The Cardiovascular Disease Fellowship Program
Srinivas Murali, MD, FACC, Interim Program Director
George Gabriel, DO, FACC, Associate Program Director
Length of program: 3 years (with optional fourth year in interventional cardiology; 4 positions available for the 3 year program and 2 positions available for the interventional cardiology program).
Program Overview
The primary objective is to offer an outstanding cardiology fellowship program that thoroughly prepares the trainees for leadership careers in any facet of cardiology, clinical or academic. To accomplish this, the Cardiovascular Disease Fellowship Program draws on the expertise and strong commitment to teaching of large full-time and voluntary teaching faculties, a very large stream of patients from western Pennsylvania, West Virginia and Ohio, superb resources for tertiary-care cardiology and extensive research resources.
Given the diversity of career paths now available within cardiology, the three-year fellowship is structured to meet the needs of trainees with a wide variety of long-term objectives. Thus, the program provides a strong set of core clinical experiences and didactic programs in all areas of cardiology as well as large blocks of elective time that can be devoted to research and/or in-depth training in one or more subspecialty areas. In addition, a fourth-year program in interventional cardiology is offered annually. While the hospital has a strong clinical electrophysiology (EP) program, it does not offer an EP fellowship. Rather, graduates are placed in leading programs throughout the country.
Full-time Faculty
The full-time clinical faculty consists of nine cardiologists in four subspecialty areas: a) echocardiography and cardiac MRI; b) clinical electrophysiology; c) nuclear cardiology; and d) heart failure/cardiac transplantation.
Noninvasive Laboratory
The Noninvasive Laboratory group teaches, conducts research and provides diagnostic services in echocardiography, including transesophageal, intraoperative, stress and dobutamine echocardiography and in cardiac MRI. The physicians also supervise the cardiology fellows' outpatient clinic and outpatient consultation services in the medical clinic and the fellows' care of their own patients in the hospital.
Research interests include: MRI coronary and coronary flow reserve imaging; MR tissue tagging for evaluation of myocardial function in ischemic and hypertrophic heart disease; left ventricular remodeling after myocardial infarction; MR contrast and dobutamine methods for detection of viable myocardium; new methods for evaluating ischemic heart disease in women; three-dimensional cardiac imaging by MRI and echocardiography; intraoperative and contrast echocardiography; hypertensive left ventricular hypertrophy; comparative efficacy of diagnostic methods for detecting myocardial ischemia; evaluation of vascular stiffness and diseases of the thoracic aorta using noninvasive imaging; and evaluation of novel echocardiographic contrast agents. A Cardiac MRI Research Center with a dedicated MR scanner, physicians, physicists, technologists and image analysts comprises a state-of-the-art research and clinical consortium. Multicenter trials are performed by the noninvasive laboratory involving the use of MRI and echocardiography to serially evaluate left ventricular structure and function both after infarction and in patients treated with novel pharmacologic agents.
Clinical Electrophysiology
The Clinical Electrophysiology (EP) group teaches, conducts research and provides a full range of noninvasive and invasive diagnostic and therapeutic services in clinical electrophysiology, including provocative invasive electrophysiologic testing, tilt testing, pharmacologic therapy, device therapy (including placing pacemakers and nonthoracotomy defibrillators) and arrhythmia ablation. The group is nationally recognized for the high quality of its program in arrythmia therapy.
Nuclear Cardiology
The Nuclear Cardiology group teaches, conducts research and provides a full range of clinical services in exercise and pharmacologic stress testing, myocardial perfusion scintigraphy and radionuclide ventriculography using state-of-the-art technology. Research interests include: early recognition of stunned myocardium in the post-infarction patient; relationship of scintigraphic findings to coronary flow reserve in coronary artery disease; ambulatory monitoring of ventricular function; comparative efficacy of diagnostic methods for detection of myocardial ischemia and evaluation of left ventricular diastolic function; and scintigraphic imaging of sympathetic innervation. In addition, the group participates in multicenter trials in the evaluation of novel nuclear scintigraphic techniques.
Heart Failure/Transplantation
The Heart Failure/Transplantation group manages a large referral population with advanced congestive heart failure using a variety of investigational drugs and supervises medical management of Allegheny's cardiac transplantation population. Research interests include new pharmacologic agents for congestive heart failure and endothelial function in heart failure.
Voluntary Faculty
The division currently includes 36 practicing cardiologists. Of these, 18 -- most of whom are members of six small practice groups -- are primarily based at Allegheny General Hospital and comprise the voluntary teaching faculty. They care for large numbers of referred patients from a wide area in western Pennsylvania and parts of Ohio and West Virginia.
Cardiac Catheterization Laboratory
The Cardiac Catheterization Laboratory teaching staff consists of practicing invasive and interventional cardiologists, who teach the fellows invasive and interventional cardiology and conduct an active clinical research. There are five angiographic rooms. In addition, Allegheny General Hospital has satellite low-risk laboratories at a number of community hospitals in the region.
The interventional cardiologists maintain both a high level of practice activity and cutting-edge clinical research programs, including the development of multicenter clinical trials with Allegheny General Hospital as the home base. Research interests include: primary angioplasty in myocardial infarction; evaluation of coronary flow reserve with intracoronary Doppler; risk factors for restenosis; radiation therapy for restenosis; new stents; and other devices. There also is an experimental animal catheterization laboratory in which faculty and fellows can pursue projects in new device development in collaboration with industry.
Organization of the Fellowship
The three-year fellowship program, with four positions per year, consists of a core curriculum in addition to 11 months of elective time. Care is taken whenever necessary to uncouple the training program from clinical needs to avoid an excessive workload for the fellows. The size and scope of the division's staff assure extensive opportunities for fellows to interact with and learn from nationally recognized experts in every field within cardiology. The core includes:
Cardiac Catheterization
A core experience of eight months in invasive cardiology is provided. There are three months in year 1, three months in year 2 and two months in year 3. Training in all techniques -- including Judkins, Sones, multipurpose and trans-septal techniques -- is available. A clinical volume of 8,500 procedures per year provides generous opportunity for training and experience. Interventional training is available during an optional fourth-year interventional fellowship, and the laboratory's volume of 2,800 primary and elective angioplasties, stents and atherectomies provides ample training opportunities. In addition to procedural training, 20 percent of the time spent on invasive rotations is devoted to inpatient clinical cardiology each month.
Echocardiography
Three months of core education and training are provided in the program's first year. Emphasis is placed on transthoracic echo, but there also is exposure to TEE, stress echo and cardiac MRI. Electives in years 2 and 3 are available that permit in-depth training in TEE, stress and dobutamine echo, intraoperative echo and cardiac MRI. The laboratory clinical volume of 8,000 procedures a year provides sufficient opportunity for both basic and advanced training.
Nuclear Cardiology
The nuclear cardiology program is based entirely in the Division of Cardiology. Two months in year 1 and one month in year 2 provide a solid grounding in thallium and sestamibi scintigraphy, both quantitative planar and SPECT, sestamibi imaging, radionuclide ventriculography and exercise, persantine and adenosine stress procedures. Advanced training, including opportunity for nuclear licensure, is available on an elective basis, and a fourth year of nuclear cardiology can be arranged for appropriate candidates. laboratory's volume of 5,000 nuclear studies a year provides plentiful material.
Clinical Electrophysiology
Three months are devoted to clinical electrophysiology (EP), two in year 1 and one in year 2. Time is spent in the EP laboratories as well as in seeing consultations and participating in inpatient and outpatient management. The EP group performs more than 500 EP studies, catheter ablations and ICD implantations per year with state-of-the-art technology.
Coronary Care Unit
The very active Coronary Care Unit (CCU) service sees patients with myocardial infarction admitted directly to Allegheny General Hospital or transferred to Allegheny General Hospital from community hospitals in the region for primary angioplasty or management of post-infarction complications. During three CCU months in the second and third years of the fellowship, the cardiology fellows direct a team of residents and students in the CCU under the supervision of the CCU attending cardiologist. The unit provides an excellent experience in managing patients with infarction, including all of the relevant invasive and noninvasive procedures. Because of a very active program in therapeutics for acute infarction, including primary angioplasty in myocardial infarction, fellows are assured a cutting-edge experience in this area.
Consultative Cardiology
Five months are allocated to noninvasive consultative and inpatient services under supervision of senior clinicians with distinguished track records as clinical teachers. Additional inpatient consultative experience is acquired on the EP service and during invasive cardiology rotations.
Outpatient Cardiology
Cardiology clinic meets two mornings a week and involves first- and second-year fellows under the supervision of attendings from the echo labs. In addition, outpatient experiences with the Heart Failure group and with selected practice groups are available. Continuity of outpatient care is provided. Additionally, inpatient care can be provided by the fellow responsible for outpatient care under the supervision of the clinic attending.
Pediatric Cardiology
Pediatric cardiology electives are available at Allegheny General Hospital and Children's Hospital of Pittsburgh.
Elective Time
Eleven months of elective time are provided -- ordinarily three months in year 2 and eight months in year 3. Fellows are expected to develop carefully thought-out, well-integrated plans for elective rotations, working closely with the fellowship directors. Fellows are required to participate in a well-planned research program under the supervision of a full-time faculty member. Fellows also can use the elective time in a coherent fashion to obtain additional in-depth advanced training and experience in one or two aspects of clinical cardiology. Used in this fashion, the elective block permits each trainee to develop a unique training program that achieves a highly individualized set of objectives, preparing each trainee for a clinical or academic career.
Conferences
A wide array of conferences complements the clinical rotations. In the first two months of each year, a series of core curriculum lectures in provided four to five mornings a week. Throughout the year, the weekly conference schedule includes: Cardiology Grand Rounds, given by nationally and internationally recognized visiting professors; Cardiology/Clinical Case conference; Fellows' Conference, devoted to topics prepared by each fellow in rotation, working closely with a faculty preceptor; echo Conference; Interventional Cardiology conference; ECG conference; ; Division Research conference; Interventional Cardiology Research Conference (optional); and Noninvasive Research Conference (optional). In addition, Fellows' Journal Club meets monthly.
Fellows' Research
The division has a strong commitment to providing rewarding research experiences for cardiology fellows, including first author presentation of abstracts and first author manuscripts in leading journals. The program includes a wide range of research interests in the areas of primary angioplasty, supported high-risk angioplasty, atherectomy and other new interventional devices, echocardiography, cardiac MRI, new tracers and devices for nuclear cardiology, pharmacologic treatment of congestive heart failure, implantable defibrillators and arrhythmia ablation and basic science. In addition, the division requires and vigorously supports applications for AHA fellowship research grants and, when appropriate, applications for National Research Service Awards.
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