1. TITLE OF THE FELLOWSHIP PROGRAM Fellowship and Training Program in Cardiovascular Magnetic Resonance at the Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London
Royal Brompton and Harefield NHS Foundation Trust is one of world’s foremost cardiothoracic centres with 350 dedicated cardiology beds, 3000 operations and 100,000 cardiology out-patients per year with prominent clinical interests in heart failure, cardiac surgery and transplantation, congenital heart disease, preventive and invasive cardiology, and imaging. It is closely allied to the National Heart and Lung Institute of Imperial College for cardiology post-graduate teaching and research for which it has a worldwide reputation. The Cardiovascular Magnetic Resonance Unit was established in 1984 making it one of the very first to specialise in cardiovascular imaging and research. The CMR Unit has pioneered contributions in the field over 33 years in the assessment of flow, rapid imaging, atheroma, coronaries, myocardial perfusion, volume/mass assessment and valvular disease. The CMR Unit is an international referral centre, performing about 10000 cardiovascular CMR studies per year. We also have a substantial number of research projects. The dedicated staff of cardiologists, physicists, computer scientists and support staff numbering 30 in total, have extensive experience in these fields allowing excellence in clinical practice, teaching and research. The course offered therefore has all the advantages of breadth of experience from the faculty, as well as a multidisciplinary approach. London is a cosmopolitan city of many millions with outstanding travel access from all around the world, with high volume travel routes allowing modest flight costs. This melting pot of many cultures makes London a vibrant place to spend a period of study with its many tourist attractions, active nightlife and excellent restaurants.
History The Unit's early success was a result of the foresight and energy of Professor Donald Longmore who originally set it up with a small team, which included David Firmin, the current Director of Physics. The many pioneering advances include: some of the earliest cardiac gated images, the accurate measurement of cardiac function, the accurate measurement of blood flow, early coronary artery imaging and coronary flow measurement, the development of rapid and interactive cardiovascular imaging, characterisation of atherosclerosis, and the measurement of myocardial perfusion. The Unit remains in the forefront of research, working within the academic environment of the Imperial College Medical School. Under its current directorship of Professor Dudley Pennell the Unit is continuing in the development of CMR, with particular emphasis on clinical applications. The Unit has four scanners, comprising of one Siemens Skyra 3T in our research centre, two Siemens Avanto Cardiac MR scanners, and one Siemens Aera Cardiac MR scanner fitted into a Bence Coachworks movable building. The CMR Unit has a unique mix of staff from medical and scientific backgrounds all with specialist expertise in imaging, and working in close collaboration with the Visual Information Processing (VIP) group of Imperial College. It is particularly well sited with excellent access to large numbers of patients with all forms of cardiovascular disease. It also collaborates with active programmes of clinical work and research, using techniques such as echocardiography, invasive angiography, nuclear cardiology and electron-beam computed tomography, all of which makes Royal Brompton and Harefield NHS Foundation Trust an ideal site to assess the comparative and incremental value of magnetic resonance in cardiovascular medicine.
3. DURATION OF THE FELLOWSHIP AND TRAINING PROGRAM Commences April and October every year, for 3 months.
4. OBJECTIVES OF THE FELLOWSHIP PROGRAM At the end of this course the participant will be able to: -Understand the essential principles of CMR -Understand potential dangers, contra-indications and safety considerations -Understand the fundamentals of stress testing and monitoring -Put patients into magnets for different types of CMR study -Understand clinical indications for CMR -Perform magnetic resonance imaging for conditions including Ventricular volume and mass measurement -Valvular regurgitation measurement -Assessment of valvular stenosis -Myocardial perfusion imaging -Coronary artery imaging -Imaging of major congenital heart malformations in adults -Aortic dissection and coarctation -Report cardiovascular magnetic resonance studies -Understand clinical and research requirements of a cardiovascular MR unit.
5. DESCRIPTION OF THE FELLOWSHIP AND TRAINING PROGRAM IN CMR During the initial 3 months training you will receive 80 hours of lectures, attend daily scanning sessions, and undergo supervised reporting. You will work with the clinical team and perform primary reporting and gain substantial experience in CMR. The training objectives are that you would be competent in reporting and directing CMR scans with level 2 (3 months training) credentialing, as defined by the Society for Cardiovascular Magnetic Resonance (SCMR) and the EACVI, to whom you would apply for certification using your training record.
The course is planned to a weekly timetable, with sessions designated for attendance of clinical scanning, lectures, seminars, meetings, and for individual work. The timetable, with a list of dates and topics to be covered, is included in the course summary provided. Topics to be covered include: -Physics Basic principles -Magnets and hardware -Image formation -Sequence design -K-space strategies and rapid imaging -Respiratory monitoring, navigators and respiratory correction -Clinical fundamentals -Set-up, safety and monitoring -Cardiac anatomy, imaging planes and appearances -Stress testing including pharmacological stress -ECG interpretation -Resuscitation skills -Comparison with echo, and nuclear techniques -Cardiac MR -Ventricular volumes, mass and function -Stenotic and regurgitant valvular heart disease -Ischaemic heart disease -Stress testing -Myocardial perfusion imaging -Coronary artery imaging and flow measurement -Ventricular remodelling -Congenital heart disease -Major congenital malformations -Surgical and interventional strategies -Functional considerations -Imaging strategies -Cardiomyopathies -Aorta -Cardiac masses and pericardial disease -MR Angiography -Renal arteries -Thoracic vessels -Management issues -Establishment and administration of a CMR unit -Planning and realisation of a research programme -Technologist training -Research
The course will offer: -Lectures and workshops – 160 hours -Physics – 30 hours -Clinical fundamentals– 40 hours -Clinical CMR teaching – 70 hours -Clinical experience - Personal attendance – Minimum 500 cases -Case reports – 6 cases -Archive case review – 20 years of cases for review -Clinical reporting – Minimum 200 cases -Project assignments -Principles and range of applications -Specific clinical application project -Log book to be kept of cases attended
The CMR Unit has four dedicated cardiovascular magnetic resonance systems: • One Siemens Skyra 3T cardiovascular MR scanner • Two Siemens Avanto Fit 1.5 Tesla cardiovascular MR scanners • One Siemens Aera 1.5 Tesla cardiovascular MR scanners All four CMR systems are linked to a computer network with image viewing and analysis available from any PC within the Unit. The department provides a mini-PACS system based around a Linux RAID system which stores DICOM images directly from the scanners enabling fast image analysis from anywhere in the building. All images are also streamed instantly to the Trust-wide Agfa IMPAX system. The images are reviewed and analysed using in-house developed software, in conjunction with the VIP department at Imperial College, named CMRTools. CMRTools is a PC Windows based program which will be used to quantify mass and volumes, velocity, flow, perfusion and lipid values. Image analysis, display and comparison is simple to learn in this environment with familiar pull-down menus and mouse operation. The provision of access of images from PCs means that all fellows can review clinical and research scans at any time without requiring heavily booked time at the scanner consoles. Fellows will attend daily reporting sessions of cases with consultants, the weekly CMR clinical review seminar, the weekly congenital disease review meeting and the weekly cardiology grand-rounds of Royal Brompton and Harefield NHS Foundation Trust. All the other academic events of NHLI and Imperial College are also available. Fellows will be able to make use of a study area equipped with computers, video viewing facilities, library of major cardiology and imaging journals and an extensive CMR case library. The CMR CD-Rom of the European Society of Cardiology will be available for study as well as the ACCSAP CD-Rom of the American College of Cardiology. There is a seminar room in the CMR Unit, as well as seminar rooms and lecture theatre accommodating regular clinical cardiovascular teaching sessions in the main hospital and adjacent National Heart and Lung Institute, where there is also an extensive medical library.
7. TEACHERS, TUTORS AND CONSULTANTS
Consultants teaching CMR are: • Professor Dudley Pennell • Professor Raad Mohiaddin • Dr John Baksi • Dr Francisco Alpendurada • Dr Cemil Izgi • Dr Sabiha Gati • Dr Inga Voges • Dr Sylvia Krupickova • Dr Sonya Babu-Narayan
8. EVALUATION MODEL
Continuous evaluation of reporting skills and clinical assessment, through daily supervised and mentored teaching.
9. CREDITS AND TITULATION At the end of the 3 month fellowship, a letter of training is issued detailing the achievement which is suitable for application for level 2 credentialing by both the Society for Cardiovascular Magnetic Resonance (SCMR) and the European Association of Cardiovascular Imaging (EACVI), to whom the fellow must apply.
10. DIRECTOR OF THE FELLOWSHIP PROGRAM Professor Dudley Pennell MD FRCP FACC FESC FRCR FAHA FMedSci Director Cardiovascular Magnetic Resonance Unit