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Task
Force 8: Training in Heart Failure and Transplantation
Sharon
A. Hunt, MD, FACC - Chairman
Michael R. Bristow, MD, FACC
Spencer H. Kubo, MD, FACC
John B. O'Connell, MD, FACC
James B. Young, MD, FACC
The treatment of heart failure has long been considered
the "bread and butter" of clinical cardiology and the
subject of transplantation one of the more esoteric
offshoots of the field. However, in the 1990s, advances
in both fields have led to increasingly specialized
and sophisticated therapy for heart failure at the same
time that the application of transplantation for end-stage
heart disease has become widely accepted and practiced.
Thus, it now seems appropriate to include specific training
in both areas in programs that train consultants in
cardiovascular medicine and to describe advanced training
for those who wish to devote a substantial part of their
career to this field.
Training
in Heart Failure
General
Training - Level 1
The fundamental concepts involved in the physiology
of congestive heart failure and its treatment should
be well understood by all trainees in cardiovascular
medicine as part of the core curriculum. Training in
clinical management of heart failure should include
supervised experience in both inpatient and outpatient
settings and involve a spectrum of underlying etiologies
for the heart failure. Trainees should be well acquainted
with the nuances of therapy of heart failure particular
to different underlying etiologies and be conversant
with the pharmacology of the standard cardiovascular
drugs used to treat heart failure. Ideally, there will
be a dedicated heart failure/transplant clinical service,
and rotation on this service will be incorporated during
the trainee's clinical nonlaboratory experience. Because
not all centers have such services, the involvement
of faculty with expertise in this area should be required
as part of the clinical training program.
Specialized
Training-Level 2
Trainees who wish to have more advanced training in
heart failure should be enrolled in programs that include
specific clinics and usually inpatient services for
patients requiring therapy for advanced heart failure.
Such programs will usually be found in institutions
pursuing active programs in cardiac transplantation
as one of the spectrum of modalities for heart failure
therapy. Such programs will also usually include research
efforts focused on the use of new or experimental treatment
modalities-both drugs and devices-as well as transplantation.
Trainees should be well versed in interpretation of
hemodynamic data with both acute and chronic interventions
and in assessment of prognosis, as well as in the nature
and status of major and ongoing advances in the field.
Advanced
Training-Level 3
For trainees who wish to pursue a career in heart failure,
an extended program is encouraged. In addition to the
recommended program for specialized training outlined
earlier, this program should include concurrent active
participation in laboratory and clinical research and
individual responsibility for research efforts. The
trainee should participate in such activities for a
12-month period beyond basic cardiovascular training.
Training
in Cardiac Transplantation
General
Standards and Environment
It is recognized that not all centers with training
programs in cardiovascular medicine also have active
programs in cardiac or cardiopulmonary transplantation.
Thus, it will not be possible (and probably not desirable)
for all cardiovascular trainees to have hands-on experience
with the management of cardiac transplant recipients.
With the large number of heart transplants performed
annually (currently ~2,500) and the excellent survival
rates (80% to 90% at 1 year), a rapidly increasing number
of long-term transplant recipients requiring sophisticated
care is accruing, and cardiovascular specialists can
expect to be called on to participate in their care.
It is important, therefore, that training in any program
include both didactic and practical experience with
the role of transplantation in the management of various
types of end-stage heart disease and with the thoughtful
selection of (and referral of) such patients for transplantation
procedures. Trainees should also have a basic understanding
of a number of transplant-related issues, including:
1) overall success rates and survival rates to be expected;
2) the atypical physiology of the denervated heart;
and 3) the major types of long-term complications to
be anticipated, especially allograft coronary artery
disease and complications due to immunosuppression.
Advanced
Training
For trainees who wish to devote a substantial portion
of their career to transplant-related research and patient
management, further training beyond other clinical requirements
for cardiology training should be required. Although
there are currently very few formal training programs
in transplant cardiology, a number of centers do provide
such training, and an outline of the important aspects
can be drawn. Formal criteria for certification of a
cardiac transplant physician from the bylaws of the
United Network for Organ Sharing (UNOS), the U.S. organ
procurement and transplantation network, are included
in the Appendix.
Training
resources and faculty
Training should be obtained at a center that has an
established program in clinical cardiac transplantation
and a reasonable volume of transplant procedures, preferably
>20 procedures/year. The training program should be
staffed by one or more board-certified cardiologists
with recognized training and expertise in and commitment
to cardiac transplantation. The program will of necessity
also be staffed by one or more board-certified cardiovascular
surgeons and usually encompasses a training program
in transplant surgery as well. Centers with such programs
will also require the availability of highly qualified
consultants in infectious disease, nephrology and pulmonary
medicine and will have periodic meetings and conferences
devoted to cardiac transplantation. This period of advanced
training will usually be simultaneous with advanced
training in heart failure as outlined above and may
occur during the trainee's period of regular cardiology
training; such training would satisfy minimum UNOS criteria.
However, most programs offering such advanced training
should require participation for a 12-month period beyond
basic cardiovascular training.
Training
experience
The advanced trainee in cardiac transplantation should
spend 1 year involved in all phases of pretransplant
and posttransplant clinical management and will usually
participate in laboratory or clinical transplant-related
research as well. He or she should have hands-on experience
with the care of acute and chronic heart failure, recipient
selection, postoperative immunosuppressive management,
histologic interpretation of myocardial biopsies for
rejection and long-term outpatient follow-up. The trainee
should have acquired a working knowledge of donor selection,
the use of mechanical assist devices, methods of organ
procurement and preservation and transplant surgical
procedures and perioperative management. He or she should
be competent in the performance of right ventricular
endomyocardial biopsies in addition to the more standard
invasive procedures learned earlier in training. Such
training will qualify the cardiologist under current
UNOS guidelines as a cardiac transplant physician.
Evaluation
of Trainees
Evaluation by the program director and faculty should
be an integral part of the educational process, and
procedures for regular evaluation of clinical competence
and research progress should be established in each
program. There should also be provisions for regular
feedback on this evaluation to the trainee and for keeping
of records of these evaluations. There are currently
no types of formal examination or certification for
the added qualification in heart failure and transplantation.
It is the responsibility of the program director to
confirm and document the individual's competency and
thoroughness of training. The director should be prepared
to certify specifics of the training experiences to
UNOS (and other organizations in the future) that require
them for program certification.
Appendix
Criteria for Cardiac Transplant Physicians (From: UNOS
By-Laws, Appendix B, Section IIIC. Unos Update, 1991;7(3):11-3.)*
(1)(b)
Transplant Physician
Thoracic Organs. Each transplant center must
have on site a qualified transplant physician. The cardiac
transplant physician will be board certified or have
achieved eligibility in adult or pediatric cardiology
or the subspecialty of his or her major area of interest
by the American Board of Internal Medicine or the American
Board of Pediatrics. To qualify as a cardiac transplant
physician, the training/experience requirements will
be met if the following conditions of either (aa),
(bb), (cc) or (dd)
are met:
(aa)
Training/experience during the applicant's cardiology
fellowship.
- That
the individual will have been involved in 20 or more
cardiac transplantations under the direct supervision
of a qualified cardiac transplant physician and in
conjunction with a cardiac transplant surgeon at a
UNOS-approved cardiac transplant center that conducts
20 or more heart transplants each year.
- That
the individual has been involved with and has acquired
a working knowledge of cardiac transplantation, including
the care of acute and chronic heart failure, donor
selection, use of mechanical assist devices, recipient
selection, pre- and postoperative hemodynamic care,
postoperative immunosuppressive therapy, histologic
interpretation and grading of myocardial biopsies
for rejection, and long-term outpatient follow-up.
In addition, the individual should participate as
an observer in 5 organ procurements and subsequent
transplants.
- That
the above training be in addition to other clinical
requirements for cardiology training.
- That
the individual has a letter sent directly to UNOS
from the director of the individual fellowship training
program as well as the supervising qualified cardiac
transplant physician verifying the fellow has met
the above requirements and that he or she has qualified
to become a medical director of a cardiac transplant
program.
- That
the above training be performed at a hospital with
an American Board of Internal Medicine certified fellowship
training program in adult cardiology and/or an American
Board of Pediatrics certified fellowship training
program in pediatric cardiology.
(bb)
When the training/experience requirements for the cardiac
transplant physician have not been met during a cardiology
fellowship, they can be met during a separate 12-month
transplant medicine fellowship if all of the following
conditions are met, and the individual is a board certified
or eligible cardiologist.
- Same
as (i) above.
- Same
as (ii) above.
- That
the individual has a letter sent directly to UNOS
from the director of the individual fellowship training
program as well as the supervising qualified cardiac
transplant physician verifying that the fellow has
met the above requirements and that he or she has
qualified to become a medical director of a cardiac
transplant program.
- Same
as (v) above.
(cc)
If the cardiologist has not met the above requirements
in a cardiology fellowship or specific cardiac transplant
fellowship, the requirements can be met by acquired clinical
experience if the following conditions are met, and the
individual is a board certified cardiologist.
- Same
as (i) above.
- Same
as (ii) above.
- That
the cardiologist should write a detailed letter to
UNOS outlining his or her experience in a cardiac
transplant program. In addition, there should be two
supporting letters one of which is from the heart
transplant surgeon at the cardiologist's institution
who has been directly involved with the individual
and can certify his or her competence.
(dd)
If the physician is not a cardiologist, he/she can qualify
as the cardiac transplant physician to operate in conjunction
with the continuing involvement of a board certified or
eligible cardiologist if the following conditions are
met.
- Same
as (i) above.
- Same
as (ii) above.
- That
a board certified cardiologist or a cardiologist who
has achieved board eligibility is an active participant
in pre- and post-transplant recipient management in
the cardiac transplant program where this non-cardiology
board certified or eligible individual functions as
a cardiac transplant physician.
- That
the physician should write a detailed letter to UNOS
outlining his/her experience at the UNOS approved
cardiac transplant program. In addition, there should
be two supporting letters, one of which is from the
heart transplant surgeon at that institution who has
been directly involved with that individual and can
certify his/her competence.
*Form
UNOS By-Laws, Appendix B, Section IIIC, Unos Update,
1991;7(3):11-3.
Copyright © 1995 American College
of Cardiology
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