Advanced Heart Failure + Transplant Cardiology Fellowship

During the inpatient experience, each fellow will:

• Become familiar with the differential diagnosis of dilated cardiomyopathy and the means by which a diagnosis is established, if necessary. This includes a working knowledge of indications for endomyocardial biopsy.
• Learn the various therapeutics in the acute setting including the use of oral medications such as diuretics, ACE inhibitors, beta-blockers, digoxin, nitrates and other vasodilators.
• Understand the use of and indications for intravenous inotropic and vasodilator therapy, including dobutamine, nesiritide, dopamine and milrinone.
• Gain and understand the indications for mechanical support in heart failure patients such as intra-aortic balloon counterpulsation and ventricular assist device therapy.
• Become familiar with the appropriate work-up and management of patients with heart failure and coronary artery disease who may benefit from surgical revascularization and/or mechanical ventricular assist devices.
• Gain a working knowledge of the risks and benefits of cardiac transplantation, including the appropriate pre-transplant evaluation and the absolute and relative contraindications to cardiac transplantation.
• Participate in the care of patients immediately post-transplant, including the use of complex hemodynamic monitoring, inotropic and mechanical device support when needed.
• Become familiar with the use and actions of immunosuppressive drugs in the cardiac transplant recipient, including cyclosporine, tacrolimus, azathioprine, mycophenolate mofetil, sirolimus and prednisone.
• Develop a working knowledge of the treatment of both acute and chronic allograft rejection.
• Understand the diagnosis and management of other post-transplant complications, including bacterial, viral and fungal infections, malignancy and late graft vasculopathy.
• Gain extensive experience in the selection and management of patients with mechanical circulatory assist devices.
• Develop extensive experience in the performance of endomyocardial biopsy.

Fellows attend weekly heart failure clinics where they participate in caring for patients who are established patients and those newly referred patients. These clinics are aimed at caring for patients with chronic heart failure, those being considered for cardiac transplantation, those following cardiac transplantation and those following left ventricular assist devices. During their outpatient experience, fellows will:

• Become proficient in the outpatient evaluation of patients with heart failure including the physical exam, differential diagnosis of their particular condition (systolic vs. diastolic dysfunction) and appropriate pharmacologic therapy.
• Understand the appropriate counseling and emotional support of these often chronically ill patients, including maximizing the patient’s own participation in their care (i.e., dietary and medical compliance, self-monitoring, etc.)
• Understand predictive variables that indicate a bad prognosis in the timing of a cardiac transplantation.
• Participate in the outpatient evaluation and counseling of those patients referred for cardiac transplantation. The fellow should understand factors that make a patient suitable or unsuitable for cardiac transplantation. Fellows will attend biweekly meetings of a multidisciplinary transplant team, during which new patients are presented and discussed. In addition, the status of all inpatients (either pre or post-transplantation) is discussed.
• Participate in the outpatient care of patients in the pre-transplant phase.
• Care for patients following cardiac transplantation, including managing and adjusting the immunosuppressive regimen depending on the results of periodic endomyocardial biopsies. The heart failure/transplant service holds weekly meetings to review hemodynamic, biopsy and other clinical data about individual patients. During these meetings, fellows present and evaluate data and formulate patient treatment plans.
• Develop a working knowledge of the outpatient care of transplant patients suffering from various complications of immunosuppressive therapy, including cyclosporine-induced hypertension and renal dysfunction and prednisone-induced diabetes. Fellows will also learn the appropriate diagnosis and management of infectious complications in non-acutely ill patients in the outpatient setting.
• Attend monthly meetings of the New England Consortium of Cardiac Transplantation, which is made up of transplant cardiologists, surgeons and nurses from New England hospitals performing cardiac transplants.