Current and Future Training for the Structural Proceduralist - PowerPoint Presentation

1. Current and Future Training for the Structural ProceduralistClifford J Kavinsky MD, PhD FACC MSCAIProfessor of Medicine and PediatricsDirector, Section of Structural and Interventional CardiologyDirector, Rush Center for Congenital and Structural Heart DiseaseProgram Director, Interventional Cardiology FellowshipRush university Medical Center

2. DisclosuresNothing to disclose

3. Unmet Need for Training: The ChallengeCongenital and acquired structural heart disease (SHD) in the adult is increasingly being treated with less invasive trans-catheter procedures as an alternative to cardiac surgerySkillsets for SHD procedures are much different from traditional interventional techniques which are focused on atherosclerotic vascular disease Stakeholders in this field cross multiple specialties including Interventional cardiology, Pediatric cardiology, Cardiac surgery (adult and congenital). Training in each of these fields different.SHD is largely devoid of formalized training programs (case volumes, financial resources)Many SHD procedures are nuanced, occur at low volumes and therefore difficult to teach and impart necessary experienceCurrent training is fragmented, incomplete and inconsistentMust ensure proceduralists have the necessary skillsets to safely and effectively carryout procedures

4. The Spectrum of Adult SHD/CHD InterventionsVSD ClosureValve Repair for InsufficiencyAlcohol Septal Ablation for HCMLeft Atrial Appendage OcclusionClosure of Coronary FistulasBalloon/Stent of Aortic CoarctationPercutaneous closure of Patent Ductus ArteriosusAngioplasty and stenting of surgical conduits, baffles and homograftsMitralTricuspidASD ClosurePFO ClosureBalloon ValvuloplastyParavalvular Leak ClosurePercutaneous Valve ReplacementAtrial Septostomy for Diastolic Heart FailureMitralPulmonicAorticTricuspid MitralPulmonicAorticTricuspid

5. Essential Cognitive Skillsets of the Structural ProceduralistUnderstanding pathophysiologyDiagnostic evaluationNon-invasive imagingPatient selectionComplicationsPostprocedure care and followupShared decision makingWorking in the context of a multidisciplinary teamSocietal costsEthical considerations

6. Mastery of the equipmentProcedural imagingVascular accessSafe and efficacious execution of the procedureRecognition and treatment of complicationsEssential Technical Skillsets of the Structural Proceduralist

7. Technical Skills of the Structural ProceduralistLarge bore vascular access and closure (arterial and venous)Transseptal TechniquesBalloon dilatation of the aortic, mitral and pulmonic valvesAdvanced wire managementEstablishing arterio-arterial and arterio-venous wire loopsAll forms of retrieval devices and techniquesPeripheral vascular diagnostic and interventional techniques (covered stents)Coronary diagnostic and interventional techniquesStent implantation of the right ventricular outflow tractImplantation of percutaneous aortic, pulmonic, mitral valvesPercutaneous mechanical circulatory support techniquesCatheterization and intervention of patients with complex congenital heart diseaseAdvanced imaging skills (intracardiac echo, IVUS,OCT)Left atrial occlusion techniquesClosure of coronary fistulasPercutaneous closure of prosthetic paravalvular leaksStent placement for aortic coarctation

8. Retrieved HELEX Device

9. Didactics focused on basic principlesHands-on experience with device-specific equipmentSimulationViewing live cases performed by experienced implanters in an interactive formatExperienced Device specific proctorsFellowship training Mini-fellowships at high volume centers Full one year fellowships at training centers Current Training

10. Established Structural Heart Disease Fellowship Training Programs

11. Training of Future Structural ProceduralistsNeeds to be standardized and formalizedNeed to ensure acquisition of all cognitive and technical skillsetsStandardized curriculumFormalized Fellowship -separate independent fellowship (ACGME) -separate from current interventional fellowship -embedded in current interventional training -additional year -separate certification (ABIM) -certification examinationOther stakeholders (cardiac surgeons, Pediatric interventionalists) -Training not the same -catheter skills not the same - should surgeons be expected to have same technical skillsets -what would surgical training look like -should surgical skillsets be different in depth and scope -should surgical SHD training be embedded in CV surgical fellowship -should there be one SHD fellowship for all physicians regardless of background

12. ConclusionsThe Structural Heart disease Interventional space will continue to grow and expandThe Medical community has a fiduciary responsibility to the patient to ensure safe and efficacious delivery of these important therapiesThese procedures require a unique cognitive and technical skillset not attained doing conventional coronary or peripheral vascular workProceduralists must be facile with the multiple techniques to rescue patients when complications occurFuture proceduralists will come from a variety of differing backgroundsTraining must be standardized, formalized A formalized certification based on dedicated time and an examination may be the best approachStructured structural heart disease fellowships may be the optimal path for most individualsTraining requirements will be different for surgeons entering this spaceMulti-disciplinary collaboration with shared decision making will continue to gain traction