Updated 7/2/2024
CARDIOLOGY B
ADVANCED HEART FAILURE & TRANSPLANT
Introduction:
The Cardiology B Service provides care to patients with severe heart failure, patients referred with unusual heart diseases (amyloid, sarcoid, inflammatory cardiomyopathies, etc), and patients who have undergone heart transplantation. Some patients will be transfers from the CICU following acute decompensation, some are undergoing transplant/LVAD work-up, and others are hospitalized for heart failure “tune-ups” or post-transplant complications.
Structure:
Schedule:
DAILY:
8:00 – 8:15: Sign-out from the nocturnist to the team.
8:45 – 9:00: Brief to review any urgent patient needs.
9:00 - 12:00: Rounds with cardiology attending and APPs
13:00: Meeting with the triage attending to learn about any OSH transfers, CICU transfers, anticipated admissions
13:00 - 17:00: Be available for questions and help to ARNP's or residents.
TUESDAYS:
7:30 - 8:30: Transplant conference on zoom
WEDNESDAYS:
17:00 – 20:00: You are the CCU/CICU late fellow. Be available in house to support the unit teams and card B team as needed.
THURSDAYS:
8:00 - 9:45: Transplant conference in Plaza Cafe
Staffing:
Two to Three APPs. They provide primary care for 4-6 patients each. If the census is 18, you may be asked to provide primary care on 2 patients.
A medical resident will be on the service some months. This is an elective rotation that attracts residents that are usually motivated by an interest in cardiology. On average, they take some vacation and have clinic for one full day/week while on the service.
Cardiology fellow (general or AHFTC) who provides consultation/support for ARNP’s and residents. (see expectations below).
There is a dedicated pharmacist and a dedicated social worker but no team assistant or coordinating RN.
Several nocturnists who cover the service from 8:00 PM – 8:00 AM.
Role:
Know ALL patients on the service and Cards B consult list and facilitate and execute their care by supervising APPs. You are responsible for running rounds side by side the heart failure attending
Review and assist in the decision of admissions (e.g. ED, Cards C/D)
Card B Consults: Serve as consultants on other services taking care of post-transplant patients or in need of advanced HF management (e.g inpatient rehab, Cards C, Med). The fellow will need to follow these patients with the attending during the entire duration of the consultation.
Present new patients that are being worked up for advanced therapies and update the medical status of patients on Cards B at the Tuesday and Thursday AM transplant selection committee meeting.
Urgent AHFT Clinic: You may see a few patients that are sufficiently tenous on discharge and cannot be accomodated by the ARNP clinics due to insufficient staffing or special cases of high acuity. You will staff with the inpatient attending -- This will not conflict or be an add on to your continuity clinic.
While in your continuity clinic, clinic is your responsibility and the Cards B attending will support the ARNP’s and resident. Sign out your pager to your attending if you're paged repeatedly
Learn about cardiac transplant patients. We assume that you have had no previous exposure to this very specialized patient group. Rejection and infection are the two most common reasons for admission. You need to consider cardiac rejection (either cellular or antibody mediated) in patients with dyspnea, shortness of breath, heart failure, arrhythmia, hypotension, unexplained tachycardia, RUQ abdominal pain, or troponin elevation. When in doubt get an echo. There is a stereotypical temporal pattern of infections after transplant: the most frequent infection in the post transplant patient is CMV; half of infections after six months are community acquired. Early imaging is important in the evaluation and management of immunosuppressed patients.
Participation in the biopsy lab was previously a requirement and is now an option. Let us know if you are interested. Biopsies are performed on Monday, Tuesday, Wednesday and Thursday. It is a great option to improve right heart catheterization skills if desired.
You will need to help assess patients being admitted from the Emergency Room if there is a question of need for admission vs outpatient follow up, or if the patient is borderline for floor status vs ICU. Reach out to your attending
Conferences:
1. The second year fellows are expected to attend all Wednesday Morning Conferences and Friday Cardiology Grand Rounds. Attendance is required
2. Transplant Conference is weekly on Tuesday morning from 7:30 - 8:30 on zoom AND Thursday morning from 8:00 – 9:45 in Plaza Cafe (Rooms A&B). Be prepared to present the in-patients who are being considered for advanced heart failure therapies. There is a template above that needs to be completed for each patient being presented. Following the presentation, the templated note should be updated with the results of the discussion (list, turn down for X reason or continuing work-up, needs XYZ completed) and cc’d to the patient’s attending. Attendance required.
3. MCS Conference is weekly on Thursday from 16:00 – 17:00. Patients being considered for MCS and patients who have received MCS are reviewed. This is an important conference to make sure that any patient who is being worked up for MCS is on the “VADar” of the MCS service. Attendance recommended
4. Transplant Pathology Conference is held monthly on the first Wednesday of the month from 8:30 – 9:30 in the pathology conference room on the second floor (NE 140 G). Endomyocardial biopsy specimens, LVAD core pathology, and explanted heart pathology are reviewed. This is an excellent conference. Attendance required
5. Transplant/HF Educational Conference is held monthly on the last Wednesday of the month from 4:00 - 5:00 in the CT Surgical conference room. Attendance required
Tips and Tricks:
AVOID NSAIDS and AMINOGLYCOSIDES under (virtually) any circumstance
SHORTNESS OF BREATH in a POST TRANSPLANT patient is REJECTION UNTIL PROVEN OTHERWISE – this cannot be stressed enough.
There is a great deal of "ART" to management of these advanced heart failure patients--while this can be confusing when attendings are changing, ask them about their practice and learn each of their styles.