In this presentation from July 20, 2021, Dr. Doreen DeFaria Yeh reviews the specific medical issues that develop among children and adults born with a complex congenital heart condition called tetralogy of Fallot.
Explore This Fellowship
The Structural Heart Disease Fellowship program at Massachusetts General Hospital is organized under the support of Dr. Ignacio Inglessis, who serves as Program Director. The fellowship is a one-year program, which functions as an integral component of the subspecialty programs in the Cardiology Division. The program is designed to provide training in structural heart disease procedures for fellows with prior cardiac catheterization and interventional cardiology experience. Candidates for the Structural Heart Disease Fellowship program should be highly qualified physicians with a minimum of 12 months’ experience in cardiac catheterization and coronary interventional procedures.
Training focuses on the comprehensive acute, chronic and preventive care of adults, with adults with heart disease being defined as anyone over the age of sixteen. The goal of training in Structural Heart Disease Interventions is to provide physicians with a broad perspective in the care of the adult patient with complex structural heart disease. The trainees will include those who train for 2-3 years prior to careers in Cardiology subspecialty fields and careers in scientific research. The duration of training is 1 year. The challenge for the program is to maintain core requirements for all trainees as well as meet with particular needs of each chosen career path.
Requirements of the Structural Heart Disease Fellowship Program include:
- A minimum of 12 months experience in cardiac catheterization, angiography and coronary interventions
- Completion and passing of all three USMLE steps
- ABIM board certified or board eligible
- The accepted applicant must be eligible for a Massachusetts Full or Limited License
- A valid ECFMG certificate for all foreign medical graduates
- Only J1 visas accepted
- Completion of previous interventional cardiology fellowship training is required
The patient population in the Cardiac Catheterization Laboratory allows the fellow to gain knowledge of multiple manifestations of structural heart disease. Fellows rotate through the catheterization laboratory for one year. The objective is to make all fellows’ educational experiences more uniform from month to month. The first time a fellow rotates through the catheterization laboratory, many of the concepts of pathophysiology and management will be new. It is our hope that with repetition of a core didactic session, in addition to clinical experience obtained from prior rotations, the fellow will learn new layers of complexity each time. It is expected that the case mix will vary from month to month, allowing for teaching opportunities outside of those outlined below.
Central to the teaching mission is the use of the resident’s physical diagnostic skills in concert with the array of invasive and non-invasive, diagnostic and therapeutic modalities available. Fellows should become facile with reading electrocardiograms, chest radiographs, hemodynamic tracings and coronary angiograms, vascular angiography and the recognition of basic echocardiographic anatomy.
- Physical examination skills, particularly identification of murmurs, gallops (especially S3), pericardial rub and examination of jugular venous pressure
- Obtaining central venous access
- Identification and interpretation of data from invasive hemodynamic monitoring devices, specifically right and left-sided cardiac filling pressures, pulmonary arterial tracings and systemic arterial tracings
- Cardiac output and index measurements (including indicator methods such as green dye, thermodilution) and systemic vascular resistance
- Use of mixed venous and/or comparative saturations for diagnostic purposes
- Therapy for acute ST-elevation myocardial infarction
- Therapy for unstable angina and other acute coronary syndromes
- Acute MI risk stratification and indicators of prognosis
- Complications of MI including cardiogenic shock, ventricular rupture, ventricular septal rupture, ventricular tachycardia, heart block and congestive heart failure
- Therapy for cardiogenic shock
- Congestive heart failure: etiologies and relation to intensive therapy, “dobutamine holiday” and cardiac transplant evaluation
- Critical valvular disease: aortic stenosis, mitral stenosis, etc.
- Thoracic aortic aneurysm and dissection: imaging and therapy
- Peripheral vascular disease: imaging non-invasive and invasive, and therapy
- Congenital heart disease: diagnosis, non-invasive and invasive, evaluation and imaging, and treatment
- Intra-aortic balloon counterpulsation: basic concepts, indications/contraindications and role in various clinical settings
- Ventilator management in cardiac patients
- Percutaneous pulmonary valve replacement
Mastering Risk, Techniques and Indications
During the year of structural heart disease interventional training, fellows are expected to master the risks, techniques and indications of structural heart disease practice. They will be expected to develop the judgment and experience necessary to select patients and function as independent operators during interventional procedures in patients with a wide variety of structural heart disease including adults with congenital heart disease.
A major component of the fellowship will involve the performance of procedures in the adult cardiac catheterization laboratories. The Knight Laboratories comprise six state-of-the-art high-resolution digital fluoroscopy units, which are networked throughout the hospital. A wide variety of diagnostic interventional procedures are performed in these laboratories. Approximately 5,000 cases are done annually. Of these, over 1,500 are coronary interventions.
Congenital Heart Disease Experience
The present adult congenital heart disease population numbers over 1 million in the US alone, and the role of interventional cardiac catheterization in the management of these complex patients is increasing steadily. Knowledge of congenital heart disease diagnosis and management, as well as interventional proficiency in these cases will thus be essential to major academic interventional centers. This program will be unique in providing this experience and expertise.
Non-Coronary Cardiac Interventions
At the core of the Structural Heart Disease Intervention program are the unique non-coronary cardiac interventions undertaken. These include transcatheter valve insertion at the aorta and pulmonary valve positions, transcatheter repair of the mitral valve with the MitraClip, percutaneous balloon valvuloplasties, transcatheter closure of intracardiac communications (ASD, PFO, PDA, and VSD), alcohol septal ablation for hypertrophy obstructive cardiomyopathy and the catheter treatment of adult congenital heart disease. There will be clinical training in the selection, management and follow-up of patients undergoing cardiac interventional procedures.
Conferences and Learnings
The fellowship program includes formal didactic sessions, a weekly clinical catheterization conference, a combined surgery-catheterization conference, in addition to a conference in interventional techniques designed to improve outcomes, troubleshoot problems and increase proficiency. The fellows are given ample opportunity to become meaningful participants in research on new devices and techniques in both the pre-clinical and clinical phases. Current areas of investigation include novel device designs, application of new interventional techniques to specific high-risk populations, e.g., patients with diabetes mellitus, quantitative imaging analysis, adjunctive pharmacology, long-term follow-up of percutaneous mitral commissurotomy, etc. Fellows interested in in-depth investigation will work closely with senior mentors who act as principal investigators on projects.
The clinical fellow will be responsible for seeing structural heart disease patients pre- and post-cath. They are involved in the daily care of these patients, including their pre-catheterization evaluation. The clinical fellow participates in daily rounds on these patients. All cases are discussed in the morning prior to the day’s procedures. There is a comprehensive core curriculum lecture series that includes didactic presentations, as well as a journal club and an intensive morbidity and mortality review.
It is our anticipation that the number of structural heart disease interventions performed by each fellow will be approximately > 120 interventional cases while in the program. Fellows will be primary operators in most these cases. Our curriculum concurs with the requirements specified by the American College of Cardiology for an interventional program; our high volume provides an excellent foundation to develop expertise as an independent operator.
Highly Qualified Colleagues and Center
The Structural Heart Disease Fellowship Program allows fellows the opportunity to work with a variety of highly qualified invasive cardiologists in the setting of an extremely active program that performs approximately 250 cases per year. The case material is varied and challenging, as Mass General serves both as the primary hospital for the local neighborhood as well as a tertiary referral center which draws patients from affiliated hospitals and health centers throughout Massachusetts. Mass General also attracts patients from across the United States and internationally. Furthermore, the Interventional Program is academically based and has approximately 20 active research protocols including multicenter and investigator-driven trials. This provides ample opportunity for fellows to purse their research interests. Finally, a state-of-the-art animal research facility is available to fellows who wish to focus on translational research.
How to Apply
Next available positions will begin July 1, 2022. The deadline to submit applications is July 30, 2021. Interviews will be held (virtually) in August 2021.
To apply, please submit the following documents to Christina Alva :
- Personal statement
- Three letters of recommendation
- USMLE transcripts
- Valid ECFMG certificate (if foreign medical graduate)
**Please note that a prior Cardiology Fellowship and Interventional training is a pre-requisite of the program.
Meet Our Faculty
Learn more about the faculty members of the Structural Heart Disease Program.
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