Bosko Margeta, M.D., Fellowship Program Director
1901 W. Harrison St.Chicago, IL 60612
The Department of Cardiology strives to provide excellent training in all aspects of inpatient and outpatient clinical cardiology. Cardiologists at Cook County Health see patients with an unusually broad range of diseases.
The busy inpatient services (the coronary care unit and the consult service) as well as the eventful outpatient clinics offer fellows ample opportunity for personal experience in the diagnosis and treatment of virtually every sort of cardiovascular condition. In addition, didactic sessions, conferences, teaching rounds and one-on-one experience with cardiology faculty ensure that fellows receive a thorough education in cardiovascular disease.
The department also works to provide excellent training in the invasive and non-invasive procedures. Fellows as first operators perform a large number of diagnostic cardiac catheterizations, and also participate in many interventional procedures including PCI and IVUS. Experience in electrophysiology procedures occurs at Rush University Medical Center, where our fellows assist in complex ablations and device implantation. All standard non-invasive diagnostic techniques are performed at the John H. Stroger, Jr. Hospital of Cook County. Fellows obtain extensive hands-on exposure to ECGs, event recorders, echo, stress testing in all modalities, nuclear cardiology, and cardiac CT and MR.
We provide an environment of academic freedom in which the highest quality of clinical research can be conducted, with the aim of training new investigators who will provide novel approaches to the diagnosis and treatment of diseases. Fellows participate in a wide variety of ongoing multicenter trials and also paricipate in research studies initiated here at the Cook County Health, including fellow-initiated projects.
- To provide excellent training in all aspects of inpatient and outpatient clinical cardiology. Cardiologists at Cook County Health see patients with an unusually broad range of diseases. The busy inpatient services, including the coronary care unit and the consult service, and the busy outpatient clinics offer fellows ample opportunity for personal experience in the diagnosis and treatment of virtually every sort of cardiovascular condition. In addition, didactic sessions lectures, conferences, teaching rounds and one-on-one experience with cardiology faculty ensure that fellows receive a thorough education in cardiovascular disease.
- To provide excellent training in the selection, performance, and interpretation of noninvasive and invasive diagnostic techniques. All standard noninvasive diagnostic techniques are performed at Cook County Health. Fellows obtain extensive hands-on exposure to electrocardiography, echocardiography (including transthoracic, transesophageal, and stress echo), treadmill and pharmacological stress testing, nuclear cardiology, and ambulatory electrocardiographic monitoring.
- Fellows perform a large number of diagnostic cardiac catheterization procedures as first operator during their training at Cook County Health, and also participate in all percutaneous coronary interventional procedures. Experience in electrophysiology procedures is provided by having fellows spend two months during their training at Rush-Presbyterian-St. Luke’s Medical Center, where they assist in the performance of diagnostic and therapeutic studies.
- To provide experience in the planning, performance, and interpretation of cardiovascular research. For several decades, cardiology has been fortunate to experience an incredible advancement in knowledge of basic pathophysiology, a marked increase in the number and utility of noninvasive and invasive diagnostic techniques, and remarkable progress in the identification and introduction of effective new pharmacological and interventional therapies, and the pace of progress shows no signs of slowing. Remaining up to date is critical for every cardiologist.
Cook County Health offers a fully accredited, three year fellowship training program. The philosophy of the Cardiology Fellowship Training Program is that providing exceptional training to our cardiology fellows is intimately related to providing excellent clinical care to our patients.
One of the best ways to learn to understand the cardiology literature is to perform research. Fellows have the opportunity to participate in a wide variety of ongoing research studies at Cook County Health and are encouraged to initiate their own projects.
Applicants interested in the program should apply through the ERAS online application system and register their applications via the National Residency Matching program (NRMP). During the interview process, candidates will have the chance to see both teaching sites, visit all labs, and meet with the fellows and faculty.
Cardiac Critical Care Unit
This clinical assignment is two to three blocks in the first year, one of them is to be done at Rush University Medical Center. Critical care experience focuses on acute coronary syndrome management with large exposure to ST elevation as well as NST elevation MIs, arrhythmia management, hemodynamics, and cardiogenic shock. This covers both pharmacologic and mechanical therapy including temporary transvenous pacemaker placement, Swan-Ganz catheter insertions, DC cardioversion, and resuscitation. Fellows are responsible for all critical care cardiology consults and management. They will be running the unit as a primary team with the internal medicine residents assigned to the rotation.
This rotation involves two blocks in the first year, three blocks in the second year and four blocks in the third year. During this rotation, fellows are responsible for pre-procedure assessment, they are the primary operators from groin access until the end of the diagnostic procedure, they participate as a secondary (and sometimes primary operators) in the intervention as well. Fellows are able to do an average of one hundred cases during their first year of fellowship, and many of them perform more than four hundred cases by the end of the fellowship. Fellow assigned to this rotation are expected to collect and present interesting cases for Tuesday morning conference when discussion with the faculty about each case gives high quality teaching. During this rotation fellows will have exposure to:
- Diagnostic right and left heart catheterization
- Percutaneous interventions
- Intravascular ultrasound
- Temporary pacemakers
- Peripheral vascular angiography
- Intra-aortic balloon pumps
One Block in the second year and one block in the third year done at Rush university medical center. During these two blocks, fellows develop essential understanding of noninvasive and invasive electrophysiology techniques, arrhythmia management, and Pacemaker interrogation. Under the supervision of the electrophysiology faculty ( Dr. Trohman and Dr. Krishnan ), fellows are responsible for inpatient consultations, and help in the outpatient clinics. Studies performed:
- Pacemaker implantation
- Intracardiac defibrillator implantation
- Electrophysiology studies
- Advanced intracardiac mapping
- Intracardiac ultrasound
- Trans-septal punctures
- Catheter ablations for both supraventricular and ventricular arrhythmias
- Holters and Loop recorders
- Tilt-table testing
- Signal-averaged EKG interpretation
Three blocks every year. Two fellows per block. Fellows are responsible for Dobutamine Echo procedures, Trans-esophageal echo, and Echo with bubble/contrast. They also try to pre-read transthoracic echo studies before they read together with the attending in the afternoon. With the help of highly experienced lab technicians and faculty, this rotation is essential to learn how to perform a standard transthoracic echo study with all views and how to optimally operate the machines.
Two blocks in first year, two blocks in second year. In this lab, fellows have the opportunity to observe performance of different modalities of stress testing. Fellows will have broad spectrum of EKGs to read and review with faculty; they also will have the opportunity to review holters and event recordings as well. This rotation is usually considered to be a light rotation by our fellows as they will have a good amount of time to read in the afternoons. Testing performed:
- Treadmil exercise EKG stress test
- Treadmil exercise imaging stress test
- Treadmill exercise Echo
- Adenosine/Dobutamine thalium stress test
- Holter monitors and event recorders
- T-wave alternans
- Tilt table testing, both spontaneous and provactive
Cardiac Consult Service
Two blocks in the first year.
This is one of the best and busiest rotations we have in the program. The consult fellow will carry the 1922 pager which is a well known pager in the hospital, as all stat consults will be directed there. The consult fellow will be the first one to respond to STEMI calls, Cardiac Tamponade, and unstable arrhythmias; he also will be responsible for regular cardiology consults as they appear in the computer system. He will have three to five residents working with him, usually from the internal medicine department, but sometimes from anesthesia or Loyola University Family Practice Program. In addition to managing the consult service the fellow will be a teacher for both residents and medical students, as he is expected to give daily lectures.
As our hospital is a level one trauma center, the consult fellow will expect calls to perform stat echo in trauma resuscitation unit when a patient with blunt chest trauma, gunshot or stabbing chest wound arrives.
Two blocks every year of fellowship, all at Rush University Medical Center.
Fellows read nuclear studies, including stress tests, viability, and MUGA scans daily with attendings. It is an excellent experience where fellows from different years and from both CCH and Rush participate together in reading. Fellows also perform cardiac CT angiography and participate in reading cardiac MRs.
Heart Failure and Transplant (CMT)
This rotation is done at Rush university medical center, one block in the third year and an optional block in the second year. During this rotation, the fellow will be primarily responsible for residents in the heart failure unit; he will perform right heart caths and muscle biopsies under supervision of Dr. Pisani and Dr. Mendez. He will be working very closely with heart failure nurses as to follow up inpatients post transplant. Also he will attend heart failure/transplant clinics.
Congenital Heart Disease
In addition to the unparalleled experience that fellows gets when reading congenital heart disease echoes with Dr. Shapiro (as most congenital heart disease patients will be transferred to his care in Stroger hospital), fellows will also have the opportunity to work with Dr. Hijazi, the president of The Society of Cardiovascular Angiography and Interventions(SCAI) in an elective at Rush University; they will also help in his clinic and scrub with him in procedures (septal defects closure, aortic valvuloplaty, peripheral aortic valve placement, pulmonary valvuloplasty and others).
Half a day weekly.
In this very busy clinic, fellows will serve as the primary cardiologist caring for patients with variable cardiac diseases. They will follow their patients that they cared for in CCU and consut service in addition to seeing new consults. Supervision from attendings is available in case it is needed.
Although the main focus of clinic is preventive cardiology for coronary artery disease, cases of heart failure, different arrhthmias, and congentital heart disease are frequently encountered.
Fellows work closely with cardiothoracic surgeons in this clinic as they often review cath, echo and nuclear procedures together.
As there is high volume of acute presentations (including STEMI, post trauma cardiac tamponade) to our hospital, fellows do in-house calls. During the call, the fellow would be responsible for guiding CCU residents in managing the unit and in urgent consults, he will be able to respond promptly to calls for stat Echo and activating cath lab.
More than half of calls are considered by the department to be moonlighting and these paid calls are distributed equally between fellows.
Each fellow selects a faculty mentor during his first year and initiates a research project depending on his interest. As we don’t have an animal lab at CCH, fellows have the option to participate in basic science research and animal labs at Rush University. Fellows also help the department by participating in multicenter clinical trials that Stroger hospital is part of. All these activities are designed to run concurrent with clinical experience throughout the fellow’s training. It is expected that these projects will be presented at a national or international meeting or submitted to a refereed journal.
Some of the research and publications accomplished by our fellows recently include (click to read full article):
- Baseline left bundle branch block with right bundle branch escape complexes in a patient with coronary artery disease, presents like an alternating bundle branch block: a case report. By Bhimaraj & Margeta
- Bacillus Cereus Endocarditis in a permanent pacemaker: a case report. By Bhimaraj & S. Khadra
- Myocardial degradation and left bundle branch block predict conversion to low ejection fraction in heart failure with preserved systolic function. By Rahaby
- The effects of statins and renin-angiotensin system blockers on atrial fibrillation recurrence following antral pulmonary vein isolation. By Muradi
- Perioperative myocardial infarction in a patient with metabolic syndrome. By S. Khadra
- TASER X26 discharges in swine produce potentially fatal ventricular arrhythmias. By Margeta
- Risk stratification in patients with unstable angina and non-ST segment elevation myocardial infarction: evidence-based review. By Doukky
- Increased TIMI frame counts in cocaine users: a case for increased microvascular resistance in the absence of epicardial coronary disease or spasm. By Sattar & Kelly
- Circadian rhythm of spectral indices of heart rate variability in healthy subjects. By Palusinski
Fellows attend special programs held at the University of Chicago regarding cardiac rehab; they participate in a series of lectures and observe patients while getting rehab post MIs.
Conferences & Lectures
- Daily morning conference being held at Dr. Kelly’s conference room. This covers a series of lectures that represents core structure for teaching. Lectures would be given by attendings from CCH, and guests pioneering in specific topics would be invited on a monthly basis. These lectures would concentrate mainly on cardiology related topics (CAD, cardiomyopathies, valve disease, vascular diseases, congenital heart disease, arrhythmias, EKG, echo, stress tests, etc…), but also will have some lectures covering topics cardiologist deal with frequently (Ventilators, diabetes, rehab, etc…).
- Basic fellow guide lectures: a series of lectures aiming to facilitate fellow transition into the program. The goal of these lectures is to give basic tips about what the fellow has to deal with in each rotation, how to survive it and expectations as far as number of procedures needed to be certified. It would also focus on ACC/AHA guidelines for diagnostic testing, how to perform procedures, and how to interpret test results.
- Collaborative conference with cardiothoracic surgery: every Tuesday morning we meet at Dr. Kelly’s conference room with surgeons to discuss cases related to surgery, and fellows get valuable input from a surgical prospective regarding their own clinic, consult, or CCU patients.
- Case-conference: every other Thursday, we hold a noon conference, focusing on management of interesting cases and challenging fellows with optimal management. Dr. Margeta with chief fellows prepare this conference to gain most teaching value.
- Grand rounds conference: every Friday at the Cardiology Conference Room in Rush university medical center, cases would be presented by Rush and CCH fellows in presence of faculty from both hospitals. This conference is usually modulated by Dr. James Calvin from Rush.
- Nuclear-Cath correlation conference: every other Monday morning, held at Rush, modulated by Dr. Rami Doukky and Dr. Jeffery Soble. It focuses on reading nuclear studies and comparing results with coronary angiogram.
- M&M conference: Once a month, a fellow would present a case that had major complication to discuss implications and ways of improvement.
- Journal Club: Once a month. During this conference a fellow presents one of the new articles and discussion would focus on clinical aspects as well as statistics.
With regards to examinations:
- In service exam every year; both Rush and Cook County fellows participate.
- Questions are prepared by Dr. Kavinsky.
- The questions cover all aspects of cardiology.
- Comprehensive EKG exam every year; also, both Rush and Cook County fellows participate.
- Questions prepared by Dr. Margeta.
- The questions cover both common and rare cases that a fellow may encounter during training.
- Monthly EKG exam.
- 5 EKGs per session.
- After the EKGs, full discussion is held.
- Most of our fellows have their Echo Board Exam by the second year.
- Fellows take an Echo Study Session prior to this exam.
- Most of our fellows have their Nuclear Board Exams by their third year.
Fellows take a Nuclear Study Session prior to this exam.