Taking the Leap Towards an Additional Fellowship Year in Advanced Structural Heart Disease Training

Structural heart disease is a relatively new discipline within cardiology, especially in regard to interventional procedures. Moreover, the type and number of procedures for structural heart disease is rapidly increasing. Accordingly, training in interventional structural heart disease is evolving, and often differs in individual institutions. The role of the structural interventionalist in individual practice settings may also vary. Therefore, consistent with our goal of being the home for structural heart disease, we thought that it would be important to provide a forum for trainees and early career physicians in the field. Kim Atianzar, who had completed some fellowship training at UCSD, agreed to organize this new section in the Journal. In this issue Kim presents a first article directed to training in structural heart disease. In the future she will also solicit contributions from colleagues in the field, and we are hopeful that many fellows and early career physicians will provide us with their unique perspectives. Structural heart disease fellows will make major contributions to the evolution of the discipline, both during and after training. We hope to garner their thoughts and energy.—Anthony N. DeMaria, MD, Editor-in-ChiefStructural Heart: The Journal of the Heart Team Almost half-way through my year of dedicated training in structural intervention, I am privileged to take the lead in the Fellowship Forum of Structural Heart: The Journal of the Heart Team. I have given some thoughts to the topic of a structural intervention fellowship, and am happy to present them below. Over the past 15 years, structural heart disease has not only emerged as a distinctive discipline of cardiology, but is also the driving force for the extensive growth and advancement of transcatheter therapies. With the emergence of structural heart disorders and treatment modalities, so has the need for dedicated fellowship training in the field. Many interventional cardiology fellowships attempt to integrate some structural heart disease exposure for their fellows. The exposure ranges from only transcatheter aortic valve replacement to mitral valve therapies, atrial septal defect/patent foramen ovale (ASD/PFO) left atrial appendage occlusion, to research devices involved in clinical trials. However, the amount of structural experience interventional fellows actually acquire during their interventional cardiology fellowship varies, and is usually not enough to be confident that they are fully structurally trained. Therefore, although it is impossible to obtain all the desired experience in 1 year of training, completing a dedicated additional training year in structural heart disease is generally essential for becoming a completely trained structural interventionalist. The decision to pursue an additional year of structural heart disease training may be difficult. In my experience, the decision should involve several steps. First, discussion is warranted with your mentors, who may include both your current interventional Program Director and other attendings who have trained you in either general or interventional cardiology. It is important to hear their opinion on why or why not doing the additional year is necessary for this career path. Your mentors will be able to impart to you the characteristics that the structural fellowship should offer to enable you to be well equipped to start a career as an interventional structuralist. Second, before making the decision to leap into the application process, open dialogue with those who constitute your support system, including family and significant others, must be initiated, because the career choice to do an extra year to sub-sub-specialize in structural heart will also have an impact on their lives for the next year. It is also wise to recognize that this will be another year of a fellow’s salary and there is very little negotiation on this aspect, even if part of the fellowship duties includes performing as a junior interventional attending. Thus, further fellowship training may impose a number of financial and other sacrifices upon the fellow and their family. Therefore, choosing this career pathway involves a multitude of considerations. Once one decides to pursue a structural heart fellowship, the tedious task of exploring and applying to the existing structural heart fellowships must be undertaken. While the number of fellowships has increased significantly over the years, the number of open spots is still very small. Almost all the fellowships are limited to one fellow per training year, and some are already “filled/booked” up to 2 years from the time one is applying. Some institutions have now made their interventional cardiology fellowships a 2-year program in which the structural training year will serve as the second interventional training year. Therefore, it is not possible to apply to these fellowships unless their current fellow does not want to proceed with the second non-accredited training year. While the American College of Cardiology (ACC) and the Society for Cardiovascular Angiography and Interventions (SCAI) both have lists of Structural Training Programs in the United States and Canada, updates to these lists are necessary and these lists include those fellowship programs in which structural training is incorporated as a second year to an initial interventional cardiology fellowship. There are approximately 30 structural heart fellowship programs in the United States and Canada (see the Appendix). It can be challenging to find these lone standing additional year fellowships in structural heart disease. Therefore, we are also providing an updated and detailed list of structural heart disease fellowships below, to assist highly interested fellows in their pursuit of this rapidly advancing field in cardiology. Because structural interventional training is not accredited by the Accreditation Council for Graduate Medical Education (ACGME), there is no established curriculum guidelines which training programs must follow. This has led to various concepts of what a structural fellowship should entail by the different programs. A fellow’s time may be unevenly split between structural training, general cardiology, and interventional cardiology duties depending on the program, since there is no consensus on the training components. Additionally, one fellowship may consider it important to integrate advanced cardiovascular imaging into the curriculum, whereas another may rather focus on outpatient hours. Furthermore, some fellowships may not emphasize research whereas others may feel that research is as important as hands-on skills. Some fellowships focus training only on aortic valve therapies with minimal involvement in other valvular and structural disorders. Without a uniform consensus on a structural interventional training curriculum, obtaining a well-rounded fellowship requires careful search. In view of the heterogeneity of curriculum, it is prudent to first get in contact with either the past or current structural fellows at programs that you are interested in. They should be able to speak honestly about their programs, the pros and cons, and give insight as to what their particular fellowship truly has to offer. When you are invited for an interview, learn as much as you can about the program during the interview. Since all structural heart fellowship programs offer training in transcatheter aortic valve replacement, it is useful to ask what percentage exposure to currently commercially available valves (Edward Sapien vs. Medtronic) one will receive during the year. This is important to know as some programs may lean heavily towards one valve over the other. From a fellow’s standpoint, it is important to have adequate training in both, since your future job may only utilize one commercial valve due to group/hospital pre-existing relationships or contracts. Thus, having hands-on experience and knowledge with all commercial prostheses during your 1-year fellowship is vital. Additionally, it is good to ask if the fellowship is involved with any national clinical trials investigating other valves. Inquire what other structural therapies are taught during the fellowship, including treatments for the mitral valve, left atrial appendage, paravalvular leak, atrial septal defects and patent foramen ovales, pulmonary valve, and left ventricular hypertrophy. Additionally, a few structural fellowships also integrate some peripheral vascular interventional training due to the nature of the transcatheter therapy delivery system and sheath sizes. For all procedures, ask about volume and how many cases they predict you will have performed by the end of the fellowship. It is also important to be fully informed of how much autonomy, primary operator proficiency, and hands-on experience one will have as a fellow. Given the lack of standardization, it is extremely important to know the fundamental procedural training a structural fellowship will provide during the year. A structural heart fellowship should not only provide the essential procedural skills, but it should also impart the fundamental adjunctive skills necessary for any structural heart interventionalist. These adjunctive skills are not only complementary to procedural training, but are crucial to becoming a true structuralist. It is important to know cardiac anatomy well, which is the foundation for structural heart interventions. This can be accomplished from an advanced cardiovascular multimodality imaging standpoint, including transthoracic and transesophageal echocardiograms, cardiac computed tomography, cardiac magnetic resonance imaging, and intra-cardiac echocardiography. Additionally, it is important to master cardiovascular hemodynamics, mechanical circulatory support and bailout peripheral interventions, which are all complementary for a robust structural heart training experience. Your structural fellowship may not directly provide formal teaching of these basic tenets in a step-by-step manner, but as a structural fellow, one must take the initiative to fully absorb these adjunctive skills. Therefore, during fellowship, ask for help in all these areas from your structural heart attendings. The pursuit of advanced interventional training in structural heart disease can be challenging, especially due to the limited number of positions available in the United States. Structural heart disease fellowships vary in exposure to specific therapies, procedural volume, and curriculum. Therefore, it is important to gather as much information as possible about the programs before and during interviews. Throughout a structural heart fellowship, one should not only master the procedural skills, but should also gain expertise in the adjunctive structural skills including multimodality imaging for cardiac anatomy, advanced hemodynamics, and peripheral bailout skills. Whether the ultimate goal is to start or grow an existing structural program, it is imperative to learn the administrative and financial aspects of your training program. It is important to remember that structural heart disease therapy involves a heart team approach. Respecting each person’s role and collaborating with various services will lead to an efficient and productive structural heart program. Overall, structural heart disease is an exciting and flourishing field and, if one is able to obtain a structural heart fellowship, can provide a promising career as a structural interventionalist. Tabled 1Structural heart fellowship programs in the United States and Canada.StateProgramArizonaBanner-University Medical Center, Phoenix, ArizonaNumber of positions:1Fellowship length:1 yearProgram director:Ashish Pershad, MDProgram contact/coordinator:Angela FrancoEmail:[email protected]Phone:(602) 839–6743ConnecticutYale University School of Medicine, New Haven, ConnecticutNumber of positions:1Fellowship length:1 yearProgram director:John Forrest, MDProgram contact/coordinator:Joanna WhiteheadEmail:[email protected]Phone:(203) 785–6484/785–4129Other:Application form available on websiteFloridaUniversity of Miami Miller School of Medicine, Miami, FloridaNumber of positions:1Fellowship length:1 yearProgram director:Eduardo de Marchena, MDProgram contact/coordinator:Jamilee (Jami) Martinez, MSWEmail:[email protected]Phone:(305) 243–7067Other:Application form will be emailed upon request; Spanish fluency requiredIllinoisPrairie Heart Institute, Springfield, IllinoisNumber of positions:2Fellowship length:1 yearProgram director:Jeffrey A. Goldstein, MDProgram contact/coordinator:Sadie SamsonEmail:[email protected]Phone:(217) 492–9115Rush University Medical Center, Chicago, IllinoisNumber of positions:1Fellowship length:1 yearProgram director:Clifford J. Kavinsky MD, PhDProgram contact/coordinator:Marilyn MaiersEmail:[email protected]Phone:(312) 942–8771Other:Application form available on websiteMarylandThe Johns Hopkins Hospital, Baltimore, MarylandNumber of positions:1Fellowship length:1 yearProgram director:Jon Resar, MDProgram contact/coordinator:Tammy ThompsonEmail:[email protected]Phone:(410) 955–5999MassachusettsMassachusetts General Hospital, Boston, MassachusettsNumber of positions:2Fellowship length:1 yearProgram director:Ignacio Inglessis-Azuaje, MDProgram contact/coordinator:Lisa DeFabritiisEmail:[email protected]Phone:(617) 643–3238University of Massachusetts School of Medicine, Worcester, MassachusettsNumber of positions:1Fellowship length:1 yearProgram director:Nikolaos Kakouros, MDProgram contact/coordinator:Raechel StromEmail:[email protected]Phone:(508) 856–3064Other:Application form emailed on requestMichiganHenry Ford Hospital, Detroit, MichiganNumber of positions:2Fellowship length:1 yearProgram director:Marvin Eng, MDProgram contact/coordinator:William O’Neill, MDTheresa GaryEmail:[email protected]Phone:(313) 916–2871Detroit Medical Center, Detroit, MichiganNumber of positions:1Fellowship length:1 yearProgram director:Theodore Schreiber, MDProgram contact/coordinator:Venicia ForemanEmail:[email protected]Phone:(313) 832–0303William Beaumont Hospital, Royal Oak, MichiganNumber of positions:1Fellowship length:1 yearProgram director:Robert Safian, MDProgram contact/coordinator:Toni HaggertyEmail:[email protected]Phone:(248) 898–4198MinnesotaMinneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MinnesotaNumber of positions:1Fellowship length:1 yearProgram director:Mario Goessl, MDProgram contact/coordinator:Andrea SweeneyEmail:[email protected]Phone:(612) 863–8258MissouriWashington University School of Medicine, St. Louis, MissouriNumber of positions:1Fellowship length:1 yearProgram director:Alan Zajarias, MDEmail:[email protected]Phone:(314) 454–8475New HampshireDartmouth-Hitchcock Medical Center, Lebanon, New HampshireNumber of positions:1Fellowship length:1 yearProgram director:Megan Coylewright, MD, MPHProgram contact/coordinator:Brandy SaloEmail:[email protected]Phone:(603) 650–3539New JerseyHackensack University Medical Center, Hackensack, New JerseyNumber of positions:1Fellowship length:2 yearsProgram director:Carlos Ruiz, MD, PhDProgram contact/coordinator:Soraya GuzmanEmail:[email protected]Phone:(551) 996–5566Rutgers Robert Wood Johnson Medical School, New Brunswick, New JerseyNumber of positions:1Fellowship length:1 yearProgram director:Issam Moussa, MDProgram contact/coordinator:Diane PalmerEmail:[email protected]Phone:(732) 235–8909New YorkColumbia University Medical Center, New York, New YorkNumber of positions:1–2Fellowship length:1–2 yearsProgram director:Susheel Kodali, MDProgram contact/coordinator:Katherine MalaveEmail:[email protected]Phone:(212) 305–2708New York University Langone Health, New York, New YorkNumber of positions:1Fellowship length:1 yearProgram director:Mathew Williams, MDProgram contact/coordinator:Eleonora VapheasEmail:[email protected]Phone:(646) 501–0264Lenox Hill Hospital, New York, New YorkNumber of positions:1Fellowship length:1 yearProgram director:Chad Kliger, MDProgram contact/coordinator:Tatiana GriffithEmail:[email protected]Phone:(212) 434–6839North CarolinaDuke University Medical Center, Durham, North CarolinaNumber of positions:1Fellowship length:1 yearProgram director:J. Kevin Harrison, MDProgram contact/coordinator:Arlene MartinEmail:[email protected]Phone:(919) 668–0950Other:Application form available on websiteUniversity of North Carolina Medical Center, Chapel Hill, North CarolinaNumber of positions:1Fellowship length:1 yearProgram director:John Vavalle, MD, MHSEmail:[email protected]Phone:(919) 966–5201PennsylvaniaLankenau Medical Center, Wynnewood, PennsylvaniaNumber of positions:1Fellowship length:1 yearProgram director:Eric Gnall, DOProgram contact/coordinator:Rose WellsEmail:[email protected]Phone:(484) 476–2682Rhode IslandBrown Alpert School of Medicine, Providence, Rhode IslandNumber of positions:1Fellowship length:1 yearProgram director:J. Dawn Abbott, MDProgram contact/coordinator:Jane FreerEmail:[email protected]Phone:(401) 444–8689TexasThe Heart Hospital Baylor Plano, Plano, TexasNumber of positions:2Fellowship length:1 yearProgram director:Elizabeth Holper, MDProgram contact/coordinator:Nikie SewellEmail:[email protected]Phone:(469) 814–4716Methodist DeBakey Heart and Vascular Center, Houston, TexasNumber of positions:1Fellowship length:1 yearProgram director:Neil Kleiman, MDProgram contact/coordinator:Melanie WinfieldDanielle HawkinsEmail:[email protected][email protected]Phone:(713) 441–4952VirginiaCarilion Clinic, Roanoke, VirginiaNumber of positions:1Fellowship length:1 yearProgram director:Jason R. Foerst, MDProgram contact/coordinator:Kayla BeagleyEmail:[email protected]Phone:(540) 224–1008WashingtonSwedish Heart and Vascular Institute, Seattle, WashingtonNumber of positions:1Fellowship length:1 yearProgram director:Sameer Gafoor, MDProgram contact/coordinator:Irina Penev, PAEmail:[email protected]Phone:(206) 320–8100Other:Application available upon requestUniversity of Washington, Seattle, WashingtonNumber of positions:1Fellowship length:1 yearProgram director:Creighton Don, MDProgram contact/coordinator:Theresa Wittenberg-ShugartEmail:[email protected]Phone:(206) 685–1397CANADAToronto General Hospital, Toronto, OntarioNumber of positions:1Fellowship length:1 yearProgram director:Eric Horlick, MDProgram contact/coordinator:Carole RyanEmail:[email protected]Phone:(416) 340–3835 Open table in a new tab

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