Rotations

Each CCEP fellow will rotate 6-8 months per year through the clinical electrophysiologic laboratories, which offer a broad mix of patient procedures, including:

  • Conventional and investigative mapping and ablative procedures
  • Conventional and investigative pacemaker and implantable cardioverter-defibrillator implantation
  • Diagnostic electrophysiologic studies
  • Pacemaker and implantable cardioverter-defibrillator lead extraction via traditional and laser approach

During this rotation, you will have access to two state-of-the art electrophysiology laboratories. One laboratory, with biplane fluoroscopy, is primarily dedicated to ablative procedures and diagnostic electrophysiologic studies, while the other single-plane laboratory is primarily for device implantation and follow-up.

You will play an integral role in the procedures performed here. Initially, you will assist the attending faculty, but in time, you will be encouraged to perform the procedures. At the completion of all of the electrophysiology laboratory rotations, you will have performed approximately:

  • 160 diagnostic electrophysiology studies and ablations
  • 150 cardioversions
  • 60 new pacemaker implantations and programming
  • 15 pacemaker lead revisions
  • 15 pacemaker generator replacements
  • 40 defibrillator implantations (new implants and generator replacements)
  • 40 defibrillator tests with programming

The designated clinical cardiac electrophysiologist in the laboratory will provide you with close supervision. Case-by-case feedback, as well as day-by-day feedback, will be given. Along with the written monthly evaluation, you will review your progress with the Director of the CCEP Resident Program in regular, 6-month intervals. Also, you will present a clinical laboratory case and review of the pertinent literature at the weekly electrophysiologic case conference.

You will rotate 3 months per year in the electrophysiologic consultation service. This service provides consultative care for inpatients, including:

  • Evaluation of patients with arrhythmic problems
  • Bedside learning
  • Physical diagnosis
  • Electrocardiogram analysis
  • Complex arrhythmia management

You will also receive training in the Arrhythmia Prevention Center in noninvasive, risk-stratification techniques, including the interpretation of Holter monitor recordings, signal averaged electrocardiograms, T wave alternans, heart rate and QT variability, and genotyping for long QT syndrome. In addition, you will perform cardioversions and tilt table tests during this rotation.

During your rotation, you will see patients under the supervision of one of the electrophysiologic faculty. Your work will happen in multiple settings, including:

  • Outpatient. One half day per week will be spent in outpatient clinic work, in which you will obtain experience in diagnosing, evaluating and managing patients with arrhythmic problems.
  • Inpatient. Our inpatient electrophysiologic consultation service is held in a 742-bed hospital. Approximately four to eight consults are referred each day. Inpatients are referred from internists, family practitioners, emergency department physicians, anesthesiologists and surgeons. You will see each of the consults with the electrophysiologic consult attending.
  • Clinics. There are ongoing active outpatient arrhythmia clinics, as well as a separate outpatient device clinic. In the device clinic, you will also become experienced in troubleshooting and maintaining pacemakers and implantable cardioverter-defibrillators. You will play a prominent role in patient management and in decisions regarding the timing and choice of devices.  

An attending electrophysiologist will supervise all aspects of patient care. In most cases, you will collect and assimilate the data, examine the patients, and start to formulate a diagnostic and/or therapeutic plan prior to rounding with the attending electrophysiologist. The attending will examine the patient, review the data and talk with you about each patient’s care and management.

You will have daily feedback during bedside clinical rounds. You will read Holter monitors, electrocardiograms and event monitors every day during the inpatient consultation service, and the attending will review the tracings with you each day. At the end of the month/ each rotation, you'll be provided with a written evaluation of your work, and that report will be discussed with you.

During the first year of fellowship, you will be strongly encouraged to identify a mentor, write a mini-proposal and obtain preliminary data. During the second year of fellowship, the emphasis of your training will shift to research. You will continue clinical activity, but you will also analyze data and write and publish the results.

The research rotation is designed to provide you with training in the scientific method as it applies to cardiac electrophysiologic research. This rotation will also help to highlight the translation of research data to the practice of cardiac electrophysiology. Through your work, you will learn to:

  • Identify relevant research questions
  • Formulate testable hypotheses
  • Prepare a competitive research proposal
  • Interpret data
  • Communicate results and conclusions in written and oral format
  • Hone your critical thinking/review skills

Each CCEP resident will participate in conferences designed to enhance their understanding of cardiac electrophysiologic research. These include a formal lecture series on cardiovascular electrophysiology, journal clubs, weekly basic and clinical research cardiology grand rounds presentations, basic science research seminars at Rammelkamp Center for Education and Research, and special CCEP resident sessions designed to train CCEP residents on the process of formulating hypotheses and conveying research in written and oral format.

While you conduct your research project, you will follow these steps:

  • Meet with CCEP Program Director and Chief of Cardiology to outline the timeline for research
  • Identify a mentor and a project
  • Submit a research proposal to the Director of Heart and Vascular Research
  • Present proposed research at the electrophysiology conference and cardiology grand rounds
  • Modify protocol based on the above
  • Obtain final approval of the protocol by the Director of Heart and Vascular Research
  • Present progress quarterly at the electrophysiology conference

During your rotation, you will be able to utilize the start-of-the-art clinical electrophysiologic laboratories at MetroHealth Medical Center and core laboratories of Rammelkamp Center for Education and Research.  These facilities include a fully equipped animal electrophysiologic laboratory, whole-cell and patch-clamp apparatus, confocal and fluorescent microscopy, optical mapping with fluorescent indicators, and standard molecular and biochemical laboratory equipment.

There is a broad range of active research programs available, reflecting our institution’s cell-to-bedside approach in electrophysiology. In addition, the academic environment is greatly enhanced by ongoing research programs in the department in areas of molecular biology of ion channels, ion channel physiology, cell biology and whole animal research. 

The electrophysiology faculty members have played a primary role in several multi-center trials. The faculty is also involved in basic electrophysiologic research. Major areas of interest include:

  • Mechanisms of cardiac repolarization
  • Autonomic control of the heart
  • Electrical stimulation of autonomic nerves
  • Mechanisms of antiarrhythmic drug action
  • Genotyping of long QT syndrome
  • Genotyping of atrial fibrillation
  • Mechanisms of atrial and ventricular defibrillation
  • Electrophysiology of heart failure
  • Ion channel heterogeneity of the heart

Prediction and prevention of sudden cardiac death by risk stratification by electrocardiogram and electrogram signal processing, including T wave alternans and heart rate/QT variability

In addition to primary faculty within the electrophysiologic section, you will interact with other faculty whose principal research focus is in cardiac electrophysiology.

Your designated research mentor will provide you with close supervision. Along with the quarterly formal presentation of research progress, you will meet with the Director of Heart and Vascular Research at regular intervals. Also, you will be expected to submit their research for presentation at national meetings and for publication in a peer reviewed journal.