The CardioNerds are thrilled to launch The Cardiac Critical Care Series! The series Co-Chairs – Dr. Mark Belkin (Advanced Heart Failure FIT, U Chicago), Dr. Yoav Karpenshif (FIT, U Penn), Dr. Eunice Dugan (CardioNerds Academy Chief Fellow and FIT, Cleveland Clinic), and Dr. Karan Desai (CardioNerds Academy Editor and FIT, U Maryland) – join CardioNerds Co-Founders, Amit Goyal and Daniel Ambinder to delve into high-yield topics in critical care cardiology.

We kickstart this series with one of the early pioneers and national leaders in cardiac critical care – Dr. Jason Katz, Director of Cardiovascular Critical Care and Co-Director of Mechanical Circulatory Support and the CICU at Duke University Medical Center.

In this episode, we learn about Dr. Katz’s career path and what motivated him to train in Critical Care Cardiology. He shares early struggles, notable changes in this field’s nascent period, and ongoing challenges in training and practice. We discuss collaboration with other cardiac and non-cardiac specialties and their importance in comprehensive care. Furthermore, we discuss how to advance critical care research, including the Critical Care Cardiology Trials Network and future randomized controlled trials to inform our practice and develop standardized protocols. In this small but rapidly growing field, we learn there is much to discover together. Audio editing by CardioNerds Academy Intern, Hirsh Elhence.

Claim free CME for enjoying this episode! Disclosures: None

Pearls • Notes • References • Guest Profiles • Production Team

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1. “I think it’s really important not to be afraid of change in order to potentially succeed […] it’s okay to not entirely know what you want to do.” – Dr. Katz when sharing his non-direct career path in a novel field.
   
2. “There is no greater team sport in cardiology than Cardiac Critical Care” and “I oftentimes think of the Critical Care Cardiologist as sort of the conductor that helps to orchestrate [the team]…” – Dr. Katz when discussing the importance of multidisciplinary teams and need to collaborate with other cardiac and non-cardiac sub-specialties.
   
3. Many general surgical or medical residency/fellowship graduates are not comfortable caring for patients in the critical care setting. There is a need to revamp critical care training without significantly prolonging training time in order to complement and enhance our current workforce to care for complex, critically ill cardiac patients.
   
4. “I don’t think there’s necessarily a one size fits all model, and I think we should be malleable or adaptable to the needs of our trainees and the needs of our patients.” – Dr. Katz when discussing training pathways in Critical Care Cardiology or combining Critical Care with other subspecialties like Interventional Cardiology or Advanced Heart Failure.
   
5. Dr. Katz suggests that when choosing a Critical Care Cardiology training program: “consider geography, the flexibility of the curriculum, the overall fellowship and social experience, and the clinical setting. Everything that’s really important to choosing a cardiology fellowship is more important in my mind than if they actually have a standardized, cardiac critical care pathway.”
   

1. What are some recent changes in the field of Critical Care Cardiology?

• Compared to even just a decade ago, there is a growing interest from medical students to young faculty in pursuing a career in critical care cardiology.
  
• At the same time there is evidence that the patient demographics in our CICUs are changing, including more multi-organ dysfunction and many non-cardiac diagnoses. In a recent paper from the Critical Care Cardiology Trials Network (CCCTN), the proportion of patients with a primary diagnosis of acute coronary syndrome was only approximately 32%. Following overall trends in heart failure, a greater proportion of CICU patients have heart failure and/or heart failure phenotype cardiogenic shock requiring clinicians to be facile with the spectrum of mechanical support devices.
  
• These demographic and workforce trends are requiring cardiologists to re-think how to best meet the needs of the modern CICU.
  

2. What continue to be some challenges in practicing Critical Care Cardiology?

• CICU patients are a heterogenous group with varying baseline characteristics, comorbidities, illness severity, and treatment responses. Since distinct pathophysiologic targets are lacking, challenges exist when devising strategies to improve outcomes. Similarly, these challenges extend to developing and executing research protocols to inform management.
  
• As Dr. Katz discussed on the episode, the lack of standardization, consistent terminology, and even who belongs in the CICU, remains a barrier to devising who should staff the CICU and how we train physicians to care for CICU patients.
  
• Dr. Katz described the cardiac intensivist as akin to the conductor of an orchestra working with multiple cardiac and non-cardiac subspecialists, and other professionals such as RNs, dieticians, physical therapy, social work, chaplaincy etc.  Understanding the roles of multidisciplinary members can help inform resource utilization and allocate costs.
  

3. What are some challenges in Critical Care Cardiology training?

• There continues to be a supply-demand mismatch when it comes to the growing clinical need and the availability of trained cardiac critical care clinicians.
  
• Many surgical or medical residency/fellowship graduating trainees do not feel comfortable caring for critically ill patients. Thus, Dr. Katz advocates for outside the box thinking to find novel ways to supplement current cardiovascular training – whether it be in general fellowship, advanced heart failure or interventional training – with adequate critical care training for interested trainees.
  
• Accomplishing this goal without excessive increases in numbers of years in training – and assuring competency and exposure to aspects of critical care medicine not seen in general cardiology training – may require creating more blended pathways
  
• Furthermore, the optimal timing of when to obtain critical care training remains unclear. As few integrated options currently exist, trainees most commonly pursue critical care training after general cardiology or subspecialty cardiology fellowship training. Without integrated options, however, there is concern that trainees may not maintain their cardiac clinical skills or competency in areas such as echocardiography during dedicated critical care medicine years.
  

4. What about combining critical care with other cardiac-subspecialities like Interventional Cardiology or Advanced Heart Failure?

• There isn’t a “one size fits all” model. Training pathways should be flexible to accommodate the needs and interests of trainees. Recent opinion pieces have suggested blending Advanced Heart Failure training with Critical Care Training in a preferably 5-year pathway.
  
• Regardless of who is staffing the CICU, optimal care requires continued collaboration – not just during admission but frequent revisitation of management plans with cardiac subspecialists to direct patient care.
  

5. What can we learn from our cardiac intensivist colleagues in Europe?

• Europe has a more established training pathway for cardiac critical care with a dedicated scientific symposium, credentialing pathway, and journal.
  
• Although we have different regulatory authorities and settings for care of delivery, with colleagues in Europe having been through the process of establishing this new field, we can learn from their struggles and successes.
  
• Furthermore, there are opportunities for multinational collaboration in research, training, and education.
  

Il’Giovine ZJ, Menon V. The Intersection of Heart Failure and Critical Care: The Contemporary Cardiac Intensive Care Unit and the Opportunity for a Unique Training Pathway. J Card Fail. 2021 Oct;27(10):1152-1155. doi: 10.1016/j.cardfail.2021.03.014. PMID: 34625134.

Katz J, Turer A, Becker R. Cardiology and the critical care crisis: a perspective. Journal of the American College of Cardiology. Published online 2007. doi:10.1016/J.JACC.2006.11.036

Bhatt AS, Berg DD, Bohula EA, et al. De Novo vs Acute-on-Chronic Presentations of Heart Failure-Related Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry. J Card Fail. 2021 Oct;27(10):1073-1081. doi: 10.1016/j.cardfail.2021.08.014. PMID: 34625127; PMCID: PMC8514080.

Dr. Jason Katz is the Director of the Cardiac ICU, Mechanical Circulatory Support, and LVAD programs at Duke University. After completing his Internal Medicine residency at UT-Southwestern, he went on to complete a Cardiology Fellowship at Duke University, a Clinical Research Fellowship with the DCRI, and a finally Critical Care Fellowship at Duke. He has published over 100 articles across a range of topics within Cardiac Critical Care, including multiple reviews and statements addressing the role of, and training options for, Cardiac Intensivists. He is considered an early pioneer, and continues to be a leader, in this growing field, currently serving as the immediate past-President of the AHA Acute Cardiac Care Committee.

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  Karan Desai, MD
  
  
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  Dr. Mark Belkin
  
  
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  Amit Goyal, MD
  
  
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  Daniel Ambinder, MD