Level 2 training is expected to be completed following an additional 4 months of exposure to invasive cardiology during the second and third years of the fellowship. Second- and third-year fellows often spend blocks of 2-3 months in the catheterization laboratory. At this time, the fellows participate in the laboratory activities as outlined for the Level 2 training with the exception that they are given more responsibility during the procedures in accordance with their technical skills and level of interest.
Fellows are also responsible for the complete work-up and hemodynamic assessment of the patients undergoing catheterization and, in consultation with the attending cardiologist assigned to the case, they are responsible for developing a therapeutic plan for these patients. The latter includes, when appropriate, consultation with the cardiothoracic surgeon.
By the completion of Level 2 training, all fellows have participated in at least 150 diagnostic procedures and an appropriate number of interventional procedures. At this time, the trainee is expected to be able to:
- direct and completely interpret a hemodynamic evaluation protocol with a high level of sophistication
- act as the primary operator (with an attending as the "supervisor”) on a routine left heart or right and left heart diagnostic procedure
- be conversant with the indications for cardiac catheterization
- be facile in the management of patients before and after the invasive procedure
- be competent in interpretation of all invasively acquired data
- be able to make appropriate clinical recommendations
- be conversant with other invasive procedures such as endomyocardial biopsy, pericardiocentesis, and intra-aortic balloon pump insertion
Competency in invasive cardiology is assessed by the catheterization laboratory director or his designee. In addition, the catheterization laboratory director may certify Level 2 trainees who have evidenced appropriate skill and commitment to perform diagnostic catheterization.
Level 2 Cognitive Knowledge
- All Level 1 items
- Understand radiological imaging, including design and operation of X-ray cineradiographic units, digital imaging and storage, radiation physics, factors influencing image quality, radiation quality assurance, and physiology of X-ray contrast media
- Understand the basic operation of physiologic recorders, pressure transducers, oximeters, and oxygen consumption measurement equipment
- Understand how to differentiate the hemodynamics of constrictive pericarditis from restrictive cardiomyopathy
- Understand coronary physiology using techniques such as Doppler flow and fractional flow reserve
- Understand the indications for and complications of vascular closure devices
Level 2 Technical Skills
- All Level 1 items
- Perform percutaneous vascular access from the femoral artery and vein and subclavian or internal jugular vein.
- Perform right heart catheterization using a balloon flotation catheter
- Perform temporary right ventricular pacemaker insertion.
- Perform left heart catheterization and coronary angiography (of native arteries) under supervision. Perform left ventriculography including calculation of ejection fraction.
- Perform vascular access from the femoral, radial, or brachial route
- Perform left heart catheterization and coronary angiography, as well as visualization of venous bypass and internal mammary artery grafts
- Perform angiography of the cardiac chambers and aorta
- Perform intra-aortic balloon insertion and operate a balloon pump
- Perform cardiac catheterization in common types of valvular, adult congenital, and cardiomyopathic heart disease
- Perform pericardiocentesis
- Perform vascular closure device insertion