Rotations at the University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Health System are described briefly below. The links provide additional details of the specific curriculum for each rotation, including the overall purpose, the fellow responsibilities and specific duties, the method of supervision, the learning objectives, patient characteristics, mix of diseases encountered, types of clinical encounters and procedures performed, teaching methods, evaluation methods, and a bibliography.

Adult Congenital Heart Disease (ACHD)

This rotation is organized in collaboration with faculty members from pediatric cardiology at the University of Iowa Stead Family Children's Hospital, which is part of the University of Iowa Hospitals and Clinics, who are board-certified in adult congenital heart disease (ACHD). This rotation provides comprehensive exposure to the diagnosis, assessment and management of outpatient presentations of most forms of congenital heart disease commonly encountered in adults. Fellows participate in ACHD clinics, imaging and cardiac catheterization of adult patients with congenital heart disease, and combined medical-surgical conferences to review adult patients being considered for surgery.

Cardiac Catheterization

At least two general cardiology fellows are assigned to the cardiac catheterization laboratories each block, and they divide their effort daily between the cardiac catheterization laboratories at the University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Health System. Fellows evaluate all patients referred for cardiac catheterization and review them with the faculty member prior to performing any procedure. All invasive cardiac procedures are performed under the direct supervision of an invasive or interventional attending cardiologist. Fellows gain an understanding of coronary anatomy and hemodynamics and acquire the technical, cognitive and motor skills required to gain venous and arterial access and to perform coronary angiography, ventriculography, pericardiocentesis, and endomyocardial biopsies. Fellows become familiar with the indications for and the risks and the benefits of these procedures. Knowledge of comorbid factors that increase the risk of a procedure are acquired. Fellows become familiar with the pharmacology of medications used for conscious sedation, contraindications for their use, their side effects, and monitoring of sedation. Fellows learn to recognize and to treat complications of these procedures.

Cardiac Electrophysiology (EP) Procedure Elective

The purpose of the elective rotation is to gain an understanding of the anatomy, physiology, pharmacology and technology central to the field of cardiac electrophysiology, to acquire a deeper knowledge of patient presentations and diagnostic testing, and to develop the technical, cognitive and motor skills required to gain the venous and arterial access needed to perform device implantations and catheter studies, to place intracardiac catheters, and to understand intracardiac electrograms.  It is important to emphasize that the rotation is not designed to develop full clinical competence in device implantation and EP study/ablation, but rather to develop skills and knowledge in this field that will serve as a foundation for further training in an EP fellowship program, or to support future practice in cardiology that will intersect with EP.

Consultations

Fellows are exposed to complex cardiovascular problems encountered in a quaternary care hospital (University of Iowa Hospitals and Clinics), including the medical services, as well as on surgery, gynecology, psychiatry, and neurology services, in the intensive care units, in the emergency department, and in pregnant patients. The patient population includes men and women of all adult ages and of varied ethnic and socioeconomic background. Special populations include patients with transplanted organs. Consultations often are for diagnosis and management of chest pain, unexplained dyspnea, and dysrhythmias or syncope, and for preoperative cardiac risk evaluation or perioperative cardiac management. Initial consultation and inpatient follow-up are included. The fellow has primary responsibility for all patients referred to the service, under the supervision of the faculty member. Medical residents assist the fellow and are primarily responsible for a subgroup of patients on the service. The fellow supervises the medical residents in this capacity and reports directly to the faculty member. The faculty member conducts rounds daily with all members of the consultation team (fellow, medical residents, and students). Thus, during this rotation, the fellow is expected to acquire skills related to the clinical management of complex cardiovascular problems, and to develop supervisory and teaching skills.

Cardiac CT and MRI

Fellows become familiar with cardiac MRI and cardiac and vascular CT studies performed at the University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Health System. Studies are reviewed with faculty in a centralized multimodality reading room in the Heart and Vascular Center. Advanced training in cardiac CT and MRI are offered for fellows who select cardiac imaging as their major career focus. The fellowship will allocate 12 months to this training, either as a component of the individual fellow’s scholarly and elective blocks, or as an additional year of training following completion of 36 months general cardiology fellowship. Each fellow will assume graduated responsibility for completion of CT or MRI studies, including patient selection, image acquisition, image analysis, data reporting, and consultation with the referring physician. In addition, each fellow who selects this career path will engage in at least one research project that is centered on advanced imaging. COCATS 4 certification at our institution requires demonstration of independence in all aspects of clinical CT or MRI, and at least one peer-reviewed publication.

Cardiovascular Intensive Care

Fellows receive comprehensive training in the evaluation and management of common cardiovascular disorders and other life-threatening illnesses that may present with cardiovascular manifestations. Common clinical problems include acute coronary syndromes, cardiac arrest, cardiogenic shock, cardiac dysrhythmias, congestive heart failure, valvular heart disease, myocardial and pericardial heart disease, and aortic and hypertensive emergencies. Fellows become proficient in the performance and interpretation of several cardiac procedures including, but not limited to, pulmonary artery catheter placement, temporary venous pacemaker insertion, intra-aortic balloon pump management, and elective cardioversion. Review and integration of laboratory, radiographic, hemodynamic, and cardiac diagnostic studies is emphasized. A strong mentoring relationship with faculty is developed and emphasizes leadership skills for managing a healthcare team. In the cardiovascular intensive care unit (CVICU) at the University of Iowa Hospitals and Clinics, medical residents are primarily responsible for all patients. The fellow is responsible for supervising the residents assigned to the CVICU and assists in the management of the patients. A dedicated CVICU faculty member oversees all aspects of the fellow’s duties and conducts twice daily rounds with the fellow. The fellow is jointly responsible with the faculty member for core curriculum teaching as required for the education of medical residents, including didactic lectures and daily teaching on patient care issues.

Echocardiography

Fellows acquire the necessary expertise to perform and to interpret transthoracic, transesophageal, and stress echocardiography studies that are routinely encountered in the practice of cardiology, including the evaluation of patients with general cardiac disorders such as heart failure, coronary artery disease, valvular disorders, pericardial diseases, and cardiac masses. Fellows personally perform at least two transthoracic echocardiographic studies with the sonographers each day. Fellows pre-read at least 10 studies each day, and then formally read all studies performed during the day with the faculty member in a centralized multimodality reading room in the Heart and Vascular Center. Fellows participate in performing contrast echocardiography or amyl nitrite studies and transesophageal echocardiograms, as well as supervising, performing and interpreting exercise and dobutamine echocardiography studies. Fellows learn the indications, limitations, and risks of procedures such as transthoracic echocardiography, transesophageal echocardiography, stress echocardiography, sedation, and echocardiographic contrast. Fellows gain an understanding of the anatomy and physiology of a broad variety of cardiac disorders.

Electrophysiology

Fellows acquire knowledge and experience in the diagnosis and the management of arrhythmias, the indications and the limitations of electrophysiologic studies, the appropriate use of antiarrhythmic agents and defibrillator devices, the use of noninvasive and invasive techniques to assess patients with arrhythmias, and pacemaker and implantable cardioverter defibrillator (ICD) management and interrogation. The fellow is the point of contact for the electrophysiology consultations service at University of Iowa Hospitals and Clinics. This service includes all inpatient and most outpatient consultations from other clinics and the emergency department. The fellow conducts daily rounds on all electrophysiology inpatients and communicates management plans to the patient’s primary team. The fellow evaluates patients in the electrophysiology clinic. The fellow assists the faculty member during procedures such as interrogation of devices or cardioversions. The fellow participates in performing and interpreting Holter monitor studies, event recorders, exercise stress tests for dysrhythmia management, tilt table tests, and signal-averaged electrocardiograms.

Heart Failure and Transplant

Fellows gain extensive experience in the diagnosis and management of patients with acute and chronic congestive heart failure and an introductory experience to cardiac transplantation in both the inpatient and the outpatient settings. The primary responsibilities of fellows are to manage a busy inpatient care team at the University of Iowa Hospitals and Clinics under the supervision of the faculty member, to complete inpatient consultations with faculty oversight, and to teach medical students and residents on the rotation. In addition, fellows perform central line placements, pulmonary artery catheterizations, vasodilator challenges, and endomyocardial biopsies; manage heart failure and pulmonary hypertension in an outpatient clinic setting; participate in review of cardiac biopsies; supervise and interpret cardiopulmonary exercise tests; and gain familiarity with ultrafiltration. Fellows also perform outpatient invasive procedures and evaluate patients in the heart failure clinic under the direct supervision of the faculty member.

Nuclear Cardiology and Stress Testing

Fellows learn about the indications, the performance, the interpretation, and the limitations of diagnostic nuclear cardiology and stress testing. Fellows are expected to understand the basic principles of radioisotopes, myocardial perfusion imaging, and multigated acquisition (MUGA) scans, and gain skills required to interpret studies independently. Fellows are given primary responsibility to perform stress tests, under direct supervision of a faculty member or a specially trained exercise physiology professional. Fellows are instructed in the complementary roles of myocardial perfusion and left ventricular function in patient assessment and management, the interpretation of stress testing following myocardial infarction to identify high-risk patients and to prescribe appropriate exercise regimens for cardiovascular rehabilitation, the role of stress testing in preoperative cardiac risk assessment, and the value and limitations of stress test results in patient diagnosis, prognostication, and clinical management. Studies that are performed routinely include maximal and submaximal exercise tests, pharmacologic tests with dobutamine or regadenoson, and MUGA scans. Fellows pre-read all stress electrocardiograms and imaging studies in preparation for the afternoon reading session with the faculty member in a centralized multimodality reading room in the Heart and Vascular Center.

Vascular Medicine

Fellows perform and become familiar with non-invasive assessments of peripheral vascular disease using ultrasound methods with the assistance of vascular laboratory technicians. A full range of noninvasive tests is available in the Vascular Laboratory at the Heart and Vascular Center including:

• Peripheral arterial disease (PAD)
  • Doppler arterial exams of the legs or arms (physiologic testing)
  • Duplex ultrasound scan of the extremity arteries
• Cerebrovascular disease
  • Carotid artery duplex scan
• Deep venous thrombosis (DVT)
  • Venous duplex scan of the arms or legs
  • Inferior vena cava (IVC) scan
• Renal artery disease
  • Renal artery duplex scan
  • Duplex scan of the renal veins
• Aneurysms
  • Aortic duplex scan
  • Duplex scan of peripheral arteries

Fellows attend clinics with faculty in the Vascular Surgery Clinic at the Heart and Vascular Center. Fellows also receive didactic lectures in peripheral vascular disease at core curriculum conference and during the weekly clinical conference of the Division of Vascular Surgery.

VA Inpatient Service

Fellows receive broad exposure to a wide variety of common and rare cardiovascular disorders in the inpatient setting at the Iowa City Veterans Affairs Health System. Fellows have primary responsibility for all patients referred to the service under the supervision of one faculty member dedicated to this rotation. Fellows provide cardiology consultation on inpatients, including preoperative and perioperative patients and critically ill cardiac patients. Teaching by the faculty members occurs daily on attending rounds and is supplemented as needed for urgent consultations. The faculty member reviews the detailed consultations prepared by the fellow, provides bedside teaching of clinical history and cardiac examination skills, and reviews noninvasive and invasive studies with the fellow, including electrocardiograms. Fellows also interpret all electrocardiograms, Holter monitors, and event monitors performed on outpatients or inpatients.