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Indiana University School of Medicine
Indiana University School of Medicine
Department of Medicine

Pulmonary Hypertension Curriculum

This curriculum is designed to provide a comprehensive understanding of the management of pulmonary hypertension patients, including pathophysiology, evaluation, diagnosis and treatment. Fellows will manage patients in both outpatient and inpatient settings and be involved in the CTEPH program at Methodist Hospital. Fellows will become proficient in the interpretation of diagnostic data including imaging modalities of CT, echo, VQ, cardiac MRI, pulmonary function testing, and cardiopulmonary exercise testing. Our programs are designed to allow fellows to become proficient procedurally as well with right heart catheterization as well as interpretation of cardiopulmonary hemodynamics with the utilization of fluid challenges, vasoreactivity agents, exercise, and pulmonary angiography. The pulmonary hypertension program works closely with the lung transplantation team, advanced heart failure, heart transplantation, advanced liver disease, high risk maternal fetal medicine and many other services across multiple hospitals. The broad patient exposure allows our pulmonary hypertension fellows to obtain superior training.

The fellow's education is performed through dedicated didactic learning from pulmonary hypertension specialists throughout the year. Along with this is robust bedside clinical education as well while rounding inpatient. Fellows will also have simulation encounters and training for advanced procedures and interpretation. Our fellows come out uniquely prepared to perform not only RHC but also TTE and TEE.

Our fellows are encouraged to perform research as well. Indiana University School of Medicine has renowned research support and availability through multiple institutional pathways as well as external research support. The pulmonary hypertension team work extensively in lab research as well as participating in large clinical trials. Our fellows present at national conferences as well as the division research day. The expectation is that the pulmonary hypertension fellow disseminate knowledge throughout the Pulmonary and Critical Care Fellowship as well as grand rounds and to house staff.

Pulmonary Hypertension Team

Rotations

  • One month orientation
  • One month lung transplant
  • One month interstitial lung disease
  • One month critical care echocardiography
  • One month elective
  • One month ECMO
  • Six months pulmonary hypertension inpatient and outpatient 

In order to gain expertise in pulmonary hypertension, fellows will have both an ambulatory and inpatient role in patient care.

Outpatient

During their outpatient rotation, fellows will spend time on a longitudinal basis providing care for our pulmonary hypertension patients and building a relationship with them. This will be performed at Methodist Hospital where the home of our PH program exists. Clinic opportunities are available at other sites as we expand our treatment of PH across the state of Indiana.

Clinic Location: Methodist Professional Center (MPC) 2. 2nd floor. Advanced Lung and Heart Disease Clinic. 2000.

Inpatient

Fellows will rotate at multiple sites across the Indiana University campus. The pulmonary hypertension service is a consult service available at Methodist Hospital, University Hospital, and Riley Hospital. While on service fellows will cover and round on patients at these institutions to help provide specialty care. These rotations are supported with NP and APP coverage as well.

Locations:

  • Methodist Hospital
  • University Hospital
  • Riley Hospital

Curriculum

  1. Pulmonary Hypertension
    1. Normal pulmonary vascular function and anatomy
    2. Hemodynamic definitions of Pulmonary Hypertension
    3. Histopathology of Pulmonary Hypertension
    4. Mechanistic mediators
    5. Epidemiology

  2. Classifications
    1. Group I PAH
    2. Group II PAH
    3. Group III PAH
    4. Group IV PAH
    5. Group V PAH

  3. Pulmonary Hypertension Diagnostics
    1. History and physical examination
    2. Laboratory studies
    3. Chest imaging
      1. CXR
      2. CT
      3. VQ
    4. Functional testing
      1. SMWT
      2. PFT
      3. CPET
    5. Cardiac imaging
      1. TTE with bubble
      2. TEE covered in the Echo curriculum
      3. Non-invasive calculations
      4. cMRI
    6. Right Heart Catheterizations
      1. Timing of and indications for RHC
      2. Components of RHC
        1. Pressures
        2. Hemodynamics
        3. Saturation run
        4. Shunt and shunt physiology
        5. Interventions with vasoreactivity, fluid challenge, exercise, pulmonary angiogram
      3. Indications for simultaneous LHC
        1. LVEDP
        2. Constrictive and restrictive pathophysiology
        3. CAD

  4. Pulmonary Hypertension Medical Pharmacology
    1. PDE5-I
    2. ETRA
    3. Prostanoids
      1. Inhaled
      2. PO
      3. Parenteral
    4. Riociguat
    5. Anticoagulation
    6. Exercise and cardiopulmonary rehab
    7. Experimental agents and future expansion
      1. FK-506
      2. Rituximab
      3. Imatinib

  5. Major Pulmonary Hypertension Medical Therapeutic Trials
    1. Group 1
    2. Group 2
    3. Group 3
    4. Group 4

  6. Surgical Therapies for Pulmonary Hypertension
    1. Atrial septostomy
    2. Pulmonary thromboendarterectomy
      1. Indications
      2. Contraindications
      3. Peri-operative complications
      4. Long term therapeutics and follow up care
      5. Alternative procedures
    3. Pulmonary balloon angioplasty
    4. Mechanical support
      1. Right heart assist devices
      2. ECMO
    5. Lung transplantation
      1. Covered in the lung transplantation curriculum
      2. Special topics in PH:
        1. Lung allocation score with updates in PH
        2. Complications of lung transplant in PH

  7. Special Considerations in Pulmonary Hypertension
    1. Peri-operative Care
      1. Patient risk assessment
      2. Surgical Risk assessment
      3. Preoperative management
    2. Intra-operative care
      1. Anesthesia planning
      2. Monitoring planning
      3. PH medications and continuation
    3. Post-operative care
      1. Plans for monitoring
      2. Complications
    4. Pregnancy
      1. Physiologic changes in pregnancy
      2. Pathophysiologic changes in pregnancy pulmonary hypertension patients
      3. Pulmonary hypertension medications in pregnancy
      4. Prenatal care
      5. Peri-natal care
      6. Medications peri-delivery
    5. Pulmonary hypertension in critical care
      1. Effects of mechanical ventilation
      2. Sepsis and pulmonary hypertension
      3. Strategies for medical management of acute/chronic right heart failure
    6. Pericardial effusions in pulmonary hypertension
      1. Etiology
      2. Indications and contraindications to drainage

  8. Other Pulmonary vascular diseases
    1. Pulmonary AVMs
      1. Hereditary hemorrhagic telangiectasia
      2. Hepatopulmonary syndrome
    2. Pulmonary vasculitis
    3. Pulmonary vascular tumors
    4. Acute pulmonary embolism
      1. Indications for thrombolysis both systemic and local
      2. Indications for surgical thrombectomy