Cardiology Fellowships: Urban Community Program

Program Design: The Mount Sinai Hospital

The Mount Sinai Hospital, a 1,200-bed teaching hospital, shares a four-block campus with Mount Sinai School of Medicine on the Upper East Side of Manhattan. Adjacent to Central Park, the campus extends from 98th Street to 102nd Street and eastward from Fifth Avenue to Park Avenue. This area, known as Carnegie Hill, is a residential neighborhood and designated historical district. The campus is also bordered by East Harlem, a predominantly low income community, and Yorkville, one of the nation's most affluent communities. The neighborhood provides a broad mix of cultural, socioeconomic, and ethnic diversity that makes the educational and health service opportunities at Mount Sinai unique.

Mount Sinai is a tertiary referral center for patients not only in the tri-state area of New York, New Jersey, and Connecticut but literally for cases from around the world. More than 1,000 attending physicians on staff attract a wide range of clinical pathology, not only in the cardiovascular field, but in all areas of health care, bringing to the medical center a patient population of diverse socioeconomic and medical circumstances.

Established by Dr. Valentin Fuster, the Cardiovascular Institute (CVI) integrates virtually all facets of clinical and research activities in cardiovascular diseases. It provides an academic framework for the collaboration of cardiologists, vascular surgeons, radiologists, pediatric cardiologists, cardiothoracic surgeons, endocrinologists, other medical subspecialists, basic scientists in vascular biology and other areas, clinical trialists and health care policy experts. Within The Mount Sinai Hospital, the CVI’s clinical entity is the Cardiac Care Center, which encompasses patients with cardiac and vascular disease. Clinical facilities of the CVI are described below.

Fellows participate in the rounds and care of patients within the Division of Pediatric Cardiology under the supervision of Dr. Ira Parness. A close working relationship with the Department of Cardiothoracic Surgery (headed by Dr. David H. Adams) provides fellows with complete exposure to the surgical management of coronary artery disease, valvular heart disease, congenital heart disease, and arrhythmias, as well as cardiac transplantation. Investigation in valvular disease, robotic surgery and minimally invasive procedures is planned. Dr. Randall B. Griepp, immediate past chairman of Cardiothoracic Surgery, is recognized worldwide for his surgery of the aorta.

In addition to working with the full-time faculty, fellows gain clinical experience through interaction with our extensive voluntary staff. The voluntary staff includes many outstanding cardiologists in active clinical practice who are eager to share their experience with fellows. For example, Dr. José Meller, widely recognized as one of the nation’s leading cardiology practitioners, holds weekly conferences to discuss management of difficult or unusual cases.

On a broader level (and not covered below), The Mount Sinai Hospital includes several intensive care units, each containing 14 beds (coronary care unit, cardiothoracic surgery ICU, cardiac surgical progressive stepdown/pediatric cardiology ICU, medical ICU, surgical ICU, neurosurgical ICU) as well as extensive pre- and post-anesthesia care areas. There is an active urban emergency room and there are four cardiac operating rooms. The data generated by all the cardiac laboratories is contained in a single, integrated cardiology computer network, a major resource for clinical research. Reports produced by the laboratories are uploaded, via the cardiology network, to Mount Sinai’s order entry and reporting system (TDS) and online enterprise data repository (EDR), facilitating patient care throughout the hospital. The hospital also maintains full training programs in cardiothoracic and vascular surgery, pediatric cardiology, and cardiac transplantation.

Cardiac Catheterization Laboratory

The Cardiac Catheterization Laboratory is comprised of four fully equipped rooms for cineangiography (including one biplane lab) and state of the art computerized hemodynamic studies, one dedicated electrophysiology suite (and a second one underway) and a separate facility for myocardial biopsies. Presently, the laboratory performs approximately 9,000 procedures per year, including 2,400-2,500 interventional procedures which involve percutaneous transluminal angioplasty, directional and rotational atherectomy, intracoronary stenting, balloon valvuloplasty, intracoronary brachytherapy, alcohol septal ablation, and peripheral vascular interventions. Interventional procedures are expected to increase by about 15 percent each year.

The faculty of the catheterization laboratory includes six full-time attending physicians, one part-time attending physician, five interventional cardiology fellows (in an ACGME-accredited program), and two or three other cardiology fellows on rotation in the laboratory. There are also two nurse practitioners. During a typical training rotation in the catheterization laboratory, fellows learn diagnostic angiography by working closely with an attending cardiologist. Fellows typically perform right-heart catheterizations and participate in the left-heart procedures. The main educational focus of this rotation is for fellows to gain an understanding of cardiac hemodynamics and cineangiogram interpretation, while developing expertise in the performance of procedures.

The Phyllis and Lee Coffey Non-Invasive Area: Echocardiography Laboratory

The Echocardiography Laboratory at The Mount Sinai Hospital performs approximately 30 echocardiograms per day, six of which are interventional and/or stress studies (pharmacological and exercise). Studies are done with the latest and most sophisticated equipment (Acuson Sequoia, ATL HDI5000, multiplane transesophageal echocardiography) and are performed with complete pulsed and continuous wave and color Doppler interrogation. When indicated, intravenous precision microbubble contrast is used to enhance images. Completed studies are read and stored digitally on a state-of-the-art system. Transesophageal echocardiography (TEE) is performed by fellows under the supervision of experienced attending echocardiographers. Full-time cardiac nurses are assigned to the laboratory to assist with TEE and pharmacologic stress studies. The physician staff of the laboratory consists of two full-time and three part-time echocardiographers. The technical staff includes a technologist supervisor and four technologists. Fellows rotate through the laboratory as part of their first year of training and become proficient in both the interpretation and performance of transthoracic echocardiograms. Those desiring additional exposure to TEE, or other specialized ultrasound techniques, may spend additional time in the second and third years.

The Phyllis and Lee Coffey Non-Invasive Area: Nuclear Cardiology and Stress Laboratory

The Nuclear Cardiology and Stress Electrocardiography Laboratory performs almost 4,000 noninvasive tests annually for the diagnosis of cardiac disease and the assessment of its severity. The tests performed include electrocardiographic stress tests, SPECT myocardial perfusion studies with thallium-201 or Tc-99m Sestamibi, combined with either exercise or pharmacologic stress (dipyridamole, adenosine or dobutamine infusion). The laboratory staffing includes one full-time and two part-time nuclear cardiologists, three to four nurses, one or two rotating cardiology fellows, nuclear medicine and radiology residents and nuclear technologists. The equipment consists of four automated treadmills, one supine bicycle stress table, three SPECT gamma cameras, one portable gamma camera, and several processing computers including a high-speed central processing/reading/archiving computer system — all interconnected by a network. Positron emission tomography (PET) is also used to assess myocardial ischemia and viability. Rotating fellows and residents learn how to perform and interpret exercise and pharmacologic stress tests, along with wall motion and perfusion imaging studies.

Electrocardiography and Electrophysiology Section

The Electrocardiography (ECG) and Electrophysiology (EP) Section provides a variety of services throughout the hospital. The ECG area provides electrocardiograms, signal averaged ECGs and 24-hour Holter monitors. The EP service provides electrophysiology studies, radiofrequency catheter ablations, cardioversion, tilt-table tests, implantation of cardioverter defibrillators (in collaboration with cardiothoracic surgery), intraoperative mapping and cryoablation (in collaboration with cardiothoracic surgery), an arrhythmia clinic, and follow-up and consultation services. The staffing of this section includes three full-time attendings specializing in electrophysiology. Other staffing includes two dedicated EP nurses, a technician, and two clinical nurse specialists. The program provides training in all aspects of clinical electrophysiology, with the cardiology fellow on rotation able to assist in procedures in the EP laboratory and in the operating room. The fellow also reviews EP intracardiac tracings, signal-averaged tracings and ECG Holter tracings, attends clinic and provides consultations to inpatients with rhythm disturbances. There are two dedicated electrophysiology fellows training in an ACGME-accredited program.

Telemetry

The 100-bed inpatient service of the Cardiac Care Center provides a high level of nursing care with 24-hour telemetry monitoring. Patients include those with general medical problems who require intense monitoring, those with congestive heart failure and arrhythmias, those with severe heart failure who are pre-transplant patients (on inotropic and/or mechanical support) and those early or late after heart transplant. They are cared for by medical house staff (one PGY-3, one PGY-2, two PGY-1s) or dedicated cardiac nurse practitioners. The fellow makes daily rounds with one cardiology attending and nurse practitioners. In addition, the fellow provides teaching and consultative support to the house staff.