The Ohio-ACC FIT Bootcamp has a new look this year, chaired by Dr. Marissa Edmiston and Dr. Salvatore Savona. Here’s what you can expect:

• A new, focused topic each week
• Concise, high-yield teaching points
• An exclusive video for in-depth learning

This carefully curated content allows you to learn at your own pace, fitting seamlessly into your busy schedule. This Bootcamp is your launchpad to excellence in cardiology. Get ready to embark on this exciting journey of growth and discovery.

EPISODE 1 – Pulmonary Embolism and Cardiogenic Shock

Our first episode begins with pulmonary embolism, a condition that many of you have seen previously. It is an evolving field of advanced therapies including lytics, catheter-based therapies, and ECMO. This week’s episode reviews the clinical signs, symptoms, and role of imaging in patients diagnosed with pulmonary embolism and cardiogenic shock. The last portion of the episode focuses on a thorough review of mechanical support options for patients in cardiogenic shock.

Teaching points:

• Pulmonary embolism can mimic acute coronary syndrome. It should always remain in the differential for troponin elevation.
• Be able to identify echocardiographic findings of PE including: RV enlargement and strain, McConnell signs, 60/60 sign
• Risk stratification of a patient with PE is important in understanding appropriate advanced therapies for acute PE
• Pulmonary embolism can lead to cardiogenic shock requiring pressor support and, in some cases, ECMO.
• There are multiple options for mechanical support that have its indications/contraindications.

EPISODE 2 – Cardiac Tamponade

Cardiac tamponade is a life-threatening condition due to accumulation of fluid within the pericardial sac. It requires prompt diagnosis so that it can be appropriately treated. Tamponade is a clinical diagnosis but the use of echocardiogram is an important tool of confirmation. The following review goes over the pathogenesis, clinical findings, and treatment of a pericardial effusion with tamponade.

Teaching points:

• Rate of accumulation of pericardial fluid influences clinical presentation and tamponade.
• Cardiac tamponade is a clinical diagnosis. Understanding the signs and symptoms of cardiac tamponade allows for early intervention.
• Be able to identify importance echocardiographic indicators of tamponade including: IVC dilation, RV diastolic collapse, respiratory variation of mitral/tricuspid/aortic inflow, RA systolic collapse, hepatic vein doppler reversal, left atrial collapse.
• Location of the fluid matters. Once hemodynamically significant tamponade is diagnosed, pericardiocentesis is usually indicated.
• The cause of the pericardial effusion is important to consider. There are important contraindications to pericardiocentesis, especially concomitant pulmonary hypertension and dissection.

EPISODE 3 – Worst Case Nightmares

Starting fellowship can be nerve-wracking. With time and experience, you will become more comfortable with these “worst case nightmares.” This next seminar goes over a few of those scenarios. The most important advice you will hear from anyone: if you have any questions or concerns, call your attending. There is a steep learning curve that goes along with the first year of fellowship. You will get through it, and soon you will be a cardiology attending yourself.

Teaching points:

• Arrhythmias including brady- and tachy-arrhythmias are common, especially amongst transplant patients. Understanding the management of hemodynamically unstable arrhythmias is crucial.
• Myocardial infarction complications such as VSD and acute mitral regurgitation are uncommon but must be recognized early for appropriate treatment.
• Massive pulmonary embolism can mimic ST elevation MI. It is important to understand advanced therapies of acute PE for hemodynamically stable and unstable patients.
• Diagnosis of endocarditis utilizes physical exam and important imaging modalities such as echocardiogram. Endocarditis clinical presentations can vary but it is important to be mindful of the complications.

EPISODE 4: Arrhythmia Differentiation and Management Intro

Arrhythmia differentiation is necessary for the appropriate management of patients hospitalized. Arrhythmias will be encountered early on in fellowship training, and it is important to embrace the ECG and become comfortable differentiating arrhythmias. An important point in the management of all arrhythmias is the hemodynamic assessment, as a cardioversion or defibrillation is warranted for an unstable patient. This seminar provides an excellent overview by Dr. Mackall on the differentiation and management of arrhythmias.

Teaching points:

• Arrhythmia mechanisms can be attributed to re-entry or abnormal impulse formation
• The hemodynamic assessment is the first step in the evaluation of a patient with an arrhythmia
• A cardioversion or defibrillation should be performed if there is hemodynamic instability
• If stable, determine narrow complex tachycardia (NCT) or wide complex tachycardia (WCT), as well as regularity to differentiate underlying mechanism
• Many criteria available for VT diagnosis (Brugada), though VA dissociation in consistent with VT

Management

• AF- cardiovert if unstable, acute rate control with beta-blocker or calcium channel blocker, anticoagulate all cardioversions acutely, rhythm control options for chronic management
• MAT- treat underlying cause
• AVNRT- vagal maneuvers, adenosine, ultimately an ablation for long term management
• AVRT- adenosine (have patient on defibrillator given risk of VF if develops AF in patients who have baseline pre-excitation), ultimately an ablation, if pre-excitation at baseline and stable can use procainamide or ibutilide
• AT- rate control, AAD vs ablation
• MMVT- beta-blocker, AADs, cardioversion vs defibrillation
• PMVT/TdP- assess for ischemia, treat underlying cause, increase heart rate if QT prolongation dependent, AAD (avoid QT prolonging medications), electrolyte replacement

EPISODE 5: On-Call Device Dilemmas

Device dilemmas are often anxiety-provoking while on call and early on in cardiology training. It is important to become familiar with the appearance of devices on imaging studies as well as troubleshooting common causes of device malfunction. This video provides a succinct breakdown of the common causes of device malfunction with examples of management principles.

Teaching points:

• Become comfortable identifying devices based on chest x-ray and performing and interpreting device interrogations.
• Review the ECG at the time of a potential malfunction.
• Understanding results in asynchronous pacing.
• When an ICD provides a therapy (shock or ATP), first assess if the therapy was appropriate, and treat the underlying cause.
• If any ICD provides a shock, ensure that the shock was effective.

EPISODE 6: Vascular Access and Related Complications 

A key understanding of vascular access-related complications is paramount for the inpatient management of cardiac patients. This episode examines strategies to reduce complications that are addressed initially, with guidance that applies to vascular access for all types of procedures. An understanding of the acute and chronic management of complications, which can be life-threatening, is also of equal importance when managing these patients.

Teaching points:

• Radial arterial access is safer and more common, though femoral access is still utilized for challenging anatomy, structural heart interventions, and EP procedures.
• Femoral access complications can be reduced with the use of a Micropuncture (12G) needle, ultrasound guidance, and an angiogram prior to proceeding.
• Most common femoral complications include hematoma, pseudoaneurysm, and RP bleed.
• Access site bleeding management starts with holding pressure, followed by resuscitation and reversal of anti-thrombotic/anticoagulants if necessary.
• If a patient remains unstable despite above interventions, may need endovascular intervention vs. surgery.