Cardiovascular Fellowship Training in Cardio-Obstetrics: JACC Review Topic of the Week.

The United States has the highest maternal mortality in the developed world with cardiovascular disease as the leading cause of pregnancy-related deaths. In response to this, the emerging subspecialty of cardio-obstetrics has been growing over the past decade. Cardiologists with training and expertise in caring for patients with cardiovascular disease in pregnancy are essential to provide effective, comprehensive, multidisciplinary, and high-quality care for this vulnerable population. This document provides a blueprint on incorporation of cardio-obstetrics training into cardiovascular disease fellowship programs to improve knowledge, skill, and expertise among cardiologists caring for these patients, with the goal of improving maternal and fetal outcomes.

Impact of Virtual Interviewing on Geographic Placement for Cardiology Fellowship Recruitment.

Background Virtual interviewing for cardiology fellowship was instituted in the 2021 fellowship application cycle because of the COVID-19 pandemic and restricted travel. The impact on geographic patterns of fellow-training program matching is unknown. This study sought to determine if there was a difference in geographic placement of matched fellows for cardiology fellowship match after initiation of virtual interviews compared with in-person interviewing. Methods and Results All US-based accredited cardiovascular disease fellowship programs that participated in the 2019 to 2021 fellowship match cycles and had publicly available data with fellowship and residency training locations and training year were included. Each fellow was categorized based on whether their fellowship and residency programs were in the same institution, same state, same US census region, or different census region. Categories were mutually exclusive. Of 236 eligible programs, 118 (50%) programs were identified, composed of 1787 matched fellows. Compared with the previrtual cohort (n=1178 matched fellows), there was no difference in the geographic placement during the 2021 virtual cycle (n=609 matched fellows) (P=0.19), including the proportion matched at the same program (30.6% versus 31.5%), same state but different program (13% versus 13.8%), same region but different state (24.2% versus 19.7%), or different region (35% versus 33.1%). There was also no difference when stratified by program size or geographic region. Conclusions The use of virtual interviewing in the 2021 cardiology fellowship application cycle showed no significant difference in the geographic placement of matched fellows compared with in-person interviewing. Further study is needed to evaluate the impact of virtual interviewing and optimize its use in fellowship recruitment.

Burnout and Well-Being Among Cardiology Fellowship Program Directors.

OBJECTIVES: The third annual Cardiovascular Diseases (CV) Fellowship Program Directors (PDs) Survey sought to understand burnout and well-being among CV fellowship PDs. BACKGROUND: Physician burnout is a common phenomenon. Data on burnout among cardiologists, specifically CV PDs, remain limited. METHODS: The survey contained 8 questions examining satisfaction, stress, and burnout among CV fellowship PDs. Burnout was defined based on the self-reported presence of ≥1 symptom of burnout, constant feelings of burnout, or complete burnout. RESULTS: Survey response rate was 57%. Most respondents were men (78%) and 54% represented university-based programs. Eighty percent reported satisfaction with their current job as PD, and 96% identified interactions with fellows as a driver of their satisfaction. Forty-five percent reported feeling a great deal of stress from their job. Stress was higher among women PDs, early-career PDs, and PDs of larger and university-based programs. Twenty-one percent reported some symptoms of burnout, and only 36% reported enjoyment without stress or burnout. Rates of enjoyment without stress or burnout were higher among men and late-career PDs, PDs of smaller programs, and PDs of community-based programs. Seventeen percent of PDs reported a high likelihood of resigning in the next year, of which the most common reason was the tasks of PDs were becoming overwhelming. CONCLUSIONS: Most CV fellowship PDs are satisfied with their position, but stress and burnout remain common. Women PDs, early-career PDs, and PDs of larger, university-based programs demonstrate more adverse markers of well-being. Opportunities exist to support CV fellowship PDs in their critical role.

Comprehensive assessment of coronary computed tomography angiography by using Leaman and Leiden score in overweight and obese patients.

Coronary computed tomography angiography (CCTA) is a non-invasive modality used to assess for coronary artery disease. The CT Leaman and Leiden scores utilize coronary plaque location, composition and severity of stenosis to risk stratify patients for cardiovascular events with remarkable precision. This study compares the CCTA Leaman and Leiden score between overweight and obese populations in addition to their associated baseline characteristics. All patients who underwent CCTA within the last 1 year from a single institution were included for initial analysis. Body mass index (BMI) was used to classify patients who were overweight (25.0 to < 30 kg/m2) or obese (≥ 30 kg/m2). Patients with a BMI of < 25 kg/m2 were excluded from further analysis. Patients were divided into overweight and obese groups. CT Leaman and Leiden scores, in addition to baseline characteristics were subsequently compared between the two groups. Overall, a strong correlation between CT Leaman and Leiden scores was found (R2 = 0.9831). Patients classified as obese have more coronary lesions 0.71 ± 0.12 vs 0.31 ± 0.50 in overweight patients (p = 0.02) and tended to have a higher positive CT Leiden (5.47 ± 4.10 vs 3.90 ± 1.36, p = 0.2) and Leaman (3.45 ± 2.58 vs 2.35 ± 0.90, p = 0.1). Furthermore, obese patients with a Leiden score > 5 had significantly higher scores compared to overweight patients (10.22 ± 2.54 vs 5.87 ± 0.64, p = 0.016). Obese patients had similar average CT Leaman and Leiden scores compared to overweight individuals but were more likely to have higher CT Leiden scores > 5 which may indicate a higher risk for adverse cardiovascular outcomes.

Perceptions on Diversity in Cardiology: A Survey of Cardiology Fellowship Training Program Directors.

Background The lack of diversity in the cardiovascular physician workforce is thought to be an important driver of racial and sex disparities in cardiac care. Cardiology fellowship program directors play a critical role in shaping the cardiology workforce. Methods and Results To assess program directors' perceptions about diversity and barriers to enhancing diversity, the authors conducted a survey of 513 fellowship program directors or associate directors from 193 unique adult cardiology fellowship training programs. The response rate was 21% of all individuals (110/513) representing 57% of US general adult cardiology training programs (110/193). While 69% of respondents endorsed the belief that diversity is a driver of excellence in health care, only 26% could quote 1 to 2 references to support this statement. Sixty-three percent of respondents agreed that "our program is diverse already so diversity does not need to be increased." Only 6% of respondents listed diversity as a top 3 priority when creating the cardiovascular fellowship rank list. Conclusions These findings suggest that while program directors generally believe that diversity enhances quality, they are less familiar with the literature that supports that contention and they may not share a unified definition of "diversity." This may result in diversity enhancement having a low priority. The authors propose several strategies to engage fellowship training program directors in efforts to diversify cardiology fellowship training programs.

Scar quantification by cardiovascular magnetic resonance as an independent predictor of long-term survival in patients with ischemic heart failure treated by coronary artery bypass graft surgery.

BACKGROUND: Scar burden by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is associated with functional recovery after coronary artery bypass surgery (CABG). There is limited data on long-term mortality after CABG based on left ventricular (LV) scar burden. METHODS: Patients who underwent LGE CMR between January 2003 and February 2010 within 1 month prior to CABG were included. A standard 16 segment model was used for scar quantification. A score of 1 for no scar, 2 for ≤ 50 % and 3 for > 50 % transmurality was assigned for each segment. LV scar score (LVSS) defined as the sum of segment scores divided by 16. All-cause mortality was ascertained by social security death index. RESULTS: One hundred ninety-six patients met the inclusion criteria. 185 CMR studies were available. History of prior MI was present in 64 % and prior CABG in 5.4 % of patients. Scar was present in 72 % of patients and median LVEF was 38 %. Over a median follow up of 8.3 years, there were 64 deaths (34.6 %). There was no statistically significant difference in mortality between Scar and No-scar groups (37 % versus 29 %). In the group with scar, a lower scar burden (defined either < 4 segments with scar or based on LVSS) was independently associated with increased survival. CONCLUSION: In patients undergoing surgical revascularization, scar burden is negatively associated with survival in patients with scar. However, there is no difference in survival based on presence or absence of scar alone. CMR prior to CABG adds additional prognostic information.

Relationship between routine multi-detector cardiac computed tomographic angiography prior to reoperative cardiac surgery, length of stay, and hospital charges.

While multi-detector cardiac computed tomography angiography (MDCCTA) prior to reoperative cardiac surgery (RCS) has been associated with improved clinical outcomes, its impact on hospital charges and length of stay remains unclear. We studied 364 patients undergoing RCS at Washington Hospital Center between 2004 and 2008, including 137 clinically referred for MDCCTA. Baseline demographics, procedural data, and perioperative outcomes were recorded at the time of the procedure. The primary clinical endpoint was the composite of perioperative death, myocardial infarction (MI), stroke, and hemorrhage-related reoperation. Secondary clinical endpoints included surgical procedural variables and the perioperative volume of bleeding and transfusion. Length of stay was determined using the hospital's electronic medical record. Cost data were extracted from the hospital's billing summary. Analysis was performed on individual categories of care, as well as on total hospital charges. Data were compared between subjects with and without MDCCTA, after adjustment for the Society of Thoracic Surgeons score. Baseline characteristics were similar between the two groups. MDCCTA was associated with shorter procedural times, shorter intensive care unit stays, fewer blood transfusions, and less frequent perioperative MI. There was additionally a trend towards a lower incidence of the primary endpoint (17.5 vs. 24.2 %, p = 0.13) primarily due to a lower incidence of perioperative MI (0 vs. 5.7 %, p = 0.002). MDCCTA was also associated with lower median recovery room [$1,325 (1,250-3,302) vs. $3,217 (1,325-5,353) p < 0.001] and nursing charges [$6,335 (3,623-10,478) vs. $6,916 (3,915-14,499) p = 0.03], although operating room charges were higher [$24,100 (22,300-29,700) vs. $23,500 (19,900-27,700) p < 0.05]. Median total charges [$127,000 (95,000-188,000) vs. $123,000 (86,800-226,000) p = 0.77] and length of stay [9 days (6-19) vs. 11 days (7-19), p = 0.21] were similar. Means analysis demonstrated a strong trend towards lower mean total hospital charges [$163,000 (108,426) vs. $192,000 (181,706), p = 0.06] in the MDCCTA group. In conclusion, preoperative MDCCTA is associated with a number of improved perioperative outcomes and does not significantly effect the length of stay or total hospital charges during the index hospitalization.