by Subhi J. Al’Aref, MD; and Harsimran S. Singh, MD, MSc, FSCAI
The field of interventional cardiology has seen a dramatic rise not only in the number of coronary catheterizations performed, but also in the spectrum of percutaneous, non-coronary procedures that are now available. Minimally invasive structural interventions including transcatheter aortic valve repair or replacement; alcohol septal ablation; closure of septal defects, collaterals and fistulas; paravalvular leak closure; and large vessel stenting (for example, aortic coarctation or baffle stents in complex congenital heart disease) are amongst the different categories of interventions readily treatable with a catheter.
Subhi J. Al’Aref
There is clearly a need for rigorous and organized programs for physicians-in-training in order to achieve competency in such interventions. Since the turn of the century, select academic/hospital centers have begun to offer structural interventional cardiology training, although there is considerable variability in case mix, quantity and quality of training amongst these programs.
According to the American College of Cardiology, there are 32 structural or congenital interventional fellowship programs across the United States. At first glance, the number of training programs seems inadequate, considering that approximately 12,200 patients underwent transcatheter aortic valve replacement alone at 299 U.S. hospitals between November 2011 and June 2013, and these numbers are expected to exponentially grow with emerging study data for TAVR in intermediate-risk patients.
Limitations in current training
While transcatheter valves have been the biggest catalyst for interventional cardiology’s interest in structural heart disease, it would be erroneous to conclude that knowledge of TAVR is adequate training to perform all other structural interventions. One of the most significant limitations in current U.S. training is that very few centers can provide adequate volume and breadth of experience in TAVR, let alone in other structural heart interventions. Only a select few tertiary care, high-volume centers have the volume and expertise to achieve a broader educational experience. There absolutely is overlap in the technical and clinical skills specific to TAVR including large vessel access and closure, periprocedural echocardiography and imaging, synergy of the heart team model and caring for complex population with multiple comorbid conditions. However, other categories of structural and congenital interventions require different equipment, transseptal skills, 3-D understanding of cardiac physiology and anatomy in the congenital heart patient, and technical flexibility beyond TAVR valve deployment.
Harsimran S. Singh
Better standardization, broader focus
There have been several attempts to develop guidelines to encourage better standardization and quality for structural interventional training across the country, including the Society for Cardiovascular Angiography and Interventions Expert Consensus statement published in JACC: Cardiovascular Interventions in 2010. This article, authored by leaders in the field, highlights deficiencies in fellowship training and defines the requirements for attaining an acceptable level of medical knowledge and practical experience in structural interventions. These initiatives have been further emphasized at national conferences where dedicated sections for transcatheter and structural interventional work have been established.
At the institutional level, training in structural heart disease should not have so narrow a focus as to disallow fellowship exposure in multimodality imaging, including transesophageal and intracardiac echocardiography, surgical techniques for hybrid approaches and vascular access, and appreciation for multidisciplinary collaboration between adult and pediatric cardiologists, cardiothoracic surgeons, echocardiographers, radiologists and anesthesiologists.
‘Not all structural interventions are alike’
In summary, there is growing recognition that not all structural interventions are alike — similarly few operators have both the clinical knowledge and the technical skillset to successfully and safely undertake the entire breadth of structural and congenital interventions. We hope and expect more consistent standards to be applied and enforced for training in structural and congenital heart interventions and regulations as to who performs these procedures in practice. As the field of interventional cardiology continues to evolve, we owe it to our patients to adequately equip the new generation of interventionists for the challenges that lie ahead.
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American College of Cardiology. Structural Heart Disease and Congenital Interventional Fellowship Programs. Available at: www.acc.org/membership/sections-and-councils/fellows-in-training-section/training-resources/structural-heart-disease-and-congenital-interventional-fellowship-programs.
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Subhi J. Al’Aref, MD, is an interventional cardiology fellow at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. Harsimran S. Singh, MD, MSc, FSCAI, is director of the Cornell Center for Adult Congenital Heart Disease at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, the David Blumenthal Assistant Professor of Medicine and Pediatrics at Weill Cornell Medical College and adjunct assistant professor of medicine at Columbia University College of Physicians and Surgeons.
Disclosure: Al’Aref and Singh report no relevant financial disclosures.