Cardiac Critical Care Fellowship Programs: Your Path to Becoming a Cardiac Intensivist

The landscape of patient care within the Cardiovascular Intensive Care Unit (CICU) has undergone a significant transformation in recent decades. The traditional image of the CICU as primarily a Coronary Care Unit (CCU) is now outdated. Today, acute coronary syndromes constitute less than 10% of admissions, with heart failure and cardiogenic shock emerging as the predominant conditions managed in modern CICUs.^1,2,3

Data from the Cardiology Critical Care Trials Network highlights this shift, revealing that respiratory failure is now the most frequent indication for CICU admission, followed by shock, which accounts for 21% of cases.⁴ Cardiologists practicing in contemporary CICUs require not only a comprehensive understanding of cardiology but also proficiency in managing a spectrum of noncardiac illnesses, ranging from sepsis to renal failure.^3,5 This evolution has given rise to the specialized field of Critical Care Cardiology (CCC), necessitating advanced training through dedicated Cardiac Critical Care Fellowship Programs.

Understanding the CICU Staffing Dilemma

While interest in CCC is steadily growing, the number of physicians who have completed dual training in both cardiology and critical care medicine (CCM) remains insufficient to solely staff all CICUs with cardiac intensivists. However, the increasing complexity of CICU patients, coupled with evidence suggesting improved patient outcomes in ICUs staffed by intensivists, has fostered a widespread recognition of the need for a transformation in CICU staffing models.^2,3,6-9 This demand underscores the importance of robust cardiac critical care fellowship programs to address the staffing gap.

Some institutions have opted for utilizing general intensivists to staff the CICU. However, general CCM fellowships offer limited exposure to the nuances of cardiovascular critical care.¹⁰ In the absence of dually trained cardiac intensivists, CICUs employ diverse staffing strategies to ensure adequate care for patients with both cardiac and noncardiac critical illnesses. These models range from cardiologist-led staffing with ICU consultations for specific patients to formal co-staffing arrangements involving cardiologists and intensivists. Cardiac critical care fellowship programs are designed to bridge this gap by providing specialized training.

Although current Leapfrog standards do not mandate intensivist involvement for all critically ill patients, a shift towards requiring intensivist-level care is anticipated.^3,11,12 One of the primary obstacles to increasing the availability of cardiac intensivists is the current scarcity of integrated cardiovascular critical care training pathways and dedicated cardiac critical care fellowship programs.^13,14

Recognizing this need, organizations such as the ACC, American Heart Association (AHA), and the European Society of Cardiology have published statements recommending the incorporation of critical care training within general cardiology fellowship curricula. They also advocate for an increase in the number of formally CCM-trained cardiologists.^2,6,9,15,16 For those considering specializing in this evolving field, understanding the available cardiac critical care fellowship programs and training pathways is crucial.

Is a Cardiac Critical Care Fellowship Right for You?

Deciding whether to pursue a cardiac critical care fellowship program is a significant career choice that hinges on your professional aspirations. If your career goals include primarily working in CICUs, particularly within academic or tertiary care centers, leading a CICU, practicing in various ICU settings (cardiothoracic [CTICU], medical [MICU], etc.), or engaging in CCC-focused research, then undertaking an additional year of CCM training through a cardiac critical care fellowship program is highly advisable.

Furthermore, while formal intensivist training is not currently mandatory for staffing any type of CICU or for billing for critical care services, staffing models are expected to undergo substantial changes in the coming years. Therefore, if your primary career objective is centered on CICU practice, completing a CCM fellowship through a reputable cardiac critical care fellowship program is a worthwhile investment in your future.

Navigating Cardiac Critical Care Fellowship Programs: Training Pathways

Unlike the field of pulmonary critical care (PCC), dedicated combined programs for CCC that trainees can directly apply to after residency are not yet established. Instead, aspiring cardiac intensivists must complete cardiology fellowship and CCM fellowship training separately. This sequential training approach can sometimes lead to confusion regarding the optimal pathways to pursue cardiac critical care fellowship programs.

For physicians with an internal medicine background, there are two primary routes to become eligible for CCM board certification outside of a PCC fellowship: 1) completing a two-year ACGME-accredited standalone CCM fellowship, which can be pursued independently of any other fellowship, or 2) undertaking a one-year CCM fellowship following an internal medicine subspecialty fellowship, such as cardiology. All CCM programs, including those within cardiac critical care fellowship programs, mandate a minimum of 12 months of clinical training, with at least six months dedicated to ICU rotations.

While most programs exceed the minimum six months of critical care time, two-year programs offer greater flexibility for elective rotations and research opportunities. For those opting for the two-year CCM fellowship, the critical care training can be undertaken either before or after cardiology fellowship, each offering distinct advantages and disadvantages, as detailed by Miller et al.¹³ Careful consideration of these factors is important when planning your cardiac critical care fellowship program pathway.

Although the ACGME website provides a directory of accredited two-year CCM fellowships, a readily accessible comprehensive list of one-year fellowship programs is not available. Most CCC-bound trainees pursuing the one-year pathway typically opt to do so at their home institution, leveraging existing resources and faculty. If an institution lacks a CCM fellowship outside of PCC, trainees interested in cardiac critical care fellowship programs can collaborate with PCC leadership to potentially develop a customized track tailored to their specific needs. Such proposals can be submitted to the ACGME for approval, requiring consideration of funding and program structure.¹¹

Regardless of whether you pursue a formal two-year CCM fellowship, a pre-existing one-year CCM fellowship after general cardiology training, or a self-arranged one-year fellowship, it is prudent to engage in discussions with program leadership to ensure that your fellowship year can be aligned with your specific career objectives within cardiac critical care. Cardiac critical care fellowship programs should be flexible enough to accommodate individual goals.

For example, if you aim to practice in both a CTICU and CCU, it is essential to inquire with the CCM program director about the possibility of prioritizing additional CTICU rotations during your cardiac critical care fellowship program. Furthermore, it is important to assess the case mix of cardiac surgeries performed at the program to guarantee adequate exposure to a broad spectrum of cardiothoracic critical care scenarios.

Similarly, if you have a particular interest in mechanical circulatory support and your general cardiology training lacked opportunities for hands-on management of patients with balloon pumps, Impellas, and extracorporeal membrane oxygenation (ECMO), you should ensure that your chosen cardiac critical care fellowship program incorporates sufficient dedicated time to gain expertise in these critical areas.

Choosing the Right Cardiology Program for a Future in Cardiac Critical Care

For individuals aspiring to specialize in CCC, a common question revolves around what to prioritize when selecting a general cardiology program. It’s crucial to recognize that a substantial component of CCC expertise is rooted in cardiology itself. While a dedicated critical care year will impart knowledge of advanced airway management, sepsis management, and renal replacement therapies, the foundational cardiology knowledge essential for CCC is acquired during general cardiology fellowship. Therefore, when applying to general cardiology programs, it is paramount to ensure access to sufficiently comprehensive training that aligns with your career aspirations in cardiac critical care and future cardiac critical care fellowship programs. Here are key questions to ask program directors and fellows during interviews to effectively evaluate each program:

What is the fellow’s role in the CCU?

Inquire about the unit’s operational model (open or closed). Understand the scope of decisions fellows can make autonomously versus when attending input is required. Determine if fellows collaborate with residents and/or advanced practice providers, as these factors influence the learning environment within cardiac critical care fellowship programs.

What types of patients are treated in the CICU?

Ascertain whether patients requiring mechanical circulatory support are managed within the CCU or CTICU. Clarify the extent of exposure to intra-aortic balloon pumps, Impellas, durable left ventricular assist devices (LVADs), and ECMO. If these are primarily managed in the CTICU, explore opportunities for CTICU rotations or co-management experiences during heart failure rotations, which are valuable components of cardiac critical care fellowship programs. Investigate the presence of a transplant/VAD program and whether patients with pulmonary hypertension are managed in the CICU or MICU. Assess the program’s exposure to right heart failure cases, as this is a critical aspect of cardiac critical care.

Does the program have a pre-designed training pathway for CCC?

If a formal CCC pathway exists, inquire about the application process for this track. Determine if it is possible to speak with the CCM fellowship director to gain deeper insights into the program and application pathway. If a formal pathway is absent, investigate whether previous fellows have successfully arranged ACGME-accredited CCM years and whether the general cardiology program provides support for such endeavors, which are critical for those aiming for cardiac critical care fellowship programs.

Are there attendings in the CICU who are dual trained in cardiology and critical care?

If possible, learning from mentors who are dually trained in cardiology and critical care can significantly enrich your training experience and provide invaluable guidance as you prepare for cardiac critical care fellowship programs.

What procedures do general fellows perform in the CICU?

Determine the common utilization of pulmonary artery catheters and whether general fellows routinely place them at the bedside. Inquire about opportunities to place dialysis lines, transvenous pacemakers, and/or intra-aortic balloon pumps, as procedural skills are essential in cardiac critical care and cardiac critical care fellowship programs.

How much hands-on time with pacemaker interrogation and programming do general fellows get?

Assess the extent to which general fellows learn to manage tachycardia therapies. Explore opportunities to gain experience with anti-tachycardia pacing, as these skills are invaluable for CICU attendings, particularly in emergent situations when electrophysiology expertise may not be immediately available. Practical experience is a key component of effective cardiac critical care fellowship programs.

If desired, can I feasibly reach Level II echocardiography training during general fellowship?

While formal Level II echocardiography training (the ability to independently interpret and bill for transthoracic echocardiography [TTE] studies) may not be mandatory, proficiency in bedside TTE is crucial in cardiac critical care. The feasibility of achieving Level II training during general fellowship serves as a useful indicator of the hands-on echocardiography experience you will gain. Determine whether general fellows or imaging fellows perform transesophageal echocardiograms (TEEs), as TEE is also a significant component of CTICU management, making this experience beneficial, though not essential, for cardiac critical care fellowship programs.

What is the role of the general fellow in the cath lab?

During cath lab rotations, inquire about the ratio of femoral versus radial access procedures. While proficiency in femoral access can be acquired outside the cath lab setting, learning femoral access techniques from vascular access experts in non-urgent scenarios is advantageous. Additionally, ask about opportunities to participate in intra-aortic balloon pump and/or Impella insertions and pericardiocenteses, as these procedures are relevant to cardiac critical care and cardiac critical care fellowship programs.

Is there any flexibility in tailoring the CCM year towards critical care cardiology?

This question is best directed to the critical care medicine fellowship director or previous CCC trainees. Inquire about the possibility of spending more time in the CTICU or cardiac operating rooms to gain experience with bypass procedures and refine TEE skills. Determine the amount of elective time incorporated into the program, allowing for specialization within cardiac critical care fellowship programs.

Conclusion: Embracing the Future of Cardiac Critical Care

The field of cardiac critical care is rapidly evolving, demanding specialized expertise to effectively manage increasingly complex patients within the CICU. Cardiac critical care fellowship programs are essential for developing the next generation of cardiac intensivists equipped to meet these challenges. For those passionate about critical care cardiology, pursuing dual training through dedicated cardiac critical care fellowship programs offers a rewarding and impactful career path. By carefully considering your career goals and exploring the available training pathways and cardiology programs, you can embark on a fulfilling journey to become a leader in this dynamic and vital field.

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References

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5. Sinha SS, Sjoding MW, Sukul D, et al. Changes in primary noncardiac diagnoses over time among elderly cardiac intensive care unit patients in the United States. Circ Cardiovasc Qual Outcomes 2017;10:e003616.
6. van Diepen S, Fordyce CB, Wegermann ZK, et al. Organizational structure, staffing, resources, and educational initiatives in cardiac intensive care units in the United States. Circ Cardiovasc Qual Outcomes 2017;10:e003864.
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9. O’Malley RG, Olenchock B, Bohula-May E, et al. Organization and staffing practices in US cardiac intensive care units: a survey on behalf of the American Heart Association Writing Group on the Evolution of Critical Care Cardiology. Eur Heart J Acute Cardiovasc Care 2013;2:3-8.
10. Hill T, Means G, van Diepen S, et al. Cardiovascular critical care: A perceived deficiency among U.S. trainees. Crit Care Med 2015;43:1853-8.
11. Yuriditsky E, Pradhan D, Brosnahan SB, et al. Cardiovascular critical care training: A collaboration between intensivists and cardiologists. ATS Sch 2022;3:522-34.
12. Gasperino J. The Leapfrog initiative for intensive care unit physician staffing and its impact on intensive care unit performance: A narrative review. Health Policy 2011;102:223-8.
13. Miller P, Kenigsberg B, Wiley B, et al. Cardiac critical care. J Am Coll Cardiol 2019;73:1726-30.
14. O’Brien CG, Barnett CF, Dudzinski DM, et al. training in critical care cardiology within critical care medicine fellowship: a novel pathway. J Am Coll Cardiol 2022;79: 609-13.
15. Hasin Y, Danchin N, Filippatos GS, et al. Recommendations for the structure, organization, and operation of intensive cardiac care units. Eur Heart J 2005;26:1676-82.
16. O’Gara P, Adams J, Drazner M, et al. COCATS 4 Task Force 13: Training in critical care cardiology. J Am Coll Cardiol 2015;65:1877-86.

Keywords: Cardiac Critical Care Fellowship Programs, Cardiology Fellowship, Critical Care Medicine Fellowship, Cardiac Intensivist Training, CICU, CCM, Cardiovascular Critical Care, Fellowship Programs, Medical Education, Physician Training

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