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Clinical Rotations

Cardiac Intensive Care Unit

Nearly 1,000 patients per year are admitted to the 10-bed Cardiac Intensive Care Unit (CICU) facilities at Stony Brook University Hospital, including those with acute myocardial infarction, complications of myocardial infarction, unstable ischemic syndromes, severe heart failure, cardiogenic shock and life-threatening arrhythmias. The CICU provides a unique environment for treating patients with acute ischemic heart disease; it is supported by extensive facilities for electrocardiographic and hemodynamic monitoring, a centralized telemetry system, and direct access to the adjacent catheterization laboratories. Patients admitted to the unit may be enrolled in multicenter trials of treatments for acute myocardial infarction and unstable ischemic syndromes, and in trials seeking optimal management strategies for patients with severe heart failure. Post-CICU care is supported by an adjacent 25-bed telemetry unit.

Clinical trainees in the CICU act as consultants to residents and attending physicians, and are responsible, in consultation with the full-time attending staff, for the care of all patients. In addition, under the supervision of attending physicians, they perform all invasive procedures, are involved in a large number of clinical research protocols, and participate in the daily work and attending rounds.

Cardiovascular Imaging

The formation of a Cardiovascular Imaging section within the Division of Cardiovascular Medicine recognizes the increasing number of imaging modalities, their complexity and their often complementary ability to detect cardiovascular pathology. The stated goal of Cardiovascular Imaging at Stony Brook is to match the appropriate imaging modality or modalities to an individual patient rather than the traditional approach of bouncing a patient from one disconnected imaging laboratory to the next in the hopes of making a diagnosis. In collaboration with our colleagues in the Department of Radiology we are establishing an Imaging Consultation Service where the most complex patients can be referred for a single evaluation in which multiple imagers contribute to the creation of tailored imaging approach.

Echocardiography

The Echocardiography Laboratory at Stony Brook University Medical Center performs a full range of procedures, including transthoracic echocardiograms, transesophageal echocardiograms, treadmill stress tests and dobutamine stress tests. With a total of 10 state-of-the-art ultrasound systems, and a new treadmill and stress testing system, our laboratory performs approximately 10,000 procedures annually. The laboratory is fully digital and all studies are securely stored on a dedicated server to facilitate retrieval and interpretation of data for clinical and teaching purposes.

All cardiology fellows learn how to scan patients from our registered sonographers. The fellows are expected to preliminary read their own studies, and are encouraged to read as many studies as possible. Feed back and teaching is provided daily by our cardiologists who specialized in echocardiography.

The fellows rotating in the lab will get to learn the most innovative technologies available in echocardiography today, such as 3D echocardiography, tissue Doppler, strain and strain rate imaging, and will participate in the most cutting edge procedures, such as cardiac resynchronization therapy, pacemaker optimization and intracardiac echocardiography. As part of their training, the fellows will perform echocardiograms in the operating room, catheterization laboratory and electrophysiology laboratory and will guide innovative surgical and percutaneous procedures, such as investigational mitral valve repair, closure of intracardiac defects, and ablation of various arrhythmias.

Upon completion of cardiology fellowship, interested fellows should be able to achieve level II training in echocardiography and be prepared to pass the echo boards.

The laboratory is committed to performing research and is currently involved in various research studies, including evaluation of new technologies not yet available for clinical use. Fellows are encouraged to initiate research projects as well as participate in the on going ones.

Nuclear Cardiology

The Nuclear Cardiology Service is a collaboration between the Cardiovascular Division and the Division of Nuclear Medicine of the Department of Radiology. The service is responsible for performing diagnostic exercise and pharmacologic stress testing in over 2,500 patients each year undergoing either myocardial perfusion imaging or radionuclide ventriculography. State-of-the-art multihead single-photon emission computed tomography (SPECT) equipment is available for all clinical studies. In addition, whole-body positron-emission tomographic instruments are available for diagnostic and research studies.

Clinical trainees rotate through the Nuclear Cardiology Service and are responsible for performing and interpreting stress tests. Trainees also provide medical clearance for patient studies, review tests with the attending cardiologist, and interpret results of imaging studies with faculty members with expertise in this field. Conferences and teaching sessions explore the physiologic and pathophysiologic response to exercise; techniques for assessment of myocardial perfusion, metabolism, and function; and the diagnostic and prognostic applications of stress testing and imaging studies.

Cardiovascular MR and CT

The Advanced Cardiac Imaging Program at Stony Brook has both 1.5 and 3T cardiac MR scanners and three 64-slice MDCT scanners. One of the three 64-slice MDCT is located within the Emergency Department and is active in performing cardiac CTA for the evaluation of low to intermediate risk patients with acute chest pain. In May 2009, a brand new and dedicated Advanced Cardiac Imaging training center will be opened at Stony Brook for physicians and technologists seeking basic and advanced training in cardiac MRI and CTA. The center is equipped with dedicated workstations and teaching materials for both cardiac CT and MR training. The training program will offer SCMR and SCCT level I, II, and III training and credentialling opportunities and CME credits for physicians and physicians-in-training as well as for CT and MR technologists on a regular basis. The Advanced Cardiac Imaging Program is currently collaborating with the Stony Brook’s Center of Wireless and Information Technology (CEWIT) in the development of state-of-the-art technology for image compression, segmentation, and transfer. Others research projects include software development for cardiac MR quantitative analysis, computed-aided diagnosis for coronary CTA, and multi-center clinical trials on the assessement of cardiac viability and remodelling using cardiac MRI and the accuracy of coronary CTA in patients with stable chest pain.

Clinical Electrophysiology Service

The Clinical Electrophysiology Service performs in- and outpatient evaluation and management of cardiac arrhythmias. A multidisciplinary approach is used to provide care for patients with ventricular arrhythmias, supraventricular tachycardias, preexcitation syndromes, atrial fibrillation/flutter, derangements in sinus node automaticity, disturbances in atrioventricular conduction, syncope, and other abnormalities. The Stony Brook University Hospital Heart Center includes two dedicated electrophysiology laboratories with state-of-the-art equipment, as well as telemetry units in which computer-assisted automated equipment is used to monitor patients with complex arrhythmias.

Therapies for specific cardiac arrhythmias include investigational and conventional antiarrhythmic drugs, implantable pacemakers and defibrillators, and catheter ablation procedures for complex atrial and ventricular arrhythmias. Because of its unique stature as a clinical and investigational unit, the Arrhythmia Service offers patients the opportunity to participate in cutting-edge trials that evaluate new applications for approved devices as well early access to the latest developments in device technology.

Accurate diagnosis of electrophysiologic abnormalities is crucial to the success of therapy. A combination of programmed electrical stimulation, multichannel catheter mapping and tilt table testing is used to identify arrhythmogenic mechanisms, assess which therapies are likely to be effective, locate sites of abnormal tissue for ablation, and assess the efficacy of therapy. A major focus of interest is ablation of atrial fibrillation and ventricular tachycardia. Fellows will be exposed to the latest technology to facilitate these procedures, including 3D mapping systems with image integration, intracardiac ultrasound, and remote catheter navigation.

The Arrhythmia Service also evaluates patients who may be at high risk for life-threatening ventricular arrhythmias. These include patients recovering from myocardial infarction or those with nonischemic cardiomyopathy who may later develop sustained ventricular tachycardia or fibrillation. Risk assessment involves conventional tests of cardiovascular function as well as the interpretation of ECGs with advanced signal-processing techniques.

Arrhythmia Service attending personnel make daily teaching rounds that focus on management strategies for patients with or at risk for development of tachyarrhythmias or bradyarrhythmias. ECG rhythm strips and recordings from Holter monitors are reviewed during these rounds. In addition, several regular clinics are conducted for patients with arrhythmias and for those with pacemakers or implantable defibrillators. Analysis of pacemaker function and programming are performed in the arrhythmia clinic, with additional pacemaker surveillance available through a telephone monitoring service. Trainees have a broad exposure to indications for and effects of various antiarrhythmic drugs, radiofrequency ablation, high-resolution electrocardiography, sophisticated pacemakers, and the newest technology in implantable cardioverter-defibrillators.

Cardiac Catheterization Laboratory

Four state-of-the-art Siemens cardiac catheterization laboratories are located in a self-contained suite in the Heart Center adjacent to the Cardiac Intensive Care Unit. One of the laboratories is equipped to perform vascular interventional procedures and two of the laboratories are equipped with biplane imaging to facilitate evaluation of complex pediatric and adult patients.

More than 5,000 patients are evaluated and more than 1,500 interventional procedures are performed annually. Patients with a wide variety of heart diseases are seen in the laboratory. Stony Brook University Hospital offers the only full-service interventional program in Suffolk County, with physicians performing balloon angioplasty, intracoronary stenting, intravascular ultrasound, directional coronary atherectomy, rotational atherectomy, mitral and aortic valvuloplasty procedures, septal ablation for hypertrophic cardiomyopathy, ASD and PFO closures, carotid stenting and peripheral vascular diagnostic and interventional procedures. Our Code H program, that offers 24-7 availability of primary percutaneous coronary intervention for acute myocardial infarction, is the busiest in the area.

Attending physicians in the catheterization laboratory participate in a number of multicenter trials of new devices, techniques and drug treatments used in conjunction with cardiac interventions.

The Cardiac Catheterization Laboratory rotation for trainees is intensive, with both first- and second-year fellows participating in the prospective evaluation of all patients, the performance of all procedures, interpretation of results of hemodynamic and angiographic studies, and decisions regarding therapeutic recommendations. A fourth year of training exclusively in interventional cardiology also is available.

Heart Failure Service

The Heart Failure teaching program at Stony Brook University Medical Center is designed to provide outstanding practical and academic training to prepare residents and fellows for diverse and productive careers in Cardiology. For physicians in training, this includes attention to both clinical skills development and personal growth and within a framework of the highest professional values.

The curriculum includes the daily care of patients with cardiovascular disease under direct and indirect supervision of the attending physician, participation in multiple didactic clinical conferences, reading of the Heart Failure syllabus, routine and frequent access of the medical literature, participation in clinical research projects and an understanding of the application of basic science research and techniques to the practice of clinical cardiology.

Cardiology Consultation Service

Faculty on this service provide consultation in clinical cardiology services for inpatients. The staff includes one cardiology fellow, one senior resident and senior medical students. Trainees accompany the attending cardiologist on patient rounds and are responsible for coordinating day-to-day care for a large number of patients and for instruction of residents in Internal Medicine and medical students.

The emphasis in training is on medical history-taking and on the physical examination, as well as the prescription of relevant diagnostic tests. Trainees on this service enrich their experience in every aspect of cardiology through interaction with the Cardiac Non-Invasive Laboratory, Cardiac Catheterization Laboratory, Cardiac Intensive Care Unit, and Electrophysiology Laboratory.

Pediatric Cardiology

The pediatric cardiology rotation is designed to expose trainees in cardiovascular medicine to all aspects of this specialty. Recent advances in the treatment of pediatric patients with primary arrhythmias and with congenital heart disease have resulted in the survival of many to adulthood. The primary focus of the rotation is on outpatient evaluation, including appropriate noninvasive diagnostic testing. Strong emphasis is placed on physical diagnosis, echocardiography and magnetic resonance imaging. Trainees participate in regular conferences and inpatient rounds on patients who have undergone surgical procedures. They gain familiarity with the physical features, diagnostic manifestations and appropriate therapeutic approaches for care of patients with congenital heart disease.