Advanced Heart Failure & Cardiac Transplantation

Educational Program

The Advanced Heart Failure and Transplantation Fellowship Program in the University of Miami/Jackson Memorial Hospital is primarily located at Jackson Memorial Hospital, and directly affiliated as a subspecialty fellowship under the UM/JMH Cardiovascular Disease (CVD) Fellowship Program.

As the only Advanced Heart Failure and Transplant Program in South Florida, our fellows have access to the University of Miami Hospital and Jackson Memorial Hospital. Both hospitals serve as major referral centers for advanced heart failure and transplantation for the state of Florida. The fellow gains experience in medical management of advanced heart failure, evaluation of heart transplantation candidates, and pre-, peri- and post-transplant care. The fellow also gains experience from ventricular assist devices, both approved and investigational, which are implanted for both bridging to other forms of therapy and for destination therapy. The JMH/UM Cardiac Transplant Program has been in continuous operation for over 20 years and the clinical outcomes have consistently placed it among the top tier of centers nationally. We perform approximately 35-40 heart transplantations per year.

Heart Failure Training Education

Management of Heart Failure

1. To be able to institute an effective plan for the diagnostic evaluation of patients with new onset HF
2. Understand the role of non-pharmacologic interventions including diet and education
3. To have a full understanding of the multiple pharmacologic treatment options now available, and to recognize the appropriate indications for each therapy
4. Understand the treatment options for the management of arrhythmias in HF
5. Be aware of treatment options for the management of specific cardiomyopathies including cardiac amyloidosis, sarcoidosis, Fabry’s disease etc.
6. Understand the indications for device therapy including implantable cardiac defibrillators and biventricular pacing devices
7. To understand the indications for heart transplant consideration
8. Understand the concepts of disease management and health care delivery

Management of decompensated patients:

1. To recognize the role of hemodynamic monitoring including pulmonary arterial catheters
2. To understand the role of inotropes, vasopressors and vasodilators
3. To be able to manage volume overload using standard therapies including diuretics, and the role of ultrafiltration and hemodialysis in appropriate patients
4. To be able to recognize the need for mechanical circulatory support in patients with advanced or refractory disease, and to understand the various options now available including percutaneous support devices, temporary and permanent implantable assist devices
5. Be able to contribute to discharge planning, longitudinal care and prevention of readmission

End Stage Heart Failure/Palliative Care: To understand the role of palliative care in end-stage HF, and to be able to participate in discussions on end-of-life issues with patients, family members and other providers

Heart Transplantation Education

• To be aware of the scope, trends and outcomes of heart transplantation in the United States. To understand the role of the United Network for Organ Sharing (UNOS) and local organ procurement organizations (OPOs).
• To be aware of the indications for heart transplantation
• To understand the pre-transplant work-up process, psychological and social considerations, exclusion criteria, listing procedure and status, individual issues, HLA sensitization and techniques for desensitization, the place of retransplantation, use of inotropes and assisted circulation as a bridge to transplant.
• Understand transplant listing criteria and the prioritization of recipients for donor offers.
• To understand the indications for using inotropes and vasodilators, the place of hemodynamic monitoring using pulmonary arterial catheters and the indications for short and long term mechanical circulatory support.
• Understand the management of donor candidates, evaluation of donor offers and the procurement of organs (‘donor runs’). Be familiar with donor and recipient surgical procedures including organ preservation, biatrial technique vs bicaval. Be aware of early and medium term complications of heart transplantation.
• To understand and differentiate the pathophysiology of acute antibody mediated and cellular rejection as well as chronic rejection (see below). Be aware of typical clinical and pathological findings, the classification system for grading rejection and appropriate treatment strategies for each grade of rejection. To be familiar with surveillance strategies including endomyocardial biopsies, drug level monitoring, gene expression profiling and genomic markers of rejection, echocardiography and cardiac MR, immune function assays and antibody monitoring.
• Immunosuppression: have a firm grasp of strategies for induction therapy, drugs used for chronic immunosuppression and their side effects, and therapies used for treatment of acute rejection.
• Long term post-transplant care
  I. Complications: to be familiar with early and late complications of transplantation.
  II. Transplant vasculopathy: Late graft failure, immune and non-immune causes/factors, histopathological and clinical difference compared to atherosclerosis, treatment
  III. Chronic kidney disease: role of calcineurin inhibitors, induction therapy in preserving renal function
  IV. Infections: Early vs. late infection, opportunistic infections and activation of latent infections, prophylaxis
  V. Malignancy: leading cause of late death equaling vasculopathy, post-transplant lymphoproliferative disorders and skin cancers, role of viral factors (EBV etc.)

Program Director

• E. Joseph Bauerlein III, M.D., FACC
  Program Director, Advanced Heart Failure/Transplant Fellowship Program
  Associate Professor of Clinical Medicine, University of Miami Miller School of Medicine

Core Faculty

• Joshua Hare, MD 
  Louis Lemberg Professor of Medicine
  Director, Interdisciplinary Stem Cell Institute
  University of Miami Miller School of Medicine
  
  
• Nina Thakkar Rivera, DO
  Site Supervisor, UMH Advanced Heart Failure/Transplant Fellowship Program 
  Associate Professor of Clinical Medicine, University of Miami Miller School of Medicine

Program Coordinator

• Kristie Pino
  Phone: 305-243-7067
  Fax: 305-243-1731
  E-mail: kxp656@med.miami.edu

ACGME Accredited: Yes
Residents or Fellows per year: 1-2
Duration: 1 Year
Postgraduate Training Required: Internal Medicine Residency and Cardiovascular Fellowship
U.S. Citizenship Required: US Citizen, Permanent Residents/Green Card Holder, and J1 Visa

For further information about the application process and requirements, interested applicants can go to: https://jacksonhealth.org/graduate/advanced-heart-failure/