The Mount Sinai Hospital
The Mount Sinai Hospital, a 1,100-bed teaching hospital, shares a four-block campus with Icahn School of Medicine on the Upper East Side of Manhattan. Adjacent to Central Park, the campus extends from 98th Street to 102nd Street and eastward from Fifth Avenue to Park Avenue. This area, known as Carnegie Hill, is a residential neighborhood and designated historic district. The campus is bordered to the north by East Harlem, a predominantly low-income community, and to the south by Yorkville, one of the nation's most affluent communities. The neighborhood provides a broad mix of cultural, socioeconomic and ethnic diversity that makes the educational and health service opportunities at Mount Sinai unique.
The Mount Sinai Hospital is a tertiary referral center for patients not only from the tri-state area of New York, New Jersey and Connecticut, but from around the world. Over 1,000 attending physicians on staff attract a socioeconomically and medically diverse patient population in the field of cardiovascular medicine and in all clinical specialties.
Cardiovascular Medicine Facilities
The Zena and Michael A. Wiener Cardiovascular Institute (CVI), established by Dr. Valentin Fuster, integrates virtually all facets of clinical and research activities in cardiovascular disease. The Institute provides an academic framework for the collaboration of cardiologists, vascular surgeons, radiologists, pediatric cardiologists, cardiothoracic surgeons, endocrinologists, other medical subspecialists, basic scientists in vascular biology and other areas, clinical trialists and health care policy experts. Mount Sinai Heart embraces patients with cardiac and vascular disease. Extensive ambulatory cardiovascular care facilities are centered in the Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, emphasizing multifaceted modalities for reduction of cardiovascular disease risk, advanced imaging modalities for noninvasive detection of early and late manifestations of disease, and comprehensive diagnostic and management services.
Interdepartmental and Intradepartmental Resources
Fellows may participate in the rounds and patient care activities of the Division of Pediatric Cardiology, under the supervision of Dr. Ira A. Parness. A close working relationship with the Department of Cardiothoracic Surgery (chaired by Dr. David H. Adams) provides fellows with comprehensive exposure to the surgical management of coronary artery disease, valvular heart disease, congenital heart disease, arrhythmias, cardiac transplantation and mechanical support of the failing heart. Investigation in valvular disease, robotic surgery and minimally invasive procedures has lead to the development of a new mitral ring and other innovations. Dr. Randall B. Griepp, immediate past chairman of Cardiothoracic Surgery, is recognized worldwide for his achievements in surgery of complex aortic disease. Dr. Paul Stelzer is a world-renowned expert in the Ross Procedure. In the Department of Surgery, endovascular stenting has been a major clinical and research interest (often jointly with Cardiology, Cardiothoracic Surgery, and Radiology). Clinical and research cardiac MRI and high-resolution CT imaging are supported by collaborative efforts of radiologists, physicists, cardiologists and specialists in vascular medicine.
In addition to working with the full-time faculty, fellows gain clinical experience through interaction with our extensive voluntary staff. The voluntary staff includes many outstanding cardiologists in active clinical practice who are eager to share their experience with fellows. For example, Dr. José Meller, widely recognized as one of the nation's leading cardiology practitioners, holds weekly conferences to discuss management of difficult or unusual cases.
What Mount Sinai Offers
On a broader level, The Mount Sinai Hospital includes eight intensive care units (coronary care unit, cardiothoracic surgery ICU, cardiac surgical progressive care unit, pediatric cardiology ICU, medical ICU, surgical ICU, neurological ICU, and neonatal ICU) as well as extensive pre- and post-anesthesia care areas. Other facilities include an active urban emergency room and cardiac operating suites. The data generated by all the cardiac laboratories is contained in a single, integrated cardiology computer network, a major resource for clinical research. Reports produced by the laboratories are uploaded, via the cardiology network, to Mount Sinai's online enterprise data repository (EDR), facilitating patient care throughout the hospital. Electronic medical records (EMR) are fully integrated into the ambulatory clinics. The inpatient units are in the process of transitioning from paper records to EMR, a process that is expected to be completed in 2011. Renowned as one of the world's leading centers for postgraduate medical education, the Hospital offers residency and fellowship programs in cardiothoracic and vascular surgery, pediatric cardiology, cardiac transplantation, interventional cardiology, cardiac electrophysiology, and vascular medicine as well as in all the major disciplines of medicine, surgery, psychiatry and radiology.
The Mount Sinai Heart Resources and Divisions
Frieda and Milton F. Rosenthal Coronary Care Unit
The Coronary Care Unit (CCU) is a large, state-of-the-art, 14-bed facility. The facility cares for the most critically ill cardiac patients, including those diagnosed with acute myocardial infarction, high risk unstable angina, complicated post-percutaneous coronary intervention patients, decompensated heart failure, and life-threatening arrhythmias. The CCU also serves patients awaiting heart transplantation who require hemodynamic monitoring. The staff includes a cardiology fellow, three senior medical residents, three medical interns, and an outstanding nursing staff. Two attending cardiologists and a full-time cardiac intensivist conduct daily teaching rounds in the CCU. The Cardiac Catheterization Laboratory is adjacent to the CCU.
The 105-bed inpatient service of Mount Sinai Heart provides a high level of nursing care with 24-hour telemetry monitoring. Patients include those with general medical problems who require intense monitoring, those with congestive heart failure and arrhythmias, those with severe heart failure who are pre-transplant patients (on inotropic and/or mechanical support) and those early or late after heart transplant. They are cared for by medical house staff (one PGY-3, one PGY-2, two PGY-1s) or dedicated cardiac nurse practitioners. Cardiology fellows provide consultative support as needed.
Cardiac Catheterization Laboratory
Led by Dr. Samin Sharma, the Cardiac Catheterization Laboratory is comprised of six fully equipped rooms for cineangiography (including three biplane labs) and state-of-the-art computerized hemodynamic studies. Last year, the laboratories performed over 16,000 procedures, including over 5,500 interventional procedures: percutaneous angioplasty, intracoronary stenting, rotational atherectomy, interventions on chronic total occlusions, balloon valvuloplasty, alcohol septal ablation and peripheral vascular interventions. The volume of interventional procedures has been increasing by approximately 10% each year. Myocardial biopsies (both primary diagnostic and for heart transplant recipients) and full assessments of pulmonary hypertension are performed regularly as well.
The faculty of the catheterization laboratory includes nine full-time attending physicians and nearly a dozen part-time attending physicians. There are nine interventional cardiology fellows (seven are in ACGME-accredited spots) as well as a full team of nurse practitioners. During a typical training rotation in the catheterization laboratory, fellows learn diagnostic angiography by working closely with an interventional fellow and attending cardiologist. Fellows perform right- and left-heart catheterizations. The main educational focus of this rotation is for fellows to gain an understanding of cardiac hemodynamics, coronary anatomy, and cineangiogram interpretation, while developing expertise in the performance of catheter-based coronary procedures. There is didactic teaching and there are regular conferences.
As reported by the New York State Department of Health, the Cardiac Catheterization Laboratory has achieved the highest volume and lowest mortality rate in New York State for angioplasty procedures for over 10 years.
The Phyllis and Lee Coffey Non-Invasive Area: Echocardiography Laboratory
Dr. Martin Goldman directs the dynamic Echocardiography Section of Mount Sinai Heart, an interactive program integrating physiology, pathology and hemodynamics. The laboratory is accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL). The Echocardiography Laboratories at The Mount Sinai Hospital perform approximately 50-60 echocardiograms daily, including interventional and/or pharmacological and exercise stress studies. Transthoracic echocardiograms are also performed in two outpatient facilities (Joseph H. Hazen Ambulatory Care Center and Kravis Health Center), all of which are interpreted by fellows and attending echocardiographers. Over 14,000 studies were performed in the past year.
Studies are performed on the latest equipment from all major manufacturers with complete pulsed and continuous wave Doppler, color Doppler and Doppler Tissue Imaging interrogation. Advanced echocardiography equipment (including real-time, three-dimensional imaging) is integrated into clinical studies when indicated. Intravenous precision microbubble contrast and other sonographic contrast agents are used, when indicated, to enhance images (approximately 15% of transthoracic studies). The laboratory is currently collaborating with Siemens on its Acuson SC 2000, a real-time, full-volume ("4D") echocardiography system. (The only other sites are Columbia [animals], Massachusetts General Hospital, Cleveland Clinic and Mayo Clinic.) Completed studies are read and have been stored digitally on a state-of-the-art image server (PACS) since 2001. Transesophageal echocardiography (TEE) is performed by fellows under the supervision of experienced attending echocardiographers. Two full-time cardiac nurses are assigned to the laboratory to assist with TEE and pharmacological stress studies. Eight physicians staff the laboratory, over-reading each echo with the fellow or technologist who performed it. A highlight of the rotation is the afternoon/evening teaching sessions with fellows and attendings. The technical staff includes a technologist supervisor and five technologists in the hospital laboratory and four technologists in the ambulatory areas. Fellows usually rotate through this laboratory as part of their first and second years of clinical training and become proficient in both the interpretation and acquisition of transthoracic echocardiograms. Those desiring additional exposure to TEE or other specialized ultrasound techniques may spend additional time in the second and third years.
The Phyllis and Lee Coffey Non-Invasive Area: Nuclear Cardiology & Stress Laboratory
The Nuclear Cardiology and Stress Electrocardiography Laboratory, led by Dr. Milena Henzlova, performs over 5,000 noninvasive tests annually for the diagnosis of cardiac disease and the assessment of its severity. The Laboratory is accredited by the Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories (ICANL). The tests performed include electrocardiographic stress tests, SPECT myocardial perfusion studies with Tc-99m Sestamibi or thallium-201 combined with either exercise or pharmacologic stress (dipyridamole, adenosine, regadenoson or dobutamine infusion).The laboratory staffing includes several cardiologists, all certified in Nuclear Cardiology, Registered Nurses and Certified Nuclear Medicine Technologists. Rotations are offered to Cardiology Fellows, nuclear medicine and radiology Residents. The equipment consists of three automated treadmills, three SPECT dual head gamma cameras and several processing computers including a high-speed central processing/reading/archiving computer system — all interconnected by a network.
Rotating fellows and residents learn how to perform and interpret exercise and pharmacologic stress tests, along with evaluation of myocardial perfusion studies. Additional training is available for those wishing to achieve Level II training in Nuclear Cardiology.
Major research efforts in the Laboratory include investigation of new pharmacological stress agents, cardiac neuroimaging in congestive heart failure and ischemia memory agents.
Electrocardiography and Electrophysiology Section
The Electrocardiography (ECG) and Electrophysiology (EP) Section, led by Dr. Vivek Reddy, provides a variety of services throughout the Hospital. The ECG area provides electrocardiograms, signal-averaged ECG's, 24-hour Holter monitors and an array of cardiac events monitoring and ambulatory telemetry services. The EP service provides electrophysiology studies, radiofrequency catheter ablations, cardioversion, tilt-table tests, implantation of pacemakers, cardioverter defibrillators, resynchronization devices, intra-operative mapping and cryoablation (in collaboration with cardiothoracic surgery), an arrhythmia clinic, and consultation and follow-up services. Over 2,000 procedures were performed last year. Currently, there are two dedicated EP rooms with state-of-the-art equipment for mapping and ablation, with a third room under construction. The staffing of this section includes eight full-time attending electrophysiologists. The program provides training in all aspects of clinical electrophysiology. General cardiology fellows run the consult service and perform device interrogations in collaboration with one of the EP fellows and an attending. There is also the opportunity for general fellows to assist with procedures in the EP laboratory. Patient management is discussed with all attending at daily morning meetings, and there are weekly didactic sessions that review intracardiac electrograms.
Heart Failure and Cardiac Transplantation Program
The Heart Failure Program, led by Dr. Sean Pinney, integrates clinical care and heart failure research. Patients referred to the Heart Failure Program receive a full cardiac evaluation and optimization of their medical regimen including cardiac resynchronization devices. The heart failure evaluation customarily includes cardiopulmonary exercise testing and hemodynamic assessment. Clinical research studies are currently studying new devices for monitoring and treating heart failure, as well as new drugs for the treatment of acute decompensated heart failure. Four faculty members are joined by a heart failure fellow and dedicated nurse practitioners.
Patients with advanced heart failure are evaluated for cardiac transplantation or destination therapy with a left ventricular assist device (LVAD). More than 20 transplants and 30 LVAD implantations are performed each year. Ongoing research in this area is focused upon understanding the development and treatment of cardiac allograft vasculopathy.
The Pulmonary Hypertension Program evaluates and treats patients with primary and secondary forms of pulmonary hypertension. Treatment modalities range from oral vasodilating agents to continuous ambulatory infusions of pulmonary vasodilators, inhaled nitric oxide, and investigational agents. Research is focused upon understanding how right ventricular structure and function impacts survival.
The CVI has a dedicated Vascular Medicine section, led by Dr. Jeffrey Olin, that sees inpatients and outpatients. Dr. Olin is a nationally known expert in vascular medicine with a focus in fibromuscular dysplasia (FMD). He has extensive experience in the management of FMD, and collaborates closely with colleagues in Interventional Radiology for both diagnosis and treatment of this disease. There is an active, vascular laboratory accredited by the ICAVL (Intersocietal Commission for the Accreditation of Vascular Laboratories) where ultrasound studies are performed by technologists and interpreted by Vascular Medicine and Vascular Surgery attendings. Over 6,000 studies were performed last year. General cardiology fellows see inpatient and outpatient referrals, and have the opportunity to received training in the interpretation of vascular ultrasounds, including renal, mesenteric, and carotid studies. An additional training year is available for those wishing to specialize in Vascular Medicine.
Advanced Cardiac Imaging
Our advanced cardiovascular imaging center, led by Dr. Javier Sanz, performs over 1,000 cardiac computed tomography and magnetic resonance studies per year. We have a 1.5 Tesla Siemens Sonata magnet and a Siemens Sensation 64 MSCT with cardiac imaging capabilities. In addition, a GE Lightspeed 64-MSCT scanner came into operation in 2008 for the Emergency Department. Finally, a new state-of-the-art clinical and research cardiac imaging facility was added to our services in late 2008 with a dedicated cardiac and vascular 3.0 Tesla magnet, a 256-MSCT scanner and a dedicated cardiovascular PET system. Fellows on the CT/MR imaging rotation participate in the performance and interpretation of all studies under cardiology supervision. Level I and II certification is available based on the ACC-COCATS requirements. Clinical and research operations are under the direction of imaging cardiologists in close collaboration with radiologists, and involve activities of clinicians, clinical investigators and basic scientists. Opportunities for research in atherosclerotic plaque imaging, myocardial perfusion, scar quantification, vascular compliance, and other projects are available. Fellows are encouraged to participate and to develop their own projects.
Cardiac Rehabilitation and Preventive Cardiology
Mount Sinai's Cardiac Health Program is designed to help people with heart disease recover faster and lead healthier lives. Its rehabilitation is focused on patients with myocardial ischemia (with or without revascularization) and other post-operative states. The comprehensive, individualized program goes well beyond exercise and diet to include education, counseling, emotional support, and a growing number of other options. A physician and a nurse direct the program.
Within the CVI, an endocrinologist and a cardiologist with extensive training in preventive medicine and preventive cardiology run a busy Lipid and Diabetes Clinic as part of the Joseph H. Hazen Ambulatory Cardiac Care Center. Each patient is evaluated for the proper diet and pharmacologic agents for producing optimal cholesterol, triglyceride, and glucose levels. Individual counseling and help with weight loss is included when necessary and desired.
Joseph H. Hazen Cardiology Clinics
At Mount Sinai, the Joseph H. Hazen Cardiology Clinics are in session five times weekly. The clinics provide approximately 4,500 visits each year. Ancillary staff includes nurse clinicians, nurses, and medical assistants. Our heart disease prevention staff includes a social worker, nutritionist, counselor for smoking cessation and stress reduction, and an exercise physiologist. A recently renovated physical plant provides patient reception, consultation, and examination facilities. In addition, the clinics are equipped with computers interfacing with the cardiology and hospital information systems, which allows for enhanced access to test results and clinical data management.
Fellows are assigned to one session (four hours) weekly for the entire period of training (at least three years). The program in ambulatory care is structured as a firm-oriented consultative cardiology practice in which fellows evaluate all newly referred cases and provide ongoing care under the supervision of members of the full-time faculty. Specialized programs directed at the evaluation and management of hypertension, hyperlipidemia, congestive heart failure, and cardiac rhythm disturbances are in place.
James J. Peters (Bronx) Veterans Affairs Medical Center
Resources and Divisions
The James J. Peters (Bronx) VA Medical Center is the oldest VA facility in New York City, celebrating over 75 years of service to veterans. The Medical Center is situated on a historic site in the borough of the Bronx. Located on the highest point in New York City, it served as a strategic vantage point during the Revolutionary War. By adding several buildings throughout the years, this hospital became the second largest VA facility in the nation, with a total of 1,663 beds, and the first veterans' hospital in New York City. In 1981, new construction produced a modern, 10-floor, well-equipped facility and, in 1986, a newly constructed 120-bed nursing home care unit was opened.
Today, this VA Medical Center is a multilevel health care Center of Excellence. The facility features a flourishing outpatient service including 10 separate practices encompassing dozens of specialties and subspecialties. In addition, its inpatient wards support 311 authorized beds and a 120 bed Nursing Home Care Unit. The VA Medical Center provides tertiary services to a veteran population from the Bronx, Westchester and Rockland Counties, Northern New Jersey and the New York City metropolitan area.
Research at the James J. Peters (Bronx) VA is world-renowned. Its investigators have been recognized for numerous noteworthy projects and they have received several national and international awards, including the Nobel Prize. A separate research building, built in 1985, is attached to the main clinical setting and has been recognized for achievements in research dealing with viral oncogenesis, diabetes and endocrinology, metabolic alterations in spinal cord injury patients, psychiatric and neurodegenerative diseases, and disorders associated with alcoholism and liver disease. The Medical Center has research program centers in Geriatric Research Education Clinical Center (GRECC), the Mental Illness Research Education Clinical Center (MIRECC).
Coronary Care Unit
The Coronary Care Unit (CCU) is part of a large, state-of-the-art, 20-bed facility. At least four beds are dedicated to cardiac patients. The facility provides for patients with invasive hemodynamic monitoring, multiple intravenous medications and arrhythmia monitoring. Patients admitted to the CCU have a range of cardiac problems, including acute myocardial infarction, decompensated heart failure, unstable angina, and arrhythmias. The CCU is staffed by a cardiology fellow, medical residents and an outstanding nursing staff. An attending cardiologist makes daily teaching rounds in the CCU with the medical staff. Patients who require intervention (percutaneous or surgical) are usually referred to the VA facility in Manhattan. Device implantations (i.e., pacemakers, implantable defibrillators with or without cardiac resynchronization) are performed by a thoracic surgeon, who welcomes the participation of cardiology fellows.
The Echocardiography Laboratory has a dedicated technologist and performs approximately 1,600 echocardiograms per year on two machines (Acuson/Siemens Sequoia and Phillips). Interventional and/or stress studies (pharmacological and exercise) are performed as well; there is one treadmill in this laboratory. As at Mount Sinai, studies are done with complete pulsed and continuous wave and color Doppler interrogation. Transesophageal echocardiography (TEE) is performed by fellows under the supervision of experienced attending echocardiographers. Full-time cardiac nurses are assigned to the laboratory to assist with TEE and pharmacologic stress studies. Fellows rotate through the laboratory and become proficient in both the interpretation and performance of transthoracic echocardiograms.
Nuclear Cardiology Laboratory
The Nuclear Cardiology and Stress Electrocardiography Laboratory performs approximately 500 noninvasive tests annually. The tests performed include electrocardiographic stress tests and SPECT myocardial perfusion studies with Thallium-201 or sestamibi, combined with either exercise or pharmacologic stress (dipyridamole, regadenoson, adenosine or dobutamine infusion). There is one treadmill in this laboratory.
Cardiology Clinic is held on two afternoons per week with approximately 30 patients seen at each session by three cardiology fellows plus attending staff. (One fellow comes from Mount Sinai, in rotation, to supplement the two fellows assigned to the VA.) The VA's electronic medical record (common to virtually all VA medical centers) is a model for most others to emulate. This facilitates patient management decisions (with availability of data) and simplifies routine tasks (as renewing prescriptions).