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Building blocks of structural intervention: An approach for procedural training


Structural heart disease (SHD) intervention is the fastest-growing area in cardiology and cardiac surgery. The number of transcatheter procedures has increased from approximately 5000 procedures in 2012 to over 60,000 cases in 2018 in the United States alone ( Fig. 1.1 ). These numbers are set to increase even further as the market expands into lower-risk patients and procedures become more refined. If TAVR is routinely performed in low risk patients, annual case volume may exceed 150,000 patients per year. ,

Fig. 1.1
Transcatheter aortic valve replacement volume has expanded exponentially in the United States (TVT registry data), and similar trends are seen worldwide.

Training in SHD is evolving, with novel procedures and devices introduced every year.

This handbook of SHD training is a “how-to” practical handbook structure covering clinical pearls of wisdom, pitfalls, and tips and tricks from the experts. We will use the “building-blocks” approach, which breaks down each procedure into component blocks, enabling practitioners to more easily train in new procedures and gain competency.

Structured procedural training

The American College of Cardiology (ACC) framework for established cardiovascular training uses outcomes-based evaluations. Milestones are used to describe progression from early learner status through advanced learning until unsupervised practice is achieved. Minimal recommended procedural volumes in percutaneous coronary intervention (PCI) for both training and maintenance of competency were developed by the ACC due to the relationship between high procedural volumes and low complication rates. Although less evidence exists for a procedure volume–outcome relationship in structural intervention, selected procedures do show a similar relationship. ,

For SHD, the number of mitral interventions, left atrial appendage procedures, and paravalvular leak closures, even in high-volume sites, are small compared with coronary intervention. However, if each procedure is considered a series of steps, many of which are common between structural cases, development of a competency-based framework and maintenance of procedural numbers during training and ongoing practice becomes achievable.

Modular training using the building-blocks approach

In the modular approach, a structural intervention is considered the sum of a series of building blocks. By combining different building blocks, a complete structural procedure is assembled ( Figs. 1.2–1.4 ). Procedural competency can therefore be taught and assessed by component blocks, which remain constant, rather than by procedures, which change over time. These building blocks also provide the foundation for new procedures.

Fig. 1.2, The 10 core building blocks of structural intervention are demonstrated graphically. These are encapsulated by the cognitive skills developed during structural interventional training. Decision-making is best taken using a heart team approach. Device-specific training is coupled with the core 10 blocks to complete each procedure.

Fig. 1.3, The similarity between structural procedures is easily seen when they are broken down into component building blocks. Training in transcatheter aortic valve replacement (TAVR) may begin with performing aortic valvuloplasty. Examination of the component blocks demonstrates that the procedures are nearly identical, with the addition of device-specific training.

Fig. 1.4, For more complex interventions on the mitral valve, training and maintenance of competency may be achieved by considering the component blocks. Learning procedural fluency is aided by this approach, and novel left-sided procedures may be more easily learned when a familiar schematic is followed with the addition of device-specific training.

We describe 10 key SHD building blocks. When combined with the cognitive skills of structural intervention and device-specific training, use of these blocks aids training and assessment of competency in SHD intervention.

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