Ted E. Feldman

1.1 Core-Curriculum for Structural Intervention

The knowledge base in this growing field of structural intervention is not well defined. Many disciplines, including pediatric and adult interventional cardiology, cardiovascular and cardiothoracic surgery, vascular surgery, and interventional radiology are all spanned by the field. The knowledge base needed for practice is ideally the same for anyone who enters the field from among any of these varied disciplines. From a practical standpoint, the necessary new knowledge differs substantially depending on the prior experience and field of the operator, and especially on the interventions the operator intends to perform. At the beginning of an individual experience, the cardiologist specializing in adult intervention may have a large background with diagnostic catheterization and possibly balloon aortic valvuloplasty (BAV) for aortic stenosis. The knowledge base for further development of skills for percutaneous transcatheter aortic valve replacement (TAVR) would then be incremental.

In contrast, the needed skills for large-sized sheath insertion, removal, and complication management might come more easily to the physician with abdominal aortic stent graft experience and would require partnerships or additional experience for coronary interventional physicians with no experience with these large-sheath techniques. Management of congenital heart disease after prior surgical repair in adult patients requires a specialized background and is obviously better suited to the already-trained pediatric interventional practitioner.

There are no accreditation standards and no training programs for structural intervention. The Society for Cardiovascular Angiography and Interventions has published a core curriculum for structural heart interventions.1–4 This will most easily be utilized by training programs, but it is a useful guide for the already-practicing interventional physician interested in this field. Structural procedures have been divided into basic and complex groups (Boxes 1–1 and 1–2). This division is a useful way to define which procedures might be adopted early in an operator’s experience.

Imaging modalities have become a critical part of the structural interventional knowledge base. Patient evaluation for valve and structural procedures is easily as important as performance of the procedure itself. The interpretation of computed tomography (CT) and magnetic resonance imaging, as well as cardiac and vascular studies are new for many interventional physicians, and experience with these studies is a key part of developing a structural program. The interpretation and use of transthoracic, transesophageal, and intracardiac echocardiographic studies is integral to this field. Most structural catheterization laboratories now have an additional permanent monitor screen in the procedure room for the display of echo imaging.⁵ Although many interventional cardiologists have a strong background in imaging, just as many do not. The reliance on echocardiographic guidance for procedures for percutaneous mitral repair and especially for intracardiac shunt closure creates a substantial demand for this imaging skill set. Whereas courses exist for the acquisition of echo skills, the use of the imaging for interventional procedures is unique to the catheterization lab and requires an increasingly specialized background.

1.2 Acquiring Skills for Structural Intervention

How does one acquire basic skills? This question is complicated greatly by the wide variety of procedures that comprise this new and developing field. The basic skill sets for aortic valve, mitral valve, shunt closure, and atrial appendage occlusion are all different but, of course, interrelated. Some background in these areas as a diagnostic catheterizer is obviously helpful. The physician with a large background in balloon aortic valvuloplasty (BAV) will, of course, have experience that is helpful for entering the field of transcatheter aortic valve replacement (TAVR) therapy. Transseptal puncture is a basic building block for left atrial procedures, including all of those directed at the mitral valve, paravalvular leak closure, and left atrial appendage occlusion.

Transseptal puncture is not widely taught in basic fellowship programs, and most practicing interventional cardiologists do not have training or prior experience. The avenues to acquire skills are similar for all of these various background components and the new procedures themselves. Several courses for transseptal catheterization have been given and simulation has been helpful.

As new devices become approved, these therapies are now rolling out with training programs and on-site proctoring. These are invaluable aids to the acquisition of new procedural skills. The use of live case demonstrations at national and international meetings has been controversial but is also invaluable for understanding how these procedures are performed. The cross-pollination from one site to another that is facilitated by proctors teaching at new sites and live-case demonstrations at meetings cannot be replicated with taped cases.

One of the best pathways for entry into a particular procedure is to become involved in a research trial. The trial process provides training and provides a way into a procedure at a point when the playing field is level and no one has a substantial background in that specific procedure.⁶

A key part of training for many of the newer device trials has been simulation. Several companies have developed simulator equipment that allows practitioners to practice a new procedure. The haptics, or feel, of the procedure can be taught to some degree. The specifics of device preparation and use are easily incorporated into simulation programs. Decision making regarding the technique of the procedure or the management of a patient throughout the course of the procedure can be incorporated into simulation as well. A relatively new development has been the creation of a purely software-based simulator for training physicians in the use of percutaneous mitral repair. The simulator displays fluoroscopic, echocardiographic, and three-dimensional anatomic renderings that all move in synchrony as various procedure maneuvers are performed (Figure 1–1).

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