Fellowship Program Information
The goal of our Pediatric Cardiology Fellowship Program is to prepare physicians for careers in academic pediatric cardiology. We strive to create a training environment that will foster not only quality clinical training, but also rigorous inquiry and mentoring that will lead to development of the next generation of leaders in pediatric cardiology.
Pediatric Cardiology Fellowship Curriculum
In general, the duration of the Fellowship Program is three years. Many fellows choose to complete a fourth year to pursue a specialized clinical interest such as echocardiography or to spend time in a basic science laboratory. The exact schedule is determined in part by the fellow’s interest and previous experience, but an example is shown below.
|Month||1st Year||2nd Year||3rd Year|
|1||Inpatient Service||Research||Cardiac Intensive Care|
|3||Electrophysiology||Research||Cardiac Cath Lab|
|5||Cardiac Cath Lab||Transplant||Inpatient Service|
|6||Cardiac Intensive Care||Research||Cardiac Cath Lab|
|10||Imaging||Research||Cardiac Intensive Care or Elective|
|11||Cardiac Intensive Care||Research||Imaging|
|12||Cardiac Cath Lab||Research||Elective|
Description of Specific Clinical Rotations
Inpatient Floor-Consultation Service
The fellow is responsible for following all cardiology inpatients and performing consultations. The patients may be on the cardiology inpatient floor, in the general pediatric intensive care unit, neonatal intensive care unit, step-down or well newborn nurseries, or on another subspecialty or general pediatric ward. All patients are seen with a faculty cardiologist. Multidisciplinary rounds on the cardiology inpatient floor are held daily with the faculty cardiologist, senior (PL3) resident, 2 to 3 interns (PL1), 2 to 3 medical students, and other staff. All fellows participate actively in teaching discussions with the residents and attending physician.
During this rotation, the fellow becomes skilled in diagnosing congenital and acquired heart disease. He/she learns to treat patients with medical cardiology problems (e.g. congestive heart failure, pericarditis, rhythm disturbances, etc.), and to care for preoperative and postoperative patients.
During the course of the fellowship, the fellow assumes more responsibility for patient management. All medical records are electronic. The inpatient floor fellow is on-call each weekday night and no more than every fourth weekend each month.
Cardiac Intensive Care Unit
The fellow is responsible for managing all critically ill and postoperative cardiology patients in the cardiac intensive care unit and will work with the attending cardiac intensivist, the on-service consulting cardiologist, and the cardiac surgeons. During this rotation the fellow becomes skilled in caring for postoperative patients, understanding their physiology, and managing their various complications. In addition, he/she will become familiar with cardiac anatomy, as visualized by the surgeon, and with techniques of cardiopulmonary bypass. There are many opportunities to perform procedures.
The fellow will also participate in the care of patients on extracorporeal oxygen membrane oxygenators (ECMO) and ventricular assist devices. The fellow takes one week of night (12 hour shift) call; there is no other night call during this rotation. No fellow is in the hospital for more than 80 hours each week.
The echocardiography laboratory is staffed by Drs. Claudio Ramaciotti, Matthew Lemler, Poonam Punjwani Thankavel, and Catherine Ikemba. The goal of this rotation is for the fellow to acquire skills necessary for performing and interpreting echocardiographic studies. More than 11,800 echocardiograms (including transthoracic, transesophageal, and fetal studies) are performed each year which offers the opportunity for the trainee to be exposed to a wide variety of complex congenital/acquired heart diseases. Fellows often have the opportunity to perform the initial scan. Education is available in twice weekly echocardiographic conferences, and on a daily basis by sonographers and readers.
The initial emphasis is on transthoracic 2-dimensional, M-mode, Doppler, and color Doppler studies. Fellows will become familiar with the critical questions that the echocardiogram must answer for each defect and should also understand the relationship between anatomy and hemodynamic state. This requires knowledge of the anatomy and pathophysiology of the various defects and associated abnormalities. During the second and third years the fellow gains experience in specialized areas such as transesophageal, fetal, and exercise stress echocardiography.
Our MRI team includes Drs. Gerald Greil, Tarique Hussain, Jeanne Dillenbeck, and Animesh (Aashoo) Tandon. Under the leadership of our new Division of Cardiology chief, Gerald Greil, and in partnership with the Department of Radiology, the University of Texas Southwestern Pediatric Cardiology program will be a leader in the field of cardiac magnetic resonance imaging (CMR) in patients with acquired and congenital heart disease. CMR is an exciting, emerging field in pediatric cardiology that combines technology, physics, and clinical care to provide the most comprehensive cardiac evaluations for our patients.
We have a magnet in the Heart Center that is primarily dedicated to cardiac imaging and is physically located next to the catheterization lab, allowing combination procedures to be performed. As part of the imaging training at UTSW, fellows will have extensive exposure to cardiac MRI. Fellows will learn how cardiac MRI, CT, and echocardiography work together to answer the critical questions for each cardiovascular lesion, in conjunction with other imaging training. They will also be exposed to image acquisition techniques, study interpretation, and quantitative analysis. Advanced techniques such as 3D reconstruction including 3D printing will also be covered.
The cardiac catheterization laboratories comprise two angiographic suites. The laboratory is staffed by Drs. Alan Nugent, Vivian Dimas, Suren Reddy, and Thomas Zellers. Just over 900 total catheterizations were performed last year that include the full range of interventional procedures. Both laboratories are state of the art and are located in the interventional suite of the Heart Center which was opened in 2014. The catheterization laboratories have direct access to Prep and Recovery, Cardiac OR, MRI, and CVICU.
The overall goal for catheterization rotations is for the fellow to acquire the knowledge and skills necessary to perform a safe and thorough cardiac catheterization. The ability to obtain and interpret the necessary data to make clinical and surgical decisions is paramount to any cardiologist. A cardiology fellow is assigned for a month at a time for a minimum of four months over the three-year program. Experience in catheterization of the newborn and interventional procedures begins in the first year. Fellows with a specific interest and skill level can develop expertise by participating in a fourth year of training devoted to interventional catheterization.
Our electrophysiology staffs, Drs. Ilana Zeltser and William Scott, have a very active service. During this rotation, the fellow is exposed to all aspects of clinical electrophysiology including: noninvasive studies (ECGs, 24 hour ambulatory ECGs [Holter monitor], event monitoring, atrial electrograms, stress testing and tilt table testing); cardiac pacing (transesophageal, temporary, permanent), including implantation and analysis, and invasive studies including catheter ablation. The fellow will become proficient in interpreting electrocardiograms and 24-hour ECG recordings, performing and interpreting trans-esophageal ECG recordings, and assessing pacemaker and implanted cardioverter-defibrillator (ICD) function.
Approximately 16,000 electrocardiograms are performed each year. Over 250 pacemaker patients are currently in active follow-up and about 35 devices are implanted each year.
In addition, the fellow participates in electrophysiologic studies and catheter ablation procedures. All fellows will learn interpretation of intra-cardiac studies but only those with a specific interest will become proficient in performing intra-cardiac studies and ablations (requires a fourth year of fellowship). Typically, 100 catheter ablations and an additional 12 electrophysiology studies, are performed annually.
We are a high volume transplantation program under the direction of Drs. Maria Bano, Ryan Butts, Bibhuti Das, and David Sutcliffe. This rotation occurs during the research year (most often the second year) and lasts for four weeks. The fellow will attend transplant clinic and rounds with inpatients that are being evaluated for transplantation, awaiting transplantation or are status post transplantation.
We are a high volume transplantation program under the direction of Drs. Maria Bano, Ryan Butts, Bibhuti Das, and David Sutcliffe. This rotation occurs during the first year (often when fellows are busy studying for their pediatrics boards). The fellow attends all scheduled clinics thereby learning how the clinic works and how to work with the electronic medical record. In addition to seeing follow-up patients with various types of heart disease, the fellow will become familiar with evaluating common problems in new patients such as chest pain, dizziness and syncope, palpitations, fast heart rate, and hypertension. This prepares the fellow for his/her continuity clinic as well as for consultations (especially in the emergency room) and patient phone calls.
Rotation in Research
All fellows are expected to show evidence of scholarly activity during their fellowship. Basic science, translational science and clinical science studies, a critical meta-analysis of the literature, a critical analysis of public policy relevant to the subspecialty, and a curriculum development project with an assessment component are all considered “evidence of scholarly activity.”
We do not expect fellows to have a project defined at the beginning of the fellowship. A one month rotation during the first year allows the fellow time to explore possible areas of interest. Research may be performed in clinical or basic science areas. A fellow may choose as his/her faculty mentor a person from inside or outside the pediatric cardiology division. In general, the fellow should define his/her project during the first year and spend most of the second year working on the project. In this way, a presentation can be made at a national meeting during the third year and a publication submitted to a peer-reviewed journal before the end of the fellowship. More importantly, the experience should instill the culture and value of investigative work and lay the foundation for future contributions. The trainee will develop skills in experimental design, data analysis and presentation of results. This schedule is flexible. Fellows with previous research experience, or well-defined interests, may begin research during the first year. Alternatively, some fellows planning to spend four years may not begin their research project until the third year.
Basic Science Opportunities
UT Southwestern has an international reputation as a leading research institution and supports more than 3500 research projects annually totaling more than $400 million dollars in funding. On the basis of federal individual research grant support for basic sciences, UT Southwestern is among the top 10 biomedical research institutions in the country, and the faculty are among the most distinguished in the world. There are over 500 graduate students earning their Ph.D. degrees and over 90 students obtaining combined M.D. and Ph.D. degrees.
A vast array of research opportunities is available in the area of cardiovascular biology, as UT Southwestern currently boasts one of the largest concentration of investigators in this exciting area of science, including: Eric Olson, Ph.D., Helen Hobbs, M.D., Masashi Yanagisawa, M.D., Ph.D., Joseph Hill, M.D., Ph.D., and Craig Malloy, M.D. This critical mass has allowed the institution to successfully compete for selection as the first recipient of a Reynolds Foundation Grant, headed by Dr. Helen Hobbs, for research in the cardiovascular sciences that was recently renewed bringing the total funding to $42 million. Additional post-doctoral fellows training in cardiac development, and graduate students obtaining their Ph.D. or M.D., and Ph.D. degrees in the laboratories, provide a rich and interactive training environment. Frequent lab meetings, journal clubs and seminars are an integral part of their experience. This effort has resulted in numerous publications representing advances in our understanding of cardiac development and the genetic basis for congenital heart defects.
The research training that will be required of the fellow will depend upon his/her prior experience and interests. If you have a particular research interest, you can search for faculty interested in that area. In general, the majority of fellows focusing on basic science research will likely spend a total of four years in their training. Grants are available through the Physician Scientist Training Program (PSTP) at UT Southwestern or the Reynolds Foundation, to assist in funding for these additional years. Those pursuing more clinical research will have a rich exposure to state-of-the-art approaches in understanding the molecular basis of congenital heart disease and cardiac development through formal and informal conferences and discussion.
Clinical Science Opportunities
All of the Pediatric Cardiology faculty members are active in clinical research and as such, fellows may participate in a wide variety of projects. As indicated above, the fellows may also collaborate with investigators outside of pediatric cardiology depending on interests. Brief descriptions of current research efforts within pediatric cardiology include:
The interventional group is very active in clinical and pre-clinical research. We were involved in the post approval study for the Melody valve and continue to be involved in several multi-center clinical trials including: covered stents in Coarctation (COAST II), covered stents for RV-PA conduit tears (PARCS), Nit-Occlud PDA post approval study and post market surveillance study for closure of ASD with the Amplatzer Septal Occluder. We also contribute to the NCDR IMPACT database.
The group is very active with multiple research endeavors to improve the management of structural and functional heart disease with strong collaboration with Pediatric Cardiac Surgery. Many fellows have completed research with the interventional team. The group has been awarded intramural (Children’s Clinical Research Advisory Committee) and extramural (NIH, AHA) grants. Topics of interest are biodegradable stents, percutaneous mechanical support and expandable cardiovascular conduits. Pre-clinical research is possible due to the infrastructure and support from UT Southwestern.
The pediatric cardiology MRI group is on the forefront of research with frequent collaboration with our colleagues at UTSW, including:
- Using CMR, CT, and echo data to produce 3D printed hearts for surgical planning and research
- Access to the Advanced Imaging Research Center, UTSW’s research program dedicated to MRI research, headed by AIRC Center Director Dean Sherry, Ph.D., and Medical Director Craig Malloy, M.D., and including access to one of the few 7 Tesla CMR scanners used in human research
- Tissue characterization and noninvasive histology to better understand the pathophysiology of heart disease in children
- Use of CMR to image animal models of heart disease, such as coarctation of the aorta as an adjunct to develop new therapeutic options
- Use of CMR to evaluate coronary artery diseases in children (e.g. Kawasaki disease, heart transplant)
- Ability to test new imaging techniques through a collaborative relationship with industry
- Collaborations with other centers throughout the country and the world
In addition to continually improving quality of imaging and its impact on clinical care, research interests of faculty include congenital coronary anomalies, predicting/diagnosing rejection in heart transplant recipients by the use of strain imaging, improving assessment of progressive left ventricular systolic dysfunction in patients with myopathies, and reducing interstage mortality by frequent echocardiographic monitoring of single ventricle patients. Research opportunities for fellows are also available in the form of retrospective chart reviews and publication of interesting cases/images in pediatric cardiology.
Research activities in electrophysiology include investigation of arrhythmias in patients with complex congenital heart disease. One current analysis is based on our observation of specific arrhythmia patterns in patients with heterotaxy syndromes. Other projects are analysis of electrical storm in ICD, patients, analysis of sudden death risk in hypertrophic cardiomyopathy, and data collection to refine of ECG normative criteria based upon race. Database development is underway to more comprehensively evaluate the epidemiology and prevention of sudden cardiac death from all causes.
Training in clinical research involves more than the traditional apprenticeship with an established mentor and performing a research study. The clinician investigator must be trained in research methodology which should include techniques of patient-oriented research, hypothesis generation, study design, and statistical analysis. We require all fellows to take a course in medical statistics.
UT Southwestern has made a major commitment to the development of clinical research at the medical school and has subsequently created the Department of Clinical Sciences. This department is directed by Milton Packer, M.D., an adult cardiologist who is an expert in clinical trials and who has an impressive record for training young investigators. Additional extensive resources to support clinical research are available through the Clinical and Translational Science Awards (CTSA), which is a national consortium funded through the National Institutes of Health (NIH) National Center for Research Resources (NCRR) with the primary aim of creating a definable academic home for the disciplines of clinical and translational research.
The mission of the Department is to accelerate and enhance the training and career development of clinical investigators, promote the conduct of high-quality patient-oriented research, develop effective mechanisms to facilitate translational research, and provide a formal mechanism of institutional recognition for clinical scientists.
The following units and programs are supported by the Department of Clinical Sciences:
- Biomedical Informatics
- Outcomes and Health Services Research
- Research Ethics
The curriculum is well suited for candidates who possess both a working knowledge of clinical medicine and excellent scholastic aptitude. Required course work may include didactic courses in basic biostatistics, epidemiology, clinical research design, translational research, molecular genetics, grant-writing skills, and data analysis and management.
Fellows are expected to participate in teaching of medical students, residents, fellows, and even faculty. One is not born knowing how to teach; training in teaching skills is very important. Fellows receive specific training, and practice preparing and presenting formal lectures, shorter less formal presentations, and small group discussions. Third-year fellows are expected to lead inpatient attending rounds. Additional training is available through the “Effective Teacher” lecture series at UT Southwestern.