Background

Structural heart disease (SHD) has substantially expanded over the last few years, and is spurred primarily by the development of new devices and decreasing percutaneous coronary intervention volumes. However, there are not many dedicated training programs in SHD, and most interventional fellowships train their graduates on more common procedures such as TAVR. The level of training varies between institutions and even year to year because while there are specific COCATS requirements for training in interventional cardiology, no adjunct requirement currently exists for SHD. It then falls to the trainees based on their level of interest to seek out additional training. In addition, the faculty at the program will have to be highly competent in not only performing but also teaching the techniques.

There is also variability in the level of collaboration between interventional cardiology, pediatric cardiology, electrophysiology, interventional radiology and imaging. This can lead to significant differences in training and approach to interventions. Along with SHD, adult congenital heart disease is becoming more prevalent as more patients grow out of the pediatric cardiology practice and are seen much later in life with adult medical issues. Therefore, it is important to take advantage of the training period during fellowship to acquire as much exposure as possible prior to becoming professionally engaged. As described, most programs have an integrated SHD component, but this does not guarantee that a graduating fellow has the requisite expertise to do the procedure independently. In most programs, there are not the procedural numbers and training environment to reach a level of competence program directors consider adequate. This generated the focus on a dedicated SHD year. Again, because of the ill-defined curriculum for such training, there is no uniformity between programs.

Collaborating With a Multi-Disciplinary Team

With this as a background, it becomes difficult to describe a single SHD career path that would work for any early career interventional cardiologist. However, some basic tenets are useful. SHD should be approached as a dedicated program and not as a supplement. A first step is to determine what procedures in SHD the interventionist is interested in based on their exposure. It is much easier to focus on these interventions to develop partnerships and achieve competence while producing good outcomes. This is more likely with reproducible procedures such as TAVR and mitral-clip as opposed to para-valvular leak closures. Another consideration is the facility capacity to doing these 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 the most familiar with the challenges of SHD and in adapting devices off-label to treat patient-specific conditions.

Aside from SHD training programs, it is rare that a cardiologist early in their career has that experience. This is pertinent in procedures such as paravalvular leak closure, where there is a large component of improvisation and problem solving during the procedure and afterwards. In smaller programs, the insight from pediatric cardiology is invaluable. SHD not only deals with interventions and placing devices but also involves assessment of hemodynamics – something pediatric cardiologist, with their understanding of congenital heart disease, are expert on. Partnering with electrophysiology is also valuable. As more procedures require crossing the septum, or intra-cardiac recho (ICE), having the support of electrophysiology can be very helpful in the more difficult anatomy. A 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 trans-esophageal imaging. An echocardiographer familiar with the procedure can help facilitate success of an otherwise difficult and long procedure. Some cases take significant time away from performing daily duties on the part of the imaging cardiologist so buy-in and good will is important. Not all echocardiographers could or should guide SHD interventions but identifying those with knowledge of the procedure and willingness to spend the time to help the interventionist is important. Insufficient familiarity with imaging in the planning stages (such as CT when performing TAVR) or during the procedure (ICE imaging when performing PFO closure) produces a higher likelihood of adverse outcomes.

Institutional and Peer Support

Support from the group is important for the early career operator starting out. This is more likely to happen in academic programs or large groups with control over local cardiovascular services and referral patterns. Since it is more challenging to garner support with smaller separate groups, more time should be spent networking. If possible, obtaining a position in a larger or academic center is conducive for success in the field, although not required particularly if the focus is on single specific procedures. Aside from the operator requirements, there are specific institutional requirements to some procedures such as TAVR, while others are not so well defined. In order to safely perform SHD interventions, it is wise to assess what level of support is available such as cardiothoracic surgery, imaging support, equipment availability, etc. More so than in any other cardiac field, a multi-disciplinary approach is important. The concept of collaborating should involve all phases of the intervention beginning with planning and review of imaging and hemodynamics. It is often a good idea to invite other colleagues to scrub-in on complex and potentially difficult interventions. A shift in approach can yield success since sometimes there is no set protocol to doing these cases.

In order to develop these relationships, it is important to always be available and provide easy contact information to other cardiologists and staff. This might be challenging when trying to work full-time as an internationalist in a busy program, but demonstrating that the program is a priority and providing solutions to the other providers helps create new referral patterns towards the program. With multiple operators taking an interest there is the risk of diluting the experience especially in community programs where not one cardiologist acquires sufficient experience in a procedure to become fully competent. Early communication with the different stake-holders and reaching an appropriate care avenue wile delineating responsibility helps avoid that as much as possible.

Complications

Structural interventions have an increased risk for adverse outcomes. The operator will have to dedicate time outside of normal duties on a regular basis, especially early in their career. This might involve performing patient follow-up separate from the typical service lines in an institution or be involved in other aspects of patient care such as fielding imaging questions or responding to queries from other providers. A vital aspect of a robust program is knowing how to deal with complications. Issues with these interventions can occur rapidly and with high severity, so drawing on a wide set of skills and having a multi-disciplinary team can help curb adverse outcomes. Each procedure has its own set of possible complications, and familiarity with each and having a contingency plan is a prerequisite to being a safe operator.

Growth in the Long Term

Most programs cannot perform all SHD procedures competently, so limiting the offered procedures to what can be done safely is appropriate. This can also be expanded with the support of other divisions such as pediatric cardiology, cardiothoracic and vascular surgery. In the surrounding regions, we should offer these services by reaching out to local cardiologists. While it may be difficult to change the mindset and practice patterns in the community, it is a requirement to long-term success. One consideration is to create an environment where the referring cardiologist has control over their patients. Patient care is a team effort lead by the primary physician, where the SHD cardiologist has the role of both a consultant and technician. This reassures the referring physician that the care of the patient will be directed by the primary doctor and sets up a collegial atmosphere.

It is possible to be involved in research as more scholarly work is being focused on valvular disease. New technology such as 3D printing and hemodynamic modeling can be a gateway in academic centers to being involved in SHD and interventions. It is advised to continue pursuing additional training even in fairly straightforward procedures, as newer devices become available and patient expectations increase. This involves going to training seminars, industry sponsored classes, and local and national meetings. I also encourage operators to visit surrounding programs with a track record in excellence. In addition to becoming more skilled, this networking can help the early career physician further grow in the field.

This article was authored by Islam Abudayyeh, MD, MPH, FACC, associate professor of medicine in the Division of Cardiology at Loma Linda University Health in Loma Linda, CA.