Purpose:
The Cardiovascular imaging (CVI) fellowship program is designed to develop broad-based expertise in all forms of non-invasive CV imaging, and image processing. Upon completion of the program, fellows will be able to image all forms of cardiovascular disease with appropriate tools and to answer clinical questions with a greater degree of expertise and freedom than is generally available currently. This training program is associated with the ACGME-accredited University of Pennsylvania Diagnostic Radiology Residency and Interventional Radiology Fellowship programs.
Rotations:
Each fellow spends a 12 months in the training program. The rotations are undertaken mainly at the Hospital of the University of Pennsylvania and Presbyterian Hospital. There will be an optional rotation at the Children's Hospital of Philadelphia.
Average fellow workweek is 50-55 hours; that will be spent mostly in the CV section which is equipped with two dedicated workstations, which allow visualization and rendering of datasets acquired in Computed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA).
The CV imaging fellow participates in a call pool with MRI fellows, Abdominal Imaging fellows and senior diagnostic radiology residents to staff MRI on Saturday (supervised by an in-house attending MRI radiologist), and take MRI beeper call for a full week for emergency cases. The estimated frequency of this call is approximately 5-6 times per fellowship year.
Recognizing that cardiac and vascular imaging studies are performed in other clinical sections (the Neuroradiology and Thoracic imaging sections of Radiology Department and Section of Cardiovascular Medicine of the Department of Medicine) one-month clinical rotations in these sections will also be offered on an elective basis.
There are biweekly case conferences in which interesting current cardiac and vascular cases will be presented and discussed. It is the responsibility of the cardiovascular fellow to organize the cases for presentation and obtain follow-up where appropriate.
Twice a month the cardiovascular attending gives didactic lectures on techniques and diagnoses for cardiovascular imaging to radiology residents and cardiology fellows. CVI fellows are expected to give several of these conferences over the course of the year, and participate in the teaching of residents, other fellows, and medical students rotating on CVI. There are at least two residents on the CVI rotation. The CV fellow responsibility will be direct supervision during their rotation.
There is a yearly Cardiovascular imaging CME accredited visiting fellowship course and fellows participate both as a trainees and instructors.
Resources:
The CVI section is staffed exclusively by subspecialist CVI attending physicians that guide and supervise the program. There is a dedicated radiology technologist that performs post processing of all CV studies.
The fellowship will include rotations in other sections of radiology including neuroradiology for the purpose of learning noninvasive neurovascular techniques and diagnoses. The fellowship will also include rotations in areas outside of radiology or in areas in which radiology and cardiology collaborate. These include rotations in cardiac nuclear medicine, echocardiography and in the cardiac cath lab. Much of our current cardiac research is performed in collaboration with cardiology and/or cardiac surgery and thus these out of department rotations may help foster both better clinical knowledge/care and also better research in the field.
There are several additional senior physicians outside the CVI section that perform specific CV studies and work in close cooperation with CVI section. Neurovascular imaging attending physicians performs MR and CT of the intra- and extracranial vasculature and cardiology attending physicians conduct extensive cardiac MR research and participate in the clinical service.
Studies are interpreted on two dedicated CVI workstations that are located in MRI reading area. Studies from all HUP, Presbyterian Hospital, and Penn Medicine at Radnor MR and CT machines are transferred to them for interpretation.
CV studies are performed on eight 1.5 T MR machines (5 HUP, 1 Presbyterian Hospital and 2 outpatient) and six CT including two 16 detector machines, a 10 detector machine, and three 4 detector machines.
The caseload in the CVI section is extremely high. Approximately 500 cardiac and 4500 peripheral vascular studies performed each year at HUP and Presbyterian Hospital - almost all of them are interpreted and guided by the CVI section.
The department maintains an extremely large CVI teaching file, with more than 500 CT and MRI cases. CV radiology fellows are encouraged to attend a national meeting during their training year, and funding is provided. Secretarial assistance, electronic database searches, statistical assistance and both conventional and digital photography support are provided and is free for residents and fellows. We do not provide professional editing support for any departmental member, although of course attending-level co-authors provide editing advice to trainees. In addition to faculty and departmental reference resources, CVl radiology fellows have access to Medline and numerous e-journal subscriptions through all departmental IP addresses. The University of Pennsylvania Biomedical library lies immediately adjacent to the Hospital of the University of Pennsylvania. As one of the world's major biomedical libraries, it contains an exhaustive collection of radiological subspecialty textbooks and paper journals.
Educational objectives:
The major purpose of this fellowship training is to prepare individuals for independent careers in academic and clinical medicine. The emphasis is placed on the understanding the technical aspects of MRA, CTA cardiac CT and cardiac MR imaging, clinical indications and the physiology and pathophysiology of cardiovascular pathology.
During the year several educational goals will be achieved:
- Understanding of clinical indications for cardiac and peripheral vascular MR and CT studies
- Acquiring expert skills in acquisition techniques and interpretation of the following studies:
- Aortic, visceral and peripheral vascular (extremities) MRA and CTA
- Abdominal aortic aneurysm (AAA) CTA, pre AAA stent-graft assessment and post treatment follow-up.
- MR/CT pulmonary artery imaging
- Neurovascular (including extra and intracranial) vasculature CTA and MRA
- MR/CT venography
- MR/CT of the coronary arteries
- Anatomic and functional cardiac MRI
- MR of cardiac perfusion and vascular injury
- In depth study and understanding of CVI MR and multidetector CT physics and underlying principles
- Acquiring skills for independent conduct of CVI clinical research, including designing of clinical study protocols and obtaining regulatory approval.
Responsibility:
All of the training programs in the HUP department of radiology function on the principle of "graded responsibility," so that trainees take on greater and greater responsibility as their skills increase. The level of responsibility assigned to the fellow for a given procedure is commensurate to his/her level of experience with that particular procedure.
Assessment of patients for cardiovascular radiology procedures, supervision of cardiovascular radiology procedures, and follow-up of patients who have had cardiovascular radiology procedures is a shared responsibility of the fellow and supervising attending physician, with the degree of fellow autonomy increasing as greater experience and confidence is gained.
Similarly, the level of didactic training given, and level of staff supervision required, is commensurate to the individual expertise of the fellow in question. With greater facility come greater responsibility and a higher level of didactic teaching.
The CVI fellow is assigned to review the schedule of inpatient and outpatient cases, manage an 'add-on" schedule for urgent outpatients and emergent inpatient and ER cases, and select protocols for these cases in concert with attending radiologists. Fellows are responsible for the initial review of all CV cases and at the later stages of the fellowship, once they are comfortable with basic studies and procedures, take on important teaching roles within our department supervising residents on CV rotations both from radiology and cardiology.
Morbidity and mortality related to interventional procedures in CV radiology are very rare. Common morbidities (such as contrast allergy reactions) are discussed with each patient at the time of the procedure. Emergency numbers are given to each outpatient and inpatients that undergo procedures in our department have access to the medical or surgical services primarily responsible for their care. The department maintains a Quality Assurance program under the direction of Steve Rubesin, MD, Professor of Radiology.
Assessment:
Our radiology information system (RIS) is searchable by CPT code and radiologist. We can therefore document at any time the number and type of procedures or imaging studies performed or interpreted by any resident, fellow or staff radiologist. The CV radiology program director reviews the type and number of cases performed by the CV radiology fellows at least twice per year.
The program director of CV fellowship will verify that the program meets the level 3 (highest) criteria for credentialing in the practice requirements developed by the Clinical Practice Committee of the Society of Cardiovascular Magnetic Resonance (SCMR):
- A total of 1 year of full time training in CMR
- Supervised interpretation of a total of at least 300 CMR studies representing the range of abnormalities observed in practice, but to include substantial proportions (>25%) of both cardiac and vascular studies. For at least 100 of these, the trainee should perform the analysis and make the initial interpretation.
- Participation in an ongoing quality assurance or improvement program for the laboratory or facility in which he or she is associated
- Continuing Medical Education (ACGME-approved) in CMR for at least 40 hours every 2 years
- Primary interpretation of at least 100 cases per year
Each fellow is evaluated by the faculty of CVI section. Counseling/guidance/feedback are provided to each fellow twice a year during a one-on-one meeting with the fellow's supervisor and program director. Areas of weakness are identified and approaches to address these weaknesses are suggested at these evaluation meetings. Fellows also evaluate the program in general and the supervisor and other mentors in particular.
At the end of the training, the director of the training program will certify that the requirements at a particular level of skills have been met. The levels of skills needed are determined a priori for each individual fellow depending on their training needs as well as the skills they have already obtained. A certificate of completion of fellowship training in Cardiovascular Imaging is awarded to each fellow at the end of the training period.
Research:
The CV fellow is expected to participate in the clinical research activities of the cardiovascular and section. At any given time, a wide variety of clinical trials are ongoing, and the fellows are expected to understand the study protocols and participate in the studies. The help of the full time CVI section research assistant is available to conduct clinical trials. All CVI fellows are encouraged to submit at least one scientific paper or exhibit to a national meeting or journal.
Reading list:
- Bogaert J.,Duerinckx A.J., Rademakers F.E., Magnetic Resonance of the Heart and Great Vessels
- Manning, Warren J., Pennell Dudley J., Cardiovascular Magnetic Resonance
- Higgins Charles B., De Roos Albert, Cardiovascular MRI & MRA
Harold Litt MD-PhD
Chief, Cardiovascular Imaging Section
Department of Radiology
University of Pennsylvania Medical Center
3400 Spruce Street
Philadelphia, PA 19104
215-662-3043
harold.litt@uphs.upenn.edu
The University of Pennsylvania Health System, Philadelphia, PA © 2006,
The Trustees of the University of Pennsylvania
