Program Overview

Our fellowship is an ACGME accredited two-year, advanced fellowship. At the end of the program, graduating fellows will be eligible for board certification in Adult Congenital Heart Disease by the American Board of Internal Medicine. The ACHD fellowship is administered through the Cardiovascular Division of the Department of Internal Medicine in conjunction with the Center for Adults with Congenital Heart Disease at Washington University School of Medicine, an ACHA accredited Comprehensive Care Center for patients with ACHD that provides clinical care for over 1800 outpatient clinic visits and 250 inpatient admissions per year. This fellowship provides advanced training in the field of ACHD, high risk pregnancy, pre-conception counseling, pulmonary hypertension, critical care, CHD imaging, electrophysiology, diagnostic and interventional catheterization, advanced heart failure, including advanced therapies such as ventricular assist devices and transplantation and cardiac surgery in the adult patient with congenital heart disease.

During the pediatric cardiology categorical fellowship, fellows will spend time during their third year in the ACHD program to gain exposure to this sub-specialized field.

The CICU at St. Louis Children’s Hospital is a state-of-the-art, 16-bed, dedicated unit that provides all forms of cardiovascular intensive care for children and adults with congenital and acquired cardiovascular diseases. Approximately 400 patients are admitted to the CICU per year, with 35% of admissions for post-operative care, reflecting our internationally renowned heart failure/transplant program. Patients range in age from premature neonates to adults, and patient complexity and acuity are amongst the highest in the nation. A full range of clinical services is available, including mechanical circulatory support for heart failure patients with ventricular assist devices (Berlin Heart, HeartMate II, HeartWare, PediMag and CentriMag), the paracorporeal lung assist device system (Novalung and Quadrox oxygenators) and ECMO. Care is provided by a joint team comprised of faculty and trainees from critical care medicine, cardiology and cardiothoracic surgery. The critical care faculty are in house 24/7.

Cardiology fellows rotate in the CICU primarily during their second year (eight weeks) and also during their third year (two weeks) and are actively involved in all aspects of ICU care, including ventilator management, sedation, use of vasoactive and anti-arrhythmic drugs and performing bedside procedures. Through the demanding experience in this intense environment, fellows gain a greater understanding of cardiac pathophysiology, cardiopulmonary interactions, cardiac pharmacology and the effects of cardiac surgery. Several fellows have arranged combined fellowships in pediatric cardiology and critical care leading to dual-board eligibility.

Please refer to division’s page under Clinical Care.

The consult service rotation is an opportunity for our fellows to act with graduated autonomy during their three years of fellowship. The consult fellow handles all inpatient cardiology related requests for consultation from the PICU, Emergency Department, NICU and the subspecialty and general pediatric floors. The consult fellow also serves as a consultant to our referring pediatricians through the handling of outpatient calls. The consult fellow role encourages trainees to assess patients and their various data independently before discussing with the supervising attending physician. For many of our fellows, this rotation gives them a glimpse of “the real world” prior to graduation and allows them the opportunity to refine their skills in physical exam, telemetry review, interpretation of EKG/ECHO/Cath data and interdisciplinary communication.

Fellows enjoy starting their training with a hands-on ECHO “bootcamp” where they learn the basics of cardiac ultrasonography before starting any clinical work. Fellows are assigned three months of echo training in their first year at which time the emphasis is placed on doing the scans alongside our experienced team of cardiac sonographers. Our training program believes the ability to perform a high-quality ECHO is invaluable when it comes to learning the art of interpretation. As the fellows’ scanning skills improve, they transition into more advanced scanning (e.g. transesophageal) and interpretation. An additional one to two months is assigned during the second and third years of fellowship where the focus is primarily on advanced imaging (e.g. transesophageal, 3D and fetal echocardiography) and improving efficiency with basic transthoracic scanning and interpretation. Fellows on ECHO rotation also review the charts and images for patients being presented at the weekly Heart Center Disposition Conference. This gives the fellow a unique opportunity to distill a wide variety of clinical data into a summarized assessment and recommendation for complex patients with the guidance of senior faculty.

The pediatric EP team at Washington University has several service lines, including inpatient consults, diagnostic and therapeutic procedures and outpatient medicine, along with a robust research and advocacy program. As a moderate-large EP program in the Midwest, the EP team performs over 200 cases per year (including diagnostic EP studies, transcatheter ablations, and device implants) and see more than 1,000 clinic visits per year in EP clinics (including our specialized multidisciplinary Inherited Arrhythmia Clinic, Telemedicine Clinic and Device Clinic).

Under the supervision of an EP attending staff physician, the first-year fellow spends one month on the EP rotation and functions as a consultant for all inpatients and selected outpatients with arrhythmias. The fellow is responsible for coordinating patient management of arrhythmias including diagnosis and pharmacologic treatment, participation in esophageal electrophysiology studies, cardioversions and exercise studies and daily review and interpretation of electrocardiograms, Holter studies and event monitor transmissions. Fellows participate in interventional and surgical EP cases as well, such as radiofrequency ablation procedures and pacemaker placements.

The pediatric heart failure and transplantation program at St. Louis Children’s Hospital (SLCH) began performing pediatric heart transplants in the 1980s with over 500 heart transplants performed since its inception. SLCH is nationally recognized as a large volume transplant center with expertise in complex, high-risk patients with advanced heart failure, particularly those with congenital heart disease. SLCH also has a long history of use of ventricular assist devices (VADs) for refractory heart failure including outpatient and inpatient support with temporary and durable devices. Our team receives referrals from the St. Louis region as well as nationally.

During fellowship, categorical pediatric cardiology fellows routinely care for HFHT patients throughout the spectrum of care, including imaging, cardiac catheterization and inpatient service. Fellows spend an additional dedicated month with the HFHT service with both inpatient and outpatient care. Fellows are expected to be comfortable with the diagnosis and management of acute and chronic heart failure, indications and management of VADs, failed congenital heart disease palliation from infants to young adults, indications and peri-operative management of heart transplantation and long-term outcomes and complications of pediatric heart transplantation.

Please refer to division’s page under Clinical Care.

The call schedule gives fellows experience in the full range of urgent problems in pediatric cardiology and a focused experience in intensive cardiac care in the second and third years. Fellows take in-house call in the form of a night-shift rotation. The night-shift fellow (6:30 p.m. – 6:30 a.m.), under the supervision of the inpatient cardiology attending, is responsible for overnight management of the cardiac inpatients on the cardiology unit, for urgent consultations (in-house and from outside hospitals) and overnight echocardiograms.

Cardiac intensive care unit (CICU) night shift is separate and is covered by second and third year fellows during their CICU rotation.

Fellows participate in evaluation of outpatients referred to the cardiology clinics at St. Louis Children’s Hospital and in satellite outreach clinics throughout Missouri. Each fellow is assigned to a weekly clinic at St. Louis Children’s Hospital under the same cardiology attending preceptor for six-month blocks. Fellows also attend a monthly satellite clinic for at least two six-month blocks. Goals for this experience are to hone cardiac-focused history-taking and physical examination skills; to be able to independently assess patients referred for common problems such as murmurs, syncope, chest pain, and rule out or diagnosis cardiac disease in these patients; to coordinate care and longitudinal follow-up for patients with congenital and acquired heart disease; and to effectively communicate with referring physicians.