Nuclear Cardiology is an active, academically oriented program. Currently, the Laboratory has 2 SPECT cameras, one SPECT/CT camera and 1 PET camera and performs over 5,000 imaging procedures per year. In addition to providing clinical evaluations, the Laboratory is involved in the evaluation of new tracers, new imaging approaches for diagnosis and prognostic assessment of CAD, attenuation correction, and vascular imaging using radionuclides.
Fellows spend at least two months rotating through the lab (level I), receiving subspecialty training in cardiac stress testing and scan interpretation. Each fellow must become adept at the performance and interpretation of exercise and pharmacologic stress testing. Fellows are also expected to become familiar with the biophysical and chemical principles underlying SPECT and PET imaging. Half of each rotation is devoted to instruction in and exposure to advanced cardiac imaging, including cardiac MRI and CT. All fellows have the opportunity to acquire level II training during a 3 year fellowship. There is also opportunity for more basic research in molecular imaging using animal models for fellows in the 4 year NIH training grant.
The Cardiovascular Ultrasound Laboratory includes both cardiac and vascular imaging and performs over 25,000 procedures/year including two-dimensional/Doppler echocardiograms, transesophageal echocardiograms, stress echocardiograms and vascular studies (carotids, peripheral) at multiple sites. Fellows spend at least 3 months gaining experience in the performance and interpretation of transthoracic and stress echocardiograms and become familiar with the use of ultrasound as an imaging modality and its clinical utility in hemodynamic assessment. Experience in transesophageal echo is available to those fellows who plan to devote at least 6 months to echo training. Interpretation of vascular studies is covered during the vascular rotation. Formal training occurs through reading with attendings, interpreting and discussing interesting cases presented by a teaching attending, and through an echo syllabus and lecture series. The fellows’ technical and interpretative skills are tested at the end of each rotation. Fellows with 6 months of echo training are eligible to take the exam offered by the National Board of Echocardiography. The laboratory also offers a year of advanced training for fellows who have already completed a 3 year clinical fellowship.
As one of the preeminent and busiest cardiac catheterization centers in the world, Columbia’s lab performs over 11,000 procedures per year, including over 4,000 coronary and 500 endovascular interventions. Highly specialized procedures include chromic coronary and peripheral occlusions, carotid stenting, ASD / PFO closure, adult congenital heart disease procedures, aortic and mitral valvuloplasty, percutaneous mitral valve repair, alcohol septal ablation, endovascular abdominal and thoracic aortic aneurysm repair, stem cell therapy, and percutaneous aortic valve replacement. Columbia’s lab is on the cutting edge of technology and research, and is involved as a primary center in many important clinical trials.
Fellows rotate through the lab for at least four months, gaining competence in the performance of right and left heart diagnostic catheterizations and pre/post-catheterization evaluations. Fellows become adept at hemodynamic interpretation and are exposed to a myriad of advanced interventional procedures. Those interested in specializing in interventional cardiology can tailor their fellowship experience to optimize their time in the lab.
The Center for Advanced Cardiac Care at Columbia is one of the largest and most prominent heart failure and transplantation programs in the world, and the single largest heart transplant program in the country. Since the inception of the program in 1977, Columbia hasperformed more than 1,700 transplants. In 2005 alone, NewYork-Presbyterian Hospital/Columbia University Medical Center performed 118 heart transplants, a one-year record for any U.S. medical center.
Columbia is also recognized as a leader in the management of heart failure, the use of assist devices and novel immunosuppression protocols. This all provides for a most unique experience for the cardiology fellow.
Fellows rotate for two months each on the heart failure and transplantation services. On the CHF service, fellows become skilled in the management of advanced heart failure, from physical diagnosis to the hemodynamic interpretation of right heart catheterization and drug studies; medical management, including the use of inotropic therapy; and management of patients requiring mechanical assist devices (IABP, LVAD, RVAD, BiVAD). The fellow also becomes familiar with the evaluation and management of patients with primary and secondary pulmonary hypertension. Finally, fellows also gain experience in the medical and multidisciplinary aspects of primary transplant evaluation, and participate in weekly transplant conferences where candidates are evaluated for UNOS listing and UNOS priorities are assigned.
The transplant service is also an intense but gratifying experience. The fellow is responsible for the perioperative management of patients undergoing orthotopic heart transplantation, the care of patients undergoing acute, subacute, and chronic rejection, and the management of other complications of heart transplant and accompanying immunosuppressive therapy. After four months of heart failure/transplant experience, the Columbia fellow is comfortable with the management of some of the sickest patients and some of the most complex pathophysiology and hemodynamics.
Electrophysiology pushes the boundaries of the field and functions on the cutting edge of clinical management and intervention. On the floors and in the clinics Columbia electrophysiologists deal with a broad spectrum of arrhythmias, their medical management, interpretation of diagnostic studies and the need to address primary or secondary prevention of sudden cardiac death. In the lab, current and experimental technologies are used to perform a wide array of procedures including ICD and pacemaker implantations, SVT ablation, VT ablation, AF ablation, and complex ablations in transplant patients and adults with congenital heart disease. The EP lab performed over 1200 invasive procedures in 2006.
Fellows spend at least two months on arrhythmia during which their primary responsibility is to run the arrhythmia consult service. All cases are discussed with the ward attending and presented at EP conference. Fellows are also expected to interpret Holter monitors, signal averaged EKGs and T wave alternans studies, and perform tilt table testing. They are also expected to perform and interpret EP studies, particularly those of patients from the arrhythmia service. Interested fellows may spend one or more months of dedicated time in the electrophysiology lab.
Cardiac Intensive Care Unit
The CCU consists of 18 patient beds, a central monitoring and nursing station, and a fluoroscopy room for special procedures (right heart catheterization, transvenous pacing, IABPs). This unit cares for patients with acute coronary syndromes, cardiac arrhythmias, ventricular failure requiring hemodynamic monitoring, severe pulmonary hypertension, decompensated complex congenital heart disease, and post-operative and post-transplant complications.
The cardiology fellow serves as a consultant to the house staff, performs invasive procedures and leads daily rounds with the ward attendings. The fellow is also responsible for the education of residents and medical students through informal teaching and a didactic, structured CCU curriculum. The CCU fellow is also responsible for making triage decisions with respect to the utilization of CCU beds. Each fellow spends at least two months in the CCU.
Cardiology Consult Service
The consult service is one of the most integral parts of cardiology fellowship. Fellows run the consult service with a large degree of autonomy for at least two months during their clinical years. Each fellow is confronted with a wide variety of clinical questions and management decisions from the Medicine, Surgery, Neurology, Psychiatry and sub-specialty services. In particular, fellows gain experience in pre-operative cardiac risk assessment, perioperative cardiac surgical care, and the evaluation and management of coronary, valvular, myocardial, pericardial and congenital heart disease. Resident and medical student education is an essential part of this rotation. All cases are presented daily to the consult attending. Pre-operative cases and post-operative cases are also presented at combined surgical conference, and interesting cases are usually presented at morning report.
Adult Congenital Heart Disease
The Adult Congenital Heart Disease Program was begun at Columbia in 1987 and is one of the largest and oldest in the United States. Directed by Marlon S. Rosenbaum, MD, Columbia 's Schneeweiss Adult Congenital Heart Center provides comprehensive multidisciplinary care covering all aspects of patient management.
The team of physicians who are part of the Adult Congenital Heart Program are also leaders in their respective subspecialties which include interventional cardiac catheterization, interventional electrophysiology, complex congenital heart surgery, echocardiography, pulmonary hypertension, and cardiac transplantation. Related care by specialists in high-risk pregnancy, genetics, fetal echocardiography, GI and liver disease, pulmonary, and hematology is readily available.
During the monthly rotation at the Schneeweiss Center, each Fellow gets in-depth exposure to the entire spectrum of adult congenital heart disease covering anatomy, physical examination, natural history, surgical sequelae, and long term management. The rotation provides an important opportunity to interpret surgical and catheter interventions, congenital echocardiography, angiography, and cardiac MRI. Interested Fellows are encouraged to spend additional time in the Program and to pursue a clinical research project.
Fellows spend one month each clinical year on the EKG rotation during which they are expected to devote a significant amount of time to EKG interpretation independently, each fellow must read at least 3500 EKGs, spread over 2-3 years in order to demonstrate competence. Ideally this is done at 10 EKG’s / day. All EKGs are over read by a clinical electrophysiologist who provides constructive feedback. Fellows on this rotation also teach EKG reading to the students and residents on the consult service one afternoon per week. They are also responsible for cross-coverage of post-call colleagues who are on particular clinical rotations (usually nuclear cardiology, echocardiography). This usually amounts to approximately one day a week. The call system is set up so that fellows on intensive clinical rotations are not post-call during the week and therefore do not require coverage. There is ample time left over for each fellow to pursue additional clinical opportunities and skills (nuclear cardiology, echocardiography, cardiac catheterization, etc.). Fellows are encouraged to establish goals for their EKG month before the start of the rotation to optimize their educational experience.
Cardiology clinic provides a unique and gratifying experience. The clinic draws largely from a low-income, underserved, predominantly Hispanic patient population that lives in upper Manhattan and the Bronx. The referral base is drawn from community physicians, medicine residents, and the cardiology ward services at Columbia University Medical Center. Proficiency in Spanish is helpful but certainly not required as multiple translators solely dedicated to clinic are in house and readily available. The spectrum of cardiac pathology seen in clinic is extremely broad and truly runs the gamut from atypical chest pain to advanced heart failure, challenging arrhythmias, and complex coronary, valvular and congenital disease.
Clinic sessions are scheduled for one half day per week for at least three years of fellowship training. Each session has a dedicated attending responsible for hearing each case, seeing patients when necessary, teaching, and overseeing diagnosis and management. Clinic patients are often presented in morning report and combined surgical conference; however, the fellow has a large degree of autonomy regarding management and clinical decision making. The longitudinal outpatient experience complements the rest of the fellowship experience and further refines clinical acumen.
Fellows spend two weeks attending lipid clinic and both inpatient and outpatient cardiac rehabilitation sessions.
Fellows spend at least two weeks on the Vascular Medicine service during which there is a structured curriculum that allows for time spent on the inpatient vascular medicine vascular consult service and in clinic, the cardiac catheterization lab (peripheral interventions), and the non-invasive vascular lab (performance and interpretation of vascular ultrasound studies including carotid duplex and non-invasive flow studies). Each fellow has the opportunity to spend more time on the service during EKG months and dedicated elective months.