Establishing a Contemporary Training Curriculum for the Next Generation of Interventional Cardiology Fellows

HomeCirculation: Cardiovascular InterventionsVol. 10, No. 4Establishing a Contemporary Training Curriculum for the Next Generation of Interventional Cardiology Fellows Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBEstablishing a Contemporary Training Curriculum for the Next Generation of Interventional Cardiology Fellows Harsh B. Golwala, MD, Ankur Kalra, MD and David P. Faxon, MD Harsh B. GolwalaHarsh B. Golwala From the Brigham and Women's Heart and Vascular Institute, Boston, MA (H.B.G., D.P.F.); Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.K.); and Weill Cornell Medical College, New York, NY (A.K.). , Ankur KalraAnkur Kalra From the Brigham and Women's Heart and Vascular Institute, Boston, MA (H.B.G., D.P.F.); Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.K.); and Weill Cornell Medical College, New York, NY (A.K.). and David P. FaxonDavid P. Faxon From the Brigham and Women's Heart and Vascular Institute, Boston, MA (H.B.G., D.P.F.); Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.K.); and Weill Cornell Medical College, New York, NY (A.K.). Originally published6 Apr 2017https://doi.org/10.1161/CIRCINTERVENTIONS.117.005273Circulation: Cardiovascular Interventions. 2017;10:e005273The best preparation for tomorrow is to do today's work superbly well.—William OslerThe last decade has witnessed several groundbreaking innovations in medical and interventional therapies for cardiovascular diseases.1 The field of interventional cardiology, which began with percutaneous transluminal coronary angioplasty in the 1980s with no formal training programs, now encompasses coronary stent technology with various platforms—metallic scaffolds, bioresorbable polymers, and bioabsorbable vascular scaffolds and percutaneous treatment of complex chronic total occlusions. Furthermore, the field of interventional cardiology has expanded to include peripheral vascular interventions, involving superficial femoral, iliac, and renal artery interventions, to the more complex carotid, subclavian, below-the-knee interventions and endovascular repair of abdominal and thoracic aortic aneurysms. The interventional subspecialty that has exploded and caught the attention of many over the past 5 years is the field of structural heart interventions. Transcatheter aortic valve replacement (TAVR), which is now the standard therapy for patients with intermediate- and high-risk aortic stenosis, has been recognized among the top 10 innovations of the decade.2,3 Currently, TAVR is growing at a rate of >16% per year, and further growth is expected as new valves become available for widening indications. If TAVR is shown to be as effective as surgical aortic valve replacement in low-risk patients, the volume of cases is expected to significantly increase rapidly. In addition, percutaneous mitral and several tricuspid valve therapies are on the horizon that are expected to expand the gamut of structural heart procedures.4 Similar growth is expected in peripheral vascular interventions. Estimates are that endovascular procedures are growing at a rate of 6% to 8% per year, in part because of earlier identification of the disease, and a shift away from surgery toward interventions. In tandem, venous interventions are also expanding.5 These trends support the expansion of the training programs to adjust to the future demands of interventional cardiology.With all these advances, there are several questions that arise. How long should the interventional cardiology training be? In how many areas should a trainee be expected to be proficient in after completion of training? What should be the curricula for advanced training in coronary, peripheral, or structural heart interventions? Should the Accreditation Council for Graduate Medical Education accredit the subspecialty tracks within interventional cardiology training or should the duration of training increase to accommodate the need to learn all aspects of interventional cardiology?6–8 In accordance with the current Accreditation Council for Graduate Medical Education requirements, it takes ≤7 to 8 years after medical school completion to become an interventional cardiologist (Figure 1). Although the duration of training seems exhaustive, there may be a few stages that seem redundant. One of the recent welcome initiatives by the American Board of Internal Medicine involves a combined internal medicine/general cardiology fellowship program of 5 years' duration.9 Another alternative is to short track both internal medicine and cardiology postgraduate medical education and training programs to 2 years each for fellows to allow at least 2 years of intensive, focused training in all aspects of interventional cardiology, with the goal of providing training that is relevant to the practice of interventional cardiology.Download figureDownload PowerPointFigure 1. Current pathway of training in interventional cardiology.Although the duration of training still remains controversial, the scope of advanced interventional training is not well defined. The Core Cardiology Training Statement 4 requires 250 coronary interventions and 50 peripheral interventions for level II training, with a lack of similar standards set for advanced training in complex coronary, peripheral, and structural heart interventions.10 These fields have now grown substantially to an extent that requires immediate attention by professional societies.The field of structural heart disease interventions, in particular, has multiple facets associated with it. It not only requires proficiency in outpatient evaluation of these really complex, elderly patients with valvular heart disease, but also involves correlating them with imaging findings on transthoracic/transesophageal echocardiograms and cardiac computed tomographic scans to determine the final treatment plan for each individual patient. Furthermore, managing inpatient consultations, as well as postprocedural follow-up care of these patients, is equally crucial.11 In terms of structural procedures, apart from TAVR, exposure to several other procedures, such as MitraClip (Abbott Laboratories, Abbott Park, IL), left atrial appendage occlusion devices, paravalvular leak closure, atrial septal defect/patent foramen ovale closure, and interventions for tricuspid and pulmonic valves, is needed. How many hands-on TAVR procedures are sufficient? How many other hands-on structural heart interventional procedures should a trainee be exposed to in order to be identified as a structural heart interventionalist? Should there be a prerequisite level of training in adult echocardiography and cardiac computed tomography for fulfilling the eligibility requirements for a structural heart interventional fellowship?12,13 And finally, given the burgeoning structural heart field, should there be levels of training (levels I, II, and III) for every interventional trainee? Answers to all these questions are critical now, and a dedicated curriculum that standardizes all these components is quintessential as programs in the United States offering structural heart fellowship training are growing expeditiously.A recent consensus statement by leaders in the field has proposed 1 of the 2 approaches for training of the next-generation interventionalists.7 One of these involves training a super interventionalist in his/her second year of training (after basic coronary interventional training), where he/she will be trained in advanced coronary, peripheral, and structural procedures in 1 additional year. However, as aptly described in their article, although this approach sounds attractive, it might be difficult to be proficient in all of the above in 1 additional year, and second, after training, it may be questionable whether the volume of procedures would be sufficient enough to maintain skill sets in all of the aforementioned interventional subspecialties. Also, not all programs may have the volume to provide such training. A second, more putative approach might be to train the fellow in 1 or 2 of the 3 subspecialties after basic coronary interventional training—advanced coronary and advanced peripheral and structural heart interventions (Figure 2). This approach might achieve a fair balance of achieving interventional skills and acquiring the necessary consultative and imaging skills required for advanced training in each specific subset. With pros and cons of both the above approaches, it is extremely crucial to develop a training curriculum that would not only enrich training, but also allow fellows to complete it in a reasonable duration.Download figureDownload PowerPointFigure 2. Proposed pathway of training in interventional cardiology.We urge the professional societies (eg, American College of Cardiology and Society for Cardiovascular Angiography and Interventions) to convene an expert panel to make recommendations to modify the current training programs so that Core Cardiology Training Statement recommendations can be changed, and the American Board of Internal Medicine and Accreditation Council for Graduate Medical Education can accommodate the changes in the board examinations and program structure. We feel that a more comprehensive training makes most sense because it will better reflect the changing practice of interventional cardiology. This important change will allow programs to become more flexible without constraints intrinsic to a 1-year program. Fellows will naturally gravitate to the areas of most interest and can gain strong skills in ≥1 areas if desired.In conclusion, training in interventional cardiology is undergoing a major metamorphosis. With advancements and growth in complex coronary, peripheral, and structural interventions, we need a more comprehensive approach toward duration, type, and quality of future training during interventional cardiology fellowship.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the American Heart Association.Correspondence to David P. Faxon, MD, Brigham and Women's Heart and Vascular Center, Harvard Medical School, 70 Francis Street, SH 5152, Boston, MA 02115. E-mail [email protected]References1. Faxon DP, Williams DO. 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Where are we going?, European Heart Journal, 10.1093/eurheartj/ehy668, 40:5, (422-440), Online publication date: 1-Feb-2019. Carreras E and Williams D (2018) Interventional Cardiology, Circulation: Cardiovascular Interventions, 11:4, Online publication date: 1-Apr-2018. April 2017Vol 10, Issue 4 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.117.005273PMID: 28385700 Originally publishedApril 6, 2017 Keywordsinterventional cardiologyfellowshipcurriculumstructural heartperipheralPDF download Advertisement SubjectsPeripheral Vascular DiseaseTreatment