Structural heart disease (SHD) interventions have emerged as a new field in interventional cardiology over the last decade. The need for highly specialized cardiologists has increased, and advances in SHD interventions are continuing to emerge, especially with transcatheter aortic valve replacement, pulmonic valve implantation, mitral valve repair, and shunt closure procedures. Currently, the Accreditation Council for Graduate Medical Education (ACGME) accredits interventional cardiology fellowship programs. Accreditation is provided when they demonstrate a high-quality and well-established training curriculum in coronary and peripheral interventions. Training in SHD interventions, however, remains in its infancy in the United States.
The Society for Cardiovascular Angiography and Interventions (SCAI) has published an expert consensus statement that defines the training needs and knowledge base for future structural interventional cardiologists. It also describes the difficulties in providing ACGME certification in this complex field. The SCAI Structural Heart Disease Early Career Task Force was established in 2011 to provide a forum for interventional cardiologists seeking advanced SHD training or currently involved in an SHD program. “SHD interventions are continuing to change significantly each year, especially in Europe and Canada,” says Mehmet Cilingiroglu, MD, FSCAI, FACC, FESC. “These new interventions require specialized training in order to optimize patient outcomes.”
Surveying Opinions on Structural Interventional Training
In Catheterization and Cardiovascular Interventions, Dr. Cilingiroglu and colleagues from the SCAI Structural Heart Disease Early Career Task Force had a study published that assessed the opinions of interventional cardiology program directors in ACGME-accredited institutions actively involved in structural interventional training. “We surveyed directors across the country about their ideas and suggestions regarding an ideal SHD fellowship and other potential training pathways for gaining these skills without going through a dedicated training year,” Dr. Cilingiroglu says. The study also assessed views about the minimum number of procedures needed to be performed for a physician to be “signed off” as being proficient at independently performing complex procedures.
According to the results (available at www.scai.org), about 86% of the 50 ACGME-accredited interventional cardiology programs surveyed were involved in the percutaneous treatment of SHD. Among those, only 29% offered a 1-year training program in SHD after completion of interventional cardiology training (Figure 1). The majority integrated structural training with coronary and peripheral intervention training. More than one-third of training was achieved by assigning cases throughout the year to fellows, while a quarter took place by participating in specialized conferences or courses.
The average number of structural procedures performed per year in the studied institutions was small (Figure 2). “Our study showed that more than half of program directors believe time dedicated to SHD training in the first year of interventional cardiology training was not enough,” says Dr. Cilingiroglu. In only four of the 15 procedures was the average number of procedures performed higher than what program directors felt was the number necessary to achieve skill proficiency. There was not a single center in the U.S. that offered sufficient training in all advanced SHD interventions.
Challenges Persist for Optimal SHD Interventions
The SCAI Structural Heart Disease Early Career Task Force survey identified challenges to achieving optimal training for SHD interventions, both through current programs and in trying to develop additional training and fellowship programs. The average number of SHD procedures performed per year in the studied institutions oftentimes was less than the recommended number of procedures to gain proficiency. “Perhaps the biggest challenge is that funding for SHD training remains ill-defined,” adds Dr. Cilingiroglu. “Efforts are needed to identify the most appropriate funding resources for structural programs.”
As care continues to advance for patients, it is essential that clinicians establish structured training programs with standardized requirements that can help new interventional cardiologists build their skills in this area. While most interventional cardiology training programs are involved in some sort of structural interventions, only a few offer a dedicated SHD fellowship program.
“No single interventional cardiology fellowship program can offer sufficient training in all 15 types of structural interventions in a single year,” says Dr. Cilingiroglu. “To overcome this problem, it may be possible to combine rotations in different institutions. Computer-based hands-on training simulators might be an approach to achieve training in all the required types of advanced structural interventions. Since it will be difficult to define a uniform training curriculum, we need to think outside the box to find ways to enhance education and training for interventional cardiologists.”
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