2017 acc/aha/hfsa/ishlt/acp advanced training statement … · advanced training statement 2017...

J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y V O L . 6 9 , N O . 2 4 , 2 0 1 7

ª 2 0 1 7 B Y T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N D A T I O N ,

A M E R I C A N H E A R T A S S O C I A T I O N , I N C . , H E A R T F A I L U R E S O C I E T Y O F AM E R I C A ,

A N D I N T E R N A T I O N A L S O C I E T Y F O R H E A R T & L U N G T R A N S P L A N T A T I O N

I S S N 0 7 3 5 - 1 0 9 7 / $ 3 6 . 0 0

h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . j a c c . 2 0 1 7 . 0 3 . 0 0 1

P U B L I S H E D B Y E L S E V I E R

ADVANCED TRAINING STATEMENT

2017 ACC/AHA/HFSA/ISHLT/ACP
Advanced Training Statement onAdvanced Heart Failure and TransplantCardiology (Revision of the ACCF/AHA/ACP/HFSA/ISHLT 2010 Clinical CompetenceStatement on Management of Patients With Advanced Heart Failure and Cardiac Transplant) A Report of the ACC Competency Management Committee
Writing Mariell Jessup, MD, FACC, FAHA, Chair
CommitteeMembers
MarkH.Drazner,MD,MSC,FACC,FAHA,FHFSA,ViceChair

Wendy Book, MD, FACCJoseph C. Cleveland, JR, MD, FACC*Ira Dauber, MD, FACC, FAHA, FACPySusan Farkas, MD, FACCMahazarin Ginwalla, MD, MS, FACC*Jason N. Katz, MD, MHSzPeggy Kirkwood, RN, MSN, ACNPC, CHFN, AACCMichelle M. Kittleson, MD, PHD, FACCJoseph E. Marine, MD, FACC

The document was approved by the American College of Cardiology Lifelo

Advisory and Coordinating Committee, the Heart Failure Society of Amer

plantation Board of Trustees, and the American College of Physicians Board

ecutive Committee in March 2017. For the purpose of transparency, disclos

approval body of the convening organization of this document, is available

The American College of Cardiology requests that this document be cited as

Ginwalla M, Katz JN, Kirkwood P, Kittleson MM, Marine JE, Mather P, Morri

ISHLT/ACP advanced training statement on advanced heart failure and trans

competence statement on management of patients with advanced heart fail

Committee. J Am Coll Cardiol 2017;69:2977–3001.

This article has been copublished in Circulation: Heart Failure and the Jou

Copies: This document is available on the World Wide Web sites of the A

(http://professional.heart.org), Heart Failure Society of America (www.hfsa.o

and American College of Physicians (www.acponline.org). For copies of this d

e-mail [email protected].

Permissions: Multiple copies, modification, alteration, enhancement, and

permission of the American College of Cardiology. Requests may be compl

author-agreement/obtaining-permission).

Paul Mather, MD, FACC, FACP, FAHA, FHFSAxAlanna A. Morris, MD, MSCzDonna M. Polk, MD, MPH, FACC, FAHAAntoine Sakr, MD, FACCKelly H. Schlendorf, MD, MHSyEsther E. Vorovich, MD, MSCE, FACC

*Official International Society for Heart and Lung Transplantation

Representative. yOfficial Heart Failure Society of America Representative.

zOfficial American Heart Association Representative. xOfficial American

College of Physicians Representative.

ng Learning Oversight Committee, the American Heart Association Science

ica Board of Trustees, the International Society for Heart & Lung Trans-

of Regents in February 2017, and by the American Heart Association Ex-

ure information for the ACC Lifelong Learning Oversight Committee, the

online.

follows: JessupM, DraznerMH, BookW, Cleveland JC Jr, Dauber I, Farkas S,

s AA, Polk DM, Sakr A, Schlendorf KH, Vorovich EE. 2017 ACC/AHA/HFSA/

plant cardiology (revision of the ACCF/AHA/ACP/HFSA/ISHLT 2010 clinical

ure and cardiac transplant): a report of the ACC Competency Management

rnal of Cardiac Failure.

merican College of Cardiology (www.acc.org), American Heart Association

rg), International Society for Heart & Lung Transplantation (www.ishlt.org),

ocument, please contact Elsevier Reprint Department, fax (212) 633-3820 or

/or distribution of this document are not permitted without the express

eted online via the Elsevier site (http://www.elsevier.com/about/policies/

http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/clinical-document-approval

http://www.acc.org

http://professional.heart.org

http://www.hfsa.org

http://www.ishlt.org

http://www.acponline.org

mailto:[email protected]

http://www.elsevier.com/about/policies/author-agreement/obtaining-permission

http://www.elsevier.com/about/policies/author-agreement/obtaining-permission

http://crossmark.crossref.org/dialog/?doi=10.1016/j.jacc.2017.03.001&domain=pdf

http://dx.doi.org/10.1016/j.jacc.2017.03.001

Jessup et al. J A C C V O L . 6 9 , N O . 2 4 , 2 0 1 7

2017 ATS on Advanced Heart Failure and Transplant Cardiology J U N E 2 0 , 2 0 1 7 : 2 9 7 7 – 3 0 0 1

2978

ACCCompetencyManagementCommittee

Jonathan L. Halperin, MD, FACC, Co-Chair
Eric S. Williams, MD, MACC, Chair
Jesse E. Adams III, MD, FACCJames A. Arrighi, MD, FACCEric H. Awtry, MD, FACCEric R. Bates, MD, FACCJohn E. Brush, JR, MD, FACCLori Daniels, MD, MAS, FACCSusan Fernandes, LPD, PA-C

Rosario Freeman, MD, MS, FACCSadiya S. Khan, MDJoseph E. Marine, MD, FACCJohn A. McPherson, MD, FACCLisa A. Mendes, MD, FACCThomas Ryan, MD, FACCChittur A. Sivaram, MBBS, FACCRobert L. Spicer, MD, FACCAndrew Wang, MD, FACC, FAHAHoward H. Weitz, MD, MACP, FACC

TABLE OF CONTENTS

PREAMBLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2979

1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2980

1.1. Document Development Process . . . . . . . . . . . . . 2980

1.1.1. Writing Committee Organization . . . . . . . . 2980

1.1.2. Document Development and Approval . . . 2980

1.2. Background and Scope . . . . . . . . . . . . . . . . . . . . . 2980

1.2.1. Evolution of AHFTC . . . . . . . . . . . . . . . . . . 2981

1.2.2. Levels of Training . . . . . . . . . . . . . . . . . . . . 2981

1.2.3. Methods for Determining ProceduralNumbers . . . . . . . . . . . . . . . . . . . . . . . . . . . 2981

2. GENERAL STANDARDS . . . . . . . . . . . . . . . . . . . . . . . 2982

2.1. Faculty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2982

2.2. Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2982

2.3. Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2982

2.4. Ancillary Support . . . . . . . . . . . . . . . . . . . . . . . . . 2982

3. TRAINING COMPONENTS . . . . . . . . . . . . . . . . . . . . . 2983

3.1. Didactic Program . . . . . . . . . . . . . . . . . . . . . . . . . 2983

3.2. Clinical Experience . . . . . . . . . . . . . . . . . . . . . . . . 2983

3.3. Hands-On Procedural Experience . . . . . . . . . . . . 2983

3.4. Diagnosis and Management of Emergencies andComplications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2990

3.5. Diagnosis and Management of Less CommonClinical Conditions and Syndromes . . . . . . . . . . 2990

3.6. Research and Scholarly Activity . . . . . . . . . . . . . 2991

4. TRAINING REQUIREMENTS . . . . . . . . . . . . . . . . . . . 2991

4.1. Development and Evaluation of CoreCompetencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2991

4.2. Number of Procedures . . . . . . . . . . . . . . . . . . . . . 2991

4.3. Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2991

4.3.1. Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . 2992
4.3.1.1. Initial Assessment . . . . . . . . . . . . . . 29924.3.1.2. Hemodynamic Interpretation . . . . . . 29924.3.1.3. Cardiogenic Shock . . . . . . . . . . . . . . 29934.3.1.4. Decompensated Heart Failure . . . . . 2993
4.3.2. Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . 2993

4.4. Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . 2993

4.4.1. Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . 2993

4.4.2. Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . 2993

4.5. Mechanical Circulatory Support . . . . . . . . . . . . . 2994

4.5.1. Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . 2994

4.5.2. Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . 2994

4.6. Cardiac Transplantation . . . . . . . . . . . . . . . . . . . . 2994

4.6.1. Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . 2995
4.6.1.1. Pretransplant Management . . . . . . . 29954.6.1.2. Acute Postoperative
Management . . . . . . . . . . . . . . . . . . 29954.6.1.3. Postoperative Complications . . . . . . 29954.6.1.4. InpatientHeartTransplantManagement

Following the Index Admission . . . . . 2995

4.6.2. Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . 2995
4.6.2.1. Immunosuppression . . . . . . . . . . . . 29954.6.2.2. Chronic Complications . . . . . . . . . . 2995
4.7. Shared Decision Making and Palliative Care . . . 2996

5. EVALUATION OF PROFICIENCY . . . . . . . . . . . . . . . 2996

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2996

APPENDIX 1

Author Relationships With Industry and Other Entities(Relevant) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2998

APPENDIX 2

Peer Reviewer Information . . . . . . . . . . . . . . . . . . . . . 2999

APPENDIX 3

Abbreviation List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3001

J A C C V O L . 6 9 , N O . 2 4 , 2 0 1 7 Jessup et al.J U N E 2 0 , 2 0 1 7 : 2 9 7 7 – 3 0 0 1 2017 ATS on Advanced Heart Failure and Transplant Cardiology

2979

PREAMBLE

Since the 1995 publication of its Core CardiovascularTraining Statement (COCATS) (1), the American College ofCardiology (ACC) has played a central role in defining theknowledge, experiences, skills, and behaviors expected ofall clinical cardiologists upon completion of training.Subsequent updates have incorporated major advancesand revisions—both in content and structure—including,most recently, a further move toward competency(outcomes)-based training, and the use of the 6-domaincompetency structure promulgated by the AccreditationCouncil for Graduate Medical Education (ACGME) and theAmerican Board of Medical Specialties and endorsed bythe American Board of Internal Medicine (ABIM). A similarstructure has been used by the ACC to describe thealigned general cardiology lifelong learning competenciesthat all practicing cardiologists are expected to maintain.Many hospital systems also now use the 6-domain struc-ture as part of medical staff privileging and peer-reviewprofessional competence assessments.

Whereas COCATS has focused on general clinical car-diology, ACC Advanced Training Statements defineselected competencies that go beyond those expected ofall cardiologists and require training beyond a standard3-year cardiovascular disease fellowship. This includessub-subspecialties for which there is an ABIM added-qualification designation, such as advanced heart failureand transplant cardiology (AHFTC). The AdvancedTraining Statements also describe key experiences andoutcomes necessary to maintain or expand competenciesduring practice, although over time, these will be sup-plemented by additional lifelong learning statements thataddress the commitment to sustaining and enrichingcompetency over the span of a career.

The ACC Competency Management Committee over-sees the development and periodic revision of the car-diovascular training and competency statements. A keyfeature of competency-based training and performance isan outcomes-based evaluation system. Although specificareas of training may require a minimum number ofprocedures or duration of training time to ensureadequate exposure to the range of clinical disorders andto effectively evaluate the trainee, it is the objectiveassessment of proficiency and outcomes that demon-strates the trainee’s achievement of competency. Evalu-ation tools may include in-training examinations, directobservation, procedure logbooks, simulation, conferencepresentations, and multisource (360�) evaluations, amongothers. For practicing physicians, these tools may alsoinclude professional society registry or hospital qualitydata, peer-review processes, and patient satisfactionsurveys. A second feature of a competency-based training

program is the recognition that learners develop somecompetency components at different rates. For multiyeartraining programs, assessment of selected representativecurricular milestones during training can identify learnersor areas that require additional focused attention.

The recommendations in the ACC cardiovasculartraining statements are based on available evidence and,where evidence is lacking, reflect expert opinion. Thewriting committees are broad-based, and typicallyinclude content experts, general cardiology and sub-subspecialty training directors, practicing cardiologists,and early-career representatives. All documents gothrough a rigorous process of peer-review and publiccomment. Recommendations are intended to guide theassessment of competence of cardiovascular care pro-viders who are beginning independent practice as well asthose undergoing periodic review to help ensure thatcompetence is maintained.

This Advanced Training Statement addresses theadded competencies required of sub-subspecialists inAHFTC for diagnosis and management at a high level ofskill of patients with advanced heart failure who may alsoundergo placement of mechanical circulatory supportdevices or cardiac transplantation. It is intended to com-plement the basic training in heart failure required of alltrainees during the standard 3-year cardiovascularfellowship. The training requirements and designatedclinical competencies in this report focus on the corecompetencies reasonably expected of all AHFTC special-ists. It also identifies some aspects of AHFTC that gobeyond the core expectations and that may be achievedby some AHFTC specialists based on career focus, eitherduring or following formal AHFTC fellowship training.

The work of the writing committee was supportedexclusively by the ACC without commercial support.Writing committee members volunteered their time tothis effort. Conference calls of the writing committeewere confidential and attended only by committeemembers. To avoid actual, potential, or perceived conflictof interest arising as a result of relationships with in-dustry (RWI) or other entities, each member of the writingcommittee and peer reviewer of the document is requiredto disclose all current healthcare-related relationships,including those existing 12 months before initiation of thewriting effort. The ACC Competency Management Com-mittee reviewed these disclosures to identify products(marketed or under development) pertinent to the docu-ment topic. Based on this information, the writing com-mittee was selected to ensure that the Chair and amajority of members have no relevant RWI. Authors withrelevant RWI were not permitted to draft initial text orvote on recommendations or curricular requirements towhich their RWI might apply. RWI was reviewed at the



2980

start of all meetings and conference calls and updated aschanges occurred. Relevant RWI for authors is disclosedin Appendix 1. To ensure transparency, comprehensiveRWI for authors, including RWI not pertinent to thisdocument, is posted online. Peer reviewers, along withtheir employment information and affiliation in the re-view process, are shown in Appendix 2. There are no RWIrestrictions for participation in peer review, promotingthe opportunity for comment on the document from avariety of constituencies/viewpoints to inform final docu-ment content. However, all reviewers must discloseall healthcare-related RWI and other entities to partici-pate in the review process, and their disclosureinformation is posted online. Disclosure informationfor the ACC Competency Management Committee isalso available online, as is the ACC disclosure policy fordocument development.

Eric S. Williams, MD, MACCChair, ACC Competency Management Committee

Jonathan L. Halperin, MD, FACCCo-Chair, ACC Competency Management Committee

1. INTRODUCTION

1.1. Document Development Process

1.1.1. Writing Committee Organization

The writing committee consisted of a broad range ofmembers representing the ACC, the American Heart As-sociation (AHA), the Heart Failure Society of America, theInternational Society for Heart & Lung Transplantation,and the American College of Physicians, identifiedbecause they perform $1 of the following roles: cardio-vascular training program directors; AHFTC trainingprogram directors; early-career experts through mid- andlater-career experts; general cardiologists; AHFTC spe-cialists representing both the academic and community-based practice settings as well as small, medium, andlarge institutions; specialists in all aspects of AHFTC,including mechanical circulatory support (MCS), cardiacresynchronization therapy, and pulmonary arterialhypertension; specialists in cardiothoracic surgery, crit-ical care cardiology, electrophysiology, and adultcongenital heart disease; physicians experienced intraining and working with the ACGME/Residency ReviewCommittee as well as the ABIM Cardiovascular Board andCompetency Committee; physicians experienced indefining and applying training standards according to the6 general competency domains promulgated by theACGME and the American Board of Medical Specialtiesand endorsed by the ABIM; and advanced practice nurses.This writing committee met the College’s disclosurerequirements for RWI as described in the Preamble.

1.1.2. Document Development and Approval

The writing committee convened by conference call ande-mail to finalize the document outline, develop theinitial draft, revise the draft based on committee feed-back, and ultimately approve the document for externalpeer review.

The document was reviewed by 11 official representa-tives from the ACC, AHA, Heart Failure Society ofAmerica, International Society for Heart & Lung Trans-plantation, and American College of Physicians, as well asby 35 additional content reviewers, including AHFTCtraining program directors (Appendix 2). The documentwas simultaneously posted for public comment fromNovember 1, 2016, to November 18, 2016, resulting incomments from 6 additional reviewers. A total of 445comments were submitted on the document. All com-ments were reviewed and addressed by the writingcommittee. A member of the ACC Competency Manage-ment Committee served as lead reviewer to ensure a fairand balanced peer review resolution process. Both thewriting committee and the ACC Competency Manage-ment Committee approved the final document to be sentfor organizational approval. The ACC, AHA, Heart FailureSociety of America, International Society for Heart & LungTransplantation, and American College of Physiciansapproved the document for publication. This docu-ment is considered current until the ACC CompetencyManagement Committee revises or withdraws it frompublication.

1.2. Background and Scope

The original 1995 American College of Cardiology recom-mendations for training in adult cardiology evolved fromCOCATS (1). After several iterations, COCATS 4 focuses ontrainee outcomes that require delineation of specificcomponents of competency within the subspecialty,definition of the tools necessary to assess training, andestablishment of milestones documenting the trainee’sprogression toward independent competency (2).Ultimately, the goal is for the trainee to develop theprofessional skillset to be able to evaluate, diagnose, andtreat patients with acute and chronic cardiovasculardisturbances.

Each COCATS 4 document includes individual taskforce reports that address subspecialty areas in cardiol-ogy, each of which is an important component in traininga fellow in cardiovascular disease. Task Force 12 of thatdocument addresses training in heart failure and updatedprevious standards for general cardiovascular training forfellows enrolled in cardiovascular fellowship programs(3). It addresses faculty, facilities, equipment, and ancil-lary support. It also addresses training components,including didactic, clinical, and hands-on experience, and

http://jaccjacc.acc.org/Clinical_Document/AHFTC_ATS_Author_Comprehensive_Disclosure_Table.pdf

http://jaccjacc.acc.org/Clinical_Document/AHFTC_ATS_Peer_Reviewer_Comprehensive_Disclosure_Table.pdf

http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/guidelines-and-documents-task-forces

http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy


2981

the number of procedures and duration of training.Importantly, the COCATS 4 Task Force 12 report did notprovide specific guidelines for AHFTC training.

This document focuses on training requirements forcardiologists seeking additional training in AHFTC, asubspecialty of adult cardiology. For training standardsrelated to pediatric heart failure, readers should referto the SPCTPD/ACC/AAP/AHA Training Guidelines forPediatric Cardiology Fellowship Programs Task Force 7:Pediatric Cardiology Fellowship Training in PulmonaryHypertension, Advanced Heart Failure, and Trans-plantation (4).

1.2.1. Evolution of AHFTC

In 2008, the American Board of Medical Specialtiesapproved a proposal by the ABIM to recognize the sec-ondary subspecialty of AHFTC. The ACGME approved thetraining program requirements for AHFTC, effective in2013. These actions acknowledged the special compe-tencies, knowledge, and skills required to care for pa-tients with advanced heart failure, including the possibleuse of ventricular assist devices or cardiac trans-plantation. Over subsequent years, an increasing numberof cardiologists have chosen to focus their research and/orclinical practice in this area.

The ABIM requires 3 years of cardiology fellowshiptraining before fellows may sit for the certification ex-amination in cardiovascular medicine. Cardiologistsseeking additional certification in AHFTC must completea 4th year of training that provides focused experiencewith a variety of heart failure patients and procedures, asoutlined in the following text.

1.2.2. Levels of Training

COCATS 4 updated standards for training fellows in car-diovascular medicine and established consistent trainingcriteria across all aspects of general cardiology, includingheart failure (3). For the cardiovascular fellowship, thefollowing 3 levels of training are delineated for training inheart failure.

n Level I training, the basic training required of traineesto become competent consultant cardiologists, isrequired of all fellows in cardiology, and can beaccomplished as part of a standard 3-year trainingprogram in general cardiology.

n Level II training, also described in COCATS 4, refers toadditional training that enables some cardiologists toperform or interpret specific procedures or render morespecialized care for patients with certain conditions.Level II training in selected areas may be achieved bysome trainees during the standard 3-year cardiovascu-lar fellowship, depending on their career goals and use

of elective rotations. In the case of heart failure, Level IItraining is intended for individuals seeking expertise incaring for heart failure patients, particularly those withmore advanced and challenging syndromes. Level IIemphasizes more detailed hemodynamic assessment ofthese patients and focuses on transitions of care forpatients with heart failure as well as the systems ofcare necessary to avoid hospital admission or read-mission. Level II training also prepares individualsto perform initial screening of patients cared for atnontransplant/nondurable MCS facilities for advancedtherapies, in collaboration with Level III–trainedexperts at advanced therapy sites.

n Level III training, the primary focus of this document,requires training and experience beyond the cardio-vascular fellowship for the acquisition of specializedknowledge and competency to render advanced carefor patients with specific conditions. Level III training isrequired of individuals seeking subspecialty boardcertification in AHFTC. Trainees in AHFTC are expectedto have completed 3 years of a cardiovascular fellow-ship and achieved Level I competency as described inthe ACC’s Core Cardiovascular Training Statement (2)and the COCATS 4 Task Force 12 report (3) beforebeginning the AHFTC fellowship. Level II training maybe completed prior to or in conjunction with Level IIItraining.

1.2.3. Methods for Determining Procedural Numbers

The recommended number of procedures performed andinterpreted by trainees under faculty supervision hasbeen developed based on the experience and opinions ofthe members of the writing group; previously publishedcompetency statements and COCATS documents; andpolicies of the ACGME, ABIM, and United Network forOrgan Sharing. In addition, the writing committee sur-veyed AHFTC training program directors for additionalinsight into procedural volumes. Of 69 directors ofABIM–recognized training programs, 21 responded. Theprocedural volumes and number of technical experiencessuggested in this document were considered the mini-mum necessary to expose trainees to a sufficient rangeand complexity of clinical material and allow supervisingfaculty to evaluate the competency of each trainee. Theseprocedural numbers (see Section 4.2) are intended asgeneral guidance, based on the needs and progress oftypical AHFTC trainees in typical programs. Thoseconsidering these thresholds should bear in mind thefundamental nature of educational milestones—thatproficiency and outcomes, rather than length of exposureor the exact number of procedures performed, are thedominant requirements. Flexibility is inherent to this



2982

concept, and the ACGME mandates that all programsestablish milestones for the acquisition of various com-petencies by trainees during the course of fellowshiptraining.

2. GENERAL STANDARDS

2.1. Faculty

Engaged faculty committed to teaching are critical to thesuccess of an AHFTC training program. Faculty mustinclude specialists with broad knowledge of and experi-ence in advanced heart failure, including advanced ther-apies and end-of-life care; management of patients withtemporary and durable MCS devices and their complica-tions; and care of heart transplant recipients, includingmanagement of acute and long-term complications. Themost recent ACGME Program Requirements for GraduateMedical Education in AHFTC require a single designatedprogram director and at least 1 additional key clinicalfaculty member for every 1.5 fellows (5). Each of the keyclinical faculty members should be currently certified inAHFTC by the ABIM and be able to dedicate, on average,10 hours per week throughout the year to the educationalprogram. In addition to developing, implementing, su-pervising, mentoring, and evaluating the fellows’ clinicaland research education, at least 50% of key clinical fac-ulty members must also demonstrate productivity inscholarship, specifically, peer-reviewed funding and/orpublication of original research, reviews, editorials, casereports, or textbook chapters.

2.2. Facilities

Required facilities include designated areas for outpatientand inpatient care of patients with heart failure. Inpatientfacilities must provide a safe and effective environmentfor optimal management of patients with heart failure ofvarying severity, ranging from mild decompensation torefractory cardiogenic shock. A safe and sterile catheter-ization laboratory is necessary to provide instruction inright heart catheterization and endomyocardial biopsy.Trainees should have access to operating rooms and staffto enable observation of ventricular assist device im-plants, heart procurements, and transplant surgeries.Trainees should have access to outpatient facilities sup-ported by dedicated nursing staff providing exposure tocoordinated longitudinal management of patients withchronic heart failure as well as training in the consultativeaspects of outpatient heart failure cardiology. Thereshould be an established system to promote effectivetransitions of care that ensures open communication be-tween caregivers in the outpatient and inpatient settings.Access to an HLA laboratory should be provided. Appro-priate space for didactic conferences should be available.

Quality and safety initiatives should be in place to assessquality of care and clinical outcomes longitudinally acrossinpatient and outpatient arenas throughout the health-care system.

2.3. Equipment

Cardiopulmonary exercise stress testing equipment isnecessary for education in the performance and inter-pretation of this crucial modality in patients with heartfailure. Additional technology that aids in the diagnosis,risk stratification, and management of patients withheart failure, such as echocardiography, transesophagealechocardiography, computed tomography, magneticresonance imaging, positron emission tomography, inva-sive angiography, and electrophysiology facilities, shouldbe available. Equipment for interrogation of implantableelectronic devices, including cardiac resynchronizationtherapy and implantable cardioverter-defibrillatorsshould be available for both inpatients and outpatients.Trainees should have access to catheterization labora-tories equipped with both thermodilution and Fick-basedmodalities for measuring cardiac output. Equipment formanagement and interrogation of durable MCS devices(e.g., Heartmate, HeartWare, or Total Artificial Heart)should be available so trainees gain proficiency in theiruse. When institutionally available, temporary, nondu-rable MCS devices including but not limited to intra-aorticballoon pump, TandemHeart, Impella devices, and/orextracorporeal membrane oxygenation should be acces-sible to trainees. It is not expected that each institutionwill have all of these devices, but every center shouldhave some. At all facilities, resuscitation equipment mustbe readily accessible.

2.4. Ancillary Support

Level III trainees should communicate with ancillarypersonnel to ensure comprehensive, evidence-based care.Critical to success is collaborative interaction with variousphysicians from within cardiology, including inter-ventionalists, advanced imaging specialists, electrophys-iologists, congenital heart disease specialists, and otherfields of general medical and surgical practice, to addressand treat the multiple comorbidities often seen in heartfailure patients. Key specialties include but are notlimited to cardiac and transplant surgeons, palliative carepractitioners, infectious disease specialists, gastroenter-ologists, hepatologists, nephrologists, pulmonologists,pulmonary hypertension (PH) specialists, and expertsin sleep medicine. In addition, communicationwith primary care physicians, geriatricians, obstetri-cians, endocrinologists, and oncologists is importantfor specific patient populations. Also essential is interac-tion with vital healthcare professionals including nurse


2983

practitioners and physician assistants, nurses, pharma-cists, dieticians, physical and occupational therapists, andsocial workers.

3. TRAINING COMPONENTS

3.1. Didactic Program

Didactic instruction may take place in a variety of for-mats, including lectures, journal clubs, grand rounds,clinical case presentations, research conferences,simulator-based training, and patient safety or qualityimprovement conferences. Discussions should focus onheart failure, PH, MCS, heart transplantation, and themedical knowledge items outlined in Table 1. Caseconferences, in particular, will allow AHFTC traineesopportunities to reflect on and learn from complexcases, generate ideas for stabilizing or improvingpatients’ health status and systems of care, and developskills as team leaders and educators. Journal clubs bringadvances in the field to trainees and provide opportu-nities to critically review published literature, includingassessments of validity and generalizability. Neitherthe most recent ACGME Program Requirements forGraduate Medical Education in AHFTC (5) nor theCOCATS 4 Heart Failure report (3) specifies thefrequency of didactic instruction, but weekly didacticsessions are a reasonable goal. Moreover, trainingprograms should emphasize to AHFTC trainees theimportance of lifelong learning that does not end uponcompletion of fellowship. For example, trainees shoulddevelop the ability to incorporate new therapies andtechnologies into practice.

3.2. Clinical Experience

Level III training in advanced heart failure requiresrigorous clinical experiences in both the outpatient andinpatient settings, including the intensive care unit. Ineach clinical setting, trainees should participate in su-pervised patient care and act as a first-line consultant fora portion of the training period with appropriate andtimely backup from attending AHFTC physicians. In thiscapacity, Level III trainees are expected to gather accu-rate, essential information from all sources, includingmedical interviews and record review, physical exami-nation, cardiac device interrogation, and diagnostic pro-cedures, including echocardiograms and hemodynamicevaluations. In addition, trainees should issue informedrecommendations about preventive, diagnostic, thera-peutic, and palliative options and interventions based onclinical judgment, scientific evidence, and patient pref-erences, ultimately developing, negotiating, and imple-menting patient management plans. Further, they shoulddevelop the skills necessary to competently performthe diagnostic and therapeutic procedures considered

essential to the management of patients with advancedheart failure, including those undergoing MCS or cardiactransplantation. Training programs must provide accessto a patient population of sufficient size and diversity tonurture these competencies. Multidisciplinary meetings,including participation in the transplant selection com-mittee, are important parts of the trainee’s clinicalexperience.

3.3. Hands-On Procedural Experience

Hands-on experience is required for successful training,and trainees should be exposed to the full spectrum ofAHFTC procedures. Level III training in AHFTC requirescompetence in right heart catheterization and endomyo-cardial biopsy, acquired through experiences in thecatheterization laboratory. Troubleshooting of right heartcatheters in the intensive care unit provides additionalexpertise in the use of invasive hemodynamic moni-toring, including recognition of artifact. Review of endo-myocardial biopsy specimens with pathologists facilitatesskill in the assessment of rejection. AHFTC trainees mustbecome familiar with the programming and interpretationof data stored in implantable cardioverter-defibrillatorsand cardiac resynchronization therapy devices, whichcan be acquired by device interrogation. Experience in theindications and management of MCS devices providingtemporary hemodynamic support of critically ill patientswith heart failure is essential, recognizing that criteria forselection of specific devices may vary. AHFTC trainingincludes exposure to implantation, interrogation, andadjustment of durable ventricular assist devices underechocardiographic guidance. Supervision of cardiopul-monary stress tests promotes expertise in this modality.Training should also include end-of-life discussions,shared decision making, and communication with pa-tients about advance care planning. Depending uponinstitutional capabilities and trainee interest, additionalprocedural experiences may include implantation and/ormonitoring of pulmonary artery sensors, invasiveassessment of patients with adult congenital heart dis-ease, performance and interpretation of the results ofpulmonary vasodilator challenges, assessment of exercisehemodynamics, or implantation of temporary MCS de-vices. The numbers of procedures that should becompleted during the 12 months of AHFTC are summa-rized in Section 4.2, and the approach to evaluation ofcompetency is in Section 5.

The field of advanced heart failure is rapidly evolvingwith the introduction of new technologies. Althoughspecific training requirements cannot be provided for allof these, Level III AHFTC trainees who intend to performthese procedures are expected to undergo the sametraining as required for faculty members performingthem.

TABLE 1Competency Components and Curricular Milestones for Level III Training in Advanced Heart Failure andTransplant Cardiology

Milestones (Months)

MEDICAL KNOWLEDGE All (12) Add

Heart Failure

1. Know the principles of excitation-contraction coupling and the contractile apparatus of the cardiomyocyte. �2. Know the pathophysiology of heart failure, including such concepts as ventricular remodeling, neurohormonal

activation, fetal gene expression, wall stress, signaling pathways (calcium, beta-adrenergic signaling, and nitricoxide), myocardial energetics, electrical and mechanical dyssynchrony, and the role of the extracellular matrix.

�

3. Know common genetic underpinnings of both dilated and hypertrophic cardiomyopathy, their clinical phenotypes,and the role of genetic testing for patients and their families.

�

4. Know important hemodynamic principles related to heart failure, including normal cardiac physiology,contractility, preload, afterload, and interpretation of pressure-volume loops and ventricular performance(Frank-Starling) curves.

�

5. Know the epidemiology and risk determinants of left ventricular dysfunction, ventricular hypertrophy, and heartfailure (both with reduced and preserved ejection fraction), including incidence and prevalence overall and in specialpopulations.

�

6. Know classification methods of heart failure including American College of Cardiology/American Heart Associationstages, New York Heart Association classes, and INTERMACS (Interagency Registry for Mechanically AssistedCirculatory Support) profiles.

�

7. Know the risk factors, methods, and risk scores commonly used to stratify patients with heart failure, including theirlimitations, and how these methods are used to evaluate the need for advanced therapies.

�

8. Know the epidemiology and pathophysiology of acute systolic or diastolic heart failure, including new-onset andacute-on-chronic heart failure.

�

9. Know typical and atypical clinical presentations of patients with advanced heart failure (e.g., cachexia,worsening renal function, cognitive impairment, medication intolerance, ventricular tachycardia) and theirmanagement.

�

10. Know the risks of arterial and venous thromboembolic complications in patients with heart failure. �11. Know the pathophysiology, clinical presentation, and differential diagnosis of heart failure with preserved ejection

fraction and its management.�

12. Know the pathophysiology, clinical presentation, and methods of risk stratification of patients with hypertrophiccardiomyopathy and its management.

�

13. Know the distinguishing features of and appropriate diagnostic studies for specific etiologies of heart failure, includingcoronary artery disease, valvular heart disease, hypertension, myocarditis, infiltrative processes, toxins (e.g., illicitdrugs), chemotherapy, pregnancy, congenital heart disease, radiation, pericardial processes, endocrinopathies,high-output states, stress cardiomyopathy, and inherited syndromes.

�

14. Know the indications for percutaneous and surgical intervention for valvular heart disease in patients with heartfailure.

�

15. Know the evidence base, including randomized clinical trial data, supporting contemporary guideline-directed heartfailure therapy.

�

16. Know the pharmacology of common inotropes and vasopressors used in the management of low-output heart failureand shock.

�

17. Know key principles regarding transitions of care between the outpatient and inpatient setting, and vice versa,including indications for hospitalization and readiness for discharge for patients with heart failure.

�

18. Know the role of assays for natriuretic peptide and other biomarkers in the management of patients with heart failure. �19. Know the utility of noninvasive imaging (e.g., echocardiography, nuclear cardiology, cardiac magnetic resonance

imaging, and positron emission tomography) in assessment of patients with cardiomyopathy (including those relatedto valvular heart disease) and heart failure.

�

20. Know the strengths and limitations of common quality-of-life tools (e.g., Minnesota Living with Heart Failure andKansas City Cardiomyopathy Questionnaire) used in patients with heart failure.

�



2984

TABLE 1 Competency Components, continued

Milestones (Months)


21. Know which lifestyle choices and comorbidities (e.g., obstructive sleep apnea, depression, anemia, diabetes,hypertension, renal failure) contribute to the development of or clinical instability of patients with heart failure,as well as potential management options for such comorbid conditions.

�

22. Know the roles of submaximal (including 6-minute walk) and maximal exercise testing, and cardiopulmonary stresstesting in patients with heart failure.

�

23. Know the roles of implantable cardiac electronic device therapy in patients with heart failure, including cardioverter-defibrillators, pacemakers, and resynchronization devices.

�

24. Know the roles of coronary imaging, ischemia testing, viability testing, and revascularization in patients with heartfailure.

�

25. Know the role of invasive hemodynamic assessment in patients with decompensated heart failure. �26. Know the epidemiology and pathophysiology of the cardiorenal syndrome and its management. �27. Know the pathophysiology of cardiac dysfunction associated with cirrhosis and the hemodynamic consequences of

portal hypertension.�

28. Know the role of implantable technology to allow monitoring of patients with heart failure, including from afar(i.e., remote monitoring).

�

29. Know the definition of frailty, tools available for assessment of frailty, and how frailty influences diagnosis, prognosis,and candidacy for advanced therapies in patients with heart failure.

�

30. Know the roles of palliative and hospice care in patients with heart failure and the steps needed to implementthem.

�

31. Know the role of endomyocardial biopsy in the evaluation of myocarditis and infiltrative cardiomyopathies. �32. Know the various chemotherapy agents associated with heart failure and the management of cardiac complications

of chemotherapy.�

33. Know the potential contribution of arrhythmias to development of heart failure and/or decompensation andappropriate pharmacological and ablation options for therapy.

�

34. Know the roles of exercise training and cardiac rehabilitation in patients with heart failure with or without pulmonaryhypertension, cardiac transplantation, or mechanical circulatory support.

�

Pulmonary Hypertension

35. Know the World Heart Organization classification and etiologies of pulmonary hypertension. �36. Know the epidemiology, risk factors, prognostic factors, and natural history of pulmonary hypertension. �37. Know the functional classes and appropriate treatment of patients with each type of pulmonary

hypertension.�

38. Know the role of invasive hemodynamic assessment, including when to perform vasoreactivity testing to assess andmanage patients with pulmonary hypertension, including pre- and post-capillary components.

�

39. Know the classes of medications available to treat pulmonary hypertension and their use alone and in combination,including management of side effects.

�

40. Know the roles of exercise and cardiopulmonary testing to assess and manage patients with pulmonaryhypertension.

�

41. Know the indications for referral to a specialized pulmonary hypertension center. �42. Know the roles of balloon atrial septostomy, thromboendarterectomy, and lung transplantation in patients with

pulmonary arterial hypertension.�

Mechanical Circulatory Support

43. Know indications for and contraindications to both temporary and durable mechanical circulatory support for bridgingand destination therapy.

�

44. Know the expected survival following use of durable mechanical circulatory support. �45. Know clinical determinants favoring mechanical circulatory support versus transplantation as durable

strategies.�


2985


Milestones (Months)


46. Know optimal anticoagulation strategies for patients with ventricular assist devices. �47. Know the management principles for patients with cardiogenic shock, including selection of temporary mechanical

circulatory support.�

48. Know the management principles and potential complications of extracorporeal membrane oxygenation. �49. Know the anatomic, surgical, and comorbid conditions that may impact mechanical circulatory support strategies in

adult patients with congenital heart disease.�

50. Know intraoperative and early postoperative complications of durable mechanical circulatory support. �51. Know the risk factors for and presentations and management of common complications of durable ventricular assist

devices, including right heart failure, stroke, driveline infections, device thrombosis, hemolysis, gastrointestinalbleeding, and aortic insufficiency.

�

52. Know the risk scores that predict right heart failure in patients with left ventricular assist devices. �Cardiac Transplantation

53. Know the indications for and contraindications to heart transplantation. �54. Know when patients listed for heart transplant need mechanical circulatory support, and the potential benefits and

complications of this type of therapy.�

55. Know current United Network for Organ Sharing allocation listing policies for heart transplantation. �56. Know the expected short- and long-term survival rates following heart transplantation. �57. Know the role of multiorgan (e.g., heart-lung, heart-kidney, heart-liver) transplantation. �58. Know the principles of immunology that pertain to heart transplantation, including sensitization and

histocompatibility.�

59. Know and understand the efficacy, risks, and limitations of currently available methods for desensitization of patientsawaiting heart transplantation.

�

60. Know the preoperative considerations applicable to potential heart transplant recipients. �61. Know the anatomic, surgical, and comorbid conditions that may impact transplant surgery planning and outcomes in

adult patients with congenital heart disease, necessitating evaluation at a transplant center with expertise in theseconditions.

�

62. Know the intraoperative and early postoperative complications of heart transplantation and theirmanagement.

�

63. Know the process by which the heart procurement team interacts with teams procuring other organs fromdonors.

�

64. Know the factors used to assess the suitability of a potential donor heart. �65. Know the mechanisms of action, side effects, and potential drug–drug interactions of immunosuppressant

drugs.�

66. Know how cardiac denervation impacts cardiac physiology, including response to exercise and pharmacologicalagents, and clinical manifestations of myocardial ischemia.

�

67. Know the risk factors for, clinical presentations of, and treatment for hyperacute, acute cellular, and antibody-mediated rejection.

�

68. Know the risk factors, clinical presentation, International Society for Heart & Lung Transplantation grading system,and strengths and limitations of diagnostic tools for cardiac allograft vasculopathy.

�

69. Know when to consider cardiac retransplantation. �70. Know common post-transplant complications and how to monitor them in the outpatient setting, including

hypertension, diabetes, malignancy, renal dysfunction, infection, obesity, and endocrinological and neurologicalsequelae.

�

71. Know the strengths and limitations of strategies used to detect and monitor transplant rejection. �



2986


Milestones (Months)


72. Know the grades of acute cellular and antibody-mediated transplant rejection, based on interpretation of anendomyocardial biopsy.

�

73. Know the clinical presentation of common opportunistic infections in cardiac transplant recipients, as well as thepotential for donor transmission of infectious organisms.

�

EVALUATION TOOLS: chart-stimulated recall, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS All (12) Add

Heart Failure

1. Skill to oversee genetic testing of patients with cardiomyopathy, including selection of patients and collaborationwith genetic counselors.

�

2. Skills to optimize therapeutic regimens based on guideline-directed pharmacological and device-based therapies instable patients with heart failure with reduced ejection fraction.

�

3. Skill to estimate the jugular venous pressure by clinical examination. �4. Skills to optimize a diuretic regimen in both the inpatient and outpatient settings. �5. Skill to decide whether and when to hospitalize patients with heart failure. �6. Skill to optimize pharmacological therapies in patients with decompensated heart failure, including adjustments after

stabilization and prior to discharge.�

7. Skills to assess left ventricular systolic and diastolic properties noninvasively in patients with heart failure. �8. Skill to select individualized diagnostic testing for patients with a new diagnosis of heart failure. �9. Skill to minimize the risk of hospital readmission following discharge for decompensated heart failure. �10. Skills to recognize and stabilize patients with cardiogenic shock. �11. Skills to recognize and stabilize noncardiogenic shock in patients with cardiomyopathy or a history of heart

failure.�

12. Skills to perform and interpret findings from right heart catheterization in patients with heart failure. �13. Skills to assess risk of patients with heart failure undergoing cardiac or noncardiac surgery, and to manage their

hemodynamic status perioperatively.�

14. Skills to perform and interpret cardiopulmonary stress testing. �15. Skills to initiate palliative and supportive care and to address symptoms and goals of care for patients with advanced

heart failure across the care continuum.�

16. Skills to manage supraventricular and ventricular arrhythmias in patients with stable or decompensated heartfailure.

�

17. Skill to collaborate with cardiac electrophysiologists to stabilize patients with ventricular tachycardia stormcomplicating cardiomyopathy, heart failure, or mechanical circulatory support.

�

18. Skill to collaborate with cardiac surgeons, interventional cardiologists, or members of a structural heart careteam to determine whether percutaneous or surgical valve intervention is necessary for patients withheart failure.

�

19. Skills to work effectively with experts in adult congenital heart disease to assess and manage patients with theseconditions, including determining when to employ mechanical support or cardiac transplantation.

�

20. Skill to determine the indications for coronary revascularization in patients with ischemic cardiomyopathy. �21. Skills to interrogate implantable cardioverter-defibrillators, cardiac resynchronization pacemakers, and cardiac

resynchronization-defibrillator devices in patients with cardiomyopathy and/or heart failure to determine the burdenof arrhythmias, diagnostic information, and basic device functionality.

�

22. Skill to determine when patients are inotrope-dependent and to manage them in the outpatient setting. �23. Skill to work effectively with obstetricians in the care of pregnant patients with a cardiomyopathy and/or heart

failure.�


2987


Milestones (Months)


24. Skill to provide self-help tools to patients with heart failure to minimize the risk of decompensation. �25. Skills to educate heart failure patients about warning signs that signify or predict clinical instability, and to help them

develop action plans in the event warning signs appear.�

Pulmonary Hypertension

26. Skill to evaluate patients with pulmonary hypertension to determine etiology. �27. Skill to recommend the initial pharmacological regimen for patients with pulmonary arterial hypertension. �28. Skills to assess functional capacity and risk stratify patients with pulmonary arterial hypertension. �29. Skills to perform serial noninvasive assessments of right ventricular function and pulmonary arterial pressure and

integrate these data in the management of patients with pulmonary hypertension.�

30. Skills to detect clinical deterioration in patients with pulmonary hypertension and adjust treatment accordingly,including determining when hospitalization is necessary.

�

31. Skill to stabilize patients with acute right ventricular failure in the setting of pulmonary hypertension. �Mechanical Circulatory Support

32. Skill to identify appropriate options for temporary hemodynamic support for patients in cardiogenic shock. �33. Skill to identify appropriate candidates for durable ventricular assist devices. �34. Skills to interrogate, interpret, and manipulate pump parameters in patients with temporary and durable

hemodynamic assist devices.�

35. Skill to recognize the indications for total artificial heart or right ventricular assist device rather than left ventricularassist device alone.

�

36. Skill to optimally set the speed of durable ventricular assist devices. �37. Skills to select and interpret noninvasive and invasive data to evaluate patients with temporary and durable

ventricular assist devices (e.g., ramp study, aortic valve opening, or right ventricular assessment).�

38. Skills to identify and manage right heart failure in patients with left ventricular assist devices. �39. Skill to manage long-term durable mechanical circulatory support in the outpatient setting. �40. Skills to recognize and manage complications of durable mechanical circulatory support, including stroke, device

thrombosis, right heart failure, hypertension, or arrhythmias.�

41. Skills to recognize left ventricular recovery and assess patients with left ventricular assist devices for potentialexplantation.

�

42. Skill to determine whether and when to hospitalize patients with durable ventricular assist devices. �43. Skill to select management options (including hospitalization and diagnostic investigation) for patients with durable

ventricular assist devices and gastrointestinal bleeding.�

44. Skills to collaborate with anesthesiologists and procedural specialists to optimize management during invasiveprocedures or noncardiac surgery in patients with continuous flow, durable ventricular assist devices.

�

Cardiac Transplantation

45. Skill to determine whether and when patients warrant cardiac transplantation. �46. Skill to recognize comorbidities that preclude cardiac transplantation. �47. Skill to recognize irreversible pulmonary hypertension that precludes isolated heart transplantation. �48. Skill to assess the suitability of a given heart for transplantation in a potential recipient. �49. Skills to adjust immunosuppressant therapy to minimize the risk of rejection, while balancing competing risks of

infection, malignancy, renal failure, and other toxicities.�

50. Skill to collaborate with colleagues in the histocompatibility laboratory to assess a heart transplant recipient’s reactiveantibody panel, preformed and post-transplant antihuman leukocyte antigen antibodies, and immunologicalcompatibility with a donor heart.

�

51. Skill to manage heart transplant recipients in the immediate post-transplant period, including those withcomplications, in conjunction with a multidisciplinary team.

�

52. Skill to determine whether and when illness in heart transplant recipients requires hospitalization. �



2988


Milestones (Months)


53. Skills to interpret with a pathologist the findings of endomyocardial biopsies to determine the need for treatment ofacute cellular or antibody-mediated rejection, and oversee treatment.

�

54. Skills to collaborate with other members of a multidisciplinary team in managing common comorbidities andcomplications following heart transplantation, including hypertension, dyslipidemia, renal insufficiency, infection, andcancer.

�

55. Skills to collaborate with invasive and interventional cardiologists in the prevention, recognition, and treatment oftransplant vasculopathy.

�

56. Skills to interpret noninvasive tests, including echocardiograms, gene expression profiling (e.g., Allomap testing), andother biomarkers to evaluate for rejection in heart transplant recipients.

�

57. Skill to perform endomyocardial biopsy to assess for transplant rejection. �58. Skill to prescribe therapies to prevent opportunistic infections, including Cytomegalovirus, Nocardia, and

Pneumocystis Jiroveci pneumonia in heart transplant recipients.�

59. Skill to oversee the use of immunizations in patients before and after cardiac transplantation. �

EVALUATION TOOLS: chart-stimulated review, direct observation, and multisource evaluation.

SYSTEMS-BASED PRACTICE All (12) Add

1. Utilize appropriate care settings and teams for patients with various profiles and stages of heart failure before or aftermechanical circulatory support or transplantation.

�

2. Incorporate risk/benefit analysis and cost considerations in diagnostic and treatment decisions, including the adoptionof new technologies.

�

3. Utilize an interdisciplinary, coordinated team approach for patient management, including care transitions, palliativecare, and employment-related issues.

�

4. Effectively utilize an interdisciplinary transitional-care approach to monitor the progress of ambulatory patients withheart failure to maintain stability and avoid preventable hospitalization.

�

5. Collaboratively work with all members of the advanced heart failure and transplant cardiology team, including cardiacsurgeons, palliative care specialists, other medical consultants, nurses, nurse practitioners, physician assistants, socialworkers, dietitians, physical and occupational therapists, and pharmacists.

�

6. Identify the financial, cultural, social, and emotional barriers to successful outcomes after mechanical circulatorysupport or transplantation.

�

7. Effectively utilize an interdisciplinary approach to care for patients with or at risk of advanced heart failure, pulmonaryhypertension, and mechanical circulatory support or cardiac transplantation.

�

EVALUATION TOOLS: chart-stimulated recall, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT All (12) Add

1. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performanceimprovement.

�

2. Utilize decision support tools to access guidelines and pharmacological information at the point of care. �3. Incorporate feedback from faculty and staff to improve performance. �4. Develop habits of regular and critical reading of the heart failure/transplant literature to maintain current knowledge

of the field and promote lifelong learning.�

EVALUATION TOOLS: conference presentation, direct observation, global evaluation, reflection, and self-assessment.

PROFESSIONALISM All (12) Add

1. Show compassion for and effective management of end-of-life issues, including discussions of death and dying, acrossthe spectrum of patients with heart failure, pulmonary hypertension, mechanical circulatory support, or hearttransplantation.

�


2989


Milestones (Months)

PROFESSIONALISM All (12) Add

2. Clearly and objectively discuss available therapies for advanced heart failure, including palliative care, mechanicalcirculatory support, or transplantation.

�

3. Interact respectfully with patients, families, and all members of the healthcare team, including ancillary andsupport staff.

�

4. Demonstrate high ethical standards, including the recognition and management of overt and more subtle potentialconflicts of interest, when making diagnostic or therapeutic decisions.

�

EVALUATION TOOLS: conference presentation, direct observation, multisource evaluation, reflection, and self-assessment.

INTERPERSONAL AND COMMUNICATION SKILLS All (12) Add

1. Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomicbackgrounds.

�

2. Engage in shared decision making, including the potential role of palliative care and discussing the risk of death, withpatients and their families considering mechanical circulatory support and/or transplant.

�

3. Effectively lead the interdisciplinary heart failure team to promote comprehensive and balanced decision making withrespect to the selection of mechanical circulatory support versus heart transplantation.

�

4. Skill to discuss the potential for donor transmission of infectious agents to the recipient, and ability to use a shareddecision-making approach with recipients when assessing a donor at risk.

�

5. Skill to provide emotional support to patients and their families before and after mechanical circulatory support orcardiac transplantation.

�

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ Additional competencies that extend beyond the core expectations and that may be achieved by some advanced heart failure and transplant cardiology (AHFTC) specialistsbased on career focus, either during or following formal AHFTC fellowship training (see text for details).



2990

3.4. Diagnosis and Management of Emergencies andComplications

All trainees should be certified in advanced cardiovascular lifesupport and well versed in the recognition and managementof complications and emergencies encountered in theadvanced heart failure population. Examples include cardio-genic shock, such as INTERMACS (Interagency Registry forMechanically Assisted Circulatory Support) 1 patients; life-threatening arrhythmias, such as ventricular tachycardiastorm and complete heart block; severe cardiac complicationsin pregnant patients; respiratory failure in patients with heartfailure and concomitant pulmonary illness; severe rejectionwith allograft failure; or life-threatening infection in immu-nosuppressed transplant recipients. Complications of endo-myocardial biopsy and pulmonary artery catheterizationshould be recognized and managed, with emphasis uponknowing when to seek assistance from an interventionalcardiologist or cardiothoracic surgeon in such circumstancesas cardiac perforation or pericardial tamponade. Traineesshould be taught to recognize and initiate management forcomplications of MCS devices, including thrombosis, stroke,infection, bleeding, and pump malfunction. They should befamiliar with advanced life support in patients receiving

mechanical support (6). All such complications should bedocumented and reported in accordance with institutionalrequirements and reviewed at patient safety or qualityimprovement conferences.

3.5. Diagnosis and Management of Less Common ClinicalConditions and Syndromes

Level III trainees should become familiar with less com-mon conditions associated with heart failure symptoms.These include myocardial noncompaction, hypertrophiccardiomyopathy, cardiac amyloidosis, muscular dystro-phy, arrhythmogenic right ventricular cardiomyopathy,glycogen storage disease, congenital heart defects,sarcoidosis, hemochromatosis, and pulmonary artery hy-pertension, as well as other infectious, nutritional, andautoimmune conditions. Several uncommon inflamma-tory conditions have the potential to cause cardiomyop-athy and heart failure, including fulminant giant cellmyocarditis and acute hypersensitivity myocarditis.Metabolic or endocrine disorders such as pheochromo-cytoma and acromegaly can lead to cardiomyopathy andheart failure. Other less common conditions presenting asheart failure include cardiac neoplasms, constrictive


2991

pericarditis, or acute right ventricular failure (RVF). TheLevel III trainee should be aware of these less-commonconditions and understand their pathophysiology andmanagement. The Level III trainee may not be expert inmanaging these conditions, but should be able to stabilizepatients with them and seek guidance from the literatureand from experts.

3.6. Research and Scholarly Activity

All trainees are expected to carry out research and/orengage in scholarly activities during Level III training inAHFTC. Scholarly activity related to heart failure, PH,MCS, or transplant cardiology may include original clin-ical, basic science, translational, or interdisciplinaryresearch; quality improvement activities; presentation atinstitutional, local, and national meetings; and publica-tion of original papers, reviews, chapters, or case reports.Trainees should be encouraged to develop and maintainhabits of self-learning and continuous professionalimprovement by reading heart failure and heart trans-plantation journals and attending journal clubs, confer-ences, and appropriate scholarly meetings. A trainee’sprogress in research should be monitored by mentorsthrough general oversight, direct observation, and criticalreview of presentations and manuscripts.

4. TRAINING REQUIREMENTS

4.1. Development and Evaluation of Core Competencies

Training requirements in AHFTC address the 6 generalcompetencies promulgated by the ACGME and endorsedby the ABIM: medical knowledge, patient care and pro-cedural skills, practice-based learning and improvement,systems-based practice, interpersonal and communica-tion skills, and professionalism. The ACC has used thisstructure to define and depict the components of theclinical competencies for cardiology. The curricularmilestones for each competency and domain also providea developmental roadmap for fellows as they progressthrough various levels of training and serve as an un-derpinning for the milestones reported to ACGME. TheACC has adopted this format for its competency andtraining statements, career milestones, lifelong learning,and educational programs.

Table 1 depicts the 6 competency domains and theirassociated curricular milestones for training in AHFTC, aswell as examples of evaluation tools suitable for assessingcompetence in each domain. The focus of this documentis on delineation of the core competencies expected of alltrainees in AHFTC upon successful completion of a stan-dard 1-year ACGME–accredited AHFTC fellowship. Thesecompetencies are marked under the column “All.” Certainareas of advanced knowledge or procedural skills arenot typically encountered enough during a standard

12-month period of training to develop and demonstratecompetence, and therefore, require additional dedicatedexposure. These selected Level III competency compo-nents are designated in the “Add” column of the table,usually require additional training, and represent a skilllevel beyond that necessary for AHFTC certification. Oneyear of formal training beyond the standard 3-year gen-eral cardiovascular fellowship, for example, is unlikely toconfer expert competency in the management of the mostcomplex patients undergoing heart transplantation orventricular assist device implantation or those requiringother more specialized knowledge or procedural skills.These additional competencies may be obtained during orafter the standard AHFTC fellowship, depending on thetrainee’s career focus and the opportunities available atthe training program. The milestone interval indicates thestage by which the typical trainee will have achieved aparticular competency. Although the competency com-ponents included in the “All” column should be achievedby all trainees and are appropriate areas for assessment,not every component needs to be individually assessed inevery trainee. Rather, as with all educational activities,assessment is a sampling process that should be tailoredto the needs of the individual trainee and program.

4.2. Number of Procedures

An essential component of training an AHFTC practitioneris robust understanding of the indications for, contrain-dications to, and complications of procedures commonlyperformed in patients with advanced heart failure,including ventricular assist devices and cardiac trans-plantation (Table 2). Each trainee should maintain a re-cord that documents the indications, outcomes, anddiagnoses associated with procedures that he or she per-formed or attempted, along with the name of the super-vising faculty member.

It is axiomatic that direct supervision of invasive pro-cedures performed by trainees must occur until thetrainee demonstrates sufficient proficiency and judg-ment, attainment of which must be documented by theProgram Director. Faculty members must teach and su-pervise trainees in the performance and interpretation ofprocedures. Trainees must participate in preproceduralplanning and postprocedural management.

In addition to the skills to safely perform procedures,the trainee must possess the skills to determine theappropriate procedure, obtain and interpret proceduraldata, and utilize the data to optimize patient care. Thesuggested minimum procedural volumes during AHFTCtraining are shown in Table 2.

4.3. Heart Failure

The AHFTC trainee should know the pathophysiology of heartfailure at the molecular, cellular, and organ levels, including

TABLE 2Recommendations for Minimum ProceduralVolume or Technical Experience to Achieve andDemonstrate Competence in AHFTC

Procedure/Technical Skill Numbers*

Observe and interpret CPX 5 (observe)20 (interpret)

Perform and interpret right heartcatheterization

50 (of which at least 30 should bepretransplantation)

Perform and interpret pulmonaryvasodilator challenge in pulmonaryhypertension†

5

Interrogate ICDs and CRT devices 20/20 (or document comparabletraining during general cardiologyfellowship and review 3 ICD and3 CRT interrogations with an EPattending who attests to thecompetency expected of AHFTCphysicians)

Observe implantation of VADs 3

Perform and interpret VADinterrogation

10

Oversee the medical care, includinganticoagulation and VAD speedsetting, of LVAD recipients

15 (of which 5 must be during indexhospitalization of LVADimplantation)

Perform and interpret LVAD rampprocedures†

10

Observe procurement of donor organs 3

Observe cardiac transplant surgery 3

Oversee the medical care, includingimmunosuppressive regimen, of acardiac transplant recipient

30 (of which 5 must be during indextransplant hospitalization)

Perform endomyocardial biopsies,femoral access

5

Perform endomyocardial biopsies,internal jugular access

45

Review endomyocardial specimens,with a range of pathology, incollaboration with a pathologist

20

Interpret the severity of CAV from acoronary angiogram utilizing theISHLT Cardiac AllograftVasculopathy Grading scale

10

Participate in end-of-life and/orpalliative care discussions

10

*Recommendations for number of procedures required are based on consensus rec-ommendations and indicate numbers that should be performed and/or interpretedsuccessfully to achieve competence. These numbers are intended as general guidance,based on the educational needs and progress of typical AHFTC trainees. Competency toperform each procedure must be based on evaluation by the supervising physician andmay exceed or be below the threshold number shown in Table 2. †Acquired duringadditional months beyond a dedicated 12-month advanced heart failure/transplantfellowship.

AHFTC ¼ advanced heart failure and transplant cardiology; CAV ¼ cardiac allograftvasculopathy; CPX ¼ cardiopulmonary exercise testing; CRT ¼ cardiac resynchronizationtherapy; EP ¼ electrophysiology; ICD ¼ implantable cardioverter-defibrillator; ISHLT ¼International Society for Heart & Lung Transplantation; LVAD ¼ left ventricular assistdevice; and VAD ¼ ventricular assist device.



2992

the roles of neurohormonal activation and ventricularremodeling in disease progression. They also should know thediagnostic and management strategies for patients with heartfailure due to ischemic and nonischemic forms of heart dis-ease, including infiltrative cardiomyopathies, inherited

cardiomyopathies, and cardiomyopathies related to endo-crinopathy, pregnancy, chemotherapy and other toxins suchas illicit drugs, as well as those with adult congenital heartdisease (3). Trainees should become proficient in the man-agement of both acute and chronic heart failure using avail-able pharmacotherapies, and acquire a deep understanding ofthe evidence base developed from randomized trials thatunderlie guideline-directed therapies (7). They should befamiliar with the epidemiology, common genetic abnormal-ities, and risk factors for heart failure and know how to assessand manage commonly encountered comorbidities in pa-tients with heart failure. The AHFTC trainee should developthe skills to identify advanced heart failure, direct an evalu-ation, and determine the appropriateness of patients for car-diac transplantation, MCS, or palliative care (3).

4.3.1. Inpatient

The AHFTC trainee should learn the pathophysiology andepidemiology of various acute heart failure syndromes,including coronary ischemia, accelerated hypertension,decompensated heart failure, cardiogenic shock, and rightheart failure, in patients with and without heart trans-plantation or MCS. As the prevalence of heart failure withpreserved ejection fraction is approximately 50%, traineesshould know the pathophysiology (e.g., impaired diastolicrelaxation, myocardial stiffening, ventricular-arterialcoupling), clinical presentation, differential diagnosis andmanagement of acute decompensations of patients with thistype of heart failure. Trainees should also become skilled inselection of an optimal diuretic regimen, know the role ofvasodilator and inotropic therapy, employ measures to pre-vent thromboembolic complications, know criteria fordischarge of hospitalized patients with heart failure, andfacilitate safe transition to the outpatient setting.

4.3.1.1. Initial Assessment

The AHFTC trainee should rapidly identify patients withheart failure in danger of hemodynamic collapse or deathand know how to stabilize them. A key element of theinitial assessment is to identify factors that precipitatehospitalization for heart failure. In addition, proficiencyin obtaining a history and performing a physical exami-nation is essential to assessing a patient’s hemodynamicprofile (8), and this must be integrated with hemody-namic and physiological data in patients presenting withdecompensated heart failure.

4.3.1.2. Hemodynamic Interpretation

Although invasive hemodynamic monitoring is notroutinely indicated in the management of patients withacute heart failure, trainees should become familiar withindications for pulmonary artery catheterization as sup-ported by the 2013 ACC/AHA Guideline for the Manage-ment of Heart Failure (7). Trainees should acquire the


2993

skills to troubleshoot pulmonary artery catheters in thecatheterization laboratory and intensive care unit, and tointerpret hemodynamic parameters measured by thistechnology, including right atrial pressure, pulmonaryartery pressure, pulmonary capillary wedge pressure,cardiac output and index, and derived variables includingpulmonary and systemic vascular resistances. Traineesshould learn to utilize echocardiographically derived es-timates of filling pressures and cardiac output to guidetherapy.

4.3.1.3. Cardiogenic Shock

The AHFTC trainee should recognize and stabilize pa-tients with cardiogenic shock, and distinguish this fromother causes of shock. Trainees should learn the in-dications for, contraindications to, and clinical pharma-cology of intravenous vasopressor and inotropic agents inpatients with advanced heart failure, and recognize pa-tients chronically dependent upon these agents. Traineesshould promptly identify patients with refractorycardiogenic shock and assess candidates for temporaryMCS devices in the context of long-term treatment goals(implantable ventricular assist devices, explantation aftermyocardial recovery, heart transplantation, bridging todecision, or palliative care). Familiarity with availabletemporary support device is crucial, and trainees shouldtroubleshoot temporary MCS devices in conjunction witha multidisciplinary team. Trainees should know the roleof palliative and hospice care in patients with advancedheart failure. Ongoing care should address symptomcontrol, psychosocial distress, health-related quality oflife, end-of-life care, caregiver support, and access toevidence-based disease-modifying interventions.

4.3.1.4. Decompensated Heart Failure

Trainees should become proficient in supervising patientshospitalized with decompensation of chronic heart failurethrough initial stabilization and optimization of therapy.Management issues include optimizing volume statusthrough selection of an appropriate diuretic regimen,recognition of risk factors for the cardiorenal syndrome,implementation of inotropic therapy when indicated,considerations in use of renal replacement therapy, con-version from intravenous to oral diuretic medications,and initiation or modification of guideline-directed med-ical therapy during the hospitalization and at discharge.Trainees should become facile with other aspects ofmanagement that may arise during hospitalization,including treatment of arrhythmias, interrogation ofimplantable cardioverter-defibrillators or cardiacresynchronization therapy devices to determinearrhythmia burden and functionality of the device, andassessment of the role of coronary revascularization.Trainees should be able to identify patients whose clinical

course is on a downward trajectory, including those whoshould receive MCS, cardiac transplantation, or end-of-life care. Trainees should become proficient in facili-tating safe transitions of outpatient care that minimizethe likelihood of readmission for heart failure.

4.3.2. Outpatient

Trainees should learn the various methods of classifyingheart failure, including the ACC/AHA stages, New YorkHeart Association functional classes, and INTERMACSprofiles, as well as the epidemiology and risk determinantsapplicable to patients with heart failure with reduced andpreserved ejection fraction. The AHFTC trainee should learnhow to direct the outpatient evaluation of patients withrecently identified heart failure to identify specific etiol-ogies and understand the role of genetic testing. Varioustools are available to assess patients with heart failure,including the clinical history and physical examination,multimarker risk scores, quality of life assessments,natriuretic peptide testing, stress testing includingcardiopulmonary stress tests, and noninvasive imagingtechniques. Trainees should become comfortable witheach of these modalities and know their strengths andlimitations. Trainees should learn how to up-titrateguideline-directed medical therapy to achieve appropriatetargets. Clinical deterioration in an outpatient and in-dications for hospitalization should be recognized. Traineesshould learn how to incorporate advanced care planningand end-of-life discussions in the outpatient setting.

4.4. Pulmonary Hypertension

PH treatment involves important elements of hemody-namic management of pulmonary artery pressures andright heart failure. The AHFTC trainee should be able tomanage, or co-manage with a PH care team, patients withPH from class I to advanced class IV stages.

4.4.1. Inpatient

AHFTC trainees should learn how to detect clinical dete-rioration in hospitalized patients with PH, adjust treat-ment accordingly, and stabilize those with acute RVFusing parenteral therapies in conjunction with a multi-disciplinary team. Further, they should learn the appro-priate use of invasive hemodynamic monitoring andknow when to refer patients to a PH specialist.

4.4.2. Outpatient

In coordination with a PH care team, the AHFTC traineeshould learn to classify patients according to the WorldHeart Organization criteria regarding etiology, risk-stratify patients with respect to treatment requirements,understand the role of exercise testing, and initiateguideline-based therapy for patients with PH, cognizantof the pharmacological options for PH, including



2994

combination therapies and their side effects. The traineeshould recognize clinical worsening, adjust treatment asnecessary, and appropriately refer patients for moreadvanced PH care, including balloon atrial septostomy orlung transplantation.

4.5. Mechanical Circulatory Support

A much broader group of individuals will seek compe-tency in advanced heart failure cardiology than willdirectly manage patients with durable left ventricularassist devices (LVADs) on a daily basis. Nevertheless, MCSis an important therapeutic option for patients withadvanced heart failure, including those with cardiogenicshock, and all AHFTC trainees should acquire competencyin the use of these technologies. Trainees should under-stand the results of relevant clinical trials and registrydata, maintain currency on contemporary guidelines formanagement of patients with mechanical support (9–11),and keep abreast of emerging MCS technologies. It isessential that trainees learn to identify appropriate can-didates for temporary hemodynamic support and durableventricular assist devices. Trainees should appreciate thevalue of a multidisciplinary team approach to MCS byfostering collaborative relationships with cardiac sur-geons, intensivists, advanced practice providers, socialworkers, infectious disease specialists, palliative carespecialists, ventricular assist device coordinators, andother team members.

4.5.1. Inpatient

The trainee must acquire the medical knowledge and clinicalskills to identify candidates for temporary and/or durableMCS, including those needing biventricular support. Thetrainees should know the indications for and contraindica-tions to temporary hemodynamic support, be able to trou-bleshoot devices used in their institution, and develop skillsto manage patients in the early post-implant period inconjunction with the multidisciplinary team.

Patients on durable LVAD support may present with avariety of complications. These complications includeRVF, gastrointestinal bleeding, driveline infections, ar-rhythmias, pump thrombosis, and aortic insufficiency.The trainee should know and recognize risk factors forthese complications, and understand how to managethem. Because early RVF portends a poor prognosisfollowing LVAD implantation, the trainee should recog-nize preoperative risk factors for RVF, understand peri-operative management strategies aimed at minimizingrisk of RVF, and appreciate circumstances in whichbiventricular support or transplant may be indicated. Thetrainee should master the skills necessary to manage RVFthat develops after LVAD deployment. The skillset mustalso include: 1) understanding of durable LVAD deviceparameters and how to interpret or manipulate changes in

these parameters in clinical context; 2) management ofanticoagulation; 3) recognition and management of pumpthrombosis; 4) development of professional rapport withsurgical, gastrointestinal, and infectious disease col-leagues, all of whom play an integral role in helping tomanage LVAD complications; and 5) management of pa-tients facing imminent death, including relief of symp-toms. Interested trainees should develop the abilities toperform and interpret ramp echocardiograms to assesslikelihood of LVAD thrombosis, although these skills mayrequire additional training beyond the typical 12-monthAHFTC fellowship.

Finally, because failure to communicate openly andfully with patients and caregivers may contribute to un-realistic expectations or unmet needs for care, the traineeshould master the ability to communicate effectivelyregarding prognosis, level of understanding, and end-of-life preferences, and foster a close working relationshipwith palliative care specialists.

4.5.2. Outpatient

Patients supported with durable ventricular assist devicesrequire frequent monitoring in the outpatient setting. Thetrainee should develop the skills to manage patients inthis setting, including: 1) optimal titration of pharmaco-therapies for heart failure, hypertension, and anti-coagulation; 2) diagnostic interrogation of device-specificpump parameters to inform therapy, including optimiza-tion of LVAD speed; 3) identification of complications thatrequire hospital admission; and 4) recognition of patientswith left ventricular recovery who may benefit from de-vice explantation.

4.6. Cardiac Transplantation

The 12 additional months of an AHFTC fellowshiprequired for Level III training may not provide the expe-rience in cardiac transplantation required for qualificationas a heart transplant physician under United Network forOrgan Sharing criteria (12). A broader group of individualswill seek competency in advanced heart failure cardiologythan will directly manage patients undergoing cardiactransplantation. Nonetheless, many programs offer anexperience within the Level III curriculum to establishcompetency in the care of patients undergoing trans-plantation that meets the United Network for OrganSharing criteria.

Most importantly, through interaction with a widevariety of patients at different stages in the transplantprocess, with different levels of acuity, socioeconomicand cultural backgrounds, healthcare knowledge, andpreferences, the trainee will acquire necessary compe-tence and expertise in pretransplant and post-transplantmanagement, as outlined in the competency milestones(Table 1).


2995

4.6.1. Inpatient

4.6.1.1. Pretransplant Management

Trainees must learn the approach to recipient selection,focusing on identification of candidates ill enough tomerit transplantation yet free of medical or psychosocialcontraindications (13), and also know how to evaluate thequality of a potential donor heart. Trainees should learnUnited Network for Organ Sharing allocation listing pol-icies, including when to apply for exception for candi-dates who do not meet stated criteria for a given statusyet have a comparable severity of illness. Trainees shouldbecome familiar with the management of the sensitizedpatient, including interpretation of panel reactive anti-bodies, and understand desensitization regimens,including but not limited to plasmapheresis, intravenousimmune globulin, rituximab, and bortezomib. Traineesshould be exposed to the unique issues involved inconsidering transplantation for patients with adultcongenital heart disease.

4.6.1.2. Acute Postoperative Management

The postoperative management of heart transplant re-cipients starts with donor evaluation and organ procure-ment. Trainees should become familiar with the logisticsof these steps and gain experience interpreting virtual,prospective, and retrospective cross-matches; deter-mining the need for induction therapy; and managinginitial post-transplant immunosuppression and infectionprophylaxis.

4.6.1.3. Postoperative Complications

Trainees should become familiar with early postoperativehemodynamics and be able to direct subsequent testing todistinguish such complications as primary graft dysfunc-tion, delayed hyperacute rejection, right heart failurerelated to PH, and cardiac tamponade. They shouldbecome competent as part of a multidisciplinary team incaring for patients requiring temporary mechanical sup-port such as extracorporeal membrane oxygenation.Trainees should develop the skills to manage potentialdonor-derived infections and malignancies, includinginforming patients and families of these events, andappropriately consult specialists for further evaluationand management. Trainees should be able to manageother common complications in the early postoperativesetting, including early rejection, bradyarrhythmias andtachyarrhythmias, thromboembolism, delirium, andinfections.

4.6.1.4. Inpatient Heart Transplant Management Followingthe Index Admission

Heart transplant patients may be readmitted months oryears after transplantation for cardiac or noncardiac

problems, such as acute cellular or antibody-mediatedrejection, graft failure, transplant vasculopathy, in-fections, or malignancy. Trainees will be exposed to hearttransplant recipients with these complications and shouldacquire the skills to direct the care of such patients.Trainees should collaborate with cardiac pathologistsinterpreting biopsies, interventional cardiologistsconsidering percutaneous intervention, and infectiousdisease specialists treating opportunistic infections (14).Given that the side effects and toxicities of immunosup-pression affect many organ systems, the AHFTC traineewill consult with numerous other specialists as well. It isparticularly important for trainees to learn the extrac-ardiac toxicities of immunosuppression, such as theneurotoxicity and nephrotoxicity of calcineurin in-hibitors, pulmonary toxicity of proliferation signal in-hibitors, and gastrointestinal toxicity of mycophenolatemofetil, as patients will likely present symptoms of theseconditions initially to the AHFTC specialist (15).

4.6.2. Outpatient

4.6.2.1. Immunosuppression

The major goal of outpatient management of a hearttransplant recipient is to maximize benefit and minimizetoxicity of immunosuppression. Level III trainees shouldbecome familiar with strategies to individualize immu-nosuppression based on the patient’s risk of rejection andinfection, as guided by a history of rejection or infection,medication tolerance, antibody sensitization, compliance,presence of transplant vasculopathy, malignancy, pe-ripheral blood gene-expression profiling, and results ofT-cell immune function assays. They should learn the roleof standard triple-drug immunosuppression with a calci-neurin inhibitor, an antimetabolite (most commonlymycophenolate mofetil), and corticosteroids, and knowwhen to consider proliferation signal inhibitors sirolimusor everolimus. Trainees should become familiar withmethodologies for rejection surveillance and adjunctiveimmunotherapies for patients with recurrent rejection.

4.6.2.2. Chronic Complications

Chronic immunosuppression places patients at risk ofhypertension, obesity, drug-drug interactions, renaldysfunction, gout, diabetes, dyslipidemia, osteoporosis,infections, malignancy, and other disorders. Thus,trainees should learn appropriate screening and preven-tion strategies, including immunization, and develop theskills to manage complications in conjunction with otherproviders. Long-term care of heart transplant recipientsincludes screening for and management of transplantvasculopathy. Trainees should learn the appropriatetriage to revascularization, retransplantation, or end-of-life management.



2996

4.7. Shared Decision Making and Palliative Care

According to the ACCF/AHA Guideline for the Manage-ment of Heart Failure, “palliative and supportive care iseffective for patients with symptomatic heart failure toimprove quality of life” (7). Furthermore, given the acuityof illness to which patients with heart failure are prone,trainees require advanced communication skills to carefor critically ill patients and those with complicationsfollowing LVAD implantation or cardiac transplantation.Trainees should incorporate palliative care throughoutthe spectrum of illness and know when to consult palli-ative care specialists. Discussions focused on shared de-cision making provide patients, families, and providersopportunities to work together to make decisions aboutcare and choose treatment options that are aligned withthe patient’s values, goals, and preferences (16). Forexample, trainees should acquire experience re-evaluating and revising the medical regimen and modifydevice-based therapy as goals of care change toward theend of life.

5. EVALUATION OF PROFICIENCY

Evaluation tools in AHFTC training include direct obser-vation by instructors, case logbooks, conference and casepresentations, multisource evaluations, trainee portfolio/curriculum vitae, in-training examination, and simula-tion. Self-assessment programs are available through theACC and Heart Failure Society of America. Program di-rectors and trainees are encouraged to incorporate theseresources into the course of training. Following comple-tion of AHFTC training, trainees will be eligible to take theABIM Board Certification Examination in AHFTC.

Judgement, case management, and bedside and pro-cedural skills must be evaluated regularly in everytrainee. Quality of care and follow-up; reliability; judge-ment or decisions or actions that result in complications;interaction with other physicians, patients, and labora-tory support staff; initiative; and the ability to makeappropriate decisions independently should be consid-ered. Trainees should maintain records of participationand advancement in the form of a Health InsurancePortability and Accountability Act–compliant electronic

database or logbook that meets ACGME reporting stan-dards and summarizes pertinent clinical information(number of cases, diagnoses, disease severity, outcomes,and disposition for each encounter).

Under the guidance of the program director, facultyshould verify and document each trainee’s experiences,assess performance, and confirm satisfactory achieve-ment. The program director is responsible for confirmingexperience and competence and reviewing the overallprogress of individual trainees with the Clinical Compe-tency Committee to ensure achievement of selectedtraining milestones and identify areas in which additionalfocused training may be required.

PRESIDENTS AND STAFF

American College of Cardiology

Richard A. Chazal, MD, FACC, PresidentShalom Jacobovitz, Chief Executive OfficerWilliam J. Oetgen, MD, MBA, FACC, Executive Vice

President, Science, Education, Quality, and PublishingDawn R. Phoubandith, MSW, Director, Competency

ManagementKimberly Kooi, MHA, Education Design AssociateAmelia Scholtz, PhD, Publications Manager, Science,

Education, Quality, and PublishingAmerican Heart Association

Steven Houser, PhD, FAHA, PresidentNancy Brown, Chief Executive OfficerRose Marie Robertson, MD, FAHA, Chief Science andMedicine OfficerGayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice

President, Office of Science OperationsHeart Failure Society of America

Mandeep R. Mehra, MD, FHFSA, PresidentMichele Blair, Chief Executive OfficerInternational Society for Heart & Lung Transplantation

Maryl R. Johnson, MD, PresidentAmanda W. Rowe, Executive DirectorAmerican College of Physicians

Nitin S. Damle, MD, MS, MACP, PresidentDarilyn V. Moyer, MD, FACP, Executive Vice President,

Chief Executive Officer

R EF E RENCE S

1. COCATS guidelines for training in adult cardiovas-cular medicine: Core Cardiology Training Symposium.June 27–28, 1994. American College of Cardiology.J Am Coll Cardiol. 1995;25:1–34.

2. Halperin JL, Williams ES, Fuster V. COCATS 4 intro-duction. J Am Coll Cardiol. 2015;65:1724–33.

3. Jessup M, Ardehali R, Konstam MA, et al. COCATS 4task force 12: training in heart failure. J Am Coll Car-diol. 2015;65:1866–76.

4. Webber SA, Hsu DT, Ivy DD, et al. Task force 7:pediatric cardiology fellowship training in pulmonaryhypertension, advanced heart failure, and trans-plantation. J Am Coll Cardiol. 2015;66:732–9.

5. Accreditation Council for Graduate Medical Education.ACGME program requirements for graduate medical ed-ucation in advanced heart failure and transplant cardi-ology (internal medicine). Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/

159_advHeartFailure_transplantCard_2016_1-YR.pdf.Accessed July 12, 2016.

6. Garg S, Ayers CR, Fitzsimmons C, et al. In-hospitalcardiopulmonary arrests in patients with left ventric-ular assist devices. J Card Fail. 2014;20:899–904.

7. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: areport of the American College of Cardiology Foun-dation/American Heart Association Task Force on

http://refhub.elsevier.com/S0735-1097(17)30791-X/sref1













https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/159_advHeartFailure_transplantCard_2016_1-YR.pdf











2997

Practice Guidelines. J Am Coll Cardiol. 2013;62:e147–239.

8. Nohria A, Lewis E, Stevenson LW. Medical man-agement of advanced heart failure. JAMA. 2002;287:628–40.

9. Feldman D, Pamboukian SV, Teuteberg JJ, et al. The2013 International Society for Heart and Lung Trans-plantation guidelines for mechanical circulatory sup-port: executive summary. J Heart Lung Transplant.2013;32:157–87.

10. Peura JL, Colvin-Adams M, Francis GS, et al. Rec-ommendations for the use of mechanical circulatorysupport: device strategies and patient selection: ascientific statement from the American Heart Associa-tion. Circulation. 2012;126:2648–67.

11. Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on

the use of percutaneous mechanical circulatory sup-port devices in cardiovascular care. J Am Coll Cardiol.2015;65:e7–26.

12. UNOS. Attachment I to appendix B of UNOS bylaws:designated transplant program criteria. Available at:https://www.unos.org/wp-content/uploads/unos/Appendix_B_AttachI_XIII.pdf. Accessed July 14, 2016.

13. Mehra MR, Canter CE, Hannan MM, et al. The 2016International Society for Heart Lung Transplantationlisting criteria for heart transplantation: a 10-year up-date. J Heart Lung Transplant. 2016;35:1–23.

14. Husain S, Sole A, Alexander BD, et al. The 2015International Society for Heart and Lung Trans-plantation guidelines for the management of fungalinfections in mechanical circulatory support andcardiothoracic organ transplant recipients: executivesummary. J Heart Lung Transplant. 2016;35:261–82.

15. Costanzo MR, Dipchand A, Starling R, et al.The International Society of Heart and Lung Trans-plantation guidelines for the care of heart transplantrecipients. J Heart Lung Transplant. 2010;29:914–56.

16. Allen LA, Stevenson LW, Grady KL, et al. Decisionmaking in advanced heart failure: a scientific statementfrom the American Heart Association. Circulation.2012;125:1928–52.

KEY WORDS ACC/AHA/HFSA/ISHLT/ACPTraining Statement, advanced heart failure,cardiomyopathy, clinical competence, fellowshiptraining, heart transplantation, mechanicalcirculatory support, pulmonary hypertension,training milestones, transplant cardiology,ventricular assist devices





















https://www.unos.org/wp-content/uploads/unos/Appendix_B_AttachI_XIII.pdf

https://www.unos.org/wp-content/uploads/unos/Appendix_B_AttachI_XIII.pdf






















2998

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)—2017

ACC/AHA/HFSA/ISHLT/ACP ADVANCED TRAINING STATEMENT ON ADVANCED HEART FAILURE

AND TRANSPLANT CARDIOLOGY

Institutional/

Committee Member Employment ConsultantSpeakersBureau

Ownership/Partnership/Principal

PersonalResearch

Organizational orOther Financial

BenefitExpertWitness

Mariell Jessup (Chair) Leducq Corporation—Chief ScientificOfficer*

None None None None None None

Mark H. Drazner(Vice Chair)

University of Texas SouthwesternMedical Center—Professor, Internal

Medicine

None None n Trevena† None n St. JudeMedical†

None

Wendy Book Emory Healthcare—Director, EmoryAdult Congenital Heart Center

None None None n Actelion None None

Joseph C. Cleveland, Jr. University of Colorado—SurgicalDirector, Cardiac Transplantation and

Mechanical Circulatory Support;Professor of Surgery

None None None n HeartWaren St. Jude

Medical

None None

Ira Dauber Centura Heart Colorado—MedicalDirector for Heart Failure; SouthDenver Cardiology Heart Center—Medical Director for Heart Failure;University of Colorado—AssociateClinical Professor of Medicine


Susan Farkas Sanford Heart and Vascular Center—Director of Echocardiography;

University of North Dakota SMHS—Clinical Associate Professor of

Medicine


Mahazarin Ginwalla University Hospitals Cleveland MedicalCenter—Medical Director of HeartFailure; Assistant Professor of

Medicine


Jason N. Katz University of North Carolina School ofMedicine—Divisions of Cardiology andPulmonary/Critical Care Medicine;

Director, Mechanical Heart Program;Director, Cardiac Intensive Care Unit;Director, Cardiovascular & Thoracic

Surgical Intensive Care Unit and CriticalCare Service; Director, CardiovascularClinical Trials; Associate Professor of

Medicine

None None None n Thoratec None None

Peggy Kirkwood Mission Hospital—Cardiovascular andPalliative Care Nurse Practitioner


Michelle M. Kittleson Cedars-Sinai Heart Institute—Director,Heart Failure Research; Director, Post-Graduate Education in Heart Failure

and Transplantation; AssociateProfessor of Medicine


Joseph E. Marine Johns Hopkins University School ofMedicine—Vice-Director, Division ofCardiology; Associate Professor of

Medicine


Paul Mather Perelman School of Medicine,University of Pennsylvania—Professorof Clinical Medicine Heart Failure–

Transplant Program‡


Alanna A. Morris Emory University—Assistant Professor n Novartis None None None None None

Donna M. Polk Brigham and Women’s Hospital—Director, Cardiovascular Fellowship


Antoine Sakr Loma Linda University Medical Center,Department of Cardiology—Co-

Director, Advanced Heart Failure andTransplant; Assistant Professor of

Medicine


Continued on the next page

Committee Member Employment ConsultantSpeakersBureau

Ownership/Partnership/Principal

PersonalResearch

Institutional/Organizational orOther Financial

BenefitExpertWitness

Kelly H. Schlendorf Vanderbilt Heart and VascularInstitute—Co-Director, Advanced HF/Transplant Training Program; Assistant

Professor in Medicine


Esther E. Vorovich Northwestern University FeinbergSchool of Medicine—Assistant

Professor in Medicine–Cardiology

n ArgonMedical

n Plexus†

None None None n Rex Medical† None

This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships werereviewed and updated in conjunction with all conference calls of the writing committee during the document development process. The table does not necessarily reflect relationshipswith industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of $5% of the voting stock or share of thebusiness entity, or ownership of $$10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s grossincome for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwisenoted. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories or additionalinformation about the ACCFDisclosure Policy forWriting Committees. Please refer to http://jaccjacc.acc.org/Clinical_Document/AHFTC_ATS_Author_Comprehensive_Disclosure_Table.pdffor a list of corresponding comprehensive healthcare-related disclosures for each author.*Dr. Jessup was employed by University of Pennsylvania School of Medicine as a Professor of Medicine during most of the writing effort.†Significant relationship.‡Dr. Mather was employed by Jefferson Heart Institute as Director, Advanced Heart Failure and by the Sidney Kimmel Medical College of Thomas Jefferson University as the LubertFamily Professor of Cardiology during most of the writing effort.

ABIM ¼ American Board of Internal Medicine; ACC ¼ American College of Cardiology; ACP ¼ American College of Physicians; AHA ¼ American Heart Association; APFED ¼ AmericanPartnership for Eosinophilic Disorders; CDC ¼ Centers for Disease Control and Prevention; HFSA ¼ Heart Failure Society of America; ISHLT ¼ The International Society for Heart & LungTransplantation; NHLBI ¼ National Heart, Lung, and Blood Institute; and NIH ¼ National Institutes of Health.

APPENDIX 1. CONTINUED


2999

APPENDIX 2. PEER REVIEWER INFORMATION—2017 ACC/AHA/HFSA/ISHLT/ACP ADVANCED TRAINING

STATEMENT ON ADVANCED HEART FAILURE AND TRANSPLANT CARDIOLOGY

Name Employment Representation in Peer Review Process

Juan Aranda, Jr. University of Florida—Professor of Medicine; Director, Heart Failureand Cardiac Transplantation

Official Reviewer, ACC Lifelong Learning OversightCommittee

Christian S. Breburda Maricopa Medical Center, University of Arizona Phoenix—Professor ofMedicine; Director, Noninvasive Cardiology

Official Reviewer, ACC Board of Governors

R. Ford Bursey Memorial University of Newfoundland—Professor of Medicine Official Reviewer, American College of Physicians

Rosario V. Freeman University of Washington—Professor of Medicine; Fellowship ProgramDirector, Cardiology

Official Reviewer, ACC Competency ManagementCommittee Lead Reviewer

Sharon A. Hunt Stanford University—Professor of Cardiovascular Medicine; MedicalDirector, Post Transplant

Official Reviewer, International Society for Heart & LungTransplantation

Kenneth B. Margulies Perelman School of Medicine, University of Pennsylvania—Professorof Medicine

Official Reviewer, American Heart Association

Michael X. Pham Sutter Health, California Pacific Medical Center—Medical Director,Advanced Heart Failure, Cardiac Transplantation, and Mechanical

Circulatory Support

Official Reviewer, International Society for Heart & LungTransplantation

Sean P. Pinney Mount Sinai Health System—Director, Heart Failure andTransplantation

Official Reviewer, Heart Failure Society of America

Joseph Rogers Duke University—Professor, Division of Cardiology Official Reviewer, Heart Failure Society of America

Lynne Warner Stevenson Brigham and Women’s Hospital—Director, Heart Failure andCardiomyopathy

Official Reviewer, American Heart Association

Soma Wali David Geffen School of Medicine, Olive View-UCLA Medical Center—Professor of Medicine; Chair, Medicine

Official Reviewer, American College of Physicians

Patrick C. Alguire American College of Physicians—Senior Vice President, MedicalEducation

Organizational Reviewer, American College of Physicians

Mirvat Alasnag King Fahd Armed Forces Hospital—Director, CatheterizationLaboratory

Content Reviewer, ACC Early Career Section LeadershipCouncil

James A. Arrighi Rhode Island Hospital—Director, Graduate Medical Education Content Reviewer, ACC Competency ManagementCommittee


http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy

http://jaccjacc.acc.org/Clinical_Document/AHFTC_ATS_Author_Comprehensive_Disclosure_Table.pdf


Luis Arroyo Tampa General Hospital—Director, Advanced Heart Failure andTransplant Fellowship

Content Reviewer, AHFTC Training Program Director

David A. Baran Newark Beth Israel Medical Center—Director, Heart Failure andTransplant Research


Eric R. Bates University of Michigan—Professor of Internal Medicine Content Reviewer, ACC Competency ManagementCommittee

Craig J. Beavers University of Kentucky Healthcare and University of Kentucky,College of Pharmacy—Cardiovascular Clinical Pharmacy Coordinator

Content Reviewer, ACC Cardiovascular Team Council

Rachel Bijou Columbia University—Program Director, Advanced Heart Failure andTransplant Cardiology


Javed Butler Stony Brook University—Professor of Medicine Content Reviewer, ABIM Cardiology Board andACC/AHA/HFSA Heart Failure Guideline

Sandra V. Chaparro University of Miami—Associate Professor of Medicine; Director, HeartFailure and Transplant Fellowship Program; University of Miami

Hospital—Director, Heart Failure Clinic


Teresa De Marco University of California, San Francisco—Professor of Medicine;Fellowship Program Director, Advanced Heart Failure and TransplantCardiology; Director, Advanced Heart Failure Therapies Program;

Medical Director, Heart Transplantation; Director, Adult PulmonaryHypertension Comprehensive Care Center


Sondra M. DePalma American Academy of Physician Assistants—Director, Regulatory andProfessional Practice

Content Reviewer, ACC Cardiovascular Team Council

Sarah J. Goodlin VA Portland Health Care System—Chief, Geriatrics Content Reviewer, Palliative Care Expert

Luanda Grazette Keck Medical School, University of Southern California—AssociateProfessor; Director, Advanced Heart Failure and Cardiomyopathy


Linda L. Hart Bon Secoures Heart and Vascular Institute—Acute Care NursePractitioner, Cardiology

Content Reviewer, ACC HF&T Council

Maryl R. Johnson University of Wisconsin School of Medicine and Public Health—Professor of Medicine


Kiran K. Khush Stanford University—Associate Professor of Medicine Content Reviewer, AHFTC Training Program Director

Rachel Klinedinst Hospital of the University of Pennsylvania, Penn Heart and VascularCenter—Palliative Care Nurse Practitioner

Content Reviewer, Palliative Care Expert

David E. Lanfear Henry Ford Health System—Section Head, Advanced Heart Failure andTransplant


Grace Lin Mayo Clinic—Assistant Professor of Medicine, Department ofCardiovascular Diseases; Director, Heart Failure Services


Vallerie McLaughlin University of Michigan—Professor of Medicine; Director, PulmonaryHypertension Program

Content Reviewer, Pulmonary Hypertension Expert

Burhan Mohamedali Rush University Medical Center—Medical Director, Heart Failure Content Reviewer, ACC HF&T Council

James Mudd Oregon Health and Science University—Associate Professor ofMedicine; Director, Heart Failure, Heart Transplant, and Advanced

Cardiac Devices


Sandra Oliver-McNeil Wayne State University—Assistant Professor; Nurse Practitioner Content Reviewer, ACC Cardiovascular Team Council

Gurusher Panjrath George Washington University School of Medicine and HealthSciences—Assistant Professor of Medicine; Director, Heart Failure and

Mechanical Support Program


Parag C. Patel Mayo Clinic—Assistant Professor of Medicine Content Reviewer, AHFTC Training Program Director

Marwan Refaat American University of Beirut Faculty of Medicine and MedicalCenter—Assistant Professor of Medicine; Director, Cardiovascular

Fellowship Program

Content Reviewer, ACC Electrophysiology SectionLeadership Council

Tina Shah Michael E. DeBakey VA Medical Center, Baylor College of Medicine—Assistant Professor of Medicine


Richard Shemin David Geffen UCLA School of Medicine—Robert and Kelly DayProfessor; Ronald Reagan UCLA Medical Center—Chief, Cardiac

Surgery; Executive Vice-Chairman, Surgery; Co-Director,Cardiovascular Center; Director, Cardiovascular Quality

Content Reviewer, ACC Surgeons Section LeadershipCouncil

Jooyoung Julia Shin Montefiore Medical Center, Albert Einstein College of Medicine—Associate Professor of Medicine; Director, Advanced Heart Failure and

Transplant Cardiology Fellowship






3000


Shashank S. Sinha University of Michigan—Fellow-in-Training Content Reviewer, ACC Early Career Section LeadershipCouncil

Karen Stout University of Washington—Professor of Internal Medicine; AdjunctProfessor of Pediatrics

Content Reviewer, ACC Adult Congenital and PediatricCardiology Section Leadership Council

Nancy K. Sweitzer University of Arizona—Professor of Medicine; Chief, CardiologyDivision

Content Reviewer, COCATS 4 Training in Heart FailureTask Force Member

Hector O. Ventura University of Queensland—Professor of Medicine; Ochsner HealthSystem—Section Head, Heart Failure Heart Transplant


Gaby Weissman Medstar Heart and Vascular Institute, Washington Hospital Center/Georgetown University—Program Director, Cardiovascular Disease

Fellowship

Content Reviewer, ACC Cardiovascular Training SectionLeadership Council

This table represents the individuals, organizations, and groups that peer reviewed this document. Please refer to http://jaccjacc.acc.org/Clinical_Document/AHFTC_ATS_Peer_Reviewer_Comprehensive_Disclosure_Table.pdf for a list of corresponding comprehensive healthcare-related disclosures for each reviewer.

AHFTC ¼ advanced heart failure and transplant cardiology; COCATS ¼ Core Cardiovascular Training Statement; HF&T ¼ Heart Failure & Transplant; VA ¼ Veterans Affairs; otherabbreviations as in Appendix 1.



3001

APPENDIX 3. ABBREVIATION LIST

AB

AC

AC

AH

AH

CO

LV

MC

PH

RV

RW

IM ¼ American Board of Internal Medicine

C ¼ American College of Cardiology

GME ¼ Accreditation Council for Graduate MedicalEducation

A ¼ American Heart Association

FTC ¼ advanced heart failure and transplantcardiology

CATS ¼ Core Cardiovascular Training Statement

AD ¼ left ventricular assist device

S ¼ mechanical circulatory support

¼ pulmonary hypertension

F ¼ right ventricular failure

I ¼ relationships with industry



2017 acc/aha/hfsa/ishlt/acp advanced training statement … · advanced training statement 2017...

Documents