Cardiac computed tomography (CT) is a new and rapidly evolving imaging modality which is poised to alter the clinical practice within Cardiology. Cardiac CT has the ability to provide accurate anatomical and functional information which will have both diagnostic and prognostic value. Cardiac CT angiography (CTA) is an accurate modality for imaging coronary anatomy. Since CTA is rapid and carries few risks, it may become a viable alterative to conventional invasive coronary angiography.
In addition to having the ability to provide detailed anatomical information, CT has the potential to deliver important functional information such as ventricular function, valvular function and myocardial perfusion. The understanding of the principles of: X-ray, radiation safety, cardiac anatomy and cardiac physiology is essential for the adequate performance, interpretation, and application of Cardiac CT.
Standards for training cardiologists and cardiology residents in Cardiac CT were recently published by the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) (J Am Coll Cardiol 2005;46:384-402). We recommend that Canadian standards be similar to those recommended by ACCF/AHA and those for Nuclear Cardiology, PET and Echocardiography. (Nuclear Cardiology Subcommittee of the Canadian Cardiovascular Committee on Standards, American College of Cardiology and American Society of Nuclear Cardiology (J Am Coll Cardiol 1995;25:1-34).
Training in Cardiac CT is divided into 3 levels:
- Basic training (CCS level 1), consisting of a 1 month (4 weeks) training period achieved by all Cardiology residents during the 3 year Cardiology program
- Advanced training (CCS level 2), 3 months (12 weeks) of training during the 3 year Cardiology program
- Fellowship training (CCS level 3), consisting of an additional 6-12 consecutive months beyond the completion of the 3 year Cardiology program
CCS Level 1
Duration of Training: 4 weeks
Examinations Performed: None
Examinations Interpreted: > 50
CCS Level 2
Duration of Training: 12 weeks
Examinations Performed: > 50
Examinations Interpreted: > 150
CCS Level 3
Duration of Training: 6-12 months
Examinations Performed: > 100
Examinations Interpreted: > 300
With advanced training (CCS level 2), individuals can interpret and perform Cardiac CT studies in an established facility. Fellowship training (CCS level 3) is required to independently operate a Cardiac CT facility, to train other physicians and may serve as a stepping stone to an academic career in Cardiac CT.
Individuals completing Royal College of Physicians and Surgeons of Canada accredited training in Diagnostic Radiology may wish to undertake additional training in Cardiac CT to gain further experience in the supervision and interpretation of these examinations and to achieve a better understanding of the clinical implications of this new technique in order to embark upon an academic career in Cardiac imaging.
Candidates for the Cardiac CT fellowship (6-12months) include residents who have completed a 3 year accredited training program in Cardiology or 5 year an accredited Diagnostic Radiology training program. Individuals who have achieved basic (CCS level 1) during their 3 year Cardiology program may proceed to Level 3 Fellowship Training.
The general objectives of this 6-12 month fellowship training program in Cardiac CT are to provide sufficient experience and training for the trainee to be in charge of a Cardiac CT imaging program and train other physicians. For cardiology residents without advanced training (CCS level 2), the additional objectives would be to provide sufficient training for the individual to interpret Cardiac CT studies without heading up a program.
The training period will consist of an additional 6-12 consecutive months beyond the completion of a 3 year Cardiology training program for individuals having achieved basic (CCS level 1) training in Cardiac CT as part of their Cardiology training program and for Diagnostic Radiologists having passed their end of training qualifying exams.
At the end of the Cardiac CT fellowship, individuals will have:
- Technical and theoretical understanding of the operation of CT scanners and related computer systems (cardiology trainees as this knowledge is acquired during radiology residency)
- Knowledge of radiation protection and safety and regulatory aspects (cardiology trainees as this knowledge is acquired during radiology residency)
- The ability to interpret Cardiac CT (including CTA) studies from a broad patient mix
- Learned how to teach technicians, resident trainees and other staff in cardiac CT
- Learned to critically appraised the current Cardiac CT literature
- Skills needed for Cardiac CT research
The trainee will be required to perform in their entirety 100 Cardiac CT studies and interpret an additional 300 studies with clinical correlation.
Trainees with a Radiology background will be expected to complete the additional following items:
- Observe a minimum of 50 coronary angiographic procedures with CTA correlation and participate in the conferencing of those cases
- Observe a minimum of 100 echocardiograms and participate in the conferencing of those cases
- Have a detailed knowledge of a) cardiac hemodynamics, b) exercise physiology, c) standard cardiovascular pharmacology, d) echocardiography, and e) rest and stress electrocardiography
- Complete the ACLS course
- Institution - The trainee will be a team-member of the Department of Cardiac Imaging, Cardiac Radiology Nuclear Cardiology and Cardiac PET at the University of Ottawa Heart Institute to obtain training in Cardiac CT. The University of Ottawa Heart Institute is a large tertiary care Cardiac facility serving patients in Eastern Ontario and Western Quebec. The University of Ottawa Heart Institute has inpatient and outpatient services, critical care and coronary care units, cardiac catheterization/angiographic facilities, a cardiac surgical program and an active Emergency Room.
- Laboratory - The Cardiac Radiology Laboratory is located in the University of Ottawa Heart Institute and has formed out of collaborative efforts between Cardiology and Radiology. With the development of the Cardiovascular CT program, more than 2000 Cardiac CTs will be performed annually. Currently, over 5,000 patient examinations are performed in Nuclear Cardiology (exercise stress and pharmacologic stress myocardial perfusion studies and gated blood pool imaging) and over 500 clinical and research Cardiac PET studies each year.
- Staff - The physician staff for Cardiac Radiology includes 1 full-time Cardiologist and 1 Radiologist. Both the Cardiologist and Radiologist have advanced training in Cardiac Imaging and Cardiac CT and are dedicated to the establishment of a “premiere” Cardiac CT program. The two will work closely together ensure the clinical and academic success of all trainees.
The Cardiac Imaging Laboratory (Cardiac Radiology, Nuclear Cardiology and PET Unit) have a full complement of CT/X-ray technologists, nuclear technologists, nursing staff, a physicist and a PET radiochemist.
Evaluation and Examination Process
- Assessment will be ongoing with the training supervisor and the laboratory staff physicians.
- Written and practical tests will occur every 3 months. The trainee will be interviewed every 3 months and advised of his progress in terms of results of the written and practical tests in the ongoing assessment. Criticisms and deficiencies will be noted.
- Upon completion of the 6-to-12 month program, there will be a final examination, consisting of a written and oral examination testing the knowledge of Cardiac CT and interpretation of Cardiac CT scans.
- The trainee will participate in regular educational/teaching sessions, Journal Clubs and review of the current medical literature.
- The trainee will be expected to initiate and develop a research protocol leading to data collection, analysis, abstract preparation and manuscript submission during the Fellowship training program.
Cardiac Imaging Program (CT/PET/Nuclear Cardiology)
(This is a separate program and should be submitted separately.)
Specific training in Cardiac PET and Nuclear Cardiology may occur concurrently with training in Cardiac CT and will, in most cases, be part of an additional 24-36 consecutive months beyond the completion of a 3 year Cardiology training program or Radiology training program. Successful training in Nuclear Cardiology and Cardiac PET will include:
- Technical and theoretical understanding of the operation of Nuclear Medicine cameras and computer systems
- Knowledge of radiation protection and safety and regulatory aspects
- Ability to interpret stress planar and tomographic myocardial perfusion studies and gated blood pool studies from a broad patient mix
- Experience in performance and interpretation of exercise and pharmacologic stress tests
- Radiopharmacy experience sufficient to run a Nuclear Cardiology facility
- Knowledge of substrate metabolism in the normal and diseased heart, knowledge of PET tracers for perfusion, metabolism, and neuronal activity imaging
- Knowledge of radioisotope production and radi otracer synthesis
- Principles of tracer kinetics and their in vivo application for the noninvasive measurements of regional metabolic and functional processes
- Knowledge of physics of positron decay, imaging instrumentation specific to PET, quality control and handling of ultrashort-life radioisotopes
- Appropriate radiation protection and safety and regulatory aspects
- Demonstration of teaching ability to technicians, resident trainees and other staff
- Clinical appraisal of current Nuclear Cardiology/PET research
- Participation in Nuclear Cardiology/PET research
The trainee will be required to perform in their entirety 50 gated blood pool imaging studies, 50 exercise SPECT myocardial perfusion studies and 50 pharmacologic stress SPECT perfusion studies and interpret an additional 500 studies with clinical correlation.
The trainee will be required to perform in their entirety, 40 PET myocardial perfusion studies and 40 metabolic studies and interpret an additional 400 studies with clinical correlation.