael White and Mark Woodruff) who are all board certified in interventional cardiology. In addition, the fellow will have access to faculty with expertise in general cardiology, cardiac surgery, pediatric cardiology, radiation oncology, hematology and research.

    1. Faculty Orientation

      a. The program director, Dr. Michael Del Core, will be primarily responsible for the organization, implementation and supervision of the training program.

      b. The assistant program director, Dr. Paul Biddle, will also be responsible for the organization, implementation and supervision of the training program.

      c. Key clinical faculty members: Dr. Paul Biddle, Dr. Michael Del Core, Dr. Tom Lanspa, Dr. Michael White and Dr. Mark Woodruff, will assist in the general administration of the program and preparation of the curriculum.

    2. Fellowship Committee

    The Fellowship Committee consists of the key clinical faculty, a member of the general cardiology faculty and the division chief. The committee is chaired by the program director. The committee meets on a monthly basis. The responsibilities of the committee are:

      a. Fellow selection - the committee reviews, interviews and participates in the selection of all applicants for the position.

      b. Fellow evaluation - the committee evaluates the trainee's progress in relation to his cognitive knowledge, technical skills and responsibility.

      c. Program administration - the committee is venue for the development of policies and procedures in the administration of the program.

A. Objectives

    The objectives of the Cardiac Cath Lab Teaching Program are to provide an educational environment in which the Cardiology Fellow will learn:

    1. Patient selection, including risk and benefits.
    2. Selection of vascular access, catheters, and radiographic contrast.
    3. Cardiac catheterization techniques.
    4. Acquisition and interpretation of angiographic images.
    5. Recognition of artifacts in angiographic and hemodynamic data.
    6. Acquisition and interpretation of hemodynamic data.
    7. Avoidance, recognition and management of complications.
    8. Formulation of appropriate treatment after cardiac catheterization.
    9. Dictation of reports, which address all pertinent considerations.
    10. Develop a thorough understanding of radiation safety.

B. Teaching Strategies

    1. The Cardiac Catheterization Laboratory (CCL) teaching service consists of several teaching attendings, two clinical cardiology fellows, and one interventional cardiology fellow.
    2. On the CCL teaching service, one fellow is usually "scrubbed" with the teaching attending, so the "hands-on" aspect of the educational experience involves a direct one-on-one arrangement between the fellow and attending. This arrangement permits close interaction with the fellows and attending staff, and offers superb fellow experience and close attending supervision. As fellows demonstrate increasing competence with increasing experience, they will have more independence.
    3. Although most of the technical aspects of cardiac catheterization are learned best in the CCL, most of the cognitive training take place in several venues:
      a. Weekly interdisciplinary cardiac Case Management conference
      b. Journal club
      c. Self learning by study of ACC/AHA guidelines for cardiac catheterization, percutaneous revascularization, and cardiac surgery
      d. Self learning by study of the ACC Cath SAP

C. Attending Responsibilities

    1. Teach the interventional fellow the indications for procedures; selection of equipment and angiographic views; review findings; and discuss complications and patient follow-up.
    2. Discuss cost effectiveness of various interventional strategies, quality assurance issues, safety, and effective documentation for medicolegal purposes.
    3. An attending physician is required to be immediately available during all diagnostic procedures; The interventional fellow will participate in the following teaching faculty cases:
      a. left heart catheterization
      b. selective coronary angiography
      c. intracoronary thrombolytic therapy
      d. intraaortic balloon pump counterpulsation
      e. brachial arteriotomy/venotomy repair
      f. ventriculography, aortography, pulmonary angiography
      g. temporary pacemaker insertion
      h. right heart catheterization
      i. pericardiocentesis
    4. The Cath Lab Director (or surrogate) will meet with the interventional fellow at the end of the monthly rotation to verbally review the fellow's written evaluation and performance. The attending will complete a formal evaluation of fellows' performance using New Innovations.

D. Fellow Responsibilities

    Patient Care

    1. Procedure Evaluation
      a. The interventional fellow will be responsible for the preoperative evaluation of the patients coming to the lab for a procedure.
      b. In all circumstances this will be performed the day prior to the catheterization. Any patient scheduled the day before a procedure will have pre-op evaluation that day. The fellow is not excused from his/her responsibilities to the catheterization lab until all pre-op evaluations are performed for the next day. Patients scheduled for cardiac catheterization by the on-call team will have a pre-op evaluation by the fellow on call. If time does not permit for this while on call, it is the responsibility of the call fellow to notify the catheterization lab at 7:30 a.m. of the need for a pre-op evaluation.
      c. Before the procedure, the fellow should review the medical chart and obtain a confirmatory history and physical examination, with specific attention given to factors known to increase the risk of the procedure such as vascular disease, renal failure, history of contrast reaction, congestive heart failure, anemia, active infection and conditions known to increase the risk of bleeding.
      d. If no contraindications exist for the procedure, The interventional fellow will explain the nature of the procedure to the patient in a way the patient can understand. An explanation of the risks/benefits should be given. Instructions should be given to the patient regarding oral intake, IV's, voiding, etc.
      e. The first six patients will be told to be NPO after midnight. Additional patients will be given a liquid breakfast.
      f. If no questions exist regarding the procedure, The interventional fellow will then fill out a pre-catheterization data sheet from the lab and a pre-catheterization order sheet from the unit. The pre-catheterization data sheet should be returned to the lab in the folder. A note should be placed on the chart stating the patient has been given instructions regarding the procedure and understands the risks.

    2. Performance of the procedure
      a. The interventional fellow will wear a radiation monitoring badge during procedures that require x-rays.

    3. Post Procedures Management
      a. It will be the responsibility of the interventional fellow to learn and perform appropriate hemostasis technique.
      b. The interventional fellow will demonstrate appropriate hemostasis technique without complication in 50 patients during their cardiology training. Fifty patients for each access site (femoral, radial) will be documented in the log book and signed by a staff physician or catheterization lab nurse.
      c. The interventional fellow who performs hemostasis should follow up on that patient to assess for postoperative complications; this includes a hospital visit 24 hours following the procedure. All complications should be noted.
      d. After the procedure, a preliminary catheterization report or note should be placed in the patient's chart. The trainee should monitor the patient's status and be available to respond to any adverse reactions or complications that may arise, such as hypotension, vascular complications, heart failure, renal failure, bleeding or myocardial ischemia. If a complication occurs, the trainee should participate in the follow up and management of the complication.
      e. The interventional fellow are responsible for keeping a log book of all procedures performed, listing any complications which may arise. These need to be signed by the staff physician. This should be done on a daily basis.

    Medical Knowledge

    1. During their cardiology training the fellow will develop the cognitive knowledge to:
      a. Understand coronary anatomy, its variations and congenital abnormalities.
      b. Understand coronary physiology.
      c. Understand cardiac hemodynamics, including the measurement and interpretation of pressure, flow, resistance and cardiac output.
      d. Interpret hemodynamic findings in a variety of cardiac conditions including various forms of myocardial disease, pericardial disease, valvular stenosis and regurgitation, congenital heart disease and pulmonary vascular disease.
      e. Understand basic principles of x-ray imaging, radiation protection and radiation safety.
      f. Interpret coronary, ventricular, atrial and aortic angiography and determine left ventricular ejection fraction.
      g. Perform right heart catheterization using a balloon flotation catheter.
      h. Perform temporary right ventricular pacemaker insertion.
      i. Perform left heart catheterization and coronary angiography (of native arteries) under supervision.
      j. Understand radiologic imaging including design and operation of x-ray cineradiographic units, digital imaging and storage, radiation physics, factors influencing image quality, radiation quality assurance and physiology of x-ray contrast media.
      k. Understand the basic operation of physiologic recorders, pressure transducers, oximeters and oxygen consumption measurement equipment.
      l. Understand how to differentiate the hemodynamics of constrictive pericarditis from restrictive cardiomyopathy.
      m. Understand coronary physiology using techniques such as Doppler flow and fractional flow reserve.
      n. Perform vascular access from the femoral, radial or brachial route.
      o. Perform left heart catheterization and coronary angiography, as well as, visualization of venous bypass and internal mammary artery grafts.
      p. Perform angiography of the cardiac chambers and aorta.
      q. Perform intra-aortic balloon insertion and operate a balloon pump.
      r. Perform cardiac catheterization to common types of valvular, adult congenital and cardiomyopathic heart disease.
      s. Perform pericardiocentesis.

    Practice-Based Learning

    1. During their cardiology training, the fellow will develop the cognitive knowledge to:
      a. Understand the indications for cardiac catheterization.
      b. Understand the indications for, and complications of, temporary transvenous pacing.
      c. Understand the indications for, and complications of, pericardiocentesis and recognize tamponade physiology.
      d. Understand the indications for, and complications of, other laboratory procedures such as endomyocardial biopsy, intra-aortic balloon counterpulsation and retrieval of foreign bodies.
      e. Understand the anatomy of, and methods to access, cardiac chambers and coronary arteries via the femoral, brachial and radial access sites.
      f. Understand the indications for, and complications of, contrast agents and drugs commonly used for invasive procedures, such as heparin, low-molecular-weight heparin, glycoprotein IIb/IIIa receptor antagonists, other antiplatelet drugs, thrombolytic drugs, vasopressors, vasodilators and antiarrhythmic drugs.
      g. All fellows will participate in the screening of patients for research studies. Fellows in the catheterization lab will be responsible for identifying patients and preparing presentations for case management conference.

    Interpersonal & Communication Skills

    1. If no contraindications exist for the procedure, the fellow will explain the nature of the procedure to the patient in a way the patient can understand. An explanation of the risks/benefits should be given. Instructions should be given to the patient regarding oral intake, IV's, voiding, etc.
    2. Communicate with the patient and family to alleviate anxiety and fear and explain what measures will be utilized to alleviate pain, discomfort and anxiety.
    3. Communicate with the attending about excessive patient concerns, unforeseen complications or anything out of the ordinary.
    4. Communicate with catheterization lab holding room nurses, since they are most familiar with the patient's progress, before and after cardiac catheterization.

    System-Based Practice

    1. Read, understand and implement ACC/AHA guidelines for cardiac catheterization, percutaneous coronary intervention and coronary artery bypass graft surgery.
    2. Utilize various written and web-based resources to enhance self-study of cardiac catheterization including:
      a. Textbook of Cardiac Catheterization and Intervention (Baim & Grossman): basic principles of hemodynamics and angiography.
      b. Manual of Interventional Cardiology (Safian & Freed): catheter selection, angiography and angiographic views, x-ray equipment, radiation exposure, complications.
      c. ACC Catheterization SAP (CD-ROM): evidence-based approaches; all aspects of cardiac catheterization.

    Professionalism

    1. The interventional fellow will be available between 7:00 a.m. and 5:00 p.m. or until all procedures and evaluations have been completed for the day.
    2. Always maintain a positive and professional attitude toward the patients.
    3. Maintain professional interactions with the nursing staff, technical staff and physicians.
    4. Do your best to alleviate patient fear, anxiety and discomfort by thoughtful communication and use of appropriate conscious sedation.

    Evaluations

    1. The interventional fellow will be evaluated on a monthly basis at the end of the Cath Lab rotation, as follows (360° Evaluation):
      a. A formal evaluation will be completed by the Cath Lab attending(s) using New Innovations and the content of the evaluation will be reviewed verbally with the fellow. Deficiencies must be forwarded to the Program Director. A monthly evaluation will also be completed by the Nursing manager of the CCL.

    2. The interventional fellow will complete a formal evaluation of the Cath Lab attending(s) each month using New Innovations. This evaluation will be reviewed on an annual basis with the Program Director and Chief of Cardiology.