The overall purpose of the Cardiomyopathy, Heart Failure and Transplant rotation is to provide trainees with extensive experience in the diagnosis and management of patients with acute and chronic congestive heart failure and to provide an introductory experience to cardiac transplantation.

Each cardiology fellow will rotate on this service for 2 months during the course of their fellowship. On this rotation, the fellow will learn how to evaluate and manage patients with heart failure related disorders in both the inpatient and outpatient setting. The fellow will also be introduced to the performance of common procedures performed on heart failure and cardiac transplant patients, such as right heart catheterization and RV biopsy.

The overall duties and responsibilities on this rotation include:

1. Primary: Manage a busy inpatient care team under the supervision of the cardiomyopathy, transplant faculty; complete inpatient consultations with faculty oversight and teach medical students and residents on the clinical rotation.
2. Secondary: Perform central line placement, pulmonary artery catheterization, vasodilator challenge, and endomyocardial biopsy; manage heart failure and pulmonary hypertension in an outpatient clinic setting; participate in clinical trial enrollment and subject treatment; participate in review of cardiac biopsies; supervise and interpret Cardiopulmonary Exercise Tests and again gain familiarity with ultrafiltration.
3. Training will include predominantly in the inpatient setting on the inpatient heart failure/ transplant service. Fellows will also perform outpatient invasive procedures and evaluate patients in the heart failure clinic under the direct supervision of the attending on the heart failure/transplant service.

The fellow is the point of contact for the Congestive Heart Failure/Transplant service at UIHC Monday through Friday from 8 am to 5 pm and on every other weekend. The CHF/TXP fellow will also be responsible for the management of all CHF/TXP patients admitted to the CCU service. On weekends, the CHF/TXP patients are seen by the cardiology fellow on service. The fellow receives and reviews all Congestive Heart Failure/Transplant inpatients in the ICU and on the inpatient service (non intensive care unit) from other services, performs the initial evaluation, reviews all pertinent laboratory data and related test results, develops an initial management strategy, presents the patient to the Congestive Heart Failure/Transplant attending, The fellow will work closely with the Internal Medicine residents or others involved in the care of CHF/TXP patients. The fellow will teach and supervise these team members and assist them in patient presentation. The fellow will conduct daily rounds on all Congestive Heart Failure/Transplant inpatients and will review each patient with the Congestive Heart Failure/Transplant attending physician during the morning rounds. The fellow will attend Congestive Heart Failure/Transplant Meetings. The fellow will assist the Congestive Heart Failure/Transplant attending during procedures performed in the Cath Lab or on the wards and will progress to higher levels of participation as the fellow’s skill level allows. Fellows will participate in cardio-pulmonary exercise testing and receive training to develop expertise in physical rehabilitation for patients with heart failure. The fellow will communicate the patient’s study information to the house staff post-procedure, write a procedure note, and do the appropriate post-procedure checks (x-ray, operative site, labs, etc).

The staff physician and fellow will care for patients as a team to facilitate patient care and teaching as it relates to the etiology, pathogenesis, clinical presentation, natural history, and the treatments of the various Congestive Heart Failure/Transplant disorders seen. The attending will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, and review and supplement the fellow’s teaching of other members of the team. The attending may assign readings or other learning activities as necessary. The attending will supervise the fellow during invasive procedures based on the level of the fellow’s skills.

The objectives of this rotation are as follows:

1. Learn to diagnose and treat acute, decompensated heart failure and cardiogenic shock; chronic heart failure decompensation in patients with both systolic and diastolic heart failure; decompensated pulmonary hypertension; common complications of heart transplantation; common complications of ventricular assist device insertion (A, B)
2. Understand the indications and contraindications for the following advanced heart failure and pulmonary hypertension therapies including biventricular pacing; cardiac transplantation; ventricular assist device implantation; pulmonary vasodilators; lung and heart-lung transplantation (A, B)
3. Improve general inpatient management skills in critical care, telemetry, and consultation settings by developing critical thinking and clinical analysis; developing a comprehensive approach to diagnosis; practicing evidenced based medicine and to develop procedural skills in right heart catheterizations, placement of central venous lines and peripheral arterial lines. (A, B, F)
4. Learn to appreciate and use a multidisciplinary team in the treatment of cardiomyopathy and pulmonary hypertension by overseeing residents and work with an integrated care team of doctors, nurses (team and floor), nurse practitioners, nutritionists, social workers, pharmacists (A, D, E, F)
5. Learn common outpatient management strategies and treatment guidelines for heart failure and pulmonary hypertension (A, B)
6. Become knowledgeable of and participate in clinical trials (A, B, C)
7. Understand the salient features of allograft rejection, myocarditis, infection, and other pathology on cardiac biopsies (A, B)
8. Develop teaching skills via didactic and clinical opportunities with residents and students by encourage critical thinking and clinical analysis; encouraging a comprehensive approach to diagnosis and encouraging evidenced based thinking (C, D, E, F)
9. Fellows who desire additional training in management of cardiomyopathy and cardiac transplantation may spend an additional year to acquire the necessary clinical skill and develop investigative research skills (A, B)
10. Become familiar with the current medical literature as it relates to CHF and cardiac transplantation to help facilitate the practice of evidence-based management of CHF and post-transplant patients. (C)

Junior Fellows (first year fellows)

Every patient on the CHF/TXP service will be primarily managed by the fellow with close faculty supervision as part of a team of hospitalists, nurse practitioners, and the CHF subspecialty fellow. The fellows will initially assess patients admitted to the service. The faculty will review the history and physical findings with the team as well as any pertinent laboratory studies. The team will then formulate a plan with the faculty. The fellow may also be involved in procedures performed in the catheterization lab (right heart catheterization, biopsies, coronary angiography).

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.

Training occurs at University of Iowa Hospitals & Clinics and provides experience in a wide range of cardiac pathology in a diverse patient population. Both men and women of all adult ages and of various ethnic backgrounds are seen. Clinical encounters include predominantly inpatient consultation, outpatient consultation in the heart failure clinic, and peri-procedural care. Both non-invasive and invasive procedures are performed, including the interpretation of ECGs, cardiopulmonary stress testing, right heart catheterization, and RV biopsy.

The supervising physician will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, review and review and supplement the fellow’s teaching of other members of the team. The attending physician may assign readings or other learning activities. The attending will supervise the fellow in the performance of procedures. The fellow will assume progressive levels of responsibility for patient care and procedure performance under the supervision of the attending.

1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
2. The fellow’s progress will be reviewed verbally mid-rotation.
3. A standard fellow evaluation form will be completed by the attending at the end of the rotation.
4. The final evaluation by the supervising physician will be based on the fulfillment of the rotation objectives as determined by:
   1. Personal observation during interaction with the fellow.
   2. Evidence of extensive literature reviews appropriate for the individual patient and topic.
   3. Ability to construct a logical management plan.
   4. Inclusion of appropriate physical examination.
   5. Appropriateness of use of diagnostic tests.
   6. Correct interpretation of diagnostic tests.
   7. Appropriate selection of pharmacologic and non-pharmacologic therapies.
   8. Competent performance of cardiac procedures relative to the fellow’s level of training.
   9. Appropriate follow-up.
   10. Feedback from other team members, other healthcare providers, and patients.

• University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
• www.cardiosource.com
• Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
• www.hfsa.org