The Growing Specialty of Adult Structural Heart Disease

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. 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. 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.