Developing a Niche in Structural Heart Disease

Structural heart disease (SHD) field has rapidly expanded over the last few years. Most think of transcatheter aortic valve replacement (TAVR) procedures as the prototypical structural procedure, but the field really encompasses multiple non-coronary interventions. While there are few training programs dedicated to this subspecialty, most interventional fellowships provide some training for their graduates on the more common procedures, especially TAVR. The level of training varies between institutions and even year to year. While there are specific COCATS requirements for training in interventional cardiology, no adjunct requirements exist for structural heart disease procedures. It then falls on the trainees, based on their level of interest, to seek out additional training. There is also variability in the level of collaboration that exists between the interventional cardiology, pediatric cardiology, electrophysiology, interventional radiology and imaging subspecialties. That, in itself, can lead to significant differences in training and approaches to interventions.

Along with structural heart disease, adult congenital heart disease is becoming more important as more patients live longer and grow out of the pediatric cardiology practice, being seen much later in life with complex medical issues. A recently published document has proposed training methodology and requirements for the training needs and knowledge base for the developing field of structural heart disease intervention. Most programs have an integrated SHD component but this does not guarantee that a graduating fellow has the expertise to perform these procedures independently. In many programs, the volume of procedures is limited and insufficient to reach the level of competence that program directors would consider adequate. Therefore, a dedicated SHD training year would be needed for those wishing to specialize in such procedures.

How do you develop a SHD career path? First, during your fellowship SHD should be approached as a dedicated training program, not as a supplement. You need to determine what procedures you would be performing in the future and focus on getting as much hands-on experience with those. Early after training, when choosing a job, it is important to understand the institutional capabilities for supporting such procedures.

Procedures in SHD draw on the skill-sets from different fields within cardiology. When initially becoming vested in the program, it is important to develop strong collaborative ties with pediatric cardiology. Pediatrics has long been focusing on challenging SHD conditions and adapting devices off-label to treat patient-specific conditions. This is particularly pertinent for such procedures as paravalvular leak closure, where there is a large component of improvisation and case-by-case problem-solving. In smaller programs, the insight from pediatric cardiology can be invaluable.

Partnering with electrophysiology can also be very valuable. As more procedures require crossing the septum or intra-cardiac echocardiography (ICE), having the support of electrophysiology colleagues can be very helpful, particularly in cases with complex anatomy. Another vital component of the structural program is imaging. While some procedures, such as patent foramen ovale and atrial septal defects, can be addressed with ICE, others require transesophageal echocardiography. An echocardiographer familiar with the SHD procedures can help facilitate the success of an otherwise difficult and prolonged procedure. Some cases can take significant time away from other activities on the part of the imaging cardiologist, so departmental buy-in and good will are important. Insufficient familiarity with imaging (such as CT when performing TAVR) in the early stages, can result in a higher likelihood of adverse outcomes.

When starting out, getting support from your division or group will be important. This may be easier in academic programs or large groups with control over local cardiovascular services and referral patterns. It is more challenging to garner support within smaller separate groups and more time would need to be spent networking. If possible, obtaining a position in a larger academic setting would be conducive for success in the field, although not necessarily if the focus will be only on specific procedures.

Aside from the operator requirements, there are specific institutional requirements for some procedures such as TAVR, while requirements for rare procedures are not always well defined. In order to safely perform SHD interventions, it is wise to assess the level of support available (e.g. cardiothoracic surgery, imaging support, equipment availability, etc.).

Once again, more so than in any other cardiac field, a multi-disciplinary approach is a key in SHD procedures. The concept of collaboration should involve all phases of the case, beginning with planning and review of imaging and hemodynamics. It is often a good idea to invite subspecialty colleagues to scrub-in on complex and potentially difficult interventions. In order to develop long-term relationships it is important to always be easily available. This might be challenging early on when trying to build caseload in a busy program, but demonstrating that the program is a priority and providing solutions to the other providers helps generate new referrals for the program.

Structural interventions can be associated with an increased risk of adverse events. A vital aspect of a robust program is being ready to deal with complications. Complications can occur quickly and with high severity so, as mentioned previously, drawing on a wide set of skills and having a multi-disciplinary team in place can help with prevention and management of adverse events. Each procedure has its own set of possible complications, so familiarity with each and having a contingency plan is a prerequisite to being a safe operator.

Most programs cannot perform all SHD procedures, thus limiting the offered procedures to those that can be done safely is appropriate. The program can always be expanded later with the support of other divisions like pediatric cardiology, cardiothoracic and vascular surgery. It may be challenging at the beginning to change the referral patterns in your community but that is a requirement to long-term success. Continuous communication with referring cardiologists is always a good practice. Patient care is a team effort, but ensuring that it is the primary care physician or patient's cardiologist that directs the treatment and long-term management plan, sets up a collegial atmosphere. It is advisable to continue pursuing additional training even in fairly straightforward procedures as newer devices become available and procedural techniques change. This involves going to training seminars, industry-sponsored classes, local and national meetings. I would also encourage operators to visit surrounding high-volume programs with excellent track record. In addition to acquiring more skills, such networking can help the early career physician succeed and grow in the SHD field.

This article was authored by Islam Abudayyeh, MD, MPH, FACC, assistant professor of medicine in interventional cardiology at the Loma Linda University.