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Fellowship in Cardiology

Fellowship in Cardiology

INTRODUCTION

Fellowship in Interventional Cardiology is a three years Fellowship Programme of Chitwan Medical College (CMC), Bharatpur. The curriculum is based on the current competency-based model followed in the world in any specialist training of the medical professionals. The training will be conducted in CMC, Bharatpur. CMC Teaching Hospital is a 750-bedded hospital with state of art critical care facility. CMC has a unit of cardiology with cardiac ward, fully functional coronary care unit and well equipped, fully functional catheterization Laboratory.

 

PURPOSE

Ensuring both quality of patient care, and clinical excellence in interventional cardiology is of the utmost importance.  The ability to perform diagnostic coronary angiography and right and left cardiac catheterization is still part of the general training for all Cardiologists/Internist  in most  countries, with a minimum number of procedures often indicated in the curriculum of trainees in general cardiology. Interventional cardiology is the most frequent method of coronary revascularisation but the general training in cardiology rarely offers more than the opportunity to assist a more senior operator to perform angioplasty procedures.

 

The absence of regulations to determine the level of experience and knowledge in this field, has allowed new Cardiology Specialists to start, or be involved in interventional programmes without formal training. Now that free movement of Specialists is allowed in the Nepalese Community, it is essential that a certified, uniform, training programme exists, before cardiologists practice procedures which carry a potential risk.


 

OBJECTIVES

  1. To understand and comprehend the effectiveness and limitations of coronary interventional procedures in order to select patients and procedure types appropriately for patient.
  2. To achieve and attain the appropriate level of cognitive knowledge and technical skills needed to perform interventional cardiac procedures at the level of quality attainable through the present state of the art intervention.
  3. To nurture and foster an attitude of life-long learning and critical thinking skills needed to gain from experience and incorporate new developments.
  4. To understand and commit to quality assessment and improvement in procedure performance.

 

ADMISSION CRITERIA:

Eligibility:

  1. Minimum Qualifications:
  1. MD Internal Medicine or MD cardiology or equivalent.
  2. MD degree must be a three-year fulltime residency degree and recognised by Tribhuvan University.
  • Candidates should be registered with Nepal Medical Council as an internists or cardiologist (Specialist category).

  Entrance Examination:

  1. The entrance examination will consist of theory and practical. Those candidates who obtain pass marks (50%) in theory will only be eligible for clinical examination. Candidates should achieve minimum 50% marks both in the written MCQs type entrance examination as well as in clinical assessment.
  2. The MCQs and clinical examination will be related to the basic applied sciences, critical care and related subjects
  3. Final results include theory (60%) and Clinical (40%).

Selection Criteria:

  1. Candidates with higher combined marks of written and clinical assessment will be selected as per the available seats.
  2. In case if the achieved marks are equal, marks obtained in clinical assessment will be considered to select candidates.
  3. The candidate once selected must sign a contract to attend the entire duration of the course on full time basis.
  4. The candidate will not be allowed to do any private practice during the entire residency period.
  5. The candidate registered for the course, should agree not to enter other academic university programs until the completion of the course.
  6. The candidate should agree to abide by the rules and regulations or else may face expulsion from the program on disciplinary ground.

 

STRUCTURE OF THE TRAINING PROGRAMME

 

Basic training in cardiology (including internal medicine) must be completed before the subspecialty training in interventional cardiology is undertaken

 

LEARNING STRATERGY:

Learning Objectives

  1. Appropriately select patients for percutaneous coronary revascularization and identify the optimal timing for the procedure, applying evidence-based medicine and current guidelines to the individual patient needs and characteristics, with optimal and cost-effective use of the available resources.
  2. Be able to understand, explain and discuss the individual options of medical, percutaneous or surgical treatment with patients, patient relatives, referring physicians, other cardiologists, cardiac surgeons.
  3. Acquire the theoretical knowledge and practical skills to perform coronary angioplasty procedures in adults as an independent primary operator.
  4. Plan pre-procedural, intra procedural and post procedural patient management with particular emphasis on adjunctive pharmacological treatment, selection of vascular access, control of hemostasis and prevention of bleeding complications, prevention of allergic reactions and renal insufficiency.
  5. Identify the optimal strategy of interventional treatment including device and technique selection, development of alternative plans in case of failure of the initially chosen approach, and handling of unexpected complications.
  6. Plan long- term clinical follow up including secondary prevention and pharmacological treatment.

 

Learning Strategy:

Apprenticeship learning

Apprenticeship learning is the mainstay of the training process in interventional cardiology. Candidates will be required to be involved in procedure planning, assessment of indications and contraindications, specific establishment of the individual patient risks based on clinical and angiographic characteristics.

The trainee should:

  1. Handle patient admission to the ward, obtain informed consent, prescribe pre-procedure drug therapy, and organize appropriate non-invasive testing.
  2. Perform supervised angioplasty procedures with progressive increase in the level of involvement based on incremental operator experience and case complexity. The trainee must discuss the procedure with his/her educational supervisor, who will also ensure appropriate tutorship in the catheterization laboratory.
  3. The trainee must be involved in post procedural management including timely preparation of the report, monitoring of the patient’s status with special attention to the complications at the catheter entry site, heart and renal failure, bleeding and recurrent myocardial ischemia. The trainee should participate in the selection of the pharmacological treatment before, during and after the procedure based on established protocols and after discussion with the supervisor.
  4. The trainee must participate in the cardiology night and weekend on-call with the aim to optimize exposure to acute interventional treatment in the setting of acute myocardial infarction and other emergency cardiology conditions.
  5. Every trainee must be exposed to techniques of intravascular imaging and functional assessment of lesion severity (intravascular ultrasound, intra coronary pressure measurement).

Rotation:

First Year  

Trainee should study basic, clinical and noninvasive cardiology along with observer-ship in Cath lab. During noninvasive cardiology posting at least following number of procedures should be performed by the candidate/trainee (Table I):

Table I: Minimum no of procedures to be performed by the Trainee

Procedures

No of Procedures Performed

Electrocardiography (ECHO)

200

Treadmill Test (TMT)

100

Holter Analyzed

50

 

  • In the next two years, training includes activities in the ward and in the Catheterization Laboratory. Details are as under:

Second Year

First stage: Trainee mainly prepares the patient for the intervention, including diagnostic angiography, and assists the supervisor or another experienced interventionists performing the angioplasty procedure.

Second Stage: The trainee starts working as primary operator for simple angioplasties under close supervision and assists in the most complex angioplasty procedures (bifurcations, thrombus containing lesions, chronic occlusions, diffuse disease, severe calcifications, etc).

Third Year

Third stage: The trainee performs simple angioplasty procedures as independent operator, with the supervisor still available to plan the procedure, judge the results and advise in case of complications. The trainee will start performing complex procedures under closer supervision.

Fourth stage: If the trainee has developed appropriate competencies, he/she will work as primary and independent operator in both simple and complex coronary interventional procedures.

  • Additionally during stages 3 and 4, the trainee may undertake elective/advanced training in peripheral vascular intervention (e.g. carotid , renal and other peripheral angioplasties), valvular (Percutaneous transvenous balloon mitral commissurotomy, Balloon Pulmonary valvotomy, Balloon aortic valvotomy ), RHC and congenital interventions, Pacemaker implantation and coil closure of peripheral vessels and device closure of simple congenital heart diseases.

*Workshops related to teaching/learning and research will be conducted during First Year of training.

*Teaching of other fellow Surgery residents, interns and students if available is part of the training.

ADVANCED TRAINING

The following procedures may be part of the curriculum but should be considered as an “optional” part of the training programme. The supervisor of the training process should separately indicate whether the trainee has achieved enough experience and proficiency to perform them as primary operators.

  1. Mitral and aortic valvuloplasty (in the future percutaneous valve repair might be included)
  2. Closure of atrial septal defects and patent foramen ovale (possibly including closure of post MI ventricular septal defects and paravalvular leaks)
  3. Septal alcoholisation for hypertrophic cardiomyopathy.
  4. Carotid stenting
  5. Renal stenting
  6. Iliac stenting
  7. Subclavian stenting
  8. Other peripheral vascular procedures

 

The trainee may be sent to other recognized national/regional/international institutions for learning advanced procedures/techniques.  

 

Formal Learning:

 

  • Formal learning will be organized at the Cardiology Department including CME, Journal club and other academic activities. The training program must ensure that trainees have the required cognitive knowledge base of all the subjects included in the Syllabus. Also, formal learning include national and international courses in Interventional Cardiology, including live courses, learning through journals, textbooks and the Internet. Attendance at various academic activities need to be certified

 

  • All trainees must be exposed by the training programme to research in interventional cardiology. Participation as co-investigator in single centre or multi centre trials, handling data collection or participation in the analysis, presentation of results and investigators’ meetings are part of the training programme. A statistical background sufficient to allow independent interpretation of results is a recommended component of training. Trainees will be required to provide documentation of attendance at accredited formal training courses. Copies should be maintained in the records of the trainee (logbooks).

 

  • The interventional cardiology training programme must include:

           - Regular cardiac catheterization conferences to present clinical data, non-invasive

             imaging results (scintigraphy, cardiac MR, multislice CT), haemodynamic measurements

             and angiographic images of patients selected for intervention

           - multi-specialist medical surgical conference

           - meetings to review the results of simple and complex procedures

           - morbidity and mortality meetings.

 

  • Trainees must have knowledge of peripheral arterial anatomy and participate in revascularization procedures for:

           - carotid stenoses

           - subclavian stenoses

           - renal artery stenoses

           - iliac artery stenoses

           - other vascular procedures, such as abdominal aortic aneurysm.

         (v) Workshops related to teaching/learning and research will be conducted during First

               Year of training.

Procedural Requirements:

The trainee will have performed at least the following number of procedures (Table II):

Minimum number of procedures to be performed by the Trainee

Procedures

Observed

Assisted

Performed

Coronary angiogram

100

100

100

Coronary Angioplasty (Primary + Elective)

100

100

50

Temporary Pacemaker implantation

50

50

05

Permanent Pacemaker implantation

25

25

25

PTMC/BPV/BAV

20

20

10

Pericardiocentesis

25

25

50

Peripheral Angiogram/Angioplasty

25

25

25

RHC

20

20

20

 

SYLLABUS SPECIFIC PROGRAMME CONTENT

  1. Basic Science
  2. Anatomy and physiology: cardiac, vascular and coronary artery anatomy, including anatomical variants and frequent congenital abnormalities; basic circulatory physiology, myocardial blood flow regulation, myocardial physiology and metabolism.
  3. Vascular biology, including the processes of vaso-reactivity, plaque formation, vascular injury and healing, restenosis, SVG, atherosclerosis, cardiac allograph vasculopathy.
  4. Function of progenitor cells and their possible role in angiogenesis and myogenesis.
  5. Haematology, including platelet function and aggregation, clotting cascade, and fibrinolysis.
  6. Coronary anatomy and physiology, including Classification of coronary segments and lesion characteristics; Assessment of lesion severity, intracoronary pressure and flow velocity measurement, fractional flow reserve (FFR); Assessment of collateral circulation.
  7. Pharmacology
  8. Biologic effects and appropriate use of vasoactive drugs, antiplatelet agents, thrombolytics, anticoagulants, antiarrhythmics, inotropic agents, and sedatives.
  9. Biologic effects and appropriate use of angiographic contrast agents, including prevention of renal dysfunction and allergic reactions.
  10. Atherosclerosis prevention in PCI candidates focusing on optimal care of hypertension, dyslipidemia, diabetes and smoking cessation.

III. Imaging

  1. Radiation physics, radiation risks and injury, and radiation safety, including glossary of radiological terms, methods to control radiation exposure for patients, physicians, and technicians.
  2. Specific imaging techniques in interventional cardiology, such as quantitative angiography and intravascular ultrasonography.
  3. Principles of cardiac computed tomography, potential role for non-invasive coronary imaging.
  4. Digital archiving and tele-communication of angiographic images.
  5. Indications for treatment and patient selection
  6. Indications for elective cardiac catheterization and related catheter-based interventions in management of ischaemic and valvular heart disease, in accordance with the ESC/AHA guidelines and evidence-based medicine.
  7. Indications for urgent catheterization and management of acute myocardial infarction, including differentiation between patients who require primary or rescue angioplasty, coronary bypass surgery or conservative treatment.
  8. Indications for mechanical support devices in the management of haemodynamically compromised patients (intra-aortic balloon pump etc.)
  9. Present indications for surgical re-vascularisation in coronary artery disease
  10. Procedural Techniques
  11. Vascular access including principles of femoral, radial, and brachial procedures, closure techniques, detection and treatment of complication.
  12. Appropriate catheter selection to achieve optimal opacification and support.
  13. Selection of optimal projections for lesion visualisation and treatment.
  14. Knowledge of angioplasty material and proper selection of guide wires, balloon catheters, and stents.
  15. Knowledge of types and characteristics of bare metal and drugelutingstents including post implantation pharmacological treatment and their risk of thrombosis and restenosis.
  16. Classification, mechanisms, and therapy of in-stent restenosis.
  17. Knowledge of ancillary interventional techniques, including
  18. Therapeutic: anti-embolic protection with filters and occlusive balloons, rota blator, laser, atherectomy and thrombectomy devices.
  19. Diagnostic: intravascular ultrasound, Doppler and intracoronary pressure measurement
  20. Indications for mitral, aortic, and pulmonary valvuloplasty in management of valvular disorders, including factors that differentiate patients who require surgical commissurotomy or valve repair or replacement.
  21. Indication for catheter-based interventions in management of congenital heart disease in adults, such as closure of intracardiac defects (ASD, PFO, VSD, PDA).
  22. Indications for septal alcoholisation in obstructive hypertrophic cardiomyopathy

 

  1. Management of complications of percutaneous intervention
  2. Mechanical complications, such as coronary dissection, spasm, perforation, “slow/ no reflow”, cardiogenic shock, left main trunk dissection, cardiac tamponade including pericardiocentesis, peripheral vessel occlusion, and retained components
  3. Thrombotic and haemorrhagic complications associated with percutaneous intervention or drugs.

 

VII. Implantation of Temporary and permanent pacemaker (Single/Double chamber)

VIII. Miscellaneous

  1. Peripheral angiography and angioplasty including essential radiological anatomy, indications and principles of carotid, subclavian, renal and iliac stenting.
  2. Ethical issues and risks associated with diagnostic and therapeutic techniques.
  3. Statistics, epidemiologic data, and economic issues related to interventional procedures.

LOGBOOK

All trainees will maintain a continuous record of their catheter lab-based procedures. It should be clear whether the trainee was second, primary or sole operator for the case.

The trainee’s log book must follow the template of the CARDS data standards for interventional cardiology, as recommended by Institution. In particular the database must indicate whether the case was elective, urgent or emergency. The log book must provide details of lesion complexity and type of device used and complications encountered.

The procedure log book will be reviewed and signed off on a monthly basis by the Training Coordinator.

Final appraisal must be signed by the programme coordinator involving all consultants supervising the trainee. The appraisal should take into consideration observations from other team members (surgeons, cardiologists, senior cath lab nurses, chief radiographer and cardiac technicians as well as junior staff members, Cardiology Registrars in training). The Programme Coordinator should testify that the trainee can perform adequate re-vascularization procedures as an independent operator and deliver post procedural care. Analytical evaluation of the complexity of the interventions performed as primary or secondary operator should be included, with particular attention to the incidence of complications, their cause and competent handling.

The final judgment should report the trainee’s ability to interact with cath lab staff and colleagues, attention to minimise patient risk and discuss complex procedures with more expert colleagues, ability to make independent appropriate choices and cope with emergency situation.

Knowledge of devices, drugs and material, handling of x-ray and other cath lab equipment, attention to achieve results with minimal contrast injections/x-ray exposure to the patients should also be considered in the final training assessment.

In case the final judgment is not positive, the estimated duration and characteristics of the additional training considered sufficient to achieve the ability to work as an independent operators should be clearly specified.

SUBJECT COMMITTEE

The unit chief of the cardiology ward and CCU will be the coordinator of the subject committee. Head of the department of the internal medicine, the faculties of the concerned and related specialties and head of medical education may be appointed as the members of the subject committee. Visiting faculty in inside or outside the country may be appointed to help in the formative and summative assessment as necessary by email. The responsibilities of the subject committee will include:

  • Appointment of a senior consultant faculty of the level of Professor or Associate professor managing the cardiology ward and CCU as the supervisor of the candidate
  • Rotation and posting of the candidates to acquire the required competency
  • Arrangement of applied basic science, research and ethics and medical education classes,
  • Arrangement of optional training abroad,
  • Logbook review,
  • Formative and summative assessment,
  • Question collection & discussion,
  • Helping to decide eligibility for examination as per the criteria
  • Helping to conduct examination,
  • Monitoring of the institutions and training program,
  • Supervision of students and teachers,
  • Other required activities for the program.

 

The subject committee should also develop the system of monitoring the responsibility of faculty and units and the assessment of students and evaluation of the programme

 

 

LEAVE

Fellows will be entitled to a leave of 15 days per year which will have to be preapproved from the coordinator and cannot be taken more than 7 days at a span.

 


 

ASSESSMENT METHODS:

The following methods will be used to assess the trainee, and will not be considered in isolation but as complementary techniques:

THESIS/DISSERTATION:

  • Trainee has to submit synopsis/proposal for thesis/dissertation within six months of enrolment.
  • Trainee has to write a thesis/dissertation and submit 6 months ahead of qualifying examination.
  • The thesis/dissertation will be sent to evaluation at least to one external reviewer.    

PUBLICATIONS:

  • Trainee has to publish two research articles (Review/Original) in indexed national/regional/international journals before appearing into final examination.
  • Manuscript accepted for publication may be considered (Proof required).

Assessment consist of two components:

  • Formative
  • Summative (Qualifying/Certifying Examination)

 

Formative Assessment

Formative assessment will be carried out over following activities of the Candidate:

  1. Ward work. This will be done at regular intervals by the consultants in the concerned unit.
  2. Case presentation
  3. Seminar
  4. Journal club
  5. Theory paper (SAQs, MCQs, PBQs) once in a year
  6. Clinical assessment once in a year
  7. Directly Observed Procedural Skill Assessment

Directly Observed Procedural Skill assessment is an established assessment method and will be employed at regular intervals during the 3 years programme.

  1. Learning Practical Skills outside the Catheter Lab: Simulators

Simulators have the advantage to provide objective reproducible evidence of manual skills. Currently they are of limited availability and are expensive but have the potential to be used as an internationally standardised and complementary assessment method. In the foreseeable future, simulators may become an important assessment tool in interventional cardiology at CMC.

Feedbacks will be given after each formative evaluation. If the performance is found to be unsatisfactory, the candidate will be given opportunity to improve his / her performance and would be helped in the process. Specified number of formative assessment should be completed satisfactorily before appearing in the final examination. (Details are annexed)

 

Summative Assessment (Qualifying/Certifying/Exit Examination)

PROCEDURE OF SUMMATIVE Assessment  

This will be conducted by the institute and would be the final certifying examination.

  1. Eligibility:
  • The eligibility to appear in the Summative Assessment (Qualifying/Certifying/Exit Examination) includes:
  1. a) Satisfactory formative assessment.
  2. c) Completed log book and duly signed by the specified facilitators
  3. c) Thesis accepted
  4. d) Paper accepted
  5. Summative assessment:

Final examination will consist of:

  • Written Examination- Theory Papers
  • Practical Examination- Clinical Examination

WRITTEN EXAMINATION (Theory Papers)

Total marks 300   

20% (total 60 marks) formative assessment & 80% (240) final examination

  • There will be 3 papers; all carry 80 marks. Each paper  consist of  Short Answer Questions (SAQs), Multiple Choice Questions (MCQs) and Problem Based Questions (PBQs)

Paper I:            Basic applied sciences 

Paper II:           Principles, practice and recent advances in general cardiology

Paper III:          Principles practice and recent advances in interventional cardiology

PRACTICAL EXAMINATION (Clinical Examination):

Total marks 300          20% (60 marks) formative assessment & 80% (240) final assessment

Format of final assessment:

Long/Semi-long/short cases/MiniCEX:

Chart round/Case based discussion:

CCU case discussion:

OSCE/investigations/pictures/viva:

  • The coordinator and one of the faculty members of the concerned or related subject will be the internal examiners. There will be total four examiners, out of which at least two external examiners of the concerned subject will be invited for final examination. The external examiners will also review the portfolio consisting of the fulfillment of eligibility criteria of the candidate and may make any suggestions to improve the training programme.
  • The candidate has to pass separately in both theory and clinical practical, achieving at least overall 60% each in theory examination and in clinical practical examination.

 

DEGREE:         

Candidate who has completed all the criteria of eligibility for final examination and has passed both the written and clinical practical examinations would be awarded: Fellowship of Chitwan Medical College in Interventional Cardiology (FCMC-IVC)

 


 

SUGGESTED READING MATERIAL

  1. Textbooks
  2. Heart Disease: A Textbook of Cardiovascular Medicine, Ed: Braunwald, Zipes, Libby; WB Saunders
  3. Grossman’s Cardiac Catheterization, Angiography, and Intervention, Ed: Baim& Grossman; Lippincott Williams & Wilkins.
  4. Adult Clinical Cardiology Self-Assessment Program; American College of Cardiology
  5. Mayo Cardiovascular Board Review
  6. CATHSAP, American College of Cardiology
  7. Pertinent AHA / ACC Scientific Statements and Guidelines
  8. Textbook of Interventional Cardiology, Ed: Topol
  9. Interventional Cardiology: Principles and Practice, Ed: Di Mario

 

  1. Journals and Annual Reviews
  2. Circulation
  3. Cath-Lab Digest
  4. European Heart Journal
  5. Indian Heart Journal
  6. Nepalese Heart Journal
  7. Cardio Source

 

  1. Disease specific national, regional and international guidelines
  2. ACC (American College of Cardiology)/AHA (American Heart Association) guidelines
  3. ESC (European Society of Cardiology)
  4. WHO cardiac disease guidelines

Associated Members:

  • Ms. Ambika Baniya
  • Ms. Mamata Sharma
  • Ms. Gayatri Rana
  • Ms Shakuntala Chapagain
  • Ms. Sadikshya Neupane