Our training program provides our fellows with a depth of clinical experience, covering all clinical and laboratory experience. Virtually all clinical experiences are achieved within the first two years of training, as are the COCATS 3 requirements for procedural competencies. Fellows gain level 2 training in echocardiography and nuclear cardiology within the first two years. The majority of the third year is elective, allowing fellows to round out their clinical experiences according to their personal preferences, concentrate on research developed in their first two years of training, and/or seek specific additional expertise in given sub-specialty areas of cardiology, such as echocardiography, nuclear, cath, CT/MR imaging, EP, or Interventional Cardiology.
Adult Congenital Heart Disease Through partnerships with other NYC medical institutions, fellows gain experience with managing patients with adult congenital heart disease by rotating through either Columbia University Medical Center or Montefiore Medical Center. These strong academic partnerships allow our fellows to take advantage of the expertise available in New York City. Fellows will have the opportunity to manage adult inpatients and outpatients, all the while gaining the experience and knowledge necessary to care for the complexities of congenital heart disease. Fellows will also obtain experience with interpreting pediatric echocardiograms. There are regular teaching didactics included in the rotation, and one-on-one learning time with leaders in the field of adult congenital heart disease.
Cardiac CT/Magnetic Resonance Imaging The cardiac CT program at Mount Sinai St Luke’s and Mount Sinai West consists of an in-house training experience and an outside rotation under the supervision of Dr. Seth Uretsky. Both the Mount Sinai St. Luke’s and Mount Sinai West have a 64-detector CT which perform cardiac studies. The Cardiac CT rotation is currently part of the nuclear rotation so that the fellows will read both the nuclear studies and the cardiac CT studies side by side during the afternoon reading sessions. These didactic sessions are supplemented by a weekly afternoon reading session in which the cardiac CTs for that week are reviewed with Dr Uretsky and all the fellows.
The above Nuclear/Cardiac CT rotation is supplemented by an off campus experience for Cardiac CT and MRI at Advanced Cardiovascular Imaging, a busy standalone practice in which the fellows will be exposed to a wide range of Cardiac CT and MRI studies. This rotation is performed on an elective basis.
The clinical rotations in Cardiac CT and MRI are enhanced by didactic lectures and interesting case sessions given by Dr. Uretsky thought the academic year. Furthermore, Cardiac CT and MRI are active fields of clinical research at Mount Sinai St. Luke’s and Mount Sinai West and fellows are encouraged to join these research activities.
During their cardiac CT training, fellows are expected to learn to interpret calcium scans and coronary computed tomography angiography. Fellows will be exposed to both cardiac anatomy, coronary anatomy, and vascular anatomy. Fellows will learn to perform a calcium score, to recognize calcified and non-calcified plaques, and assess the degree of coronary stenosis on CCTA.
During the Cardiac MRI rotation fellows will learn how to assess LV structure and function, valve disease, myocardial scar, and myocardial ischemia on MRI. A tutorial module will be available for fellows to learn about the MRI evaluation of cardiac structure and function, valve disease, pericardial disease, congenital heart disease, and cardiac masses.
Cardiology Clinic A central component of our Cardiology fellows’ experience is their weekly cardiology clinic, taking place one afternoon per week. Each fellow manages approximately 8 new and returning patients each clinic session, under the supervision of our skilled clinical faculty Fellows follow their patients continuously throughout their three-year fellowship.
The goal of this experience is to teach our fellows how to develop and apply the full range of their growing fund of medical knowledge and experience to clinical problems. The faculty will guide the fellows in developing reasonable and appropriate diagnostic and therapeutic skills. Through their clinic experience, it is anticipated that all fellows will come to:
- Hone their skills in designing diagnostic and therapeutic evaluations.
- Understand the role of the specialist/consultant in managing out-patient problems.
- Learn the intricacies of being a consultant and work with referring physicians on behalf of patients with CVD, such as collaborating with surgeons in clearing patients for various procedures.
- Learn data management, such as making sure that relevant information is both gathered and transmitted in an effective and efficient manner.
- Improve their history taking and physical examination skills. Unique physical finding should be shared among all fellow participants, pending patient approval.
- Learn how to utilize diagnostic and therapeutic resources in an efficient and cost-effective fashion.
All new patient encounters are reviewed with the faculty, including the plans for further evaluation and patients’ required short-term and long-term treatment. One of the central lessons to be learned from clinic experience is to match an intended treatment plan to the unique needs of each individual. This is important because patients often bring a set of unique values that are important to them. And need to be considered when developing an effective treatment plan. It is essential for the fellows to learn how to navigate through the thicket of patients’ personalities, individual insights and limitations, and social realities in this regard.
CCU: The Cardiac care units (CCU) at Mount Sinai St. Luke’s and Mount Sinai West (along with their respective step-down units) are fully integrated in the Cardiac Care unit rotation of the cardiology fellowship. The CCU at Mount Sinai St. Luke’s is comprised of 16 beds, while the CCU at Mount Sinai West is integrated within the Mount Sinai West ICU. The CCU at both hospital sites are fully staffed with nurses and respiratory technicians trained in the care of critically ill patients. The Mount Sinai St. Luke’s site has an average of 1,022 admissions per year covering a wide range of pathology such as acute coronary syndromes, unstable angina, heart failure, arrhythmias, valvular heart disease, hypertensive urgency/emergency and pericardial disease. In addition, Mount Sinai St. Luke’s and Mount Sinai West has a robust cardiovascular surgery program which works closely with the cardiology service.
Training of the cardiology fellows in critical care cardiology is at the center of the CCU rotation. While the CCU attending is responsible for teaching fellows and medical staff as well guiding all medical decisions, fellows are given responsibility according to their level of experience. As fellows advance in their knowledge they are expected to take on a greater teaching and leadership role so by their third year they may act in concert with the CCU attending. In addition, the CCU experience gives the fellows the opportunity to work with nurses and other allied health professionals in a critical care environment.
In addition to didactic lectures pertaining to critical care cardiology, fellows will have ample opportunity to perform and become proficient in a variety of emergency bedside procedures including: transthoracic and transesophageal echocardiograms, swan-ganz catheter placement, transcutaneous and transvenous pacemaker placement and emergency cardioversion/defibrillation. For those interested, numerous opportunities exist to participate in a variety of research projects involving the assessment and management of acute cardiac conditions.
Consultation service: The Cardiology consult service rotations provide our fellows with in-depth clinical experience for managing a wide range of clinical cardiology problems, while developing fellows’ skill as a consultant. On the consult service the fellow will interact with a wide variety of medical and surgical services, and hospital systems, thus helping to foster competencies such as systems based practice, interpersonal skills and communication as well as professionalism. Most consults are generated from the Emergency Department, the medical services, and the surgical services.
Primary goals of the consult experience including developing clinical expertise in in-patient and consultative cardiology; learning to act independently as a cardiologist in treating in-patient cardiac disease; and developing the skills necessary to work with other medical and surgical services toward patient care. These skills are garnered through the fellows’ exposure to a wide variety of cardiac illnesses, including chest pain (ranging from non-anginal pain to acute coronary syndromes), supraventricular and ventricular arrhythmias, valvular heart disease, cardiomyopathy, adult congenital heart disease, hypertension and hypertensive heart disease, various levels of heart failure, pericardial diseases, cardiac tamponade, cerebrovascular disease, peripheral vascular disease, lipid and other metabolic disorders, assessment of cardiac issues in pregnancy, and the pre-op clearance of patients for non-cardiac surgeries.
Among our objectives for promoting fellows’ skills as a consultant, fellows are expected to learn how to gather complete and accurate information from multiple sources and to correlate the data from various diagnostic modalities, for the purpose of developing and providing optimal treatment plans for individual patients; to suggest additional appropriate referrals and coordinate patient care as might be required of a consultant; and to show the ability to weigh diverse and contradictory information in formulating consultation recommendations and to learn how to extrapolate from the literature in making recommendations.
Echocardiography The echocardiography laboratories at Mount Sinai St. Luke’s and Mount Sinai West are unique high-volume centers. Under the direction of Dr. Farooq Chaudhry, the echo lab participates in all aspects of clinical cardiology and engages in a variety of high-level research activities. Collectively, the echo labs at Mount Sinai St. Luke’s and Mount Sinai West (as well as the outpatient cardiac imaging center, Cardiodiagnostic Services) perform and interpret well over 18,000 procedures annually.
Led by national as well as internationally recognized leaders in the field of clinical echocardiography, the echo lab provides the whole spectrum of cardiac ultrasound services, including: transthoracic echo (TTE), stress echo, transesophageal echo (TEE), intracardiac echo, contrast echo, 3-D echo, intraoperative, as well as carotid and other types of vascular imaging. As a part of both clinical and structured research activities, the echo lab also participates in advanced imaging studies such as strain and strain-rate imaging, vector velocity imaging, contrast perfusion imaging, and through coordinated efforts with our electrophysiology department, cardiac resynchronization. As director of the Mount Sinai West echo lab, Dr. Mark Sherrid founded and continues to run the Hypertrophic Cardiomyopathy Program, which continues to be a major referral center for patients in the NYC area with hypertrophic cardiomyopathy.
Cardiology fellows rotate through all the inpatient echo labs at Mount Sinai St. Luke’s and Mount Sinai West Center accumulating a minimum of 4 months experience. More specifically, fellows are asked to perform a wide variety of echo procedures ranging from full TTE studies, to stress echo and TEE. Prior to formal reading sessions with the attending, fellows are asked to pre-read studies and formulate their own interpretation of the study and how it may impact a particular patient’s clinical management. As clinically indicated, cardiology fellows also participate in urgent/emergent bedside echo studies as a part of their on-call experiences.
While all cardiology fellows achieve COCATS level II training in echo, opportunities do exist for motivated fellows to achieve level III training. In addition to participating in weekly echo conferences, fellows also can elect to attend echo research meetings and engage in a variety of mentored research projects. The echo lab continues to be one of the most active research departments in the division of cardiology with many fellows publishing abstracts and manuscripts on an annual basis.
Electrophysiology Our electrophysiology program has long held national and international distinction for its clinical excellence, academic achievement, and its ability to offer a full spectrum of services to patients with known or suspected arrhythmias, which run the gamut from benign to fatal, are associated with significant morbidity, are a major cause of cardiovascular hospitalization in the United States, and are increasingly treated with a broad array of innovative, non-pharmacologic, modalities. The learning experience in electrophysiology includes both in-patient and out-patient settings, clinical consultation, device management, and invasive diagnostic and therapeutic procedures.
Fellows’ electrophysiology training is generally provided over a 2-month period during the first two years of Cardiology fellowship. The general goal of this training is to provide fellows with the basic COCATS requirements in electrophysiology, including basic understanding of the anatomy and physiology surrounding arrhythmias, the various diagnosis and treatment options, ECG interpretation, the various broad aspects of management of pacemaker and defibrillator patients, the work-up of patients with unexplained syncope, risk stratification of patient at risk for sudden cardiac death, electrical cardioversion, pharmacology, and other important basic areas that a graduating cardiology fellow should know about basic electrophysiology. For interested fellows, additional elective time in electrophysiology is available and encouraged in the third year.
In addition to rounding on patients with arrhythmia problems on the floors, fellows may participate in our busy EP lab program, where advanced fellows may receive instruction from our EP faculty, such as in learning the techniques of inserting diagnostic electrophysiology catheters with the right atrium, His-bundle region, right ventricle, and coronary sinus and interpreting the intracardiac electrograms obtained from these various locations, and understanding the role of pacing maneuvers and three-dimensional electro-anatomic mapping in the processing of a differential diagnosis to a patient’s arrhythmia. Before EP procedures, cases are discussed in detail with the fellow, including the indications for the procedure, and various approaches to managing the patient’s cardiac condition. During the case, the relevant EP findings, as well as complications and difficulties encountered during the case are reviewed in detail with the fellow. The post-procedure management is outlined by the attending and a formal report of the electrophysiology procedure is generated together with the fellow.
The strong experiential learning garnered on the electrophysiology rotation is strongly complemented by the didactic learning that takes place during the weekly EP morning conference, as well as our weekly ECG conference.
While the experience of the first two years is not sufficient to provide fellows with the ability to become independent electrophysiologists, for those wishing to gain that level of training, we offer Level II training in electrophysiology during the 3rd year of Cardiology Fellowship training and Level III training in electrophysiology during an additional 4th year of fellowship training devoted exclusively to electrophysiology.
Heart Failure Our fellows obtain in-patient and out-patient experience and instruction on through the supervision of Dr. Marrick Kukin, Director of our Heart Failure program, and also spend a concentrated month on the heart transplant/LVAD services of Columbia or Montefiore Hospital, to provide our fellows complementary experience in the in-patient management of advanced heart failure, including the management of transplant patients.
At SLRHC, Cardiology fellow participate in our outpatient heart failure clinic experience, perform heart failure consultations and rounds in hospitalized patients, and oversee care of patients in the Close Watch Unit, which is compromised of two four-bedded units at Mount Sinai West, specifically designed to treat patients with decompensated heart failure. Fellows also participate in didactic heart failure conferences run by Dr. Kukin and can become involved in our clinical heart failure trials.
Among the objectives of the heart failure experience are the follow: to become masterful in providing cardiac consultation as to the management of new onset heart failure or acute decompensation of chronic heart failure; understand the roles of diagnostic testing in the decision making processes for heart failure; to learn how to conduct the out patient evaluation and management of heart failure; learn the pathophysiology of heart failure; gain experience in integrating the results of clinical trials into the unanswered questions and newer approaches for heart failure; and to understand the interplay between various disciplines of cardiology and heart failure- specifically: EPS and devices, catheterization lab and diagnostic/ revascularization procedures, CTS, echocardiography, nuclear, prevention, and rehabilitation.
Principle objectives of the fellows experience during their Heart Transplant/ LVAD rotation include the following: Selection criteria for heart transplant; UNOS transplant listing; care of patient immediately post transplant; introduction to immunosuppressive therapy post transplant; post transplant issues including infection, arteriopathy, rejection; and experience with LVADS (left ventricular assist devises).
Interventional Cardiology For approximately 30 years, Mount Sinai St. Luke’s and Mount Sinai West has offered formal Cardiac Catheterization lab rotations in Interventional and Invasive Cardiology. We believe this training is an essential foundation on which technical and clinical experience of treating patients with coronary heart disease is derived. Our curriculum is designed to provide the fellow with a comprehensive and extensive understanding of atherosclerotic heart disease, focusing on both the clinical and technical aspects of treatment.
All of our faculty are committed to teaching, and are actively involved in the Cardiology Training Program. We believe that “hands-on” learning is essential for developing the skills that are needed to perform diagnostic cath and interventions after training is completed. Hence, the majority of instruction from faculty comes from direct laboratory work. While working on cases in our laboratory, the attending provides an essential teaching experience to the fellow. Our faculty work closely with the Cardiology fellow, and collectively allow the fellow to obtain a practical experience of diagnostic and/or interventional cardiac cath throughout their years of training.
Teaching and instruction by our faculty do not end in the cardiac catheterization laboratory. Before the procedure, cases are discussed in detail with the Cardiology fellow, including the indications for the procedure, and various approaches to managing the patient’s cardiac condition. Following the case, the diagnostic angiogram and relevant hemodynamics, and complications, or difficulties encountered during the case are reviewed in detail with the fellow. The post-procedure management is outlined by the attending and a cath report is generated together with the fellow. Further instruction is provided during journal club and weekly conferences.
Training of fellows in the cardiac cath laboratory is available to suit the aspirations of all Cardiology Fellows to achieve any of the three COCATS training levels in this field of cardiology.
Nuclear Cardiology The Nuclear Cardiology teaching program at SLRHC is a unique program, run under the joint auspices of the Division of Cardiology and Division of Nuclear Medicine. Our program is run by internationally renowned leaders in the field of Nuclear Cardiology, employs state of the art equipment and facilities, and has a highly seasoned technical staff. We have a full time physicist and a tradition of academic research. All this supports an excellent learning environment for fellows. Our Nuclear Cardiology imaging procedures are performed at: Mount Sinai St. Luke’s, Mount Sinai West, and our outpatient stress facilities at 59th Street and at 125th Street. All nuclear studies from these sites are accessed in our main reading terminal for review by our faculty and cardiology fellows for review during our daily Nuclear Cardiology teaching conference.
Our nuclear procedures include stress-rest single photon emission computed tomography (SPECT), stress- rest planar imaging (when SPECT imaging is not possible), test-redistribution thallium studies (to assess myocardial viability or resting myocardial ischemia), and equilibrium gated blood pool radionuclide angiography (“MUGA” studies) at rest to assess LV function.
During their Nuclear Cardiology rotation, Cardiology Fellows perform daily supervision of nuclear stress testing (exercise, dipyridamole, regadenoson, and dobutamine stress) and participate in our daily afternoon reading conference, under the direction of Dr. Alan Rozanski and Dr. Gordon DePuey. Fellows are expected to pre-read each study. During the teaching conference, studies are blindly read, and then considered in light of the clinical information for each patient. A Bayesian assessment as to the likelihood of CAD (in diagnostic patients) or likelihood of myocardial ischemia (in patients with known CAD) is made in each patient.
All Nuclear Cardiology studies are systematically evaluated for acquisition and processing artifacts, and defects are evaluated for the extent and severity of induced ischemia and degree of viability within any defect zones. LV wall motion, ejection fraction, and wall thickening are analyzed from gated SPECT images. The attending staff have the fellows first verbally commit as to their interpretation of each scan during the teaching conference, and then the attending explains how they chose to interpret the scan findings. In addition, relevant information regarding exercise physiology, cardiovascular pathophysiology, and general clinical decision making and risk assessment principles and assessment are also covered in the context of this conference. Didactic teaching is supplemented by the presentation of Nuclear Cardiology cases at our imaging conference and by a series of Nuclear Cardiology core lectures. 3rd year fellows are also assigned the task of dictating the Nuclear studies results after the reading session, thus allowing fellows to receive feedback and grow in their written communication skills.
Training of fellows in nuclear cardiology is available to suit the aspirations of all Cardiology Fellows to achieve any of the three COCATS training levels in Nuclear Cardiology. All fellows qualify for level I training as part of their training and many fellows also elect to pursue level 2 nuclear training during their third year of fellowship. For those who elect to do so, there is a year long weekly didactic nuclear physics laboratory program that is supervised by our full-time Nuclear Physics Director, Dr. Marvin Friedman.
Because of the natural complementariness of Nuclear Cardiology and Cardiac CT, fellows exposure to these imaging modalities has been combined for clinical, research and teaching purposes in our program. For example, we currently obtain routine coronary calcium scans among diagnostic patients referred for stress rest myocardial perfusion SPECT at St Lukes Hospital and have a reading terminal in our nuclear cardiology suite to allow review and interpretation of all calcium scan and coronary CT angiogram studies that are performed at our Institution.