Cardiovascular Disease Fellowship

Fellows rotate for 12 weeks on the general cardiology consult service. The team consists of one fellow and attending with occasional medical students or residents joining as an elective. The general consult service provides consultation for all other adult services in the hospital and frequently includes ICU and surgical patients. Clinical decision making is often challenging with active cardiac conditions occurring in the setting multisystem illness. The census generally ranges from 10 to 20 patients. This is an excellent time for one-on-one mentorship with a faculty member and chance to formulate differential diagnosis, plans of care and review of imaging or catheterization films together.

Fellows rotate for 12 weeks on the cardiology inpatient service during their first year.  The team consists of one fellow and attending, two internal medicine residents, and one advanced care provider (ACP). This cardiology service cares for patients with primary cardiac complaints. Patients arrive by direct admission, through the ER, or as transfers from other facilities. Chest pain evaluation, non ST elevation MI, arrhythmias, congestive heart failure, and valvular disease are managed commonly. The census ranges usually from 15-25 patients.  Along with attending guidance, fellows help to direct rounds, make clinical decisions, coordinate care and supervise and teach other members.

Fellows rotate for 12 weeks on the EP consult rotation throughout three years. The team consists of one fellow and one core EP faculty member per week. The fellow is responsible for presenting the EP consults during morning table rounds to various EP faculty members. Sometimes opinions differ, and this is often a time for teaching. General plans for patient care are formulated and bedside rounds occur afterwards. The census ranges from 5-15 patients. The service provides specialized EP consultation. Common requests include evaluation for pacemaker and ICD candidacy, atrial fibrillation, complex arrhythmia such as VT storm, management of device therapies, and EP procedural complications. The fellow will become facile with ECG interpretation and device interrogation. There is ample time for self-study. Fellows present an EP case conference once per month.

Fellows rotate for 12 weeks on the CCU beginning the second year. The CRMH CCU has 12 beds. The team consists of one attending and fellow, three residents (usually one ER and two internal medicine), medical student, CCU pharmacist, and pharmacy resident. On this rotation, things that are frequently managed are STEMI patients, critical patients post-PCI, various causes of cardiogenic shock, serious arrhythmias, and mechanical complications of MI. The team rounds twice daily and serves as primary for most patients in the unit. It follows those patients until discharge to provide continuity of care. The team also does consults for other patients in the CCU who are on non-cardiology services when requested. The fellow leads in evaluating new admissions, directing care on rounds, teaching other team members, and performing or supervising bedside procedures including central lines, arterial lines, temporary pacemakers, and Swan-Ganz catheters. The fellow will also gain experience with indications and management of mechanical circulatory support including IABP and Impella.

Fellows rotate at CRMH for at least eight weeks during the three years. The echo lab is quite busy, and roughly 30-50 echos are performed daily. This rotation includes time dedicated to learning scanning with experienced echo techs, stress test supervision, independent echo review, and time for self-study. Typically the afternoons are spent reviewing studies with non-invasive faculty where teaching occurs and feedback on interpretation is provided. Beginning in the second year, fellows begin performing TEES. We typically perform 4-10 TEEs per day, allowing fellows to quickly acquire the minimum number required and many for solid comprehension by graduation. More elective months in echo can be done depending on career goals.

Fellows rotate for 12 weeks in the CHI service beginning their second year. This service is currently a non-admitting consultative service with two heart failure and one adult congenital attendings. The fellow will see challenging hospitalized advanced heart failure patients and any adult congenital patient for whom an inpatient consult is requested. The fellow is also expected to regularly attend the outpatient heart failure clinic and adult congenital clinic, learn heart failure procedures such as right-heart catheterization with vasodilator challenge, become familiar with mechanical circulatory support devices, and supervise cardiopulmonary exercise stress tests. Fellows are expected to present interesting cases encountered in the rotation in case conferences. Additional time in the rotation is spent gaining exposure to advanced cardiac imaging modalities, including cardiac CT and cardiac MRI. The fellow will supervise scanning with radiology techs and later read with expert faculty in the afternoon. This will fulfill Level I training in advanced imaging. For fellows who wish to achieve Level II in either cardiac CT or cardiac MRI, a training pathway can be devised to achieve individual goals.

Fellows rotate for a minimum of eight weeks in the cardiac catheterization labs at CRMH. They learn the basics of femoral and radial vascular access, diagnostic angiography, left ventriculography, right heart catheterization, temporary pacemaker placement, and participate in PCI. The lab at RMH is active with 4,413 diagnostic angiograms performed yearly and 1,828 PCI procedures. There are also 2 structural interventional cardiologists who perform the full spectrum of structural procedures including TAVR, mitral clip, ASD closure, alcohol septal ablation, and others. There are two interventional cardiology positions and an additional structural fellowship position available. General fellows who are interested in interventional cardiology usually achieve around 400 diagnostic angiograms, well above the number required for Level II training.

Fellows spend one afternoon session per week at the Crystal Spring office seeing outpatients in the general cardiology clinic. The clinic is well organized and efficient. The schedule consists of four to eight patients assigned to each fellow. Attendings are free of other duties during fellow clinic time, and they alternate staffing patients with two general fellows in an afternoon. There is a mix of new and follow-up patients, with many patients the fellow has already cared for in the hospital setting. Each fellow works closely with a single attending throughout the three-year training program, creating a great opportunity for mentorship and long-term patient continuity. At the clinic there is also full echo lab, stress testing (exercise and pharmacologic), a D-SPECT nuclear camera, vascular studies, tilt table testing, Holter and event monitors, and dedicated staff for implantable device checks. General radiology, including a CT scanner and a Carilion Clinic core lab, are available in the same building, allowing efficient access to testing.

Fellows spend 8 to 12 weeks a year at the Salem VA. It is a Veterans Affairs hospital that is about 15 minutes from Roanoke Memorial Hospital. They offer our fellows rotations in the cardiac catheterization rotation and an imaging rotation. They have four staff cardiologists. Two are trained in interventional cardiology and one is trained in cardiac MRI.

During their third year, fellows have ample opportunity to choose electives, allowing them to expand and tailor their expertise, and to prepare for subspecialty fellowships. Fellows have eight elective rotations during the third year, with one to two additional electives each of the first and second years. This allows focused tracks for those interested in interventional cardiology, advanced imaging, or advanced heart failure. This allows fellows to tailor their learning experience at Virginia Tech Carilion.

• Clinical Cardiology Conference – Case-based and didactic lectures include all aspects of cardiovascular pathophysiology.
• Core Curriculum Conference – Didactic lectures given by attending cardiologist that cover a comprehensive list of cardiovascular milestones.
• Journal Club  – An article of importance is presented by the fellow with discussion led by a designated faculty member.
• Research Conference – Planned, ongoing or completed research projects are discussed and presented by fellows and faculty.
• Interventional Case Conference – Case-based didactic conference emphasizing quality angiography.
• ACS Conference – Case-based conference designed to identify ways to improve rapid transport and optimal therapy for patients with STEMI and other Acute Coronary syndromes.
• Best Practices Conference – Didactic presentations designed to review guidelines and critical evidence and identify patients who are not treated according to guidelines. Outcomes data such as the NCDR reports are reviewed.
• M & M Conference - Cases with adverse outcome are reviewed and discussed.
• EP Conference – Presentation of all aspects of EP including basic science, physiology, pharmacology, clinical practice, guidelines and interesting cases.
• E&E Conference –  Echo Conference - Didactic lectures on theory and application of echocardiography as well as case review. Alternating every other week with ECG Conference – typical, interesting and challenging ECGs are presented. Fellows are called upon individually to classify ECGs according to the board-required format.