Cath Lab curriculum for ECU cardiology fellows by nuhman10


									                          CARDIAC CATHETERIZATION LABORATORY

The goals of this rotation are for the cardiology fellows to develop effective technical skills in the
performance of diagnostic and therapeutic catheter-based procedures to learn the indications, risks, and
benefits of these procedures and to develop a comprehensive understanding of the role of these
procedures in the management of patients with cardiovascular disease.

Specific educational goals for this rotation include acquiring and developing skills in the:

• Technical performance of angiographic procedures, including:
o Coronary angiography
o Right heart catheterization
o Cardiovascular hemodynamics
o Endomyocardial biopsy
o Pericardiocentesis
o Placement of temporary pacemaker wires
o Peripheral angiography

• Understanding of catheter-based interventions, including:
o Coronary angioplasty/stenting
o Septal ablation
o Peripheral vascular stenting
o Closure of patent foramen ovalae (PFOs)

• Evaluation of patients for whom procedures have been requested, with an emphasis on the indication for
the indications for the procedure and the potential risks to this individual.

• Management of common peri-procedural conditions and complications including:
o Renal dysfunction before and following the procedure
o Retroperitoneal bleeding
o Vascular complications of angiography

• Preparation of concise and accurate procedural reports.

Progressive Education
The initial cardiac cath lab rotations will focus on early technical tasks such as safe vascular access,
double flushing of catheters, use of the manifold, hemodynamic interpretation, and simple catheter
manipulation. Progression of technical skills is largely a function of experience as well as individual
learning curves. As fellows become competent with their cath lab techniques, they will be instructed in
more complex maneuvers such as selective engagement of coronary arteries and bypass grafts, moving
the table and setting up the appropriate views. By the end of their clinical training, the expectation is that
fellows will be well trained and be capable of independently and safely performing diagnostic cardiac

Patient Care
Fellows must be able to identify whether a procedure is appropriate for the patient referred, recognize
risks and benefits of planned procedures, provide patients with necessary information to give a valid
informed consent to the procedure, and follow patients following the procedure to ensure optimal
management of any procedural complications. Fellows are expected to:
• Develop skills necessary to perform procedures under supervision of the attending physician.
• Evaluate whether the procedure is appropriate for the patient
• Prepare a concise, accurate report of the procedure which was performed.
• Evaluate patients following procedures to assess whether there have been any complications.

• Each patient’s history, physical exam laboratory data and additional data are reviewed with the faculty
before the procedure is done.
• During each procedure, the attending closely monitors the fellow’s skills, judgment, and access and
intervenes directly when necessary.
• Procedural reports are reviewed by the attending faculty for accuracy and completeness

Medical Knowledge

Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological,
and social-behavioral sciences, as well as the application of this knowledge to patient care. Fellows are
expected to demonstrate:

• Knowledge of cardiovascular anatomy with emphasis on the vascular structures needed for access
• Understanding of cardiovascular hemodynamics
• Ability to evaluate patient’s medical condition and prior diagnostic evaluations to provide appropriate
risk/benefit analysis.
• Technical skills for catheter placement and manipulation
• Knowledge of indications for procedures and guidelines for patient management

• Knowledge about the indications and risks of the procedure are reviewed by an attending prior to each

• Fellows present cases at weekly interdisciplinary cardiology rounds and review all relevant data at that

Specific Training is as follows:

1. Level 1 Training
a) Understand the indications for cardiac catheterization.
b) Understand the anatomy of and methods to access cardiac chambers and coronary arteries via the
femoral, brachial, and radial access sites.
c) Understand basic principles of X-ray imaging, radiation protection, and radiation safety.
d) Understand coronary anatomy, its variations, and congenital abnormalities. Interpret coronary,
ventricular, atrial, and aortic angiography and determine left ventricular ejection fraction.
e) Understand cardiac hemodynamics, including the measurement
and interpretation of pressure, flow, resistance, and cardiac output in common forms of valvular,
myocardial, pericardial and congenital disease.
f) Understand the complications of cardiac catheterization (e.g. hypotension, acute myocardial ischemia,
congestive heart failure, renal failure, vascular complications, contrast reactions, retroperitoneal bleeding,
and cardiac tamponade) and their management.
g) Select the optimal treatment modality (medical
therapy, percutaneous coronary intervention, or surgery) for a given patient with understanding of the
indications for and
risks of each revascularization strategy.
h) Understand the indications for and complications of temporary
transvenous pacing.
i) Understand the indications for and complications of pericardiocentesis and recognize tamponade
j) Understand the indications for and complications of other
laboratory procedures, such as endomyocardial biopsy,
intra-aortic balloon counterpulsation, and retrieval of
foreign bodies.
k) Understand the indications for and adverse reactions to 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.
l) Understand the indications for and complications of vascular
closure devices.

2. Level 2 Training

a) 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 Xray
contrast media.
b) Understand the basic operation of physiologic recorders,
pressure transducers, oximeters, and oxygen consumption
measurement equipment.
c) Understand coronary physiology using techniques such as
Doppler flow and fractional flow reserve.
d) Understand the indications for and methods of performing
transseptal catheterization.

Practice- Based Learning and Improvement
Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and
assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation
and life long learning. Fellows are expected to develop skills and habits to be able to :
• Identify strengths, deficiencies and limits in one’s knowledge and expertise;
• Systematically analyze practice, using quality improvement methods, and implement changes with the
goal of practice improvement

• Fellows receive direct feedback on technique during the performance of each procedure and are
performance improvement is closely monitored by attending physicians.

Cases are presented at the regular quality assurance meetings for the cath lab

Interpersonal and communication skills: through clinical mentoring and self-appraisal, fellows will
develop and demonstrate habits of effective, smooth and timely exchange of information with
patients, families, colleagues and consultants. Specifically, fellows will:

     sharpen and focus case presentations to colleagues and consultants in the cath lab setting
     communicate effectively with patients and families the findings of cardiac catheterization and
      plan of management
     communicate effectively with cath lab support staff to ensure smooth and efficient case flow and
      safe patient care
     facilitate decisions regarding procedures with patients through thorough, accurate and supportive
     habitually and promptly convey procedure findings and results with patient families and referring
     maintain medical records including procedure reports and post-procedure orders in an accurate
      and timely fashion

 Systems Based Practice
Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health
care, as well as the ability to call effectively on other resources in the system to provide optimal health
care. Fellows are expected to:
• Incorporate considerations of cost awareness and risk-benefit analysis in patient care
• Work in interprofessional teams to enhance patient safety and improve patient care quality
• Participate in identifying systems errors and in implementing potential systems solutions

• Each procedure is reviewed by the attending for the risks and benefits before it is performed.
• Working in the catheterization laboratory requires co-ordination of care between a numbers of services.
Feedback on the fellow’s proficiency is obtained from all these sources.
• Cases are presented at the regular quality assurance meetings for the cath lab.

Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to
ethical principles. Fellows are expected to demonstrate:
• Responsiveness to patient needs that supersedes self-interest
• Respect for patient privacy and autonomy
• Attentiveness and responsiveness to patient concerns and needs are monitored not only by the attending
physician, but all by nursing and cath lab staff.
• Feedback is provided to the attending physician by the nursing staff, technicians, and cath lab staff.
Interpersonal and Communication Skills
Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of
information and teaming with patients, their families, and professional associates. Fellows are expected

• Communicate effectively with patients and families across a broad range of socioeconomic and cultural
• Work effectively as a member of leader of a health care team or other professional group

• Patients from across a broad range of socioeconomic and cultural backgrounds need to be approached
and need to establish an understanding of the risks and benefits of the planned procedures, as well as
understanding the outcome of the procedure.
• Optimizing a cardiac catheterization involves co-ordinating not only the cath lab staff, but also the
nursing staff on the wards and often additional resources, such as imaging.

Teaching Methods
Educational methods include, but are not limited to:
• Ad hoc discussions of issues relevant to the cases being performed.
• A weekly multidisciplinary (cardiology, cardiovascular surgery, cardiovascular imaging, cardiovascular
anesthesia) conference is mandatory for fellows on the cardiac catheterization rotation.
• Monthly quality assurance meetings are held for the cath lab.

Assessment Method (fellows)
Fellows are given immediate feedback on whether their assessment and plan is appropriate at the time of
presentation, and are given direct feedback during performance of the procedure.
In addition, fellows are given individual, oral feedback at the end of the rotation. Written evaluations are
entered into New Innovations. Performance of the fellows in the program is reviewed on a semiannual
basis with input from attendings on all the services. This cumulative feedback is then provided to the
fellow by the fellowship director.

Assessment Method (Program Evaluation)
At the end of the rotation, fellows are asked to provide anonymous written feedback, as well as
participating in semiannual meeting of all the cardiovascular fellows to evaluate the program.

Level of Supervision
Direct faculty supervision is provided to each fellow during each procedure
Procedure reports are reviewed and signed by the faculty member who did the procedure.

Educational Resources
WEBSITES for cardiovascular guidelines:
- American Heart Association: (search guidelines with site search function)
- American College of Cardiology: (quality and science tab)
Other resources:

Grossman's Cardiac Catheterization, Angiography, and Intervention 7th edition by Donald Baim

The Cardiac Catheterization Handbook (4th Edition) by Morton J. Kern

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